Which finding(s) would the nurse expect to assess on a patient with a diagnosis of diabetic ketoacidosis (DKA) recently admitted to the emergency department? (Select all that apply)

Rationale:
A. CAUTI (Catheter-Associated Urinary Tract Infection) is incorrect because, although burn patients often require indwelling urinary catheters for strict intake and output monitoring, CAUTIs are typically localized infections. They are rarely the direct cause of death and do not account for the high mortality seen in patients with severe burns.

B. Sepsis is correct because it is the leading cause of death in patients with severe burns. Burn injuries destroy the skin, which is the body’s primary barrier against infection. This allows bacteria to easily enter the bloodstream. Additionally, burn patients experience immune system suppression and a massive inflammatory response, increasing the risk of systemic infection, septic shock, multiple organ dysfunction, and death.

C. CLABSI (Central Line–Associated Bloodstream Infection) is incorrect because, while central lines are commonly used in burn patients and can lead to bloodstream infections, CLABSIs represent only one possible source of infection. They are not the most common overall cause of death compared with widespread sepsis from burn wounds.

D. VAP (Ventilator-Associated Pneumonia) is incorrect because some burn patients require mechanical ventilation, especially those with inhalation injuries. Although VAP is a serious complication, it is less common than sepsis as the primary cause of mortality in severe burn patients.

Rationale:
A. This patient is on droplet precautions, which requires infection control measures, but the scenario does not indicate acute instability. While monitoring is essential, this patient is not the most critical.

B. This patient is correct because an ICP of 20 mm Hg is elevated (normal ICP is 5–15 mm Hg), and an oral temperature of 104°F indicates severe hyperthermia, which can further increase cerebral edema and risk of brain injury. This combination represents an acute neurological emergency requiring immediate assessment and intervention to prevent irreversible damage or death.

C. This patient is experiencing photophobia, a common symptom of meningitis, but it is less urgent compared with a patient with elevated ICP and hyperthermia. Symptom management is important but not immediately life-threatening.

D. This mechanically ventilated patient with a GCS of 6 is critically ill, but if the patient is already intubated and ventilated, airway and breathing are likely secured. The patient with rapidly rising ICP and high fever represents a more acute and potentially reversible threat that requires immediate assessment to prevent deterioration.