Chapter 48 Diabetes Mellitus
A patient diagnosed with type 1 diabetes has had elevated blood sugar readings each morning for the past four days. Which intervention by the nurse should be performed initially? 1 Check the patient's blood sugar at 3 AM. 2 Provide the patient with an evening snack. 3 Rotate insulin injection sites between the abdomen, thigh, and arm. 4 Contact the health care provider to increase the evening insulin dose.
Answer: 1 Hyperglycemia in the morning may be caused by the Somogyi effect. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. Diabetics should be given evening snacks to prevent hypoglycemia during the night, but glucose assessment is a priority to rule out the Somogyi effect. Injection sites are rotated to prevent lipodystrophy. An increased dose of evening insulin may cause further decrease in early morning glucose and increased rebound hyperglycemia.
One of the unlicensed assistive personnel (UAP) reports to the nurse that a patient with diabetes is slow to respond, pale, and diaphoretic. What is the nurse's priority intervention? 1 Obtain a bedside glucose reading. 2 Ask patient to drink 4 ounces of orange juice. 3 Ask the unlicensed assistive personnel (UAP) to obtain a set of vital signs. 4 Administer 50 mL of 50% dextrose intravenously
Answer: 1 The patient with diabetes is exhibiting signs and symptoms of hypoglycemia. The priority intervention at this time is to validate assessment findings with a bedside glucose reading. Although vital signs may add to assessment data findings, they are not as much a priority as validating hypoglycemia and initiating treatment. Because the patient is experiencing a change in level of consciousness, management of the hypoglycemia via oral nourishment is contraindicated. If the patient has an existing intravenous (IV) line, then treatment of documented hypoglycemia with intravenous dextrose may be indicated.
The nurse is assigned to care for a patient with type 2 diabetes. To encourage the patient to become an active participant in his or her care, what action should the nurse take? 1 Assess the patient's understanding of the disease 2 Make a list of food restrictions for proper diabetes management 3 Refer the patient to a nutritionist 4 Set long-term goals to decrease the risk of complications
Answer: 1 For teaching to be effective, the first step is assessing the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. Food restrictions, nutritionist referral, and setting long-term goals can occur once the nurse is confident the patient understands what it means to have diabetes.
The nurse has taught a patient who was admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse determines that additional teaching is necessary when the patient makes which statement? 1 "Taking a hot bath every day will help with my circulation." 2 "I should avoid walking barefoot at all times." 3 "I should look at the condition of my feet every day." 4 "I need a podiatrist to treat my ingrown toenails."
Answer: 1 Hot water may injure tissue related to decreased sensation and should be avoided. Patients with diabetes mellitus should inspect the feet daily for broken areas that are at risk for delayed wound healing, avoid walking barefoot, and have a podiatrist for foot care.
The patient with diabetes should consume fiber as part of a healthy diet. The current recommendation for persons with diabetes is 1 25 to 30 g/day 2 20 to 25 g/day 3 40 to 50 g/day 4 10 to 20 g/day
Answer: 1 The American Diabetes Association (ADA) recommends that diabetics consume 25 to 30 grams of fiber daily. This is the same level recommended for the nondiabetics, because there is no evidence that a higher intake of fiber is essential. Forty to 45 grams is too much fiber for the patient to consume, and 10 to 25 grams is not enough fiber.
A nurse in the outpatient setting is teaching a patient about the importance of self-monitoring of blood glucose (SMBG) using a glucometer. What should the nurse tell the patient? Select all that apply. 1 Test blood glucose whenever hypoglycemia is suspected. 2 Test blood glucose before and after exercise. 3 Take a blood sample immediately after a meal. 4 Take a blood sample from the side of the finger pad. 5 Wash hands in cold water when preparing to puncture.
Answer: 1, 2, & 4 The nurse should instruct the patient to test blood glucose levels whenever hypoglycemia is suspected so that immediate action can be taken. The patient should test blood glucose before and after exercise to determine the effects of exercise on metabolic control. Blood sample should be taken from the side of the finger pad rather than near the center, because there are fewer nerve endings along the side of the finger. Blood glucose is generally tested two hours after a meal to determine if the bolus insulin dose was adequate for the meal. Blood glucose may also be tested before a meal by patients who use insulin pumps or multiple daily injections and base the insulin dose on the carbohydrates in a meal or make adjustments if the preprandial value is above or below target. Hands should be washed in warm water before the finger puncture is made in order to promote blood flow to the fingers.
