Chapter 44: Diabetes Mellitus

The nurse suspects that a patient with type 2 diabetes mellitus is experiencing autonomic neuropathy. What did the nurse assess to make this clinical determination? 1) Bloating 2) Foot pain 3) Tingling of the fingers 4) Numbness of the lower legs

1 Autonomic neuropathy results when there is damage to the nerves of the autonomic nervous system. Common manifestations include diabetic gastroparesis, which results when the nerves that enervate the stomach are damaged, leading to delayed or erratic emptying of stomach contents into the intestine. Clinical manifestations include symptoms such as bloating.

A patient with type 1 diabetes mellitus develops symptoms of hypoglycemia only when the blood glucose level drops to 40 mg/dL. What should be done to reverse this condition? 1) Raise glycemic targets 2) Cut insulin dose in half 3) Add an extra snack to the meal plan 4) Eliminate the evening dose of insulin

1 Individuals with hypoglycemia unawareness should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of further episodes.

A patient is newly diagnosed with type 2 diabetes mellitus. Which medication classification should the nurse expect to be prescribed for this patient? 1) Biguanides 2) Meglitinides 3) Sulfonylureas 4) Thiazolidinediones

1 Intervention at the time of diagnosis with metformin (glyburide) in combination with lifestyle changes such as diet and exercise is common. Metformin is a biguanide.

A patient is prescribed Regular insulin 5 units subcutaneous injection now. Which syringe should the nurse use for this dose if all are readily available? 1) U-30 2) U-50 3) U-100 4) U-500

1 The patient should choose the insulin syringe size according to the insulin dosage. Using the U-30 syringe allows a more accurate measurement of insulin to be administered.

The nurse is reviewing type 1 diabetes mellitus with a group of patients newly diagnosed with the disorder. What should the nurse explain as the major cause for the disorder? 1) Autoimmune process 2) Cancer of the pancreas 3) Alteration in lipid and protein utilization 4) Malfunction of carbohydrate metabolism

1 Type 1 diabetes is typically triggered by an autoimmune process in which the insulin-producing beta cells of the pancreas are destroyed, resulting in an absolute lack of insulin.

A patient with type 1 diabetes mellitus is scheduled for a hemoglobin A1c level. What should the nurse emphasize to the patient to prepare for this test? 1) Schedule the test for first thing in the morning 2) Have the test drawn at any time during the day 3) Avoid eating and drinking anything after midnight the day before the test 4) Restrict the intake of red meat for three days before having the test

2

The nurse is reviewing the results of patient's recent hemoglobin A1c level drawn to evaluate type 1 diabetes management. Which result indicates that treatment has been successful? 1) > or = 8% 2) < or = 6.5% 3) > 110 mg/dL 4) > 140 mg/dL

2

A patient with type 1 diabetes mellitus is preparing to play tennis. What should be done first before engaging in this physical activity? 1) Drink 1 liter of fluid 2) Measure blood glucose level 3) Eat one serving of carbohydrate 4) Take a dose of prescribed medication

2 In individuals taking insulin, physical activity can cause hypoglycemia if medication dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if pre-exercise blood glucose levels are less than 100 mg/dL. The blood glucose needs to be measured before ingesting a carbohydrate.

The nurse is evaluating teaching provided to a patient with type 1 diabetes mellitus. Which patient observation indicates that medication teaching has been effective? 1) Uses a 1 mL syringe to measure insulin dose 2) Places a new injection an inch away from previous injection site 3) Inserts the needle at a 25-degree angle prior to injecting the medication 4) Provides an injection in the thigh after an abdominal injection in the morning

2 Rotating sites within one area rather than moving from area to area helps decrease absorption variability from day to day. This can be done by injecting a new shot at least an inch away from the last injection site.

A patient with type 1 diabetes mellitus has not taken insulin for several days. Which observation indicates that diabetic ketoacidosis (DKA) could be developing? 1) Slow heart rate 2) Deep rapid respirations 3) Decreased urine output 4) Increased blood pressure

2 The patient develops Kussmaul's respirations, which are rapid, deep respirations that occur as a compensatory mechanism for the acidosis.

