Sugar, Sugar
Clue:
This finding is much more characteristic of DKA than HHS:
severe hyperglycemia, profound dehydration, altered mental status, or metabolic acidosis with ketones?
What is metabolic acidosis with ketones?
Teaching point: Both DKA and HHS can cause significant hyperglycemia, AMS, and dehydration. Ketoacidosis is the major distinguishing feature of DKA.
One patient can't tolerate the heat and has lost weight despite an increased appetite. Another is always cold, constipated, and gaining weight.
Who is HOT and who is COLD?
HOT = hyperthyroidism
COLD = hypothyroidism
Teaching point: Think about whether the body's metabolic processes have been turned up or down.
One patient has hyperpigmentation, weight loss, and hypotension. Another has central weight gain, fragile skin, and hypertension.
Who has Addison disease, and who has Cushing syndrome?
Addison disease = hyperpigmentation, weight loss, hypotension.
Cushing syndrome = central weight gain, fragile skin, hypertension.
Teaching point: Addison = too little adrenal cortical hormone; Cushing = too much cortisol.
A patient suddenly develops facial droop, arm weakness, and difficulty speaking.
The single most important time for the nurse to establish is this.
What is the last known well time?
Teaching point: Last known well helps determine eligibility for time-sensitive stroke interventions.
A patient begins having a generalized tonic-clonic seizure while in bed.
The nurse has four ideas:
A. Restrain the patient's arms and legs
B. Insert something between the patient's teeth
C. Turn the patient to the side and protect them from injury
D. Immediately give the patient water after the movements stop
What should the nurse do?
What is C — turn the patient to the side and protect them from injury?
Teaching point: During a seizure, focus on safety and airway protection. Do not restrain the patient or place anything in the mouth.
A patient with type 1 diabetes has vomiting and cannot tolerate food. Their glucose is 264 mg/dL. The patient says, “Since I can't eat, I shouldn't take any insulin today.”
Good plan or dangerous plan?
What is a dangerous plan?
Teaching point: Illness can increase glucose and insulin requirements even when oral intake decreases. Patients need to follow their sick-day plan, monitor glucose closely, and should not simply discontinue insulin.
A patient has:
Are they running HOT or COLD?
What is COLD — primary hypothyroidism?
Teaching point: In primary hypothyroidism, the thyroid isn't producing enough hormone, so the pituitary increases TSH in an attempt to stimulate it.
A patient with Addison disease has:
Which abnormality puts the most pressure on the heart?
What is potassium 5.7 mEq/L?
Teaching point: Hyperkalemia can alter cardiac conduction and cause dangerous dysrhythmias.
A patient arrives with sudden unilateral weakness and aphasia. The provider suspects an ischemic stroke.
Why can't the nurse assume it is ischemic and immediately prepare to give alteplase?
What is intracranial bleeding must first be ruled out with brain imaging?
Teaching point: Ischemic and hemorrhagic strokes can present similarly, but their acute treatments are very different.
A patient with Parkinson disease says:
“Sometimes my medication works really well, and then before my next dose I suddenly get stiff and have trouble moving again.”
Is this proof that carbidopa-levodopa has stopped working completely?
No. This can occur as the medication's effect wears off between doses.
Teaching point: Parkinson symptoms can fluctuate in relation to dopaminergic medication. Have students connect the medication to mobility and timing, rather than simply memorizing the drug name.
A patient arrives with DKA. Glucose is 548 mg/dL, potassium is 4.6 mEq/L (3.5–5.0), BP is 86/50 mm Hg, HR is 124/min, and the patient has dry mucous membranes.
Which comes first: IV regular insulin or isotonic IV fluids?
What are isotonic IV fluids?
Teaching point: DKA causes profound fluid losses. Restoring circulating volume and perfusion is an immediate priority before insulin therapy.
A patient has a calcium level of 7.0 mg/dL (8.6–10.2).
Which finding would fit best?
A. Constipation and generalized weakness
B. Tingling around the mouth and muscle cramping
C. Recurrent kidney stones and flank pain
D. Decreased neuromuscular excitability
What is B — tingling around the mouth and muscle cramping?
Teaching point: Low calcium increases neuromuscular excitability. Think tingling, twitching, cramping, tetany, and seizures as hypocalcemia becomes more severe.
A patient has sudden episodes of:
Between episodes, the symptoms improve significantly.
Name that adrenal disorder.
What is pheochromocytoma?
Teaching point: Excess catecholamine release produces the characteristic episodic hypertension, headache, diaphoresis, palpitations, and tachycardia.
A patient with an acute stroke has facial weakness and slurred speech. The patient's spouse asks for some water because the patient says they are thirsty.
What's your move?
Keep the patient NPO until swallowing is evaluated.
Teaching point: Stroke can impair swallowing and airway protection. Giving food, fluids, or oral medications before evaluating swallowing can increase aspiration risk.
