The nurse is continuing to care for the client.

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Blood pressure

Hemoglobin

Alanine aminotransferase (ALT)

Platelet count

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

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.

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Correct Answer is C

Explanation

A. Unstageable: An unstageable pressure injury occurs when the full thickness of tissue loss is obscured by slough or eschar. Since subcutaneous fat and tunneling are visible in this case, the injury can be staged and is not unstageable.

B. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis. They do not extend into subcutaneous tissue and do not present with tunneling or visible fat, so this stage does not fit the description.

C. Stage 3:A Stage 3 pressure injury involves full-thickness skin loss. At this stage, subcutaneous fat (adipose tissue) is visible within the ulcer. Features like tunneling (a narrow opening or passageway extending from the wound) and undermining (tissue destruction underneath the intact skin at the wound edge) are common. However, the nurse should not be able to see bone, tendon, or muscle; if these deeper structures were visible, the injury would be classified as Stage 4.

D. Stage 4:A Stage 4 pressure injury involves full-thickness skin and tissue loss. The distinguishing factor for Stage 4 is the direct visualization or palpation of fascia, muscle, tendon, ligament, cartilage, or bone within the ulcer. While tunneling can occur in Stage 4, the presence of only subcutaneous fat keeps this specific injury at Stage 3.

A. Insert a peripheral catheter to deliver intravenous fluids. B. Obtain a prescription for parenteral nutrition. C. Offer the client massage therapy: D. Initiate a referral for physical therapy.

Correct Answer is C

Explanation

A. Insert a peripheral catheter to deliver intravenous fluids: Routine IV fluid administration is not a standard intervention in hospice care unless specifically indicated for symptom management. The focus in hospice is on comfort and quality of life rather than aggressive interventions, so placing an IV line for routine hydration is generally avoided.

B. Obtain a prescription for parenteral nutrition: Parenteral nutrition is typically not initiated in hospice care because it does not improve comfort or quality of life and may cause discomfort or complications. Hospice care prioritizes symptom management, pain relief, and emotional support rather than aggressive nutritional interventions.

C. Offer the client massage therapy: Massage therapy is an appropriate intervention in hospice care as it promotes comfort, reduces pain, alleviates anxiety, and supports emotional well-being. Complementary therapies like massage are aligned with hospice goals of enhancing quality of life and providing holistic care for clients nearing the end of life.

D. Initiate a referral for physical therapy: Physical therapy in hospice is generally limited and focused only on maintaining comfort and safe mobility rather than improving function or strength. While referrals can be made if needed, massage therapy is a more direct intervention to address comfort and symptom management at this stage of care.

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The nurse is continuing to care for the client. The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's coccyx area and notes visible subcutaneous fat with tunneling. Which of the following pressure injury stages should the nurse document?

Correct Answer is C

Explanation

A nurse is planning care for a client who is to begin receiving hospice care. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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The nurse is continuing to care for the client.

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.