During a home visit the nurse is concerned that a patient with type 2 diabetes mellitus would benefit from additional teaching. What did the nurse observe to make this clinical decision? 1) Exercising with a treadmill 2) Walking barefoot in the back yard 3) Eating one-half apple and cheese for a snack 4) Stated a weight loss of 2 lbs. over the last month

2 The patient with type 2 diabetes mellitus should never walk barefoot.

Which statement best describes the pathophysiology of type 2 diabetes mellitus? 1) An absolute lack of insulin is present 2) The cells resist glucose from entering 3) Pancreatic cells stop producing insulin 4) An autoimmune disorder damages pancreatic cells

2 Type 2 diabetes mellitus involves defects at the cell membrane that prevent the normal action of insulin. Even though insulin is present, the cell "resists" its effect in transporting glucose into the cell.

A middle-aged patient is surprised to learn of the diagnosis of type 1 diabetes mellitus. What should the nurse respond? 1) "It is odd since it is usually a disease of childhood." 2) "You probably developed it because of an infection." 3) "Type 1 diabetes mellitus can occur at any stage of life." 4) "It usually means that another disease process is present."

3

The nurse notices that a patient who has been drinking large volumes of water and eating large meals throughout the day continues to lose weight. Which health problem should the nurse suspect this patient is experiencing? 1) Hypercortisolism 2) Hyperaldosteronism 3) Type 1 diabetes mellitus 4) Type 2 diabetes mellitus

3 Despite an increased appetite leading to consumption of large amounts of food, the continual breakdown of fats and proteins leads to weight loss and fatigue.

A patient with type 1 diabetes mellitus will be self-monitoring blood glucose levels at home. What is the minimum number of measurements that this patient should make each day? 1) 1 2) 3 3) 4 4) 8

3 Generally, patients with type 1 DM are advised to check their blood glucose a minimum of before meals and at bedtime or 4 times a day

A patient with type 1 diabetes mellitus is experiencing elevated blood glucose levels in the morning. Which action should be taken to determine the reason for this elevation? 1) Check urine for glucose level 2) Restrict oral fluids after 1800 hours 3) Measure blood glucose at 0200 hours 4) Limit carbohydrate intake to 45 grams with evening meal

3 In order to determine what is causing the increased blood glucose levels in the morning, the patient needs to check blood glucose levels in the early morning hours, 2 or 3 a.m., for several nights.

A patient with type 2 diabetes mellitus is being evaluated for hyperosmolar hyperglycemic state (HHS). Which finding would be consistent with this medical diagnosis? 1) pH 7.31 2) Abdominal pain 3) Blood glucose 250 mg/dL 4) Serum bicarbonate 28 mEq/L

4 An elevated serum bicarbonate level is associated with HHS.

A patient experiencing diabetic ketoacidosis (DKA) is receiving a normal saline infusion and intravenous insulin. What additional medication should the nurse expect to be prescribed for this patient? 1) Diuretic 2) Laxative 3) Antibiotic 4) Potassium

4 Care must be taken to monitor potassium levels prior to treating the hyperglycemia with insulin. As insulin is administered to decrease hyperglycemia, potassium will also move back into the cell, worsening hypokalemia. If hypokalemia is present, potassium replacement is a priority.

The nurse is caring for a patient with type 2 diabetes mellitus. Why should the nurse assess capillary refill in this patient? 1) Evaluate for diabetic neuropathy 2) Determine if foot care is being done 3) Estimate current blood glucose level 4) Assess for microvascular complications

4 Decreased perfusion secondary to microvascular changes may manifest as delayed capillary refill.

A patient with type 2 diabetes mellitus is prescribed a glucagon-like peptide-1 agonist. What clinical symptom should the nurse instruct the patient to expect when taking this medication? 1) Nausea 2) Diarrhea 3) Dry mouth 4) Decreased appetite

4 Glucagon-like peptide-1 agonists are injected subcutaneously twice a day, an hour before breakfast and an hour before dinner. They lower glucose levels by slowing glucose absorption from the intestine, increasing insulin secretion when blood glucose levels are high and lowering high glucagon levels sometimes found in diabetics after meals. A side benefit of GLP-1 agonists is the action of decreasing appetite by attaching to an appetite receptor on the hypothalamus, ultimately helping with weight loss.

An older patient with type 1 diabetes mellitus has poor oral intake. What should be considered to ensure adequate blood glucose control? 1) Hold all prandial doses 2) Consider increasing longer-acting insulin 3) Increase the frequency of correctional doses 4) Administer prandial and correctional insulin together

4 In patients with questionable or minimal oral intake, prandial and correctional insulins may be administered together after meals after adequate carbohydrate intake has been confirmed.

