Exam #2-Endocrine Crises: DKA vs. HHS

The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include: 1. Kussmaul's respirations. 2. Excessive hunger. 3. Dry, flaky skin. 4. High blood pressure

1. The client with diabetic ketoacidosis exhibits Kussmaul's respiration, as well as flushed skin, dry mouth, urinary frequency, hyperglycemia, and ketonuria. Excessive hunger and high blood pressure are not associated with diabetic ketoacidosis.

A 58-year-old homeless person is brought to the emergency department by the police after being found unconscious on the street. Following examination and evaluation of laboratory test results, a diagnosis of diabetic ketoacidosis is confirmed. Which of the following information is most crucial to document on the client's chart? Select all that apply. 1. Size of pupils and reaction of pupils to light. 2. Response to verbal and painful stimuli. 3. Skin condition and presence of any rashes, lesions, or ulcers. 4. Blood pressure. 5. Length of time the client has had diabetes. 6. Hourly urine output.

118. 1, 2, 3, 4, 6. Diabetic ketoacidosis is a potentially life-threatening problem. The state of unconsciousness requires very astute monitoring of the neurologic condition. Frequent assessments of neurologic status (including the client's ability to respond to stimuli), blood pressure, and urinary output need to be documented. Assessment of skin condition for the presence of lesions, bruises, ulcers, or bumps is documented to assess for possible injuries, such as falls associated with head injury or internal injuries. Although it would be helpful to know how long the client has had diabetes, this information is not essential to document. CN: Physiological adaptation; CL: Analyze

A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss? 1. Hypotension. 2. Decreased serum potassium level. 3. Rapid, deep respirations. 4. Warm, dry skin.

3. Due to the rapid, deep respirations, the client is losing fluid from vaporization from the lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through vaporization. Decreased serum potassium level has no effect on insensible fluid loss. Hypotension occurs due to polyuria and inadequate fluid intake. It may decrease the flow of blood to the skin, causing the skin to be warm and dry. CN: Reduction of risk potential; CL: Analyze

The elderly client with type 2 diabetes has hyperglycemic hyperosmolar syndrome (HHS). The nurse should monitor the infusion for too rapid correction of the blood glucose in order to prevent: 1. Ketone body formation. 2. A major vascular accident. 3. Fluid volume depletion. 4. Cerebral edema.

4. HHS can be caused by acute illness, such as an infection like pneumonia or sepsis. In HHS,there is a residual amount of insulin that suppresses ketosis but cannot control hyperglycemia. This leads to severe dehydration, and impaired renal function. Ketone bodies are usually absent in HHS, and they do not form as a result of too rapid correction of blood glucose. The nurse should assess the client for a major vascular accident in the elderly as an etiology for a hyperglycemic crisis. Volume depletion must be treated first in HHS. Cerebral edema is a risk with too rapid correction of blood glucose.

The nurse reviews prescriptions written for a client with diabetic ketoacidosis (DKA). Which prescription should the nurse question? Insert an indwelling urinary catheter Begin infusion of sodium chloride 0.9% IV at 200 mL/hr Administer NPH insulin Initiate continuous pulse oximetry

Administer NPH insulin Explanation: Hyperglycemia is corrected using regular insulin administered by the intravenous route, rather than NPH insulin, which is administered subcutaneously. The nurse should consult with the healthcare provider to question this prescription. The client requires isotonic fluid replacement to correct the severe dehydration that occurs with DKA. Catheter insertion can be done to monitor output to gauge the effectiveness of rehydration. Initiating pulse oximetry is a routine assessment that may be useful as part of the client's overall clinical picture.

Which valuation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar nonketotic coma (HHNK) has demonstrated improvement during the first 24 hours? Alert and oriented, blood and urine without ketones, no orthostatic BP Respirations easy and even, eats 50 to 75 percent of meals, vital signs stable Intake equals output, denies pain and shortness of breath Alert and oriented, balanced intake and output, moist mucous membranes

Alert and oriented, balanced intake and output, moist mucous membranes Explanation: HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness and hyperthermia. Ketones are not present in HHNK; thus, monitoring for ketones is inappropriate. Intake equals output, denies pain and shortness of breath and respirations easy and even, eats 50 to 75 percent of meals, vital signs stable do not address the primary problems that occur with HHNK.

