Ch 51 DIABETES

3 P's

polyuria, polydipsia, and polyphagia

Rapid acting insuline

produce a more rapid effect that is of shorter duration than regular insulin. Because of their rapid onset, the patient should be instructed to eat no more than 5 to 15 minutes after injection.

A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:

providing client education at every opportunity. P1461 Explanation: The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

What is the only insulin that can be given intravenously?

regular p1471-1472

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

suggest referral to a sex counselor or other appropriate professional. P1494 Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What is the best response by the nurse?

"Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." P1482 Explanation: Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption.

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

"It tells us about your sugar control for the last 3 months." p 1467 Explanation: The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

***A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?

"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." P1467 - Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

"You'll need less insulin when you exercise or reduce your food intake." P1467 Explanation: The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

Fasting Plasma Glucos

(blood glucose determination obtained in the laboratory after fasting for at least 8 hours), random plasma glucose, and glucose level 2 hours after receiving glucose (2-hour postload) may be used

A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply.

- "Insulin permits entry of glucose into the cells of the body." - "Insulin promotes synthesis of proteins in various body tissues." - "Insulin promotes the storage of fat in adipose tissue." - p 1457 Insulin is a hormone secreted by the endocrine part of the pancreas. In addition to lowering blood glucose by permitting entry of glucose into the cells, insulin also promotes protein synthesis and the storage of fat in adipose tissue. Somatostatin exerts a hypoglycemic effect by interfering with glucagon from the pancreas and the release of growth hormone from the pituitary.

insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those cells, insulin has the following actions:

- Transports and metabolizes glucose for energy - Stimulates storage of glucose in the liver and muscle (in the form of glycogen) - Signals the liver to stop the release of glucose - Enhances storage of dietary fat in adipose tissue - Accelerates transport of amino acids (derived from dietary protein) into cells - Inhibits the breakdown of stored glucose, protein, and fat

A nurse knows to assess a patient with type 1 diabetes for postprandial hyperglycemia. The nurse knows that glycosuria is present when the serum glucose level exceeds:

180 mg/dL P1459 Explanation: Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).

What is the duration of regular insulin?

4-6 hours p1468 The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.

What is the duration of regular insulin?

4-6hours

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5% - p1467 Normally, the level of glycosylated hemoglobin is less than 7%. Thus, a level of 6.5% would indicate that the client's blood glucose level is well controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dl. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.

Which statement is true regarding gestational diabetes?

A glucose challenge test should be performed between 24 and 28 weeks. p1459 Explanation: A glucose challenge test should be performed between 24 and 48 weeks in women at average risk. It occurs in 2% to 5% of all pregnancies. Onset usually occurs in the second or third trimester. There is an above-normal risk for perinatal complications.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of dosage - 1468 The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?

Albumin p1492 Explanation: Albumin is one of the most important blood proteins that leak into the urine. Although small amounts may leak undetected for years, its leakage into the urine is among the earliest signs that can be detected. Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria but in fewer than 5% of people without microalbuminuria. The urine should be checked annually for the presence of microalbumin.

nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation?

Ask the physician to delay the discharge because the client requires further teaching. P1477 Explanation: The nurse's primary concern should be the safety of the client after discharge. She should provide succinct information to the physician concerning the client's needs, express her concern about ensuring the client's safety, and ask the physician to delay the client's discharge. The nurse shouldn't suggest that the client rely on a friend or family member because she doesn't know if a friend or family member will be available to help. Refusing to rush and telling the charge nurse she isn't sure the client will be safe demonstrate appropriate intentions, but these actions don't alleviate the pressure to discharge the client. Asking a physician to refer the client to a diabetic nurse-educator addresses the client's needs, but isn't the best response because there's no guarantee a diabetic nurse-educator will be available on such short notice.

A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the client's symptoms to be those of diabetic ketoacidosis (DKA). Which action will help the nurse confirm the diagnosis?

Assess the client's breath odor - 1459 DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue, with eventual stupor and coma if not treated. The breath has a characteristic fruity odor due to the presence of ketoacids. Checking the client's breath will help the nurse confirm the diagnosis.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA?

Begin fluid replacement P1468 Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hypoglycemia with insulin.

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.

Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment P1459 Explanation: All the options are correct except for weight loss and anorexia. Obesity is almost always associated with type 2 diabetes.

The nurse practitioner worked with a registered dietitian to customize a 1,800-calorie diabetic diet for a 53-year-old man with special dietary needs. Which of the following percent distribution of calories should be provided?

Carbohydrates 50%, fat 25%, and protein 20% P1462 Explanation: The American Dietetic Association currently recommends the following distribution of caloric intake: 50% to 60% carbohydrates, 20% to 30% fat, and 10% to 20% protein.

Which of the following is an age-related change that may affect diabetes? Select all that apply.