The nurse is evaluating care provided to a patient with type 2 diabetes mellitus. Which data indicates that the patient is managing the disease process effectively? 1) Hemoglobin A1c level 8.2% 2) Weight gain of 3 lbs. over the last 2 months 3) Reddened area noted on the sole of the left foot 4) Eye doctor appointment scheduled for the next week

4 Taking action to detect and prevent complications by seeing an eye doctor indicates effective management of the disease process.

The nurse understands is released from the cells of the pancreas when the patient is hypoglycemic. A. glucagon, alpha B. insulin, alpha C. glucagon, beta D. insulin, beta

A

The nurse is concerned that a patient is at risk for developing type 2 diabetes mellitus. What assessment findings caused the nurse to have this concern? Select all that apply. 1) Central obesity 2) Sedentary lifestyle 3) Body mass index 29 4) Blood pressure 140/90 mm Hg 5) Fasting blood glucose 76 mg/dL

ANS: 1, 2, 3, 4 A fasting blood glucose below 100 mg/dL does not increase the risk of developing type 2 diabetes mellitus.

A patient is having testing to diagnose type 1 diabetes mellitus. Which diagnostic tests might be prescribed for this patient? Select all that apply. 1) Hemoglobin A1c 2) 2-hr postprandial 3) Serum albumin level 4) Fasting blood glucose 5) Random blood glucose

ANS: 1, 2, 4, 5 Serum albumin level measures protein in the body. It is not used to help diagnose type 1 diabetes mellitus.

A medication regimen is being planned for a patient newly diagnosed with type 1 diabetes mellitus. For which reasons should the nurse instruct the patient to self-administer doses of insulin? Select all that apply. 1) Basal 2) Prandial 3) Deficient 4) Excessive 5) Correctional

ANS: 1, 2, 5 An approach using a combination of long- or intermediate-acting insulin once or twice a day to provide basal insulin is most effective in maintaining tight glycemic control. Insulin at mealtimes to cover the intake of carbohydrates is considered prandial insulin. Correctional insulin is used to compensate for blood glucose elevations.

The nurse is reviewing data collected on a patient demonstrating signs of type 2 diabetes mellitus. Which additional findings strongly suggest that this patient has type 2 of this disorder? Select all that apply. 1) Fatigue 2) Muscle cramps 3) Visual disturbances 4) Poor wound healing 5) Recurrent infections

ANS: 1, 3, 4, 5 Muscle cramps are not identified as a manifestation of type 2 diabetes mellitus.

The nurse suspects that a patient has undiagnosed type 1 diabetes mellitus. What findings did the nurse use to make this clinical decision? Select all that apply. 1) Weight gain 2) Blurred vision 3) Extreme hunger 4) Excessive thirst 5) Voluminous urine output

ANS: 3, 4, 5 Weight gain is not a manifestation of type 1 diabetes mellitus. Blurred vision can occur when blood glucose levels are too low or too high; however, this is not used to diagnose type 1 diabetes mellitus.

The nurse correlates which laboratory value with the diagnosis of DM? A. Fasting blood glucose greater than 140 mg/dL B. Hemoglobin A1c, 5.8% C. Random blood glucose, 150 mg/dL D. OGTT, 155 mg/dL

Answer: A Rationale: A fasting blood glucose greater than 140 mg/dL indicates DM. The other values are indicative of prediabetes.

The nurse prioritizes which nursing diagnosis in the plan of care for the patient with type 2 DM? A. Risk for infection B. Risk for falls C. Risk for impaired gas exchange D. Risk for injury: hyperkalemia

Answer: A Rationale: Infection is a great risk due to poor peripheral perfusion and diabetic peripheral neuropathy which decreases sensation which may lead to undetected injury and infection.

A nurse is reviewing orders for patients newly diagnosed with type 2 DM. What initial medication orders should be anticipated? A. Metformin PO twice a day B. Nutritional insulin subcutaneously prior to meals C. Basal insulin subcutaneously before bed D. Correctional insulin subcutaneously after meals

Answer: A Rationale: Metformin is a drug used to maintain glucose levels in type 2 DM. Insulin may be used later if glucose control cannot be maintained overtime. B, C, and D are orders for a patient with type 1 DM.

