# An emergency department nurse is assessing a 24-year-old client with type 1 diabetes mellitus who reports a 6-hour history of nausea, vomiting, and abdominal pain. Which assessment finding represents the highest priority for immediate intervention?

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## 문제

An emergency department nurse is assessing a 24-year-old client with type 1 diabetes mellitus who reports a 6-hour history of nausea, vomiting, and abdominal pain. Which assessment finding represents the highest priority for immediate intervention?

## 보기

1. Blood glucose level of 380 mg/dL with polyuria
2. Ketones present in urine with glucosuria
3. Kussmaul respirations with fruity breath odor **✔ 정답**
4. Dehydration with poor skin turgor and dry mucosa

**정답: 3**

## 해설

Kussmaul respirations with fruity breath odor indicates severe DKA with metabolic acidosis, requiring immediate intervention to prevent respiratory failure. Other findings like hyperglycemia, ketonuria, and dehydration are concerning but less immediately life-threatening.

## 심화 해설

Clinical Reasoning and Priority Setting

This client presents with a classic triad of symptoms—nausea, vomiting, and abdominal pain—superimposed on type 1 diabetes mellitus, which immediately raises concern for diabetic ketoacidosis (DKA). DKA is the most serious and life-threatening hyperglycemic emergency in individuals with type 1 diabetes [1]. While all the listed assessment findings are consistent with DKA and require intervention, the question asks for the highest priority. In NCLEX-RN prioritization, the airway, breathing, and circulation (ABC) framework, combined with the concept of "what will kill the client first," guides clinical judgment. The finding that signals a failure of physiological compensation and imminent respiratory collapse takes precedence.

Pathophysiology of Kussmaul Respirations

In DKA, a profound insulin deficiency leads to severe hyperglycemia and the breakdown of free fatty acids into ketone bodies, resulting in metabolic acidosis [3]. As the blood pH drops, the body initiates a compensatory mechanism to blow off carbon dioxide (CO₂) and raise the pH. This manifests as Kussmaul respirations, which are deep, rapid, and labored breaths. The presence of a fruity breath odor is a direct clinical sign of exhaled acetone, a specific ketone body. While Kussmaul respirations are initially a compensatory response, their presence indicates severe acidosis. If left unaddressed, this compensatory mechanism will fatigue, leading to acute respiratory failure, a rapid decline in pH, and cardiac arrest. This directly threatens the "Breathing" component of the ABCs, making it the highest priority.

Analysis of Other Options

The other findings are critical components of DKA but are secondary in the prioritization sequence when a direct threat to airway and breathing exists.

- Option 1: A blood glucose level of 380 mg/dL with polyuria confirms severe hyperglycemia and osmotic diuresis. This requires aggressive rehydration and insulin therapy [1]. However, the immediate life threat from hyperglycemia unfolds over hours, whereas respiratory failure from acidotic compensation can occur more acutely.

- Option 2: The presence of ketones and glucose in the urine is a diagnostic hallmark of DKA, confirming that the metabolic derangement is driven by ketosis . This finding guides the diagnosis but does not represent an immediate physiological threat to the client's breathing.

- Option 4: Dehydration with poor skin turgor and dry mucosa reflects the significant fluid deficit from osmotic diuresis and vomiting. Aggressive intravenous fluid resuscitation is a cornerstone of DKA management [3]. While critical, this finding pertains to the "Circulation" component and is addressed simultaneously with, but not before, a rapidly deteriorating respiratory status.

The Kussmaul respirations signal that the body's compensatory buffer systems are being overwhelmed, a state that can rapidly progress to decompensation and respiratory arrest. In the emergency department setting, this finding demands the most immediate intervention, such as preparing for assisted ventilation and initiating rapid treatment to correct the underlying acidosis, placing it firmly as the highest priority per the ABC framework .References (research sources)

- [1]Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State.Research articleFayfman M, Pasquel FJ, Umpierrez GE. (2017) · DOI: 10.1016/j.mcna.2016.12.011

- [3]Management of Diabetic Ketoacidosis in Adults: A Narrative Review.Research articleEledrisi MS, Elzouki AN. (2020) · DOI: 10.4103/sjmms.sjmms_478_19

## 임상 시나리오

Clinical Guide: DKA Respiratory AssessmentPrioritizing Kussmaul Respirations in Diabetic Ketoacidosis
In a patient with type 1 diabetes and gastrointestinal symptoms, Kussmaul respirations are deep, rapid, labored breaths signaling severe metabolic acidosis. This is a compensatory mechanism to expel CO2 and raise pH. A fruity breath odor indicates exhaled acetone.

This finding represents the highest nursing priority because it indicates the body's compensation is failing. Untreated, respiratory muscle fatigue leads to acute respiratory failure, a direct threat to breathing and the most immediate life threat per the ABC framework.

CautionDo not mistake Kussmaul respirations for simple tachypnea or anxiety. This is a critical sign of decompensation requiring immediate notification of the provider and preparation for interventions like insulin infusion and airway support, not just oxygen therapy.

## 핵심 개념

- **Kussmaul respirations** — Deep, rapid, labored breathing pattern that compensates for severe metabolic acidosis by blowing off carbon dioxide to raise blood pH.
- **Diabetic ketoacidosis (DKA)** — Acute, life-threatening complication of type 1 diabetes characterized by hyperglycemia, ketonemia, and metabolic acidosis due to insulin deficiency.
- **ABC priority framework** — Triage and assessment model prioritizing Airway, Breathing, and Circulation in that order to identify and manage immediate life threats.

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