# A nurse is assessing a 68-year-old client who was recently diagnosed with pancreatic cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a 68-year-old client who was recently diagnosed with pancreatic cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

## 보기

1. Mild epigastric pain rated 4/10 that improves with positioning
2. Clay-colored stools and dark amber urine for the past week
3. Weight loss of 15 pounds over the past 3 months
4. New onset confusion with blood glucose level of 45 mg/dL **✔ 정답**

**정답: 4**

## 해설

New onset confusion with hypoglycemia (45 mg/dL) indicates a life-threatening emergency requiring immediate glucose administration. Other findings (pain, jaundice, weight loss) are concerning but not immediately life-threatening.

## 심화 해설

Clinical Reasoning Analysis

The assessment finding that is most concerning and requires immediate nursing intervention is new onset confusion with a blood glucose level of 45 mg/dL. This combination represents a critical, life-threatening state of neuroglycopenia that demands urgent action to prevent permanent neurological injury or death.

In the context of a client newly diagnosed with pancreatic cancer, this presentation is a classic red flag for an underlying insulinoma, a rare functional neuroendocrine tumor of the pancreatic islet cells. Insulinomas produce excessive, uncontrolled amounts of insulin, driving glucose out of the bloodstream and into cells, which results in profound hypoglycemia [1, 2]. The brain is almost entirely dependent on a continuous supply of glucose for energy; when the blood glucose drops to a level as low as 45 mg/dL, the central nervous system is starved of its primary fuel. This triggers neuroglycopenic symptoms, which include confusion, altered consciousness, seizures, and, if uncorrected, coma [2]. The clinical presentation can be dangerously deceptive, often mimicking primary neurological or psychiatric conditions such as stroke, acute psychosis, or, as noted in the literature, even migraine, which leads to frequent misdiagnosis [1, 2]. The nurse must recognize that the confusion is not a separate issue but a direct consequence of the critically low glucose level and a sign of severe brain glucose deprivation.

This scenario is distinct from the more gradual metabolic changes associated with pancreatic cancer. While weight loss and obstructive jaundice (indicated by clay-colored stools and dark urine) are classic and concerning signs of a pancreatic head malignancy causing biliary obstruction, they represent subacute to chronic processes. These findings require thorough investigation and management but do not pose the same immediate, minute-to-minute threat to airway, breathing, and circulation as severe hypoglycemia. The priority is to address the immediate physiological crisis. The International Guidelines for the Diagnosis and Management of Hyperinsulinism emphasize that the primary goal in such a presentation is the rapid identification and correction of hypoglycemia to prevent neurological damage [4]. The nurse’s immediate intervention must be to verify the blood glucose level with a point-of-care test and administer a rapid-acting source of glucose, typically intravenous dextrose, as per protocol, while monitoring the client’s level of consciousness and vital signs closely. The presence of an insulinoma is biochemically confirmed when symptomatic hypoglycemia is coupled with inappropriately high levels of insulin and C-peptide, a diagnostic process often completed during a supervised fast [2, 4].References (research sources)

- [2]Insulinoma initially misdiagnosed as migraine.Research articleHameed J, Ahmed I, Zaitoun AM, Syed AS, Santos C, Chee C. (2025) · DOI: 10.22551/2025.48.1203.10325

- [4]International Guidelines for the Diagnosis and Management of Hyperinsulinism.GuidelineDe Leon DD, Arnoux JB, Banerjee I, Bergada I, Bhatti T, Conwell LS, Fu J, Flanagan SE, Gillis D, Meissner T, Mohnike K, Pasquini TLS, Shah P, Stanley CA, Vella A, Yorifuji T, Thornton PS. (2024) · DOI: 10.1159/000531766

## 임상 시나리오

Insulinoma-Induced HypoglycemiaRecognizing and Managing Neuroglycopenia in Cancer Patients
A blood glucose of 45 mg/dL with new confusion is a neuroglycopenic emergency. The brain is deprived of its primary fuel, which can mimic stroke or psychosis. Immediate intervention is required to prevent permanent neurological injury.

In a patient with pancreatic cancer, suspect an underlying insulinoma. This tumor secretes uncontrolled insulin, causing profound hypoglycemia. Diagnosis is supported by Whipple's triad: hypoglycemic symptoms, documented low glucose, and symptom relief after glucose administration.

CautionDo not mistake neuroglycopenic symptoms (confusion, altered consciousness) for a primary neurological event. Always check a point-of-care blood glucose first. Administer 50% Dextrose IV per protocol or oral fast-acting carbohydrates if the patient is alert and can swallow safely.

## 핵심 개념

- **Paraneoplastic Endocrine Syndrome (PES)** — A rare disorder triggered by an abnormal immune response or hormone-like substance production by a tumor, leading to metabolic disruptions such as severe hypoglycemia independent of insulin.
- **Warburg Effect** — A metabolic phenomenon where cancer cells predominantly produce energy through high rates of glycolysis followed by lactic acid fermentation in the cytosol, consuming large amounts of glucose.
- **Neuroglycopenia** — A shortage of glucose in the brain resulting in altered mental status, confusion, seizure, or loss of consciousness, representing a medical emergency.
- **ABC Prioritization Framework** — A systematic approach to assessment that prioritizes Airway, Breathing, and Circulation; an acute change in neurological status implies a threat to airway protection and circulation.

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