A client is admitted in the ICU with diagnosis of hyperglycemic hyperosmolar state (HHS)
The nurse caring for the client knows that the client's elevated serum osmolality has pulled water out of this brain cells based on which of the following assessment findings? Select all that apply.
A) Weakness one side of the body
B) After the sole of the foot has been firmly stroked, the toes flex and flare out
C) Increase in urine output in proportion to the increase in blood glucose
D) Unable to respond verbally to questions
E) Uncontrollable twitching of a muscle group
Ans: A, B, D, E
Feedback:
HHS is characterized by hyperglycemia (blood glucose >600 mg/dL); hyperosmolarity (plasma osmolarity >310 mOsm/L); and dehydration, the absence of ketoacidosis, and depression of the sensorium. The most prominent manifestations are weakness, dehydration, polyuria, neurologic signs and symptoms, and excessive thirst. The neurologic signs include hemiparesis (weakness on one side of the body), Babinski reflex (the sole of the foot has been firmly stroked, the toes flex and flare out), aphasia (unable to respond verbally to questions), muscle fasciculations (uncontrollable twitching of a muscle group), hyperthermia, hemianopia, nystagmus, visual hallucinations, seizures, and coma.
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