Chapter 48: Diabetes Mellitus
The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. assess the patient's perception of what it means to have diabetes. b. ask the patient's family to participate in the diabetes education program. c. demonstrate how to check glucose using capillary blood glucose monitoring. d. discuss the need for the patient to actively participate in diabetes management.
ANS: A Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes.
A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. lispro b. glargine c. detemir d. NPH
ANS: A Rapid or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy.
In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? a. rotate NPH vial. b. withdraw regular insulin. c. withdraw 20 units of NPH. d. inject 20 units of air into NPH vial. e. inject 2 units of air into regular insulin vial.
ANS: A, D, E, B, C When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the long-acting insulin.
After change-of-shift report, which patient should the nurse assess first? a. 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 c. 50-yr-old patient who uses exenatide and is reporting acute abdominal pain d. 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202
ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death.
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that apply.) a. chest x-ray b. blood pressure c. serum creatinine d. urine for microalbuminuria e. complete blood count (CBC) f. monofilament testing of the foot
ANS: B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes.
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin."
ANS: D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin.
Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy? a. "Do you feel bloated after eating?" b. "Have you seen any skin changes?" c. "Do you need to increase your insulin dosage when you are stressed?" d. "Have you noticed any painful new ulcerations or sores on your feet?"
ANS: A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient.
Which nursing action is most important in assisting an older patient who has diabetes to engage in moderate daily exercise? a. determine what types of activities the patient enjoys. b. remind the patient that exercise improves self-esteem. c. teach the patient about the effects of exercise on glucose level. d. give the patient a list of activities that are moderate in intensity.
ANS: A Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program.
Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. measure the ankle-brachial index. b. check for changes in skin pigmentation. c. assess for unilateral or bilateral foot drop. d. ask the patient about symptoms of depression.
ANS: A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure.
A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 and serum potassium level of 3.1. Which action prescribed by the health care provider should the nurse take first? a. place the patient on a cardiac monitor. b. administer IV potassium supplements. c. ask the patient about home insulin doses. d. start an insulin infusion at 0.1 units/kg/hr.
ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring.
Which patient action indicates an accurate understanding of the nurse's teaching about the use of an insulin pump? a. the patient programs the pump for an insulin bolus after eating. b. the patient changes the location of the insertion site every week. c. the patient takes the pump off at bedtime and starts it again each morning. d. the patient plans a diet with more calories than usual when using the pump.
ANS: A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake.
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is important for the nurse to communicate to the health care provider regarding this test? a. the patient uses oral contraceptives. b. the patient runs several days a week. c. the patient has been pregnant three times. d. the patient has a family history of diabetes.
ANS: A Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62. Fifteen minutes later, the blood glucose is 67. Which action should the nurse take next? a. give the patient 4 to 6 oz more orange juice. b. administer the PRN glucagon 1 mg IM. c. have the patient eat some peanut butter with crackers. d. notify the health care provider about the hypoglycemia.
ANS: A The "rule of 15" indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 before notifying the health care provider.
The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31. Which goal in the plan of care is most important for this patient? a. the patient will reach a glycosylated hemoglobin level of less than 7%. b. the patient will follow a diet and exercise plan that results in weight loss. c. the patient will choose a diet that distributes calories throughout the day. d. the patient will state the reasons for eliminating simple sugars in the diet.
ANS: A The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of glucose to near-normal levels.
A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first? a. infuse 1 L of normal saline per hour. b. give sodium bicarbonate 50 mEq IV push. c. administer regular insulin 10 U by IV push. d. start a regular insulin infusion at 0.1 units/kg/hr.
ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids.
Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. choose flat-soled leather shoes. b. set heating pads on a low temperature. c. use a callus remover for corns or calluses. d. soak feet in warm water for an hour each day.
ANS: A The patient is taught to avoid high heels and that leather shoes are preferred.
A patient receives aspart insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM
ANS: A The rapid-acting insulins peak in 1 to 3 hours.
