The nurse is teaching a client with diabetes mellitus about the difference between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The client shows an understanding of the teaching by stating which of the following symptoms develop with hyperosmolar hyperglycemic state (HHS)? (Select all that apply)

Choice A reason: Kussmaul’s breathing is characteristic of DKA, not HHS, as it compensates for severe metabolic acidosis from ketone accumulation. HHS has minimal acidosis due to low ketosis, so rapid, deep breathing is not typical, making this an incorrect symptom for HHS. Choice B reason: Fruity breath, caused by acetone from ketogenesis, is a hallmark of DKA, not HHS. HHS involves severe hyperglycemia with minimal ketone production, so this odor is absent, making this an incorrect symptom for the client’s understanding of HHS. Choice C reason: Myoclonic jerking is a symptom of HHS, resulting from severe hyperosmolarity and electrolyte imbalances (e.g., hyponatremia) affecting neurological function. These involuntary muscle movements reflect CNS irritability, making this a correct symptom demonstrating understanding of HHS manifestations. Choice D reason: Anuria is associated with HHS due to severe dehydration from osmotic diuresis caused by extreme hyperglycemia. Reduced urine output reflects hypovolemia and renal hypoperfusion, making this a correct symptom indicating the client’s understanding of HHS’s clinical presentation. Choice E reason: Seizures can occur in HHS due to extreme hyperosmolarity and electrolyte disturbances (e.g., hyponatremia) disrupting neuronal activity. This neurological complication is a hallmark of severe HHS, making it a correct symptom reflecting the client’s understanding of the condition.