# A nurse is caring for a patient with type 1 diabetes mellitus who presents to the emergency department. Which assessment finding would be the highest priority for immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540460 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with type 1 diabetes mellitus who presents to the emergency department. Which assessment finding would be the highest priority for immediate intervention? A 28-year-old patient with type 1 diabetes mellitus is brought to the emergency department by family members who report the patient has been "acting confused" for the past 2 hours. The patient appears lethargic and has difficulty responding to questions appropriately. ## 보기 1. Blood glucose level of 180 mg/dL (10.0 mmol/L) 2. Ketones present in urine with a fruity breath odor 3. Blood pressure of 90/60 mmHg with heart rate of 110 bpm 4. Altered mental status with Glasgow Coma Scale score of 8 **✔ 정답** **정답: 4** ## 해설 Altered mental status with a Glasgow Coma Scale score of 8 indicates severe neurological compromise requiring immediate intervention to prevent further deterioration and potential brain damage. This question assesses the nurse's ability to prioritize among multiple symptoms in a diabetic patient. The Glasgow Coma Scale (GCS) is a standardized tool for evaluating level of consciousness, with scores ranging from 3 to 15. A GCS score of 8 indicates a severe consciousness impairment, placing the patient at high risk for airway obstruction, aspiration, and further neurological deterioration. In diabetic emergencies, altered consciousness can occur in both diabetic ketoacidosis (DKA) and hypoglycemia. Regardless of the underlying cause, a severe alteration in consciousness (GCS ≤8) is considered a medical emergency requiring immediate intervention. The patient's airway may be compromised, protective reflexes may be diminished, and there is a significant risk of aspiration. The immediate priorities are airway protection, oxygen administration, securing intravenous access, and rapid blood glucose assessment. The other options also represent findings that require attention but are not immediately life-threatening. A blood glucose of 180 mg/dL is elevated but not critically high. Urine ketones and a fruity odor suggest DKA and require treatment, but these develop over hours to days. Hypotension and tachycardia indicate hemodynamic changes that need monitoring and intervention, but the altered consciousness with a GCS of 8 poses the most immediate threat to patient safety and requires urgent neurological and airway assessment and intervention. ## 심화 해설 Clinical Priority Analysis The highest priority assessment finding requiring immediate intervention is altered mental status with a Glasgow Coma Scale (GCS) score of 8. In the context of a patient with type 1 diabetes mellitus presenting with confusion and lethargy, a GCS of 8 represents a critical and immediate threat to the airway, breathing, and circulation (ABCs). This score signifies a severe neurological depression where the patient is unable to protect their own airway, placing them at high risk for aspiration, respiratory failure, and hypoxic brain injury. Pathophysiology and Clinical Correlation The patient's presentation is highly suggestive of diabetic ketoacidosis (DKA), a severe hyperglycemic crisis. The combination of altered mental status and a low GCS is the most dangerous manifestation of a potential complication of DKA: cerebral edema. While cerebral edema is relatively uncommon, occurring in less than 1% of pediatric DKA cases, its consequences are devastating, representing a significant proportion of DKA-related deaths [1]. The systematic review highlights that even among survivors, 25% suffer permanent neurologic deficits [1]. The pathophysiology, though not fully elucidated, involves fluid shifts and cellular injury in the brain, leading to increased intracranial pressure. A declining GCS is the primary clinical indicator of this life-threatening process, mandating immediate airway protection and interventions to reduce intracranial pressure, often preceding the full correction of the metabolic abnormalities. Prioritization Using the ABC Framework The NCLEX-RN exam tests the ability to prioritize care using the ABC (Airway, Breathing, Circulation) framework and the concept of "acute versus chronic." A GCS of 8 directly indicates an inability to maintain a patent airway, which is the "A" in the ABCs. This takes absolute precedence over the other findings, which represent "C" (circulation) and underlying metabolic causes. - Option 4 (Correct): A GCS of 8 signifies a comatose state with a non-protected airway. A case