Which patient action indicates accurate understanding of the nurse's teaching about administration of aspart insulin? a. the patient avoids injecting the insulin into the upper abdominal area. b. the patient cleans the skin with soap and water before insulin administration. c. the patient stores the insulin in the freezer after administering the prescribed dose. d. the patient pushes the plunger down while removing the syringe from the injection site.
ANS: B Cleaning the skin with soap and water is acceptable.
An unresponsive patient who has type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). What should the nurse anticipate doing? a. giving 50% dextrose b. inserting an IV catheter c. initiating O2 by nasal cannula d. administering glargine insulin
ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia.
Which statement by the patient who has newly diagnosed type 1 diabetes indicates a need for additional instruction from the nurse? a. "I will need a bedtime snack because I take an evening dose of NPH insulin." b. "I can choose any foods, as long as I use enough insulin to cover the calories." c. "I can have an occasional beverage with alcohol if I include it in my meal plan." d. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."
ANS: B Most patients with type 1 diabetes need to plan diet choices very carefully.
The nurse is taking a health history from a 29-yr-old patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take? a. teach the patient about administering regular insulin. b. schedule the patient for a fasting blood glucose level. c. teach about an increased risk for fetal problems with gestational diabetes. d. schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.
ANS: B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit.
Which action should the nurse take after a patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. assess the patient for symptoms of hyperglycemia. b. give the patient a snack of peanut butter and crackers. c. have the patient drink a glass of orange juice or nonfat milk. d. administer a continuous infusion of 5% dextrose for 24 hours.
ANS: B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose.
Which patient statement to the nurse indicates a need for additional instruction in administering insulin? a. "I can buy the 0.5-mL syringes because the line markings are easier to see." b. "I need to rotate injection sites among my arms, legs, and abdomen each day." c. "I do not need to aspirate the plunger to check for blood before injecting insulin." d. "I should draw up the regular insulin first, after injecting air into the NPH bottle."
ANS: B Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently.
A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. What advice should the clinic nurse plan to give the patient? a. increase the morning dose of NPH insulin (Novolin N). b. check glucose level before, during, and after swimming. c. time the morning insulin injection to peak while swimming. d. delay eating the noon meal until after finishing the swimming.
ANS: B The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.
A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin therapy, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider? a. hemoglobin A1C level is 7.9%. b. glomerular filtration rate is decreased. c. last eye examination was 18 months ago. d. patient has questions about the prescribed diet.
ANS: B The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. fasting blood glucose b. glycosylated hemoglobin c. oral glucose tolerance test d. urine dipstick for glucose and ketones
ANS: B The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days.
Which laboratory value reported by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse to assess the patient? a. bedtime glucose of 140 b. noon blood glucose of 52 c. fasting blood glucose of 130 d. 2-hr postprandial glucose of 220
ANS: B The nurse should assess the patient with a blood glucose level of 52 for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice.
Which action by the patient who is self-monitoring blood glucose indicates a need for additional teaching? a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.
ANS: B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad.
Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide? a. glyburide decreases glucagon secretion from the pancreas. b. glyburide stimulates insulin production and release from the pancreas. c. glyburide should be taken even if the morning blood glucose level is low. d. glyburide should not be used for 48 hours after receiving IV contrast media.
ANS: B The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication.
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. the patient administers the glargine 30 minutes before each meal. b. the patient's family prefills the syringes with the mix of insulins weekly. c. the patient discards the open vials of glargine and regular insulin after 4 weeks. d. the patient draws up the regular insulin and then the glargine in the same syringe.
ANS: C Insulin can be stored at room temperature for 4 weeks.
A patient who has diabetes and reports burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline? a. amitriptyline decreases the depression caused by your foot pain. b. amitriptyline helps prevent transmission of pain impulses to the brain. c. amitriptyline corrects some of the blood vessel changes that cause pain. d. amitriptyline improves sleep and makes you less aware of nighttime pain.
ANS: B Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain.
Which patient statement indicates that the nurse's teaching about exenatide has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning."
ANS: C Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption.
A 30-yr-old patient has a new diagnosis of type 2 diabetes. When should the nurse recommend the patient schedule a dilated eye examination? a. every 2 years b. every 6 months c. as soon as available d. at the age of 39 years
ANS: C Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter.