The charge nurse is reviewing orders for a newly admitted patient with type 1 DM. It is a priority for the charge nurse to follow up with the provider about which order? A. NovoLog insulin subcutaneous at bedtime B. NovoLog insulin subcutaneous 15 minutes prior to meals C. Basal insulin subcutaneous at bedtime D. Correctional and nutritional insulin administered immediately after the meal

Answer: A Rationale: NovoLog is a fast acting insulin reserved for correctional or prandial insulin—administration at bedtime without adequate nutritional intake may result in hypoglycemia.

What is the most likely cause of the Somogyi effect? A. Basal insulin injections before bed without a small snack B. Naturally occurring release of hormones during the night C. Increased consumption of complex carbohydrates throughout the day D. Glucagon administration before breakfast

Answer: A Rationale: The increased blood glucose levels of the dawn phenomenon result from the naturally occurring release of hormones such as glucagon, cortisol, and growth hormone in the early morning. Because the body does not have sufficient insulin to control this glucose surge, blood glucose levels rise. This is most likely reflected in higher fasting blood glucose levels in the morning. The Somogyi effect results in increased blood glucose levels due to an excessive insulin dosage at night. This can occur in a patient who injects basal insulin before bed without also having a small bedtime snack. In that circumstance, blood glucose levels drop and the body responds in the same way as in the dawn phenomenon, releasing growth hormone, cortisol, and catecholamines in an effort to increase blood glucose by releasing glucose stores from the liver.

The nurse recognizes which of the following statements as correct in relation to the pathophysiology of type 2 DM? (Select all that apply.) A. It is due to a relative lack of insulin. B. It is due to insulin resistance. C. It is due to an absolute lack of insulin. D. It remains stable over time. E. It is due to an autoimmune process that destroys the beta cells of the pancreas.

Answer: A and B Rationale: Type 2 is a relative lack of insulin or due to insulin resistance. Type 1 is an absolute lack of insulin due to an autoimmune process that destroys the beta cells of the pancreas. Neither are stable over time.

The nurse monitors for which clinical manifestations in the patient newly diagnosed with type 1 DM? (Select all that apply.) A. Polyuria B. Fatigue C. Weight loss D. Polyphagia E. Decreased appetite

Answer: A, B, C, and D Rationale: Fatigue, polyuria, weight loss, and polyphagia are all clinical manifestations. Glucose is typically totally reabsorbed in the renal tubules. Hyperglycemia results in glucose excretion in the urine, which creates an osmotic effect that effectively reduces water reabsorption into the renal tubules, leading to excessive volume loss through the kidneys. Hyperglycemia also causes hyperosmolarity in the blood, which causes a shift of fluid from the intracellular space to the vascular space. The loss of intracellular water combined with the volume loss through the kidneys creates excessive thirst in the patient, or polydipsia. The lack of insulin necessary to move glucose into the cells leads to the breakdown of proteins and fat as a source of energy. This starvation of the cells leads to polyphagia, increased appetite. Despite an increased appetite leading to consumption of large amounts of food, the continual breakdown of fats and proteins leads to weight loss and fatigue.

The nurse recognizes that blood glucose monitoring before meals and at bedtime is done to achieve which outcome? (Select all that apply.) A. Maintain glycemic control. B. Prevent complications of long-term hyperglycemia. C. Facilitate insulin administration that mimics the healthy pancreas. D. Provide frequent practice with the finger stick technique. E. Prevent acute complications of type 1 diabetes.

Answer: A, B, and C Rationale: Blood glucose monitoring before meals and at bedtime facilitates insulin administration that mimics the healthy pancreas which helps maintain glycemic control and prevents complications of long-term hyperglycemia. The goal is not frequent practice. Acute complications can occur independent of glucose monitoring such as infection or stress which increase glucose needs.

The nurse correlates which laboratory values as a diagnostic for DKA? (Select all that apply.) A. Serum bicarbonate of 15 mEq/L B. Negative anion gap C. Serum glucose of 350 mg/dL D. Positive anion gap E. Arterial pH of 7.36

Answer: A, C, and D Rationale: In diabetes ketoacidosis, there is inadequate insulin for cells to obtain adequate glucose for normal metabolism. The body attempts to obtain energy by the rapid breakdown of fat stores, releasing fatty acids from adipose tissues. The liver converts the fatty acids into ketone bodies, which can serve as an energy source in the absence of glucose. The ketone bodies, however, have a low pH, resulting in a metabolic acidosis, alow serum bicarbonate, and a positive anion gap. The absence of insulin also results in an increased release of hormones such as glucagon and cortisol in response to inadequate glucose transport into the cells. This leads to gluconeogenesis and glycogenolysis, resulting in severe hyperglycemia.