Decreased renal function Taste changes Decreased vision P1461 Explanation: Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes P1483 Explanation: DKA is characterized by an elevated BUN and creatinine, rapid onset, and it is more common in type 1 diabetes. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by the absence of urine and serum ketones and a normal arterial pH level.

Which of the following insulins are used for basal dosage?

Glarginet (lantus) - p1468 Lantus is used for basal dosage. NPH is an intermediate acting insulin, usually taken after food. Humalog and Novolog are rapid-acting insulins.

**Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

High sugar pulls fluid into the bloodstream, which results in more urine production. P1483 Explanation: The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

High sugar pulls fluid into the bloodstream, which results in more urine production. P1483 Explanation: The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which symptom when caring for this client?

Hypoglycemia

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Increased urine osmolarity P1486 Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

NPH is an example of which type of insulin?

Intermediate-acting

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

Ketoacidosis

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.

Ketosis-prone Little endogenous insulin Younger than 30 years of age P1458 Explanation: Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent.

The nurse is assessing a patient with nonproliferative (background) retinopathy. When examining the retina, what would the nurse expect to assess? Select all that apply.

Leakage of fluid or serum (exudates) Microaneurysms Focal capillary single closure P1489 Explanation: Almost all patients with type 1 diabetes and the majority of patients with type 2 diabetes have some degree of retinopathy after 20 years (ADA, 2013). Changes in the microvasculature include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure.

Which type of insulin acts most quickly? (remember LAG)

Lispro P1468 The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.

Intermediate-acting insulins are called

NPH insulin (neutral protamine Hagedorn) or Lente insulin

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply.

Normal bedtime blood glucose Increase in blood glucose from 3:00 AM until breakfast Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM p1471 The Somogyi effect is nocturnal hypoglycemia followed by rebound hyperglycemia in the morning.

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Presence of islet cell antibodies - P1458 Explanation: Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

Rapid, thready pulse - p1484 This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Serum glucose level of 52 mg/dl - p1481 Explanation: Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

**Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?

Serum glycosylated hemoglobin (Hb A1c) P1467 Explanation: Hb A1c is the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.

Which category of oral antidiabetic agents exerts the primary action by directly stimulating the pancreas to secrete insulin?

Sulfonylureas P1474 A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate the action of insulin on peripheral receptor sites. Alpha-glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

A client has been diagnosed with prediabetes and discusses treatment strategies with the nurse. What can be the consequences of untreated prediabetes?

The NIDDK has developed criteria that identify people with prediabetes, which can lead to type 2 diabetes, heart disease, and stroke.

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates p1462 While assessing a client, it is important to note the client's consumption of carbohydrates because he has high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client's to be noted in a client with high blood sugar.

Protein - ADA

The meal plan may include the use of some nonanimal sources of protein (e.g., legumes, whole grains) to help reduce saturated fat and cholesterol intake. In addition, the amount of protein intake may be reduced in patients with early signs of kidney disease.

The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan?

When mixing insulin, the regular insulin is drawn up into the syringe first. P1478 When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before being drawn into the syringe. The American Diabetic Association recommends that the regular insulin be drawn up first. The most important issues are that patients (1) are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) do not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.

Type 1 diabetes (from the book):

a metabolic disorder characterized by an absence of insulin production and secretion from autoimmune destruction of the beta cells of the islets of Langerhans in the pancreas; formerly called insulin-dependent diabetes, or juvenile diabetes

type 2 diabetes (from the book):

a metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance; formerly called non-insulin-dependent diabetes, or adult-onset diabetes

prediabetes:

impaired glucose metabolism in which blood glucose concentrations fall between normal levels and those considered diagnostic for diabetes; includes impaired fasting glucose and impaired glucose tolerance, not clinical entities in their own right but risk factors for future diabetes and cardiovascular disease

26s When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

accuracy of dosage - p1468 The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

Short acting insulins

are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually given 15 minutes before a meal, either alone or in combination with a longer-acting insulin

Risk factors for heart disease

include hypertension, obesity, high cholesterol levels, abnormal resting electrocardiogram (ECG), sedentary lifestyle, smoking, male gender, and a family history of heart disease.

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

at least three times per week. - p 1465 Explanation: Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?

increased hunger

glycemic index

is used to describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

metformin p1460 Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

A patient who is diagnosed with type 1 diabetes would be expected to:

need exogenous insulin - p 1468 Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to

check blood glucose at 3 am p1471 In the Somogyi effect, the client has a normal or elevated blood glucose concentration at bedtime, which decreases to hypoglycemic levels at 2 to 3 a.m., and subsequently increases as a result of the production of counter-regulatory hormones. It is important to check blood glucose in the early morning hours to detect the initial hypoglycemia.