Which valuation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar nonketotic coma (HHNK) has demonstrated improvement during the first 24 hours? Intake equals output, denies pain and shortness of breath Alert and oriented, balanced intake and output, moist mucous membranes Alert and oriented, blood and urine without ketones, no orthostatic BP Respirations easy and even, eats 50 to 75 percent of meals, vital signs stable

Alert and oriented, balanced intake and output, moist mucous membranes Explanation: HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness and hyperthermia. Ketones are not present in HHNK; thus, monitoring for ketones is inappropriate. Intake equals output, denies pain and shortness of breath and respirations easy and even, eats 50 to 75 percent of meals, vital signs stable do not address the primary problems that occur with HHNK.

Which valuation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar nonketotic coma (HHNK) has demonstrated improvement during the first 24 hours? Alert and oriented, blood and urine without ketones, no orthostatic BP Respirations easy and even, eats 50 to 75 percent of meals, vital signs stable Intake equals output, denies pain and shortness of breath Alert and oriented, balanced intake and output, moist mucous membranes

Alert and oriented, blood and urine without ketones, no orthostatic BP

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

Ans: B Feedback: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

Ans: B, C, D, E Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 977 In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive.What is the nurses most plausible conclusion based on this assessment finding? A) The patient should withhold his next scheduled dose of insulin. B) The patient should promptly eat some protein and carbohydrates. C) The patients insulin levels are inadequate. D) The patient would benefit from a dose of metformin (Glucophage).

Ans: C Feedback: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patients ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? A) Patients who are obese and who have no known history of diabetes B) Patients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

Ans: D Feedback: HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patients daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

Ans: D Feedback: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

The client who has a long history of type 1 diabetes mellitus is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the client's clothes, and dry skin. Which action should the nurse take next? Assess blood glucose level for hyperglycemia and check urine for ketones. Assess the client for additional signs of hypoglycemia. Encourage the client to rest and to drink 8 to 10 glasses of fluids daily. Assess breath sounds to determine client's response to treatment of the infection.

Assess blood glucose level for hyperglycemia and check urine for ketones. Explanation: Assessing breath sounds to determine response to treatment of the infection does not address the client's current problem. Hypoglycemia is the opposite problem of the one the client is experiencing. Rest periods will not help treat hyperglycemia and ketoacidosis, and although fluids are needed, 8-10 glasses daily will not be enough to reverse the dehydration that accompanies diabetic ketoacidosis. Kussmaul respirations, fruity breath odor, and dry skin are signs consistent with diabetic ketoacidosis, which is characterized by hyperglycemia and ketonuria.

A 70-year-old client admitted a few hours ago with a blood glucose (BG) of 750 mg/dL is being treated for hyperosmolar hyperglycemic nonketotic syndrome (HHNS) with intravenous regular insulin at 10 units/hour, normal saline with 20 mEq of potassium per liter infusing at 250 mL/hr, and oxygen at 2 L/min. The client has been oriented when stimulated, and BG has dropped to 400 mg/dL. The client now demands to get out of bed and the skin feels cool and moist. What should the nurse do at this time? Recognize the client is feeling better and seeks control of the situation. Auscultate breath sounds and assess oxygen saturation. Assess the client for bladder distention or signs of imbalanced body temperature. Interpret this as a sign of hypoglycemia and check the blood glucose.

Auscultate breath sounds and assess oxygen saturation. Explanation: There is no risk for hypoglycemia while the BG is still elevated to 400 mg/dL. The nurse should seek a physiological basis for the change in client's status rather than seeking control, especially since the skin is cool and moist. Increased preload caused by the intravenous infusion at 250 mL/hr may exceed the myocardium's workload capacity, leading to signs of decreased cardiac output and congestive heart failure. Checking for bladder distention or fever represents a failure to directly assess for signs of possible fluid overload.

