Chapter 46: Management of Patients with Diabetes

Which statement best indicates that a client understands how to administer his own insulin injections?

"I wrote down the steps in case I forget what to do."

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."

During a routine medical evaluation, a client is found to have a random blood glucose level of 210 mg/dL. Which client statement(s) made by the client are concerning to the nurse? Select all that apply.

- "At times my vision is blurry." - "I have to void nearly every hour." - "I cannot seem to quench my thirst." - "I have lost 10 pounds without even trying."

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?

70% NPH insulin and 30% regular insulin -Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.

A client with diabetic ketoacidosis has been brought into the ED. Which intervention is not a goal in the initial medical treatment of diabetic ketoacidosis?

Administer glucose.

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

Albumin

The nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. What is an important dietary consideration for the nurse to keep in mind?

Encourage midday snack. -Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 10 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.

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

Increased urine osmolarity

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?

Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns

The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications?

Urinary tract infections -Elevated levels of blood glucose and glycosuria supports bacterial growth and places the diabetic at greater risk for urinary tract, skin, and vaginal infections. Obesity, elevated triglycerides, and high blood pressure are considered symptoms of metabolic syndrome, which can result in type 2 diabetes mellitus.

polyphagia

excessive hunger

polydipsia

excessive thirst

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

Increases ability for glucose to get into the cell and lowers blood sugar

Lispro (Humalog) is an example of which type of insulin?

Rapid-acting -Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received 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 3:00 a.m. -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.

Which factors will cause hypoglycemia in a client with diabetes? Select all that apply.

- Client has not consumed food and continues to take insulin or oral antidiabetic medications. - Client has not consumed sufficient calories. - Client has been exercising more than usual.

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

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 or no endogenous insulin - Younger than 30 years of age

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply.

- May improve blood glucose levels - Decrease the need for exogenous insulin - Help reduce cholesterol levels

Which of the following insulins are used for basal dosage?

Glargine (Lantus) -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.

A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?

This insulin has no peak action and does not cause a hypoglycemic reaction.

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:45 AM -Insulin lispro has an onset of 5 to 15 minutes. Therefore, the nurse would need to ensure that the client has his breakfast by 7:45 AM at the latest. Otherwise, the client may experience hypoglycemia.

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

"Your body is using protein and fat for energy instead of glucose." -Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

15 to 20 g of a fast-acting carbohydrate such as orange juice. -This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

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?

Insulin production insufficient -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. Pre-diabetes can lead to type 2 diabetes.

A young adult client with type 1 diabetes does not want to have to self-administer insulin injections several times a day. Which medication approach would the nurse recommend that bestcontrols the condition and meets the client's needs?

Insulin pump -The insulin pump most closely mimics regular pancreas function and increases meal and exercise flexibility. The use of the pump would meet the client's needs of not wanting to self-administer several injections of insulin every day. With one injection per day, there is difficulty controlling fasting blood glucose if the type of insulin does not last. The client could also develop afternoon hypoglycemia if the single dose is increased in order to control the morning fasting glucose level. Two injections per day might meet the client's needs of minimal self-injections; however, for this regimen, there needs to be a fixed schedule of meals and exercise and it is difficult to adjust the dose if premixed insulin is used. Self-administering insulin before each meal will not meet the client's needs since this requires more injections than any other regimen.

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

glycosylated hemoglobin level. -Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:

polyphagia. -While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose.

A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

wash and inspect the feet daily.

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 the dosage

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

Presence of islet cell antibodies -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 is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular - Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

Regular -Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.

Which instruction about insulin administration should a nurse give to a client?

"Always follow the same order when drawing the different insulins into the syringe."

A 1200-calorie diet and exercise are prescribed for a client with newly diagnosed type 2 diabetes. The nurse is teaching the client about meal planning using exchange lists. The teaching is determined to be effective based on which statement by the client?

"For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda."

A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

"I'm going to give your son some insulin. Then I'll be happy to talk with you."

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."

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective?

1/2 cup fruit juice or regular soft drink -In a client with hypoglycemia, the nurse uses the rule of 15: give 15 g of rapidly absorbed carbohydrate, wait 15 minutes, recheck the blood sugar, and administer another 15 g of glucose if the blood sugar is not above 70 mg/dL. One-half cup fruit juice or regular soft drink is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Eight ounces of skim milk is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. One tablespoon of honey or syrup is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Six to eight LifeSavers candies is equivalent to the recommended 15 g of rapidly absorbed carbohydrate.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

10 to 15 g of a simple carbohydrate. -To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10 to 15 minutes -The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?

3 months

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% -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.

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. -Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration.

Which statement is true regarding gestational diabetes?

A glucose challenge test should be performed between 24 and 28 weeks.

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome?

Administer 2 to 3 L of IV fluid rapidly. -Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly ordered fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin

Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)?

Blood glucose can be controlled through diet and exercise

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl -HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?