The nurse is screening patients for the risk of developing type 2 DM. The nurse should consider which patients at risk? (Select all that apply.) A. Women with a history of gestational diabetes B. Women with a history of multiple births C. Men with a history of pancreatic cancer D. Men who are overweight or obese E. Men and women with cardiovascular disease

Answer: A, D, and E Rationale: Multiple births or a history of pancreatic cancer do not increase the risk of type 2 DM. Pancreatic cancer may result in surgically induced type 1 DM.

The nurse documents glucose in the urine as which finding? A. Polyuria B. Glucosuria C. Hyperglycemia D. Hyperosmolarity

Answer: B Rationale: Glucosuria is glucose in the urine. Polyuria is excessive urine output. Hyperglycemia is high serum glucose and hyperosmolarity is increasedbody fluid osmolality or concentration.

The nurse is providing care for a patient newly diagnosed with type 1 diabetes. Which lifestyle modifications need to be included into the plan of care? A. Limit exercise, carbohydrate counting, self- monitoring of blood glucose B. Distribute carbohydrate intake throughout the day, control weight, limit alcohol C. Carbohydrate counting, self-monitoring of blood glucose, physician visits as needed D. Limit protein intake, distribute carbohydrate intake throughout the day, regular physician visits

Answer: B Rationale: Recommendations for the control of type 2 DM include aerobic training and resistance training, controlling weight which is associated with insulin resistance, distributing carbohydrates throughout the day in small meals and snacks, self-blood glucose monitoring, limiting alcohol as it contains carbohydrates, and regular physician visits.

The nurse understands that type 1 DM is caused by which of the following conditions? (Select all that apply.) A. Gestational diabetes B. A history of mumps or rubella C. Family history of autoimmune disorders D. Autoimmune destruction of the beta cells of the pancreas E. Obesity

Answer: B and D Rationale: Type I DM is caused by an autoimmune process in which the insulin-producing beta cells of the pancreas are destroyed. Triggers are not fully understood, but a history of mumps or rubella are sometimes implicated.

Which are considered clinical manifestations of type 2 diabetes? (Select all that apply.) A. Decreased appetite B. Poor wound healing C. Fatigue D. Hyperactivity E. Visual disturbances

Answer: B, C, and E Rationale: Decreased appetite and hyperactivity are not associated with type 2 DM. Poor wound healing is due to decreased peripheral circulation. Visual disturbances are due to microvascular effects of DM and fatigue is due to the breakdown of fats and proteins for energy needs.

In a diabetic patient, numbness, tingling, and pain in the hands and feet are all symptoms of which complication? A. Autonomic neuropathy B. Hyperosmolar hyperglycemic syndrome C. Diabetic peripheral neuropathy D. Diabetic ketoacidosis

Answer: C Rationale: Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Autonomic neuropathy results when there is damage to the nerves of the autonomic nervous system. In DKA the initial patient presentation is one of polyuria, polydipsia, and polyphagia. The patient becomes dehydrated, and electrolyte imbalance such as hyperkalemia or hypokalemia may result (see Safety Alert). The increased serum osmolarity also results in a shift of fluid from the intracellular to the extracellular space, causing a dilutional hyponatremia. The patient is also at risk for hypovolemia secondary to the osmotic diuresis. Hyperosmolar hyperglycemic syndrome is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis.

The nurse should intervene immediately if a patient has which blood glucose level? A. 200 mg/dL B. 152 mg/dL C. 80 mg/dL D. 40 mg/dL

Answer: D Rationale: As the brain can only use glucose forits metabolic functions, a glucose of 40 requires immediate treatment to avoid potential irreversible CNS dysfunction.

What is measured by the HbgA1c test? A. Amount of glucagon stored in the liver B. Specific insulin levels in blood plasma C. Levels of hemoglobin after physical activity D. Average blood glucose concentration over time

Answer: D Rationale: HbgA1c is the average blood glucose concentration over time.

The nurse is caring for a patient who just finished breakfast. The nurse understands is released from the cells of the pancreas to maintain the blood sugar within normal range. A. glucagon, alpha B. insulin, alpha C. glucagon, beta D. insulin, beta

D

The nurse recognizes the action of insulin is to: A. Transport glucose to the cell B. Metabolize glucose within the cell C. Transport glucose to the liver for storage D. Transport glucose across the cell membrane

D