Which statements are appropriate for the nurse to make to a patient newly diagnosed with Type I diabetes mellitus (DM)? Select all that apply. 1 "You should decrease your dietary sugar intake." 2 "I will teach you how to self-administer your insulin." 3 "It is important to consume a diet that is high in fats." 4 "It is important for you to reduce your physical activity." 5 "You should monitor your blood sugar as prescribed."
Answer: 1, 2, & 5 The nurse should teach the patient to decrease dietary sugar intake, self-administer insulin, and regularly monitor blood glucose levels as prescribed. A high-fat diet increases the patient's cholesterol levels and may increase the blood sugar levels. Reduction of physical exercise can also lead to increase in blood glucose level.
A patient with type 2 diabetes who takes metformin daily to manage blood sugar is scheduled for an intravenous pyelogram (IVP). Which question by the nurse is most important to ask the patient when preparing for the procedure? 1 "Have you ever skipped a dose of metformin?" 2 "When was the last time you took your metformin?" 3 "How many times a day do you take your metformin?" 4 "How long have you been taking metformin for diabetes?
Answer: 2 During an IVP, contrast dye is injected so that the urinary system can be visualized. To reduce risk of kidney injury, metformin should be discontinued a day or two before the procedure and for 48 hours following the procedure. Medication administration adherence, dosage, and history are important to assess, but will not affect the interaction.
A patient's blood glucose level before breakfast is 324 mg/dL. The nurse reviews the electronic medical record and notes that the patient receives a high dose of insulin each evening at bedtime. The nurse recognizes that the patient's hyperglycemia is most likely due to which problem with insulin therapy? 1 Lipodystrophy 2 Somogyi effect 3 Allergic reaction 4 Dawn phenomenon
Answer: 2 The Somogyi effect occurs when a patient receives a high dose of evening/bedtime insulin that produces a decline in blood glucose levels during the night. As a result, counter regulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. Lipodystrophy is atrophy or hypertrophy of the subcutaneous tissue. Allergic reactions related to insulin occur as local inflammatory reactions and do not produce hyperglycemia. The dawn phenomenon also is characterized by hyperglycemia that is present on awakening; however, it is caused by growth hormone and cortisol excretion during the early morning hours and is unrelated to the amount of insulin given at nighttime.
A patient calls the health care provider's office at 8:00 AM and states, "I just experienced an episode of low blood sugar, which responded to oral glucose tablets." To help identify the cause of the low blood sugar, an appropriate question the nurse should ask is: 1 "Did you check your urine for ketones?" 2 "Were you more active than usual yesterday?" 3 "Did you take a lower than normal dose of insulin today?" 4 "Have you been running a fever or do you have any illness symptoms?"
Answer: 2 The glucose-lowering effects of exercise can last up to 48 hours, so it is possible for hypoglycemia to occur after activity, particularly if exercise is at a greater intensity or time than normal. Asking the patient about activity level would be the most appropriate question for the nurse to ask. Ketones can be found in the urine with elevated blood glucose levels and may indicate the presence of diabetic ketoacidosis. Ketones would not be of concern with hypoglycemia. Taking a lower dose of insulin would result in higher blood glucose. Fever and illness can lead to hyperglycemia as well.
A patient prescribed metformin complains of an "upset stomach" after ingestion of the medication. The nurse asks a student nurse what suggestion he or she would make. What is the most appropriate suggestion by the student? 1 "Stop taking the medication immediately and notify the prescriber." 2 "Take metformin with food to decrease gastrointestinal (GI) side effects." 3 "Get your blood glucose checked, because it sounds like hypoglycemia." 4 "Take diphenhydramine 25 mg before taking metformin to prevent nausea."
Answer: 2 The student nurse should suggest that the patient take metformin with food to decrease GI side effects. It is not within the nurse's scope of practice to prescribe medications such as diphenhydramine for nausea. Advising the patient to stop the medication immediately may result in a hyperglycemic response and should not be done without medication prescriber guidance. Getting the patient's blood glucose checked will not address the complaints of GI distress.