The client is admitted with metabolic acidosis secondary to diabetic ketoacidosis (DKA). Understanding metabolic acidosis, the nurse should choose which high priority nursing diagnosis? Ineffective breathing pattern related to hyperventilation. Decreased cardiac output related to fluid and electrolyte imbalance. Decreased urinary elimination related to reduced output and muscle function. Anxiety related to fears of long-term outcomes and discomfort.

Decreased cardiac output related to fluid and electrolyte imbalance. This is false regarding output and does not address the metabolic problem. DKA is associated with excessive urine output, dehydration, and hypokalemia, placing the client at risk for decreased cardiac output and cardiac dysrhythmias. Ineffective breathing may or may not apply to the client but is not the priority need; in addition, this will resolve as the DKA is treated. Anxiety related to fears may or may not apply to the client but is not the priority need.

A client is diagnosed with hyperglycemic hyperosmolar nonketotic coma (HHNK) after being admitted with a blood glucose level of 720 mg/dL. The admitting orders include: normal saline infusion, insulin infusion, tylenol PRN and glucagon PRN. When should the nurse prepare to give the glucagon? For precipitous drop in blood glucose leading to unresponsiveness When the blood sugar reaches 150 mg/dL For urine output less than 60 mL/hr For symptomatic BP less than 100/60 mmHg

For precipitous drop in blood glucose leading to unresponsiveness Glucagon is given IM or SC for low blood glucose associated with unconsciousness; usually the blood glucose is less than 20 mg/dL. Hypoglycemia associated with a change in level of consciousness or seizure requires immediate interventions. Glucagon will not help urine output or blood pressure, and is not administered routinely when glucose levels fall to 150 mg/dL.

The client with diabetic ketoacidosis (DKA) is given intravenous normal saline infusion and regular insulin. In addition to hourly blood glucose monitoring, what assessment data indicate early signs of clinical improvement? Respiratory rate of 12 to 15 and normal BP in the standing position Temperature and pulse in normal range Client eats a full meal and respiratory rate is normal Improved level of consciousness and decreasing urine output

Improved level of consciousness and decreasing urine output Dehydration is usually so severe that several hours of rehydration are needed to resolve orthostatic BP. Dehydration is usually so severe that several hours of rehydration are needed to reduce pulse. Level of consciousness responds quickly to early changes in pH and restoration of fluid and electrolyte balance. Urine output decreases as hyperglycemia is resolved. This option is inappropriate because eating a full meal is not an early sign of improvement.

A client who was admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) asks how he can prevent recurrence of this illness. The nurse would instruct the client about which helpful prevention measures? Select all that apply. Monitor for signs of infection and treat infection early. Use stress management techniques because the stress response increases blood glucose. Consult primary care provider when fasting blood glucose is elevated. Use sliding-scale insulin to cover periodic snacks that are not part of the dietary plan. Maintain fluid balance by drinking 4 glasses of water daily

Monitor for signs of infection and treat infection early. Use stress management techniques because the stress response increases blood glucose. HHNS occurs in clients with type 2 diabetes mellitus, primarily older adults, and thus insulin is not necessarily a part of the ongoing treatment plan (oral antidiabetic agents may be used). Drinking 4 glasses of water daily is insufficient; 6 to 8 glasses of water are recommended for general health. HHNS is associated with hyperglycemic response to infection or other disease or illness, some medications, dehydration, stress, or a combination of these factors. Consulting a healthcare provider for elevated blood glucose does not demonstrate an understanding of how to prevent HHNS. The response to stress can increase blood glucose levels so stress management may be helpful as part of overall measures to prevent increased blood glucose

A client who was admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) asks how he can prevent recurrence of this illness. The nurse would instruct the client about which helpful prevention measures?Select all that apply . Use sliding-scale insulin to cover periodic snacks that are not part of the dietary plan. Maintain fluid balance by drinking 4 glasses of water daily. Consult primary care provider when fasting blood glucose is elevated. Use stress management techniques because the stress response increases blood glucose. Monitor for signs of infection and treat infection early.