A patient with multiple sclerosis says:
“I went to an outdoor festival yesterday when it was 95°F. By the afternoon, my weakness and vision problems were noticeably worse. I guess my MS permanently progressed.”
What would you tell them?
Heat can temporarily worsen MS symptoms and does not necessarily mean the disease has permanently progressed.
Teaching point: Increased body temperature can exacerbate neurologic symptoms in MS. Look for potential triggers before assuming a permanent decline.
Three hours into DKA treatment:
The patient suddenly develops several PVCs.
What changed that best explains the PVCs?
What is the decreasing serum potassium?
Teaching point: Insulin shifts potassium into cells. A patient can therefore develop significant hypokalemia during DKA treatment even as glucose, perfusion, and urine output improve.
A patient taking PTU for hyperthyroidism calls the clinic with four complaints:
Which complaint changes today's plan?
What is the new sore throat and fever?
Teaching point: Fever and sore throat can indicate a serious adverse effect of antithyroid therapy and require prompt evaluation.
A patient with Addison disease develops influenza with vomiting and says:
“I haven't been able to keep my hydrocortisone down since yesterday, but I'll restart it once I'm eating normally.”
The patient's BP is now 84/50 mm Hg, HR 118/min, and they report severe weakness.
What complication should the nurse be worried about?
What is adrenal crisis?
Teaching point: Illness increases the body's glucocorticoid needs. Inability to take replacement glucocorticoids can precipitate acute adrenal insufficiency with severe hypotension and possible shock.
A patient's NIHSS was 6 on admission. Two hours later, the NIHSS is 11.
The blood pressure and oxygen saturation have not significantly changed.
Good news, bad news, or meaningless number?
Bad news — the neurologic deficit has worsened.
Teaching point: A rising NIHSS indicates worsening neurologic impairment. Stable vital signs do not cancel out a significant change in the neurologic assessment.
A patient with dementia becomes increasingly confused every evening and repeatedly tries to leave the unit to “go home.”
Which approach is better?
A. Repeatedly explain that this is now their home
B. Correct the patient's inaccurate statements each time
C. Maintain a calm routine, address the emotion, and redirect the patient
D. Encourage the patient to independently find their room to maintain cognition
What is C — maintain a calm routine, address the emotion, and redirect?
Teaching point: Communication and environmental strategies should promote safety and reduce distress rather than repeatedly confronting the patient with information they may be unable to retain.
A patient being treated for DKA now has:
The patient's family asks why the insulin infusion is still running when the glucose is “almost normal.”
In one sentence: Why isn't the DKA resolved?
What is the glucose has improved, but the patient still has metabolic acidosis and ketosis?
Teaching point: Lowering glucose is not the same thing as resolving DKA. Insulin may need to continue to suppress ketogenesis and correct the acidosis; dextrose can be added as glucose falls.
Six hours after thyroid surgery, a patient reports tingling around the mouth. A few minutes later, the nurse observes hand cramping and hears the patient say, “It feels harder to swallow.”
Connect the dots: What complication is developing, and why can it become an emergency?
What is acute hypocalcemia from impaired parathyroid function, with concern for airway compromise from worsening neuromuscular excitability/tetany?
Teaching point: After thyroid surgery, don't just think bleeding and thyroid storm. Injury or disruption of the parathyroid glands can cause hypocalcemia. Once symptoms begin involving swallowing/airway function, the urgency changes.
A patient with Cushing syndrome undergoes adrenal surgery. Several hours later:
A student says, “The labs are basically normal, so I think we can just keep monitoring.”
What's wrong with that reasoning?
The clinical trend suggests developing adrenal insufficiency despite currently normal electrolyte values.
Teaching point: Don't wait for a dramatic lab abnormality when the patient's condition is changing. Following adrenal surgery, falling BP, rising HR, weakness, and nausea should raise concern for inadequate cortisol.
A patient hospitalized after an acute hemorrhagic stroke was awake and answering questions an hour ago. The nurse now finds the patient increasingly difficult to arouse. The patient vomits and develops a worsening headache.
A family member says:
“They've had a long day. They probably just need to sleep.”
What makes this more concerning than ordinary fatigue?
The patient has an acute change in level of consciousness accompanied by new/worsening neurologic symptoms, which may indicate neurologic deterioration or increasing intracranial pressure and requires immediate evaluation.
Teaching point: A changing LOC is one of the most important neurologic assessment findings. Don't normalize a new change simply because the patient already has a neurologic diagnosis.
A patient with Guillain-Barré syndrome was admitted with tingling and weakness of both feet. Several hours later, weakness has progressed to the thighs, and the patient says:
“My legs are worse, but I'm still breathing fine.”
The SpO₂ is 97% on room air.
Why should the nurse still be concerned about the patient's breathing?
Because ascending weakness can progress to the respiratory muscles, and a normal oxygen saturation does not rule out developing respiratory muscle weakness.
Teaching point: Don't wait for the pulse oximeter to announce respiratory failure. In GBS, the pattern and progression of weakness should prompt close respiratory assessment.