Chapter 51: Assessment and Management of Patients With Diabetes

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time? a) 7:45 AM b) 8:30 AM c) 8:00 AM d) 8:15 AM

a) 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.

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find? a) Blood pH of 6.9 b) Blood glucose level of 250 mg/dL c) Serum bicarbonate of 19 mEq/L d) PaCO2 of 40 mm Hg

a) Blood pH of 6.9 With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question? a) Change the second I.V. solution to dextrose 5% in water. b) Infuse 500 ml of normal saline solution over 1 hour. c) Add 40 mEq potassium chloride to an infusion of half normal saline solution and infuse at a rate of 10 mEq/hour. d) Hold insulin infusion for 30 minutes.

a) Change the second I.V. solution to dextrose 5% in water. The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? (Select all that apply.) a) Ketosis-prone b) Obesity at diagnoses c) Younger than 30 years of age d) Older than 65 years of age e) Little endogenous insulin

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

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? a) Metformin b) Glyburide c) Glipizide d) Repaglinide

a) 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.

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? a) Rapid, thready pulse b) Cool, moist skin c) Arm and leg trembling d) Slow, shallow respirations

a) 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.

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? a) Sweating, tremors, and tachycardia b) Dry skin, bradycardia, and somnolence c) Polyuria, polydipsia, and polyphagia d) Bradycardia, thirst, and anxiety

a) Sweating, tremors, and tachycardia Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

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: a) at least three times per week. b) at least once per week. c) at least five times per week. d) every day.

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

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What is the best response by the nurse? a) "The fruit has less sugar than the juice." b) "Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." c) "Eating the fruit is more satisfying than drinking the juice. You will get full faster." d) "Eating the fruit will give you more vitamins and minerals than the juice will."

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

Which statement best indicates that a client understands how to administer his own insulin injections? a) "If I'm not feeling well, I can get a friend or neighbor to help me." b) "I wrote down the steps in case I forget what to do." c) "I need to wash my hands before I give myself my injection." d) "I need to be sure no air bubbles remain."

b) "I wrote down the steps in case I forget what to do." The fact that the client has written down each step of insulin administration provides the best assurance that he'll follow through with all the proper steps. Awareness of air bubbles and hand washing indicate that the client understands certain aspects of giving an injection, but doesn't confirm he understands all of the steps. Saying that he can ask a friend or neighbor for help indicates a need for further instruction.

A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents? a) "Your child is young and will soon forget this experience." b) "Your child will need less blood work as his glucose levels stabilize." c) "I'll see if the physician can reduce the number of blood draws." d) "Our laboratory technicians use tiny needles and they're really good with children."

b) "Your child will need less blood work as his glucose levels stabilize." Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician if he can reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.

The nurse is preparing to administer IV fluids for a patient with ketoacidosis who has a history of hypertension and congestive heart failure. What order for fluids would the nurse anticipate infusing for this patient? a) 0.9% normal saline b) 0.45 normal saline c) D5 normal saline d) D5W

b) 0.45 normal saline Half-strength NS (0.45%) solution (also known as hypotonic saline solution) may be used for rehydration of patients with hypertension or hypernatremia and those at risk for heart failure.

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: a) 140 mg/dL b) 180 mg/dL c) 120 mg/dL d) 160 mg/dL

b) 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).

The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively? a) 10% to 20% b) 50% to 60% c) 25% to 40% d) 85% to 90%

b) 50% to 60% One half to two thirds of the patient's usual morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery. The remainder is then administered after surgery.

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true? a) Approximately one-half of the clients diagnosed with type 2 diabetes are obese. b) Diabetes mellitus is more common in Hispanics and Blacks than in Whites. c) Nearly two-thirds of clients with diabetes mellitus are older than age 60. d) Type 2 diabetes mellitus is less common than type 1 diabetes mellitus.

b) Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor? a) Hyponatremia b) Hypoglycemia c) Polyphagia d) Ketonuria

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

A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to: a) Stimulate the beta cells of the pancreas to secrete insulin. b) Inhibit the production of glucose by the liver. c) Increase the absorption of carbohydrates in the intestines. d) Decrease the body's sensitivity to insulin.

b) Inhibit the production of glucose by the liver. The action of the biguanides can be found in Table 30-6 in the text.

