Declining level of consciousness or seizures — notify the provider immediately and protect the airway.
Before you read
Test yourself first: 5 questions
Question 1 of 5
Which client statement after total hip arthroplasty indicates a need for further teaching about preventing prosthesis dislocation?
Answer: B. Sitting on low chairs or low toilet seats flexes the hip beyond 90 degrees and risks dislocation. Clients should use elevated seats and avoid bending forward, crossing the legs, or low surfaces. The other statements reflect correct precautions.
Question 2 of 5
A client with type 2 diabetes presents with a blood glucose of 850 mg/dL, profound dehydration, and altered mental status but no significant ketones or acidosis. The nurse recognizes this as which condition?
Answer: A. Hyperosmolar hyperglycemic state (HHS) features extreme hyperglycemia (often above 600 mg/dL), severe dehydration, and high serum osmolality with little or no ketosis or acidosis, because residual insulin prevents ketogenesis. DKA, by contrast, includes marked ketoacidosis.
Question 3 of 5
A nurse assesses a client whose blood glucose is 38 mg/dL. The client is awake but confused. Which assessment finding is most consistent with this glucose level?
Answer: B. At a glucose of 38 mg/dL the brain is starved of fuel, producing neuroglycopenic signs such as confusion, slurred speech, blurred vision, and difficulty concentrating, along with adrenergic signs like diaphoresis and tremor. Warm flushed skin, deep rapid breathing, and a fruity odor are hyperglycemic findings, not hypoglycemic ones.
Question 4 of 5
A nurse is caring for an older adult with hyperglycemic hyperosmolar syndrome (HHS). Which finding best distinguishes HHS from DKA?
Answer: B. HHS is marked by extreme hyperglycemia (often above 600 mg/dL) with profound dehydration and high serum osmolality, but ketosis and significant acidosis are absent or minimal because enough insulin is present to prevent ketone formation. DKA, by contrast, features ketonemia, metabolic acidosis, and Kussmaul respirations.
Question 5 of 5
When measuring intervals on a rhythm strip, which statement about the normal QRS duration is correct?
Answer: A. A normal QRS complex represents ventricular depolarization and measures less than 0.12 seconds (under three small boxes). A QRS of 0.12 seconds or greater is considered wide and suggests a ventricular origin or a conduction delay such as bundle branch block. The PR interval (0.12-0.20 seconds) and QT interval are measured separately.
Keep the streak going with more questions like these, each with a full rationale.
What is hyperosmolar hyperglycemic state (hhs)?
It combines extreme hyperglycemia, profound dehydration, and very high serum osmolality, but with little or no ketosis or acidosis. It happens because the body still has enough insulin to block ketone production but not enough to control glucose; the very high glucose drives heavy urination and severe fluid loss. It develops gradually, often in older adults with an infection or other illness, and glucose usually exceeds 600 mg/dL. The danger is dehydration and altered mental status, so IV fluids come first.
Key points to remember
- HHS stands for hyperosmolar hyperglycemic state; older texts call it HHNS (hyperosmolar hyperglycemic nonketotic syndrome).
- Glucose is usually above 600 mg/dL, with serum osmolality above 320 mOsm/kg.
- There is little or no ketosis and no significant acidosis, so Kussmaul breathing is not expected; this separates HHS from DKA.
- Profound dehydration: severe thirst, dry mucous membranes, poor skin turgor, hypotension, and tachycardia.
- Neurologic changes range from confusion and lethargy to seizures and coma.
- Typical patient: an older adult with type 2 diabetes, often triggered by infection or illness.
- Treatment order: IV isotonic fluids first, then IV regular insulin per protocol, with potassium replacement as insulin moves potassium into cells.
Signs & symptoms
- Severe dehydration, ↑ thirst
- Altered LOC, seizures, coma
Nursing priorities
- Start aggressive IV isotonic fluid replacement first, because severe dehydration is the main threat.
- Check potassium before and during insulin therapy and replace as ordered, because insulin and fluids shift potassium into cells and can cause dangerous hypokalemia.
- Give IV regular insulin per protocol and check glucose often, lowering it gradually, because rapid correction can cause cerebral edema.
- Monitor neurologic status, vital signs, and intake and output closely, because they show how the patient is responding.
- Identify and treat the trigger, such as infection, because the precipitating illness must be treated for HHS to resolve.
Labs & values
Worked example
- Cue: An older adult with type 2 diabetes and pneumonia is confused, with dry mucous membranes, hypotension, tachycardia, glucose above 600 mg/dL, and minimal ketones.
- Meaning: HHS, with extreme hyperglycemia and dehydration but no significant ketosis.
- Priority action: Start IV isotonic fluids, check potassium, then begin the insulin infusion per protocol with close glucose and neuro checks.
- Evaluation: Blood pressure and heart rate improve, mental status clears, glucose falls gradually, and potassium stays within 3.5–5.0 mEq/L.
Patient teaching
- When you are sick, check your blood sugar more often and drink fluids to stay hydrated.
- Do not stop your diabetes medicines when you are ill unless your provider tells you to.
- Call your provider if your blood sugar stays high, or if you are extremely thirsty, urinating a lot, or confused.
Common mistakes
- Giving insulin before fluids. In HHS, fluids come first.
- Expecting ketones, Kussmaul breathing, or acidosis; those point to DKA.
- Forgetting potassium: a normal starting level can fall once insulin begins.
- Lowering glucose as fast as possible; gradual correction protects against cerebral edema.
Red flags: report now
- Declining level of consciousness or seizures — notify the provider immediately and protect the airway.
- Hypotension and tachycardia that worsen despite fluids — report signs of hypovolemic shock now.
- Falling potassium or a new dysrhythmia during insulin therapy — notify the provider; replacement needs adjusting.
- Glucose dropping very fast or worsening confusion during treatment — report; rapid correction risks cerebral edema.
References
Clinical references for this topic
