Chapter 51 PrepU - Diabetes

A client has been diagnosed with diabetes and discusses treatment strategies with the nurse. What consequences of untreated diabetes should the nurse include with client teaching?

Blindness Cardiovascular disease Limb amputation Kidney disease

After being in remission from Hodgkin's disease for 18 months, a client develops a fever of unknown origin. A healthcare provider orders a liver biopsy to rule out advancing Hodgkin's disease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. What should the nurse suspect?

Peritonitis from bleeding in the liver caused by the liver biopsy

A client who is being tested for syndrome of inappropriate antidiuretic hormone secretion asks the nurse to explain the diagnosis. While explaining, the nurse states that excessive antidiuretic hormone is secreted from which gland?

Posterior pituitary

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver?

Protein metabolism Glucose metabolism Ammonia conversion

A client with symptoms of Cushing syndrome is admitted to the hospital for evaluation and treatment. The nurse is creating a plan of care for the client. Which is an appropriate nursing diagnosis?

Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns

A nurse educator has been invited to a local senior center to discuss health-maintaining strategies for older adults. During a session on nutrition, the nurse discusses diabetes mellitus, its symptoms, and consequences. In the United States, diabetes mellitus is the _______ leading cause of death.

Seventh

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

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume?

100 to 126 grams (1.2-1.5 g/kg)

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 aware that insulin secretion increases 3 to 5 minutes after a meal and then returns to baseline. If a patient ate breakfast at 7:30 AM, the nurse would expect a baseline level by:

10:30am

What is the duration of regular insulin?

4 to 6 hours

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?

7 months

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

A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

9 units regular insulin and 21 units NPH

The following clients are scheduled for thyroid testing. Which client would be at greatest risk for inaccurate results?

A client who was given salicylates last month

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client?

Acetaminophen Ketoconazole Valproic acid

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

Albumin

Which symptom of thyroid disease is seen in older adults?

Atrial fibrillation

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA?

Begin fluid replacements

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

Below-normal serum potassium level

Insulin is secreted by which of the following types of cells?

Beta cells

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?

Carbohydrate digestion

The nurse practitioner worked with a registered dietitian 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?

Carbohydrates 50%, fat 25%. and protein 20%

Which term most precisely refers to the incision of the common bile duct for removal of stones?

Choledocholithotomy

Which of the following is considered a late symptom of hypothyroidism?

Cold intolerance

A nurse is teaching a client about hormones within the endocrine system. Which hormones would be included as the hypothalamic hormones?

Corticotropin-releasing hormone Thyrotropin-releasing hormone Gonadotropin- releasing hormone

The nurse is reviewing the laboratory and diagnostic test findings of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following would the nurse expect to find?

Decreased serum osmolarity

Which of the following would be considered a "free" item from the exchange list?

Diet soda

The nurse cares for a client with gallstones that need to be removed but is not a surgical candidate or endoscopic candidate. What procedure does the nurse recognize as being a possible treatment option for the client?

ESWL (extracorporeal shock wave therapy)

A nurse is caring for a client in the emergency department who is reporting severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value indicates further investigation?

Elevated troponin

A patient is suspected to have pancreatic carcinoma and is having diagnostic testing to determine insulin deficiency. What would the nurse determine is an indicator for insulin deficiency in this patient?

Hyperglycemia, Glycosuria, an abnormal glucose tolerance

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

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

Which factor presents the most likely cause for weight gain in a diabetic client who is controlled with insulin?

Insulin is an anabolic hormone

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

Insulin waning

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

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function

A group of students are reviewing the various types of drugs that are used to treat diabetes mellitus. The students demonstrate understanding of the material when they identify which of the following as an example of an alpha-glucosidase inhibitor?

Miglitol

A patient has been taking tricyclic antidepressants for many years for the treatment of depression. The patient has developed SIADH and has been admitted to the acute care facility. What should the nurse carefully monitor when caring for this patient?

Neurologic function Urine and blood chemistry Strict intake and output

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu?

Pancakes with butter and honey, and orange juice

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:

Phytonadione (Mephyton)

A nurse is caring for a client with suspected hyperparathyroidism. Which condition may contribute to hyperparathyroidism?