A hospitalized patient who is diabetic received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. What is the best action by the nurse to prevent hypoglycemia? a. plan to discontinue the evening dose of insulin. b. save the lunch tray for the patient's later return. c. request that if testing is further delayed, the patient will eat lunch first. d. send a glass of orange juice to the patient in the diagnostic testing area.
ANS: C Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time.
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is accurate? a. insulin is not used to control blood glucose in patients with type 2 diabetes. b. complications of type 2 diabetes are less serious than those of type 1 diabetes. c. changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. type 2 diabetes is usually diagnosed when a patient is admitted in hyperglycemic coma.
ANS: C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. What should the nurse anticipate? a. the patient may need a diet higher in calories while receiving prednisone. b. the patient may develop acute hypoglycemia while taking the prednisone. c. the patient may require administration of insulin while taking prednisone. d. the patient may have rashes caused by metformin-prednisone interactions.
ANS: C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose.
The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230. Which action will the nurse teach the patient to take? a. avoid snacking right before bedtime. b. increase the rapid-acting insulin dose. c. check the blood glucose during the night. d. administer a larger dose of long-acting insulin.
ANS: C If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM.
A 26-yr-old female who has type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and reports a blood glucose level of 210 despite taking her usual glargine and lispro insulin. What should the nurse advise the patient to do? a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120. c. monitor blood glucose every 4 hours and contact the clinic if it rises. d. decrease carbohydrates until glycosylated hemoglobin is less than 7%.
ANS: C Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated.
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. discuss the reason for the use of insulin therapy during the immediate postoperative period. c. administer the prescribed lispro insulin before transporting the patient to surgery. d. plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
ANS: C LPN/LVN education and scope of practice includes administration of insulin.
A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin? a. thigh b. buttock c. abdomen d. upper arm
ANS: C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption.
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. infuse dextrose 50% by slow IV push. b. administer 1 mg glucagon subcutaneously. c. obtain a glucose reading using a finger stick. d. have the patient drink 4 ounces of orange juice.
ANS: C The patient's clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120. What should the nurse plan to teach the patient? a. self-monitoring of blood glucose b. using low doses of regular insulin c. lifestyle changes to lower blood glucose d. effects of oral hypoglycemic medications
ANS: C The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes.
A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test? a. the patient's most recent A1C was 7.5%. b. the patient's blood glucose is 128. c. the patient took the prescribed metformin today. d. the patient took the prescribed enalapril 4 hours ago.
ANS: C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be used for 48 hours after IV contrast media are administered.
An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider? a. hemoglobin A1C level of 6.2% b. heart rate at rest of 58 beats/min c. blood pressure of 140/88 d. high-density lipoprotein (HDL) level of 65
ANS: C To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the blood pressure should be kept in normal range.
The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response? a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"
ANS: C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.
The nurse is interviewing a new patient with diabetes who takes rosiglitazone. Which information would the nurse anticipate resulting in the health care provider discontinuing the medication? a. the patient's blood pressure is 154/92. b. the patient's blood glucose is 86. c. the patient reports a history of emphysema. d. the patient has chest pressure when walking.
ANS: D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication.
Which finding indicates a need to contact the health care provider before the nurse administers metformin? a. the patient's blood glucose level is 174. b. the patient is scheduled for a chest x-ray in an hour. c. the patient has gained 2 lb (0.9 kg) in the past 24 hours. d. the patient's estimated glomerular filtration rate is 42 mL/min.
ANS: D The glomerular filtration rate indicates possible renal impairment, and metformin should not be used in patients with significant renal impairment.
After change-of-shift report, which patient will the nurse assess first? a. 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon b. 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 c. 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain d. 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
ANS: D The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed.
A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. the patient always carries hard candies when engaging in exercise. b. the patient goes for a vigorous walk when his glucose is 200. c. the patient has a peanut butter sandwich before going for a bicycle ride. d. the patient increases daily exercise when ketones are present in the urine.
ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level.