A patient with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestations associated with this classic symptom? a) Altered mental state b) Muscle wasting and tissue loss c) Weight gain d) Dehydration

b) Muscle wasting and tissue loss Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although people with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.

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: a) 25 g of carbohydrates. b) 10 g of carbohydrates. c) 15 g of carbohydrates. d) 20 g of carbohydrates.

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

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: a) 10:30 AM. b) 12:30 PM. c) 8:30 AM. d) 2:30 PM.

c) 8:30 AM. Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation? a) Ask the physician for a referral for a diabetes nurse-educator to see the client before discharge. b) Suggest the client find a supportive friend or family member to assist in his care. c) Ask the physician to delay the discharge because the client requires further teaching. d) Tell the charge nurse she doesn't believe this client will be safe and refuse to rush.

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

The nurse practitioner worked with a registered dietician to customize a 1,800-calorie diabetic diet for a 53-year-old man with special dietary needs. Which of the following percent distribution of calories should be provided? a) Carbohydrates 45%, fat 20%, and protein 15% b) Carbohydrates 35%, fat 10%, and protein 5% c) Carbohydrates 50%, fat 25%, and protein 20% d) Carbohydrates 40%, fat 15%, and protein 10%

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

A 36-year-old mother of six has been recently diagnosed with type 2 diabetes. She reports increased hunger and food consumption while continuing to lose weight. What is the term used to describe this condition? a) Polyuria b) Anorexia c) Polyphagia d) Polydipsia

c) 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. Polyphagia describes a medical symptom that means excessive hunger or appetite.

A female diabetic patient who weighs 130 lb has an ideal body weight of 116 lb. For weight reduction of 2 lb/week, approximately what should her daily caloric intake be? a) 1500 calories b) 1200 calories c) 1,800 calories d) 1000 calories

d) 1000 calories Calorie-controlled diets are planned by first calculating a person's energy needs and caloric requirements based on age, gender, height, and weight. An activity element is then factored in to provide the actual number of calories required for weight maintenance. To promote a 1- to 2-pound weight loss per week, 500 to 1,000 calories are subtracted from the daily total.

A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site? a) Wear sterile gloves when inserting the needle. b) Use clean technique when changing the needle. c) Take the ordered antibiotics before initiating treatment. d) Change the needle every 3 days.

d) Change the needle every 3 days. The nurse should teach the client to change the needle every 3 days to prevent infection. The client doesn't need to wear gloves when inserting the needle. Antibiotic therapy isn't necessary before initiating treatment. Sterile technique, not clean technique, is needed when changing the needle.

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? a) Administer insulin. b) Correct diabetic ketoacidosis. c) Determine the cause of diabetic ketoacidosis. d) Initiate fluid replacement therapy.

d) 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 of the following categories of oral antidiabetic agents exert their primary action by directly stimulating the pancreas to secrete insulin? a) Thiazolidinediones b) Alpha glucosidase inhibitors c) Biguanides d) Sulfonylureas

d) 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 insulin's action on peripheral receptor sites. Alpha glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

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: a) Glycogenesis will be decreased by the liver. b) Insulin will be released to facilitate the transport of sugar. c) The process of gluconeogenesis will be inhibited. d) The pancreatic hormone glucagon will stimulate the liver to release stored glucose.

d) 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 with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin? a) They have no effect. b) They decrease the need for insulin. c) They cause wide fluctuations in the need for insulin. d) They increase the need for insulin.

d) They increase the need for insulin. Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.

Which of the following factors is the focus of nutrition intervention for patients with type 2 diabetes? a) Blood glucose level b) Carbohydrate intake c) Protein metabolism d) Weight loss

d) Weight loss Weight loss is the focus of nutrition intervention for patients with type 2 diabetes. A low-calorie diet may improve clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action. Consistency in the total amount of carbohydrate consumed is considered an important factor influencing blood glucose level. Protein metabolism is not the focus of nutrition intervention for patients with type 2 diabetes.

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: a) increasing intake of vitamins B and D and taking iron supplements. b) eating a candy bar if light-headedness occurs. c) increasing saturated fat intake and fasting in the afternoon. d) consuming a low-carbohydrate, high-protein diet and avoiding fasting.

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

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: a) provide support for the spouse or significant other. b) provide time for privacy. c) encourage the client to ask questions about personal sexuality. d) suggest referral to a sex counselor or other appropriate professional.

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