A patient with suspected Disseminated Intravascular Coagulation (DIC) is admitted to the ICU. The nurse is reviewing the patient's lab results, which include negative D-dimer, low platelet count, prolonged PT and aPTT. The nurse understands that the patient is at high risk for which of the following complications?

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.

A. Administer iron supplements: Iron supplementation addresses anemia due to iron deficiency but does not treat the underlying immune-mediated platelet destruction or thrombotic risk associated with heparin-induced thrombocytopenia (HIT). It is not a priority intervention in this condition.

B. Use saline for flushing IV lines and IV ports: In HIT, all heparin products, including heparin flushes, must be avoided to prevent further immune-mediated platelet activation and thrombosis. Saline flushes are used as a safe alternative to maintain IV patency without exposing the patient to additional heparin.

C. Give low-molecular-weight heparin (LMWH): LMWH is structurally similar to unfractionated heparin and can cross-react in patients with HIT, potentially worsening thrombocytopenia and thrombotic complications. It is contraindicated in this situation.

D. Administer platelet transfusions: Platelet transfusions are generally avoided in HIT because adding platelets can fuel thrombus formation, increasing the risk of life-threatening clotting events. They are reserved for severe bleeding or procedural needs only.