Control blood glucose levels. -Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy. Drinking plenty of fluids does not prevent diabetic nephropathy. Taking antidiabetic drugs regularly may help to control blood glucose levels, but it is the control of these levels that is most important. A high-fiber diet is unrelated to the development of diabetic nephropathy.

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

Crying whenever diabetes is mentioned

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?

Diabetes mellitus is more common in Hispanics and Blacks than in Whites.

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

Do not mix with other insulins. -Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. Glargine is a "peakless" basal insulin that is absorbed very slowly over a 24-hour period and can be given once a day. 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 -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.

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 -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.

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection sites than at other sites. -Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

NPH is an example of which type of insulin?

Intermediate-acting

Which statement is correct regarding glargine insulin?

It cannot be mixed with any other type of insulin. -Because this insulin is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. There is no peak in action. It is approved to give once daily.

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?

It carries glucose into body cells.

Which type of insulin acts most quickly?

Lispro -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.

A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which factor should the nurse monitor when caring for the client?

Low blood glucose concentration -Clients who switch from animal to synthesized human insulin should initially be monitored for low blood glucose concentrations because the human form of insulin is used more effectively. Human insulin causes fewer allergic reactions than insulin obtained from animal sources. Polyuria and hypertonicity are symptoms of diabetes mellitus.

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

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

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

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 -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.

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) -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.

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder?

Serum osmolarity

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.

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

The client has not eaten but continues to take insulin or oral antidiabetic medications.

The pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar:

The pancreatic hormone glucagon will stimulate the liver to release stored glucose. -When sugar levels are low, glucagon promotes hyperglycemia by stimulating the release of stored glucose. Glycogenolysis and gluconeogenesis will both be increased. Insulin secretion would promote hypoglycemia.

A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible?

To restore liver glycogen and prevent secondary hypoglycemia

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. -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.

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.

polyuria

excessive urination

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes?

increased thirst, hunger, and urination -The three classic symptoms of both types of diabetes mellitus are polyuria, polydipsia, and polyphagia. Weight loss, dehydration, and fatigue are additional symptoms.

Which is a characteristic of type 2 diabetes?

insulin resistance -Type 2 diabetes is characterized by either a decrease in endogenous insulin or an increase accompanied by insulin resistance. Type 1 diabetes is characterized by production of little or no insulin; the client with type 1 diabetes is ketosis-prone when insulin is absent and often has islet cell antibodies.

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.

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." -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 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. -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 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." -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.

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply.

- Increases lean muscle mass - Increases resting metabolic rate as muscle size increases - Decreases total cholesterol - Increases glucose uptake by body muscles

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?

100 units of regular insulin in normal saline solution

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

15 g of carbohydrates. -The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

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 -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 to 6 hours -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.

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?

Fruity breath

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 -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.

A nurse is inspecting the feet of a client with diabetes and finds a tack sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?

High blood sugar decreases blood circulation to nerves. -Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness. Autonomic neuropathy is a complication of diabetes mellitus but not significant with peripheral injuries. Motor neuropathy does occur with poor glucose control but not specific to this injury. Nephropathy is a common complication that directly affects the kidneys.

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

Hypoglycemia

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

Hypokalemia and hypoglycemia -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.

The nurse is educating the client with diabetes on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?

Increase frequency of glucose self-monitoring. - Minor illnesses such as influenza can present a special challenge to a diabetic client. The body's need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis.

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 -The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

Increased urine output - Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first?

Infuse 0.9% normal saline solution 1 L/hr for 2 hours. -In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated clients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?

Initiate fluid replacement therapy. -The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

Which term refers to the progressive increase in blood glucose from bedtime to morning?

Insulin waning -Insulin waning is a progressive rise in blood glucose from bedtime to morning. The dawn phenomenon occurs when blood glucose is relatively normal until about 3 a.m., when the level begins to rise. The Somogyi effect occurs when blood glucose is normal or elevated at bedtime, decreases at 2 to 3 a.m. to hypoglycemia levels, and subsequently increases as a result of the production of counter-regulatory hormones. DKA is caused by an absence or markedly inadequate amount of insulin. This insulin deficit results in disorders in the metabolism of carbohydrates, proteins, and fats. The primary clinical features of DKA are hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis.

Which statement is correct regarding glargine (Lantus) insulin?

It cannot be mixed with any other type of insulin.

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?

It enhances the transport of glucose across the cell membrane.

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 -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.

What is the only insulin that can be given intravenously?

Regular

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 -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.

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

Sulfonylureas -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 is diagnosed with diabetes mellitus. The client reports visiting the gym regularly and is a vegetarian. Which of the following factors is important to consider when the nurse assesses the client?

The client's consumption of carbohydrates

A nurse educator been invited to local seniors center to discuss health-maintaining strategies for older adults. The nurse addresses the subject of diabetes mellitus, its symptoms, and consequences. What should the educator teach the participants about type 1 diabetes?

The participants are unlikely to develop a new onset of type 1 diabetes.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

The short-acting insulin is withdrawn before the intermediate-acting insulin. -When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy."

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance -Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.

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 -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.

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

has type 2 diabetes.

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 -Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.