A nurse finds a patient who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and reports feeling light-headed and shaky. Which complication should the nurse expect?
Select one:

A. Portal hypertension leads to complications like varices and ascites but is not the direct cause of encephalopathy.
B. Ascites is a fluid accumulation in the abdomen related to portal hypertension and low albumin, not directly linked to altered mental status.
C. High ammonia levels are the primary cause of hepatic encephalopathy in cirrhosis. The damaged liver is unable to effectively convert ammonia to urea, resulting in ammonia buildup in the blood, which affects brain function and leads to confusion, lethargy, or even coma.
D. Vitamin K deficiency contributes to bleeding problems, not encephalopathy.

A. Verifying diabetes type is important for long-term management but not the immediate priority in a critical situation.
B. Assessing vital signs is part of the nursing assessment but should come after alerting the care team in a severe hyperglycemic crisis.
C. Administering sliding scale insulin without further evaluation or orders could be dangerous at such a critically high glucose level.
D. A glucose level of 750 mg/dL is dangerously high and may indicate a life-threatening condition such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The priority action is to immediately notify the RN and provider for urgent intervention and further orders.