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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Correct Answer is B
Explanation
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
Correct Answer is B
Explanation
Choice A rationale
Type 2 diabetes is characterized by insulin resistance, not the overproduction of insulin. Over time, the pancreas may produce less insulin, but the primary issue is the body’s inability to use insulin effectively.
Choice B rationale
Type 2 diabetes involves the body’s inability to process glucose properly due to insulin resistance. This leads to elevated blood glucose levels and various complications if not managed effectively.
Choice C rationale
Hemoglobin binding to sugar is related to the measurement of HbA1c, which reflects average blood glucose levels over time. It is not a cause of type 2 diabetes.
Choice D rationale
The destruction of pancreatic cells is a characteristic of type 1 diabetes, an autoimmune condition. Type 2 diabetes is primarily due to insulin resistance and is not caused by an autoimmune response.
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