A nurse is caring for a client who has type 2 diabetes mellitus and their glucose levels are rising. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?

Choice A rationale Fruity breath is a classic clinical manifestation of diabetic ketoacidosis rather than a hyperosmolar hyperglycemic state. It results from the production of acetone as a byproduct of ketone metabolism when the body breaks down fats for energy in the absence of insulin. In hyperosmolar hyperglycemic states, there is typically enough insulin present to prevent significant lipolysis and ketogenesis, so the characteristic fruity or sweet odor on the breath is absent. Choice B rationale A glucose level of 200 mg per dL is considered hyperglycemic but is far below the diagnostic threshold for a hyperosmolar hyperglycemic state. Normal fasting glucose is generally less than 100 mg per dL. In this specific condition, blood glucose levels typically exceed 600 mg per dL. The extreme hyperglycemia leads to severe osmotic diuresis and profound dehydration. A level of 200 mg per dL would be more consistent with routine diabetes management. Choice C rationale The presence of ketones in the urine is the hallmark of diabetic ketoacidosis, which involves the metabolic breakdown of fatty acids. In a hyperosmolar hyperglycemic state, the patient usually has sufficient endogenous insulin to suppress the formation of ketone bodies. Therefore, ketonuria is typically absent or only trace amounts are found. The absence of significant ketosis is a primary factor that differentiates this condition from the more acidic diabetic ketoacidosis state. Choice D rationale Elevated plasma osmolarity is the defining characteristic of this condition. It occurs due to extreme hyperglycemia causing a shift of water from the intracellular space to the extracellular space. Normal plasma osmolarity ranges from 275 to 295 mOsm per kg. In a hyperosmolar hyperglycemic state, the osmolarity often exceeds 320 mOsm per kg. This high concentration of solutes leads to severe cellular dehydration and significant neurological impairment in the affected client.