A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? 1 6:00 PM on the evening before the test 2 Midnight before the test 3 4:00 AM on the day of the test 4 7:00 AM on the day of the test
Answer: 2 Typically, a patient is prescribed to be nothing by mouth (NPO) for eight hours before a fasting blood glucose level. For this reason, the patient who has a laboratory draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
After administering glucagon to an unconscious patient, the nurse should place the patient in which position? 1 Supine 2 Side-lying 3 High-Fowler's 4 Semi-Fowler's
Answer: 2 Nausea is a common reaction after glucagon injection. The patient should be placed in the side-lying position to prevent aspiration should the patient vomit. The supine, high-Fowler's, and semi-Fowler's positions are not advisable because of the risk of aspiration of vomitus.
A nurse is caring for a patient with diabetes mellitus who is in an inpatient unit. The primary health care provider has ordered regular insulin. The nurse is preparing the medication for subcutaneous injection. What is the most effective site for subcutaneous injection of insulin? 1 Thigh 2 Abdomen 3 Upper arm 4 Right buttock
Answer: 2 The abdomen is the preferred injection site; it provides the fastest subcutaneous absorption. The thigh, upper arm, and buttock are other sites that may be used for subcutaneous injection, but the abdomen is the best site.
A patient with type 2 diabetes mellitus (DM) receives a prescription for metformin. The nurse identifies that which statement is characteristic of this medication? 1 It causes weight gain. 2 It decreases hepatic glucose production. 3 It should not be given with sulfonylureas. 4 It is inappropriate for initial management of type 2 DM.
Answer: 2 The primary action of metformin is to reduce glucose production by the liver. Metformin often causes weight loss instead of weight gain. Metformin can be administered in conjunction with sulfonylureas. Metformin is preferred for the initial management of type 2 diabetes.
A patient with diabetes who takes long-acting and mealtime insulin calls the ambulatory center with complaints of an upper respiratory infection. The patient has a decreased appetite, fever, and cough. Which instructions should the nurse give the patient? Select all that apply. 1 "Come to the clinic if you have a single blood glucose level over 300 mg/dL." 2 "Any illness can cause a hormone response that can result in hyperglycemia." 3 "Common illnesses such as the flu cannot impact glucose or insulin requirements." 4 "Do not inject any insulin until you can eat normally because hypoglycemia may occur." 5 "If you are sick, you should check your blood sugar every four hours, even if you are not eating regularly."
Answer: 2 & 5 Any illness or surgery can cause a regulatory hormonal response that may lead to hyperglycemia. Patients with diabetes and concurrent illnesses should check their blood sugar at least every four hours, despite current eating patterns, to monitor for hyperglycemia. Many clinics will ask a patient to report to his or her health care provider for two blood glucose readings over 300 mg/dL in a row, not just one. Common illnesses such as an upper respiratory illness or the flu can cause changes in glucose requirements. Patients should be encouraged to continue their insulin injectables as prescribed and monitor for hyperglycemia or hypoglycemia. These patients should supplement with carbohydrate-containing foods or beverages as necessary.
A nurse is providing discharge teaching to a patient with a new diagnosis of type I diabetes mellitus who will need to give self-injections of insulin at home. What statement by the patient indicates to the nurse that the discharge teaching was effective? 1 "I can use my lower forearm for insulin injections." 2 "If my intermediate-acting insulin looks cloudy, I should discard the bottle." 3 "I need to rotate sites of injection to allow for better absorption of the insulin." 4 "I should push the plunger all the way down and then remove the needle as soon as possible."
Answer: 3
A patient is prescribed lispro therapy. Related to meal times, when would the nurse instruct the patient to administer the insulin? 1 On an empty stomach, between meals 2 Simultaneously with a meal 3 Within 15 minutes of mealtime 4 30 to 45 minutes before a meal
Answer: 3 Rapid-acting synthetic insulin analogs, which include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra), have an onset of action of approximately 15 minutes and should be injected within 15 minutes of mealtime. The rapid-acting analogs most closely mimic natural insulin secretion in response to a meal. Lispro is not administered on an empty stomach or simultaneously with a meal. Short-acting regular insulin, not rapid-acting synthetic insulin, is administered 30 to 45 minutes before a meal to ensure the onset of action coincides with meal absorption.