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

consuming a low-carbohydrate, high-protein diet and avoiding fasting. - p 1483 Explanation: To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

After teaching a client with type 1 diabetes who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching

"I might need insulin later on but probably not as much or as often." - p 1473 Transplanted islet cells tend to lose their ability to function over time, and approximately 70% of recipients resume insulin administration in 2 years. However, the amount of insulin and the frequency of its administration are reduced because of improved control of blood glucose levels. Thus, this type of transplant doesn't cure diabetes. It requires the use of two human pancreases to obtain sufficient numbers of islet cells for transplantation. A whole organ transplant requires a means for exocrine enzyme drainage and venous absorption of insulin.

A client with diabetes mellitus must learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

"Rotate injection sites within the same anatomic region, not among different regions." - 1479 The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

Although more research is necessary, the following guidelines may be helpful when making dietary recommendations:

- Combining starchy foods with protein- and fat-containing foods tends to slow their absorption and lower the glycemic index. - In general, eating foods that are raw and whole results in a lower glycemic index than eating chopped, puréed, or cooked foods (except meat). - Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption. - Adding foods with sugars to the diet may result in a lower glycemic index if these foods are eaten with foods that are more slowly absorbed.

Type 1 (5% of all diabetes; previously classified as juvenile diabetes, juvenile-onset diabetes, ketosis-prone diabetes, brittle diabetes, and insulin-dependent diabetes mellitus [IDDM])

- Onset any age, but usually young (<30 years) - Usually thin at diagnosis; recent weight loss - Etiology includes genetic, immunologic, and environmental factors (e.g., virus) - Often have islet cell antibodies - Often have antibodies to insulin even before insulin treatment - Little or no endogenous insulin - Need exogenous insulin to preserve life - Ketosis prone when insulin absent - Acute complication of hyperglycemia: diabetic ketoacidosis

Type 2 (95% of all diabetes: obese—80% of type 2, nonobese—20% of type 2; previously classified as adult-onset diabetes, maturity-onset diabetes, ketosis-resistant diabetes, stable diabetes, and non-insulin-dependent diabetes mellitus [NIDDM])

- Onset any age, usually >30 years - Usually obese at diagnosis - Causes include obesity, heredity, and environmental factors - No islet cell antibodies - Decrease in endogenous insulin, or increased with insulin resistance - Most patients can control blood glucose through weight loss if obese - Oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful - May need insulin on a short- or long-term basis to prevent hyperglycemia - Ketosis uncommon, except in stress or infection - Acute complication: hyperglycemic hyperosmolar syndrome

A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:

138 mg/dL, 2 hours postprandial. p 1460 Explanation: The goals for a 2-hour, postprandial blood glucose level are less than 120 mg/dL in a patient who might develop gestational diabetes.

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

8.30 am p1468 Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia P1485 Explanation: Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

Which information should be included in the teaching plan for a client receiving glargine, a "peakless" basal insulin?

Do not mix with other insulins - 1468 Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine insulin, it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

Glucagon - p1482 During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn't effective in reversing hypoglycemia

During a follow-up visit 3 months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure?

Glycosylated hemoglobin level p1467 Explanation: Glycosylated hemoglobin is a blood test that reflects the average blood glucose concentration over a period of approximately 2 to 3 months. When blood glucose is elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycosylated hemoglobin level becomes.

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Hypoglycemia P1461 Explanation: The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.

A patient with diabetic ketoacidosis (DKA) has had a large volume of fluid infused for rehydration. What potential complication from rehydration should the nurse monitor for?

Hypokalemia P1485 Because a patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal in the patient with DKA.

Regular insulin can be administered

IV

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insufficient insulin production p1459 Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence; although, it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Prediabetes can lead to type 2 diabetes.

A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?

Obtain a repeat fingerstick glucose level. P1482 Explanation: The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.

Prediabetes (previously classified as previous abnormality of glucose tolerance)

Previous history of hyperglycemia (e.g., during pregnancy or illness) Current normal glucose metabolism Impaired glucose tolerance or impaired fasting glucose screening after age 40 years if there is a family history of diabetes or if symptomatic Encourage ideal body weight, because loss of 10-15 lb may improve glycemic control

A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

Rapid acting insulin only - p1470 A continuous subcutaneous insulin regimen uses a basal rate and boluses of rapid-acting insulin. Multiple daily injection therapy uses a combination of rapid-acting and intermediate- or long-acting insulins.

Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:

Synthesis of glucose from noncarbohydrate sources. P1459 Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.

A client with a 30-year history of type 2 diabetes is having an annual physical and blood work. Which test result would the physician be most concerned with when monitoring the client's treatment compliance?

glycosylated hemoglobin P1467 Explanation: Once a client with diabetes receives a treatment regimen to follow, the physician can assess the effectiveness of treatment and the client's compliance by obtaining a hemoglobin A1c test. The results of this test reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. Normally, the level of glycosylated hemoglobin is less than 7%. Amounts of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.