A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take?

A. A client who has depression and anxiety with an established plan of care: A medical-surgical nurse can safely care for a client with stable mental health conditions when a clear, established plan of care is in place. This client does not require constant psychiatric interventions, making it appropriate for assignment.

B. A client who is trying to engage in self-harm and does not understand why they cannot leave the facility: This client is high-risk and requires a nurse with specialized mental health training to implement safety measures and therapeutic interventions. Assigning this client to a medical-surgical nurse could compromise safety.

C. A client who is being discharged and needs information on substance abuse counseling: Discharge teaching and counseling for substance abuse require specialized knowledge and therapeutic communication skills typical of mental health nurses. A medical-surgical nurse may not have the expertise to provide adequate education and support.

D. A client who has been placed in restraints and requires documentation every 15 min: Clients in restraints require frequent monitoring, crisis intervention, and mental health expertise. This high-acuity situation is not appropriate for a nurse without psychiatric training.

Rationale for correct choices

• Blood pressure: The client’s blood pressure readings are consistently elevated (162/112 mm Hg and 166/110 mm Hg), which is a hallmark of preeclampsia. Hypertension arises from abnormal placental development leading to systemic vasoconstriction. Elevated blood pressure is a primary diagnostic criterion for preeclampsia and is more directly indicative of this condition than HELLP syndrome alone. HELLP may occur without hypertension.

• Hemoglobin: The client’s hemoglobin is mildly elevated at 18 g/dL with a hematocrit of 35%, suggesting hemoconcentration and potential microangiopathic hemolysis, a component of HELLP syndrome. While preeclampsia may cause mild hemoconcentration, hemolysis is a defining feature of HELLP. This reflects red blood cell destruction associated with this syndrome.

• Alanine aminotransferase (ALT): ALT is slightly elevated at 40 units/L, reflecting liver involvement. Liver enzyme elevation can occur in severe preeclampsia due to hepatic ischemia and in HELLP syndrome due to hepatocellular injury from hemolysis and microvascular obstruction. The finding supports involvement in both conditions.

• Platelet count: The platelet count is low at 98,000/mm³, which can result from platelet activation and consumption in both preeclampsia and HELLP syndrome. Thrombocytopenia is a hallmark of HELLP syndrome and may also develop in severe preeclampsia. This finding indicates increased risk for bleeding and warrants prompt intervention and monitoring.