Renal failure

In actively bleeding patients with esophageal varices, the initial drug of therapy is usually:

Sandostatin

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

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?

Serum lipase

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

Short-acting

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

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?

Sweating, tremors, and tachycardia

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered?

Tacrolimus

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

Test your blood glucose every 4 hours

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

Ultrasonography

A client with type 1 diabetes mellitus is being taught about self-injection of insulin. Which fact about site rotation should the nurse include in the teaching?

Use all available injection sites within one area

Which factor is the focus of nutrition intervention for clients with type 2 diabetes?

Weight loss

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide?

Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered Encouraging bed rest to decrease the metabolic rate

Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice?

You should take your insulin after you eat breakfast and dinner

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

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

A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

rapid-acting insulin only

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity?

Albumin Diuretics

When thyroid hormone is administered for prolonged hypothyroidism for a patient, what should the nurse monitor for?

Angina

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?

Ask the physician to delay the discharge because the client requires further teaching

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 3am

Which of the following insulins are used for basal dosage?

Glargine (lantus)

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Hypoglycemia

A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching?

Insulin permits entry of glucose into the cells of the body Insulin promotes synthesis of proteins in various body tissues Insulin promotes the storage of fat in adipose tissue

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

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?

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

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing?

Measure abdominal girth daily Perform daily weights

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level?

Administration of calcitonin Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?

Albumin infusion

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

Deficient fluid volume related to osmotic diuresis

A characteristic of type 2 diabetes includes which of the following?

No islet cell antibodies

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis?

Normal bedtime blood glucose Increase in blood glucose from 3am until breakfast Decrease in blood sugar to a hypoglycemic level between 2 and 3am

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate?

Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Disturbed body image related to changes in appearance, sexual dysfunction, and role function

A patient is prescribed Sandostatin for the treatment of esophageal varices. The nurse knows that the purpose of this cyclic octapeptide is to reduce portal pressure by:

Selective vasodilation of the portal system

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

Most of the liver's metabolic functions are performed by:

parenchymal cells

Which factors will cause hypoglycemia in a client with diabetes?

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

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

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:

Inhibit the production of glucose by the liver

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

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates

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

Which statement is true regarding gestational diabetes?

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

A nurse understands that for the parathyroid hormone to exert its effect, what must be present?

Adequate vitamin D level

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

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

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

The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively?

50% to 60%

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 client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Administering 1 ampule of 50% dextrose solution, per physicians order

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

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?

Blood pH of 6.9

Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?

Blurred vision

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 IV 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?

Change the second IV solution to dextrose 5% in water

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Deficient knowledge (treatment regimen)

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 of the following is a characteristic of diabetic ketoacidosis (DKA)?

Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes

Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy?

Erectile dysfunction

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

Fruity breath

When the nurse inspects the feet of a diabetic, a tack is found 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

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

An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing?

Hyperglycemic hyperosmolar syndrome

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

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

Hypokalemia and hypoglycemia

client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it?

I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink,, or eat more than usual

A client with type 2 diabetes has recently been prescribed acarbose, and the nurse is explaining how to take this medication. The teaching is determined to be effective based on which statement by the client?

I will take this medication in the morning, with my first bite of breakfast

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

Increased urine output

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

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 patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient?

Ketosis-prone, little endogenous insulin, younger than 30 years of age

Which type of insulin acts most quickly?

Lispro

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to:

Low platelet count

The nurse suspects that a patient with diabetes has developed proliferative retinopathy. The nurse confirms this by the presence of which of the following diagnostic signs?

Neovascularization into the vitreous humor

A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?

Obtain a repeat fingerstick glucose level

Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus?

Patient's eating and sleeping habits

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?

Presence of autoantibodies against islet cells

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

Presence of islet cell antibodies

Which is the primary reason for encouraging injection site rotation in an insulin dependent diabetic?

Promote absorption

A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:

Providing client education at every opportunity

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

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

Rapid-acting

The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?

Reflects the amount of glucose stored in hemoglobin over past several months

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular

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 (HbA1C)

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

Sulfonylureas

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 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 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?

They increase the need for insulin

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

blood glucose level 1,100 mg/dl

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.

Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment

A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom?

Muscle wasting and tissue loss

When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day?

3am