Use stress management techniques because the stress response increases blood glucose. Monitor for signs of infection and treat infection early. Explanation: HHNS occurs in clients with type 2 diabetes mellitus, primarily older adults, and thus insulin is not necessarily a part of the ongoing treatment plan (oral antidiabetic agents may be used). Drinking 4 glasses of water daily is insufficient; 6 to 8 glasses of water are recommended for general health. HHNS is associated with hyperglycemic response to infection or other disease or illness, some medications, dehydration, stress, or a combination of these factors. Consulting a healthcare provider for elevated blood glucose does not demonstrate an understanding of how to prevent HHNS. The response to stress can increase blood glucose levels so stress management may be helpful as part of overall measures to prevent increased blood glucose.

What are manifestations of diabetic ketoacidosis (DKA) (select all that apply)? a. Thirst d. Metabolic acidosis b. Ketonuria e. Kussmaul respirations c. Dehydration f. Sweet, fruity breath odor

a, b, c, d, e, f. In DKA, ketosis leads to ketonuria in trying to decrease the blood glucose and ketonemia. The metabolic acidosis leads to the Kussmaul respirations trying to decrease the acid in the system. The sweet, fruity breath odor is from DKA. Thirst and dehydration are found with both DKA and hyperosmolar hyperglycemic syndrome (HHS).

What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)? a. DKA requires administration of bicarbonate to correct acidosis. b. Potassium replacement is not necessary in management of HHS. c. HHS requires greater fluid replacement to correct the dehydration. d. Administration of glucose is withheld in HHS until the blood glucose reaches a normal level.

c. The management of DKA is similar to that of HHS except that HHS requires greater fluid replacement because of the severe hyperosmolar state. Bicarbonate is not usually given in DKA to correct acidosis unless the pH is <7.0 because administration of insulin will reverse the abnormal fat metabolism. Total body potassium deficit is possible in both conditions, requiring potassium administration, and in both conditions glucose is added to IV fluids when blood glucose levels fall to 250 mg/dL (13.9 mmol/L).

The nurse should observe the patient for symptoms of ketoacidosis when a. illnesses causing nausea and vomiting lead to bicarbonate loss with body fluids. b. glucose levels become so high that osmotic diuresis promotes fluid and electrolyte loss. c. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy. d. the patient skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy.

c. When insulin is insufficient and glucose cannot be used for cellular energy, the body releases and breaks down stored fats and protein to meet energy needs. Free fatty acids from stored triglycerides are released and metabolized in the liver in such large quantities that ketones are formed. Ketones are acidic and alter the pH of the blood, causing acidosis. Osmotic diuresis occurs as a result of elimination of both glucose and ketones in the urine.

Upon initial admission of a client diagnosed with diabetic ketoacidosis (DKA), the nurse notices a fruity odor to the breath, Kussmaul's respirations, and lethargy. The glucose level is 700 mg/dL, positive ketones in the urine and the family member states they have not been able to afford the insulin. Which results would the nurse expect on ABGs? pH 7.38; CO2 33 mmHg; HCO3- 22 mEq/L pH 7.25; CO2 36 mmHg; HCO3- 18 mEq/L pH 7.25; CO2 36 mmHg; HCO3- 22 mEq/L pH 7.25; CO2 48 mmHg; HCO3- 29 mEq/L

pH 7.25; CO2 36 mmHg; HCO3- 18 mEq/L Explanation: Metabolic acidosis is the alteration in acid-base balance with DKA. pH 7.25; CO2 36 mmHg; HCO3- 18 mEq/L indicates metabolic acidosis. This question draws on your knowledge of ABG values. The results show uncompensated metabolic acidosis because the question asked about the initial admission. Partially compensated or fully compensated values would be expected later. pH 7.25; CO2 48mmHg; HCO3- 29 mEq/L indicates respiratory acidosis.