# A 71-year-old client with type 2 diabetes received 8 units of insulin lispro subcutaneously 1 hour ago; the lunch tray is untouched. Oxycodone 5 mg by mouth was given 4 hours ago for knee pain. The client is now diaphoretic and confused, cannot follow commands, and cannot swallow safely. Capillary glucose is 38 mg/dL (2.1 mmol/L). Heart rate is 112/min, blood pressure 148/86 mm Hg, respiratory rate 18/min, and pupils are 4 mm and briskly reactive. Movements of all four extremities are equal. A saline lock is in place in the left forearm. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617408&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 71-year-old client with type 2 diabetes received 8 units of insulin lispro subcutaneously 1 hour ago; the lunch tray is untouched. Oxycodone 5 mg by mouth was given 4 hours ago for knee pain. The client is now diaphoretic and confused, cannot follow commands, and cannot swallow safely. Capillary glucose is 38 mg/dL (2.1 mmol/L). Heart rate is 112/min, blood pressure 148/86 mm Hg, respiratory rate 18/min, and pupils are 4 mm and briskly reactive. Movements of all four extremities are equal. A saline lock is in place in the left forearm. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Opioid-induced sedation
Acute ischemic stroke
Hyperosmolar hyperglycemic state
Severe hypoglycemia

Actions to take

Select 2
Give 120 mL of orange juice by mouth
Administer prescribed 50% dextrose by IV push
Activate a stroke alert for emergency CT imaging
Turn the client side-lying with suction ready
Administer prescribed naloxone 0.4 mg IV

Parameters to monitor

Select 2
Capillary blood glucose
Serum osmolality
NIH Stroke Scale score
Level of consciousness
Pasero opioid sedation scale

## Explanation

Glucose of 38 mg/dL after rapid-acting insulin without food, with adrenergic signs and confusion, is severe hypoglycemia. Because the client cannot swallow, glucose is given by IV push through the existing saline lock, and the client is positioned side-lying to protect the airway. Glucose and level of consciousness show response. Normal respirations and pupils argue against opioid sedation, and equal limb movement with a low glucose argues against stroke.

## In-depth explanation

Quick answer
Severe hypoglycemia; give prescribed 50% dextrose IV, keep the client side-lying with suction ready, and monitor capillary glucose and level of consciousness.

Why this is correct
Rapid-acting insulin peaks about 1 hour after injection, and no food was eaten. Diaphoresis and tachycardia are adrenergic warning signs, and confusion reflects neuroglycopenia. A client who cannot swallow needs a parenteral route; IV access is already present, so IV dextrose acts fastest. Until mental status returns, a side-lying position with suction reduces aspiration risk.

Easy analogy or mental picture
Picture a car engine that has run out of fuel: the dashboard lights flash (sweating, fast heart) and then the engine stalls (confusion). You pour fuel straight into the tank (IV), not into a mouth that cannot swallow.

Memory hook
Can't swallow = nothing by mouth; low sugar + IV access = dextrose in the vein.

NCLEX decision rule
Match the glucose route to swallowing safety, and check a glucose on any client with new confusion before treating a mimic.

Why the other choices are wrong
Orange juice follows the 15-15 rule for alert clients, but aspiration risk makes it unsafe here. Opioid sedation causes slow respirations and small pupils, which are absent, so naloxone and a sedation scale do not fit. Hypoglycemia is a classic stroke mimic; with a glucose of 38 mg/dL and equal limb movement, a stroke alert and NIH Stroke Scale scoring are premature. Hyperosmolar hyperglycemic state requires marked hyperglycemia, so serum osmolality is irrelevant.

References
1MedlinePlus: HypoglycemiaSevere hypoglycemia with confusion or inability to swallow needs treatment other than food or drink.
2StatPearls — HypoglycemiaUnconscious or confused clients with hypoglycemia receive IV dextrose or glucagon rather than oral glucose.

## Clinical scenario

Scenario
One hour after insulin lispro with an untouched lunch tray, a client is diaphoretic, confused, unable to swallow, and has a glucose of 38 mg/dL; respirations, pupils, and limb strength are normal.

## Key concepts

- **Neuroglycopenia** — Brain dysfunction from low glucose, causing confusion, behavior change, seizures, or coma.
- **Insulin lispro** — Rapid-acting insulin with onset in about 15 minutes and peak effect near 1 hour.
- **Stroke mimic** — A condition, such as hypoglycemia, that produces focal or global neurologic signs resembling stroke.

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