EXAM 2: CHAPTER 50 DIABETES MELLITUS & THE METABOLIC SYNDROME

A client hospitalized with type 1 diabetes has been administered a scheduled dose of regular insulin. Which are the primary actions of insulin? Select all that apply.

-Fat storage -Glucose uptake by muscle and adipose tissue -Protein synthesis There are three actions of insulin: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

The nurse is reviewing assessment data on four clients. Select the client at highest risk for developing type 2 diabetes.

A 45-year-old obese female with a sedentary lifestyle The person most at risk for developing type 2 diabetes is the 45-year-old obese female with a sedentary lifestyle. Other risk factors include family history, over age 40, and history of gestational diabetes. The 60-year-old would have developed it before age 60, if there were additional risk factors.

A nurse is evaluating patients for the risk of developing type 2 diabetes. Which of the following patients has the highest risk?

A 45-year-old obese woman with a sedentary lifestyle The person most at risk for developing type 2 diabetes is the 45-year-old obese woman with a sedentary lifestyle. Other risk factors include family history, age older than 40, and history of gestational diabetes. The 10-year-old boy, despite family history, would be at low risk as long as obesity and sedentary lifestyle are avoided. The 60-year-old woman most likely would have developed type 2 diabetes within 20 years after the pregnancy.

Which of the following clients would be considered to be exhibiting manifestations of "prediabetes"?

A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.

The pancreas is an endocrine organ that is composed of the acini and the islets of Langerhans. The islets of Langerhans have alpha, beta, and delta cells as well as the PP cell. Which cells secrete insulin?

Beta cells Each islet is composed of beta cells that secrete insulin and amylin, alpha cells that secrete glucagon, and delta cells that secrete somatostatin. In addition, at least one other type of cell, the PP cell, is present in small numbers in the islets and secrets a hormone of uncertain function called pancreatic polypeptide.

The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. Which of these effects on blood glucose levels does the nurse teach the student epinephrine will cause?

Blood glucose will elevate. Epinephrine, a catecholamine, helps to maintain blood glucose levels during periods of stress. Epinephrine causes glycogenolysis in the liver, thus causing large quantities of glucose to be released into the blood.

When caring for the client with diabetic ketoacidosis, the nurse recognizes that fatty acids and ketones may be used for energy by most organs. Which of these organs does the nurse recognize is reliant on glucose as the major energy source?

Brain Although many tissues and organ systems are able to use other forms of fuel, such as fatty acids and ketones, the brain and nervous system rely almost exclusively on glucose as a fuel source. Because the brain can neither synthesize nor store more than a few minutes' supply of glucose, normal cerebral function requires a continuous supply from the circulation.

A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increase risks associated with exercise, the health care provider should encourage the client to:

Carry a snack with carbs to prevent profound hypoglycemia People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia. Respiratory disorders are associated with preexisting pulmonary or vascular problems exacerbated by the period of exercise.

Which of the following criteria about insulin would prompt a diagnosis of type 1 diabetes?

Complete failure of insulin secretion In type 1 diabetes there is an absolute lack of insulin due to complete failure of the pancreas. In type 2 diabetes some insulin is produced but may not be properly used.

A patient with type 2 diabetes experiences unexplained elevations of fasting blood glucose in the early morning hours. Which of the following conditions can account for this effect?

Dawn phenomenon The dawn phenomenon involves increased levels of fasting blood glucose or insulin requirement between the hours of 5 and 9 in the morning. It is not preceded by hypoglycemia. Circadian release of growth hormone and cortisol may be contributing factors. The other answer selections are not characterized by increased early morning levels of blood glucose.

A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes. The best diagnostic indicator that would support the client's response would be:

Glycosylated hemoglobin, hemoglobin A1C (HbA1C) Glycosylated hemoglobin, hemoglobin A1C (HbA1C), and A1C are terms used to describe hemoglobin into which glucose has been incorporated. Glycosylation is essentially irreversible, and the level of A1C present in the blood provides an index of blood glucose levels over the previous 6 to 12 weeks. In uncontrolled diabetes or diabetes with hyperglycemia, there is an increase in the level of A1C. The other options would not reflect the 2-month period.

A man is brought into the emergency department by paramedics who state that the client passed out on the street. The man smells of alcohol, and when roused says he has not eaten since yesterday. He is wearing a medic alert bracelet that says he is a diabetic. What would the nurse suspect as a diagnosis?

Hypoglycemia Alcohol decreases liver gluconeogenesis, and people with diabetes need to be cautioned about its potential for causing hypoglycemia, especially if alcohol is consumed in large amounts or on an empty stomach.

