A patient who has had a craniotomy is admitted to the ICU. The nurse notes that the patient is having difficulty speaking, and the right pupil is dilated and nonreactive. The nurse suspects increased intracranial pressure (ICP) and plans to assess the patient's neurological status. Which of the following should the nurse assess first?

A. Determine a Glasgow Coma Scale score: Assessing the patient’s level of consciousness using the Glasgow Coma Scale (GCS) is the most urgent step when increased ICP is suspected. Changes in mental status are often the earliest and most sensitive indicator of rising ICP, and a rapid, structured assessment allows the nurse to identify neurologic deterioration promptly. B. Obtain heart rate and blood pressure: Vital signs provide important information about hemodynamic status and may indicate Cushing’s triad in late-stage ICP elevation, but changes in consciousness usually precede these vital sign alterations. Immediate neurologic assessment takes priority. C. Assess reflexes and push pulls of feet: Reflex testing and motor strength evaluation are components of a comprehensive neurologic assessment, but they are secondary to establishing the patient’s overall level of consciousness and GCS score. Delaying initial assessment could postpone recognition of acute deterioration. D. Assess for nuchal rigidity: Nuchal rigidity is a sign of meningeal irritation, not a primary indicator of increased ICP following a craniotomy. While important to note, it is not the first assessment action when acute neurologic changes and signs of herniation are present.