report of a severe hyperglycemic crisis describes a patient presenting unresponsive with a GCS of 3 who required immediate intubation for airway protection [2]. This illustrates the direct clinical pathway from severe neurological depression to a definitive airway intervention. Without immediate airway management, the patient will deteriorate. - Option 3: A blood pressure of 90/60 mmHg and heart rate of 110 bpm indicate hypovolemia and compensatory tachycardia, a critical circulation issue in DKA. Fluid resuscitation is a cornerstone of DKA management [1]. However, in the hierarchy of ABCs, a non-patent airway will lead to death in minutes, whereas hypotension is a slightly less immediate threat that can be managed concurrently after the airway is secured. - Option 2: The presence of urine ketones and a fruity breath odor are classic diagnostic clues for DKA, confirming the body's shift to fat metabolism and ketoacid production. While this finding confirms the underlying diagnosis that requires insulin and fluid therapy [1], it is a metabolic sign, not an immediate physiological crisis like the loss of an airway. - Option 1: A blood glucose of 180 mg/dL (10.0 mmol/L) is a marker of hyperglycemia but is not severely elevated in the context of a hyperglycemic crisis. Case reports of severe DKA describe glucose levels exceeding 1,000 mg/dL [2]. This value requires treatment but does not represent an immediate, life-threatening emergency compared to a non-patent airway. The nurse's immediate intervention must be to recognize that a GCS of 8 is a critical threshold for airway compromise, summon the emergency response team, and prepare for definitive airway management, as the risk of cerebral edema and subsequent neurological devastation is the highest priority [1, 2].References (research sources) - [1]Pediatric diabetic ketoacidosis and cerebral oedema: a systematic review.Meta-analysis/systematic reviewSiddiqui EU, Othman A, Tashkandi AH, Farooq N, Jamali AA, Kazi GI, Siddiqui T. (2025) · DOI: 10.6065/apem.2448268.134 - [2]Severe Hyperglycemic Crisis: A Presentation of Diabetic Ketoacidosis Requiring Intubation.Research articlePatel KD, Persaud NA, Wallen M. (2026) · DOI: 10.7759/cureus.106087 ## 임상 시나리오 Responding to Decreased Consciousness in DKA PatientsAirway Management is Top Priority When GCS is 8 or Below If a patient is suspected of having diabetic ketoacidosis (DKA) and their GCS drops to 8 or below, their airway protective reflexes are lost. This is a major sign of cerebral edema, and preparation for immediate endotracheal intubation is required. A decreased GCS is a direct cause of hypoxic brain injury and aspiration, so ABC assessment takes priority over all fluid and insulin therapy. Administration of a hyperosmolar solution may be necessary. CautionDo not dismiss changes in consciousness in a DKA patient as simple dehydration or hyperglycemia symptoms. Permanent neurological deficits can occur in 25% of survivors, so GCS monitoring must be performed without interruption. ## 핵심 개념 - **Glasgow Coma Scale (GCS)** — A neurological scale assessing consciousness; a score of 8 or less indicates severe coma and inability to protect the airway. - **Diabetic Ketoacidosis (DKA)** — A life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. - **Cerebral Edema** — A rare but devastating complication of DKA involving brain swelling, leading to increased intracranial pressure and declining GCS. ## 같은 주제 문제 - [A nurse in the emergency department is caring for a 28-year-old client with type 1 diabete…](https://mymerci.kr/pages/nclex_q.php?qn_id=540449) - [A triage nurse in the emergency department is assessing a 28-year-old client with type 1 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=540450) - [A nurse is caring for a client with type 1 diabetes mellitus who is newly admitted with di…](https://mymerci.kr/pages/nclex_q.php?qn_id=540451) - [A nurse is assessing a patient with type 1 diabetes mellitus who was brought to the emerge…](https://mymerci.kr/pages/nclex_q.php?qn_id=540452) - [A triage nurse evaluates a 19-year-old client with type 1 diabetes mellitus who missed the…](https://mymerci.kr/pages/nclex_q.php?qn_id=540453) - [A nurse is assessing a patient with type 1 diabetes mellitus who was brought to the emerge…](https://mymerci.kr/pages/nclex_q.php?qn_id=540454) - [A nurse is assessing a patient with type 1 diabetes mellitus who was brought to the emerge…](https://mymerci.kr/pages/nclex_q.php?qn_id=540455) - [A nurse in the critical care unit is managing a 42-year-old client with type 1 diabetes me…](https://mymerci.kr/pages/nclex_q.php?qn_id=540456) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._