A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
Acetone breath.
Fever.
Serum glucose 800 mg/dL (74 to 106 mg/dL).
Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).
Insidious onset.
Correct Answer : B,C,E
Choice A rationale
Acetone breath is a characteristic symptom of diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). In DKA, the body produces ketones, leading to a fruity or acetone-like breath odor. HHS, on the other hand, does not typically involve significant ketone production.
Choice B rationale
Fever can be a manifestation of HHS, often due to an underlying infection or illness that precipitates the hyperglycemic state. Infections are common triggers for HHS, leading to elevated body temperature.
Choice C rationale
Serum glucose levels of 800 mg/dL are indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketoacidosis.
Choice D rationale
Serum bicarbonate levels of 15 mEq/L are more indicative of DKA rather than HHS. In HHS, bicarbonate levels are usually within the normal range because there is no significant ketoacidosis.
Choice E rationale
Insidious onset is a hallmark of HHS. The condition develops gradually over days to weeks, unlike DKA, which has a more rapid onset.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Polyuria (frequent urination) is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia (high blood sugar levels)15.
Choice B rationale
Sweating is a common symptom of hypoglycemia. It occurs as the body’s response to low blood sugar levels, triggering the release of adrenaline.
Choice C rationale
Blurry vision can occur during hypoglycemia due to the lack of glucose available for the proper functioning of the eyes.
Choice D rationale
Tachycardia (rapid heartbeat) is a common symptom of hypoglycemia. It occurs as the body’s response to low blood sugar levels, triggering the release of adrenaline.
Choice E rationale
Polydipsia (excessive thirst) is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia.
Correct Answer is A
Explanation
Choice A rationale
Serving cooked fruit with meals is an appropriate intervention for a client with a low WBC count after chemotherapy. Cooking fruit helps eliminate potential pathogens, reducing the risk of infection.
Choice B rationale
Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is not appropriate. A lower threshold for fever should be used, as even a slight increase in temperature can indicate infection in immunocompromised clients.
Choice C rationale
Placing the client in a room with negative-pressure airflow is not necessary for clients with low WBC counts. This intervention is typically used for clients with airborne infections.
Choice D rationale
Instructing the client to use an incentive spirometer every 4 hours is beneficial for lung health but does not directly address the risk of infection associated with low WBC counts.
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