Which Nursing Intervention for the Patient with Increased Intracranial Pressure would be first priority?

Choice A: When patient is fully oriented is incorrect because it is a positive sign of recovery from a concussion. It means that the patient is aware of their person, place, time, and situation. The nurse should monitor the patient's orientation status but does not need to report it to the doctor immediately.

Choice B: Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety are correct because they are signs of worsening brain injury or complications from a concussion. They may indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. The nurse should report these symptoms to the doctor immediately and prepare for further diagnostic tests or interventions.

Choice C: When patient is easy to arouse is incorrect because it is also a positive sign of recovery from a concussion. It means that the patient responds quickly and appropriately to verbal or physical stimuli. The nurse should monitor the patient's level of consciousness but does not need to report it to the doctor immediately.

Choice D: All of the above are incorrect because only choice b) requires immediate reporting to the doctor. Choices a) and c) are normal or expected outcomes of a concussion and do not indicate any danger or complication. The nurse should use clinical judgment and follow the guidelines for concussion management and care.

Choice A: Referral to counselor, social worker, home health care, support groups is correct because it can help the patient cope with the emotional, social, and practical aspects of living with a brain tumor. It can also provide information, resources, and assistance to the patient and their caregivers.

Choice B: Presence of family, friends, spiritual advisor, and health care personnel may be supportive is correct because it can provide comfort, companionship, and guidance to the patient. It can also help the patient express their feelings, needs, and preferences.

Choice C: Encourage independence for as long as possible is correct because it can enhance the patient's self-esteem, dignity, and quality of life. It can also help the patient maintain their physical and mental abilities and prevent complications such as depression, anxiety, or immobility.

Choice D: All of the above are correct because they are part of the holistic nursing care for the patient with nervous system metastases or primary brain tumor. They can address the physical, psychological, social, and spiritual needs of the patient and their family.