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Nursing QUESTION #9276
Question 1
A child with Type 1 Diabetes Mellitus presents with: blood glucose 28 mmol/L, pH 7.14, bicarbonate 10 mEq/L, positive ketones in urine. The child is drowsy. This presentation is BEST described as and the INITIAL fluid management priority is:
  • Hyperosmolar hyperglycemic state; rapid IV insulin bolus
  • Diabetic Ketoacidosis (DKA); IV fluid resuscitation with 0.9% NaCl 10–20 mL/kg over 1–2 hours✔️
  • Hypoglycemia with rebound hyperglycemia; 10% dextrose
  • Lactic acidosis; sodium bicarbonate infusion
Correct Answer Explanation

Diabetic Ketoacidosis (DKA) — Diagnostic criteria in children:

  • Blood glucose \(>11\,\text{mmol/L}\) (or known DM)
  • pH \(<7.3\) or bicarbonate \(<15\,\text{mEq/L}\)
  • Ketonemia/ketonuria

Severity classification:

SeveritypHHCO₃
Mild7.20–7.2910–15
Moderate7.10–7.195–9
Severe<7.10<5

This child: pH 7.14, HCO₃ 10 = Moderate-Severe DKA

Management (ISPAD/BSPED guidelines):

  1. Fluid resuscitation FIRST (not insulin first): \(10{-}20\,\text{mL/kg}\) of 0.9% NaCl over 1–2 hours if shocked
  2. Replace fluid deficit over 24–48 hours with 0.9% NaCl
  3. Start insulin infusion: \(0.05{-}0.1\,\text{units/kg/hr}\) IV (NEVER bolus in children — risk of cerebral edema)
  4. Add dextrose to IV fluid when BG \(\leq 14\,\text{mmol/L}\)
  5. Monitor for cerebral edema (most feared complication — headache, bradycardia, \(\downarrow\) consciousness)

Bicarbonate is NOT recommended in pediatric DKA — worsens cerebral edema.