For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient Fluid Volume?
A. Cool, clammy skin
B. Distended neck veins
C. Increased urine osmolarity
D. Decreased serum sodium level
Correct Answer: C. Increased urine osmolarity
In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glycosuria and polyuria, losing body fluids, and experiencing fluid volume deficit. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.
Option A: The physical examination can reveal signs of hypovolemia like hypotension, tachycardia, and dry mucous membranes. When evaluating a patient for hyperglycemia, the focus should be on the patient’s cardiorespiratory status, mental status, and volume status.
Option B: Patients with diabetic ketoacidosis may present with nausea, vomiting, and abdominal pain in addition to the above symptoms. They also may have a fruity odor to their breath and have rapid shallow respirations, reflecting compensatory hyperventilation for the acidosis.
Option D: Symptoms of severe hyperglycemia include polyuria, polydipsia, and weight loss. As the patient’s blood glucose increases, neurologic symptoms can develop. The patient may experience lethargy, focal neurologic deficits, or altered mental status. The patient can progress to a comatose state.
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