While trying to explain the physiology behind type 2 diabetes to a group of nursing students, the instructor will mention which of the following accurate information?

In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Following meals (postprandial), glucose levels are higher due to diminished efficiency of glucose clearance. The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Although muscle glucose uptake is slightly increased after a meal, the efficiency with which it is taken up is decreased, resulting in an increase in blood glucose levels following a meal. The other distractors relate to type 1 diabetes.

Which interventions are important for the nurse to teach a client diagnosed with distal symmetric neuropathy caused by diabetes? Select all that apply.

Inspect the feet daily for blisters. Wear well-fitted shoes. A patient with neuropathy is at risk for damage to their feet, such as blisters or ulcers, as they are unable to detect injuries. Patients need to inspect their feet daily, wear foot coverings (such as well-fitted closed-toe shoes) to prevent injuries, and continue exercise to improve circulation and glucose use. Insulin injection sites must be rotated for each administration.

The diagnosis of type 1 diabetes would be confirmed by:

Insulin is not available for use by the body. Type 1 diabetes is a catabolic disorder characterized by an absolute lack of insulin. In type 2 diabetes, some insulin is produced.

The metabolic abnormalities that lead to type 2 diabetes include which of the following?

Insulin resistance The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. Obese people have increased resistance to the action of insulin and impaired suppression of glucose production by the liver, resulting in both hyperglycemia and hyperinsulinemia. Lifestyle and overeating seem to be the triggering events (rather than metabolic abnormalities). Acute pancreatitis is a reversible impairment of alpha and beta cell function, with hypoinsulinemia as a complication.

A client with diabetes mellitus takes insulin, but still has unstable blood glucose levels. When the primary healthcare provider prescribes pramlintide (Symlin) the client asks the nurse how this second medication will help. What is an appropriate response by the nurse?

It slows gastric emptying and decreases appetite. Amylin is a hormone secreted by the pancreatic beta cells that works with insulin to lower blood glucose. Pramlintide is a synthetic amylin that acts to suppress glucagon release, slow gastric emptying, and decrease appetite.

The nurse has just completed teaching a client newly diagnosed with type 1 diabetes about rapid-acting insulin. The nurse determines that teaching was effective when the client selects:

Lispro There are four principal types of insulin: short acting, rapid acting, intermediate acting, and long acting. Regular insulin is short-acting insulin whose effects begin within 30 minutes after subcutaneous injection and generally last for 5 to 8 hours. The rapid-acting insulins (lispro, aspart, and glulisine) have a more rapid onset, peak, and duration of action than short-acting regular insulin and are administered immediately before a meal. Intermediate- to long-acting insulins include NPH, glargine, and detemir. These insulins have slower onsets and a longer duration of action.

A client with diabetic retinopathy develops a retinal bleed and asks the nurse, "How can I prevent this from happening again?" What response provides the most effective information?

Maintain healthy blood pressure and blood sugar levels. Diabetic retinopathy occurs when blood vessels have increased permeability, develop microaneurysms, vascular proliferation, scarring, and retinal detachment. These conditions are worsened when the client has poor glycemic control, poorly controlled hypertension, and hyperlipidemia. Laser photocoagulation can be used to stop vessel proliferation and bleeding. An annual examination will evaluate the disease, but does not prevent recurrence. Eye use patterns do not change retinopathy.

A client with severe hypoglycemia is unconscious. Which method of providing glucose should be avoided?

Orange juice orally When clients are unconscious it is not safe to attempt to have them swallow liquids. Alternate routes that reduce the risk of choking such as buccal absorption, intramuscular or intravenous injections are preferred.

A hospital client with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin?

Promotion of glucose uptake by target cells The actions of insulin are threefold: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

A client is managing his diabetes with exercise and diet. The health care provider reviews the client's most recent lab results: fasting blood sugar level at 80 mg/dL and a hemoglobin A1C of 5%. Select the response that best identifies the client.

The client is achieving normal glycemic control. The reading for the fasting blood sugar is appropriate, and the hemoglobin A1C level estimates good control of glucose levels over a 6- to 12-week period. This client should continue his exercise and diet routine as planned.

The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which of these risk factors in the teaching?

Woman with a family history of diabetes Gestational diabetes occurs most commonly in African American, Hispanic/Latino American and Native American women. It most frequently affects women with a family history of diabetes, a history of stillbirth or spontaneous abortion, women who previously gave birth newborn with fetal anomaly or had a previous large- or heavy-for-date infant, those who are obese, those of advanced maternal age, or those who have had five or more pregnancies.