The nurse is caring for a patient diagnosed with diabetes mellitus (DM) who has developed insulin resistance. Which class of glucose-lowering agents can reduce insulin resistance? 1 DPP-IV inhibitors 2 Dopamine agonists 3 Thiazolidinediones 4 α-glucosidase inhibitors
Answer: 3 Thiazolidinediones are often referred to as "insulin sensitizers." These agents improve insulin sensitivity, transport, and utilization at target tissues. Because they do not increase insulin production, thiazolidinediones do not cause hypoglycemia when used alone. Examples of thiazolidinediones include rosiglitazone and pioglitazone. DPP-IV inhibitors inactivate the hormone incretin. Dopamine agonists activate dopamine receptors and α-glucosidase inhibitors delay carbohydrate absorption in the small intestine.
A patient presents with diabetic ketoacidosis (DKA). The nurse initiates the collaborative plan of care with the understanding that the initial goal of the treatment plan is: 1 Treatment for hypokalemia 2 Rapid reduction of elevated blood glucose 3 Rehydration through intravenous fluid replacement 4 Reduction of ketosis by encouraging oral nourishment
Answer: 3 Fluid imbalance is potentially life threatening for patients with DKA. The initial goal of therapy is to establish intravenous (IV) access and begin fluid replacement. Once urine output is established, electrolyte replacement will be addressed. Potassium levels will need to be monitored, because insulin therapy, which is needed to correct the hyperglycemia, may further reduce the potassium level. Insulin therapy will be used to lower the blood glucose gradually, to prevent rapid drops in serum glucose, which could lead to fluid shifts and the potential for cerebral edema. Ketosis results from the use of fat stores for energy, because excess glucose is not being transported to the cells and used as a source of energy. Patients with DKA often present with nausea and vomiting; oral nourishment may be limited until symptoms lessen.
A college student is newly diagnosed with type 1 diabetes. The patient now has a headache, changes in vision, and is anxious, but does not have the portable blood glucose monitor with him or her. Which action should the campus nurse advise the patient to take? 1 Eat a piece of pizza 2 Drink some diet soft drink 3 Eat 15 g of simple carbohydrates 4 Take an extra dose of rapid-acting insulin
Answer: 3 When the patient with type 1 diabetes is unsure about the meaning of the symptoms he or she is experiencing, the patient should treat him- or herself for hypoglycemia to prevent seizures and coma from occurring. The patient also should be advised to check the blood glucose as soon as possible. The fat in the pizza and the diet soft drink would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.
A nurse is providing education for a patient with a new diagnosis of type I diabetes mellitus. Therapy for the patient will require subcutaneous insulin injections several times per day. When teaching the patient how to administer subcutaneous insulin, what education is the most accurate? 1 "You must use an alcohol swab on the site before self-injection." 2 "If you are planning on going jogging, you should use the thigh injection site to administer insulin." 3 "You should use one site for insulin injections so you get used to the process of administering insulin." 4 "Avoid injecting insulin intramuscularly, because rapid and unpredictable absorption could result in hypoglycemia."
Answer: 4
The nurse is teaching a patient with diabetes about proper dietary recommendations. The nurse determines that the patient understands the teaching when he or she makes which statement? 1 "I should increase my daily intake of saturated fat to decrease my blood sugar." 2 "I need more protein now that I have diabetes." 3 "I do not need to limit my alcohol intake as long as it is low in sugar." 4 "I should have no more than 60 grams of carbohydrates in each meal."
Answer: 4 The percent of dietary calories that should be eaten as carbohydrates is 55% to 60%. Protein calories make up 12% to 20% of calories; less than 30% of calories should derive from fat. Each meal should contain 45 to 60 grams of carbohydrates; protein intake is unchanged, and saturated fat should be minimized. Alcohol intake should also be limited to one drink per day for women and two per day for men.
A patient with type 2 diabetes takes oral hypoglycemics and is admitted to the hospital with a urinary tract infection (UTI). The patient asks why insulin injections have been prescribed. What explanation should the nurse provide? 1 Insulin acts synergistically with the antibiotic that was prescribed. 2 Insulin should have been prescribed for the patient to take at home. 3 Oral hypoglycemic medications are contraindicated in patients with UTIs. 4 The infection increases the glucose level, resulting in a need for more insulin.
Answer: 4 When the body is under stress, as in an acute illness, the need for insulin is more than oral hypoglycemics can provide. Insulin injections are usually required until the illness resolves. Insulin does not act synergistically with antibiotics, the patient did not need insulin at home, and oral hypoglycemics are not contraindicated in patients with UTIs.
