Med Surg Ch 44 Coordinating Care for Patients with Diabetes Mellitus

An LPN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN to report immediately? 1. fingerstick glucose reading of 185 mg/dl 2. numbness and tingling in both feet 3. Profuse perspiration 4. bunion on the left great toe

Answer: 3 LaCharity Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/dl will need coverage with sliding scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems.

A nurse is reviewing orders for patients newly diagnosed with type 2 DM. What initial medication orders should be anticipated? A. Metformin PO twice a day B. Nutritional insulin subcutaneously prior to meals C. Basal insulin subcutaneously before bed D. Correctional insulin subcutaneously after meals

Answer: A Rationale: Metformin is a drug used to maintain glucose levels in type 2 DM. Insulin may be used later if glucose control cannot be maintained overtime. B, C, and D are orders for a patient with type 1 DM.

The nurse understands that type 1 DM is caused by which of the following conditions? (Select all that apply.) A. Gestational diabetes B. A history of mumps or rubella C. Family history of autoimmune disorders D. Autoimmune destruction of the beta cells of the pancreas E. Obesity

Answer: B and D Rationale: Type I DM is caused by an autoimmune process in which the insulin-producing beta cells of the pancreas are destroyed. Triggers are not fully understood, but a history of mumps or rubella are sometimes implicated.

The nurse understands management of diabetes will not be successful without which action? A. A priority focus on medications B. A focus on regular physician follow-up C. Patient commitment to self-management D. A priority focus on appropriate diet

Answer: C Rationale: All answers are essential for DM management, but the patient's commitment for self-management, is necessary to maintain the necessary measures for optimum DM management.

The nurse should intervene immediately if a patient has which blood glucose level? A. 200 mg/dL B. 152 mg/dL C. 80 mg/dL D. 40 mg/dL

Answer: D Rationale: As the brain can only use glucose for its metabolic functions, a glucose of 40 requires immediate treatment to avoid potential irreversible CNS dysfunction.

What is measured by the HbgA1c test? A. Amount of glucagon stored in the liver B. Specific insulin levels in blood plasma C. Levels of hemoglobin after physical activity D. Average blood glucose concentration over time

Answer: D Rationale: HbgA1c is the average blood glucose concentration over time.

The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bat water is not too hot. 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe

Answer: 1 LaCharity Checking the bath water temperature is part of assisting with ADLs and is within the education and scope of practice of the UAP. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses.

A patient has newly- diagnosed type 2 diabetes. Which task should you delegate to the UAP? 1. Arranging a consult with the dietitian. 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Reminding the patient to check glucose level before each meal

Answer: 4 LaCharity The UAP's role includes reminding patients about interventions that are already part of the plan of care. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses.

The nurse understands is released from the cells of the pancreas when the patient is hypoglycemic. A. glucagon, B. insulin, C. glucagon, D. insulin

Answer: A

The nurse correlates which laboratory value with the diagnosis of DM? A. Fasting blood glucose greater than 140 mg/dL B. Hemoglobin A1c, 5.8% C. Random blood glucose, 150 mg/dL D. OGTT, 155 mg/dL

Answer: A Rationale: A fasting blood glucose greater than 140 mg/dL indicates DM. The other values are indicative of prediabetes.

The nurse prioritizes which nursing diagnosis in the plan of care for the patient with type 2 DM? A. Risk for infection B. Risk for falls C. Risk for impaired gas exchange D. Risk for injury: hyperkalemia

Answer: A Rationale: Infection is a great risk due to poor periph- eral perfusion and diabetic peripheral neuropathy which decreases sensation which may lead to undetected injury and infection.

The charge nurse is reviewing orders for a newly admitted patient with type 1 DM. It is a priority for the charge nurse to follow up with the provider about which order? A. NovoLog insulin subcutaneous at bedtime B. NovoLog insulin subcutaneous 15 minutes prior to meals C. Basal insulin subcutaneous at bedtime D. Correctional and nutritional insulin administered immediately after the meal

Answer: A Rationale: NovoLog is a fast acting insulin reserved for correctional or prandial insulin—administration at bedtime without adequate nutritional intake may result in hypoglycemia.

Which statement by diabetic patient about her home medication regimen indicates the need for further teaching? A. "My kidney problem will not affect my metformin prescription." B. "I may need to change from my metformin/ glyburide drug therapy because of the problem with my kidneys." C. "I will need to be especially careful about low blood glucose." D. "I need to be diligent with my self-blood glucose monitoring."

Answer: A Rationale: Renal disease may lead to lactic acidosis if taking metformin, so should be monitored.

What is the most likely cause of the Somogyi effect? A. Basal insulin injections before bed without a small snack B. Naturally occurring release of hormones during the night C. Increased consumption of complex carbohydrates throughout the day D. Glucagon administration before breakfast

Answer: A Rationale: The increased blood glucose levels of the dawn phenomenon result from the naturally occur- ring release of hormones such as glucagon, cortisol, and growth hormone in the early morning. Because the body does not have sufficient insulin to control this glucose surge, blood glucose levels rise. This is most likely reflected in higher fasting blood glucose levels in the morning. The Somogyi effect results in increased blood glucose levels due to an excessive insulin dosage at night. This can occur in a patient who injects basal insulin before bed without also having a small bedtime snack. In that circumstance, blood glucose levels drop and the body responds in the same way as in the dawn phenomenon, releasing growth hormone, cortisol, and catecholamines in an effort to increase blood glucose by releasing glucose stores from the liver.

The nurse recognizes which of the following statements as correct in relation to the pathophysiology of type 2 DM? (Select all that apply.) A. It is due to a relative lack of insulin. B. It is due to insulin resistance. C. It is due to an absolute lack of insulin. D. It remains stable over time. E. It is due to an autoimmune process that destroys the beta cells of the pancreas.

Answer: A and B Rationale: Type 2 is a relative lack of insulin or due to insulin resistance. Type 1 is an absolute lack of insulin due to an autoimmune process that destroys the beta cells of the pancreas. Neither are stable over time.

The nurse monitors for which clinical manifestations in the patient newly diagnosed with type 1 DM? (Select all that apply.) A. Polyuria B. Fatigue C. Weight loss D. Polyphagia E Decreased appetite

Answer: A, B, C, and D Rationale: Fatigue, polyuria, weight loss, and polypha- gia are all clinical manifestations. Glucose is typically totally reabsorbed in the renal tubules. Hyperglycemia results in glucose excretion in the urine, which creates an osmotic effect that effectively reduces water reab- sorption into the renal tubules, leading to excessive volume loss through the kidneys. Hyperglycemia also causes hyperosmolarity in the blood, which causes a shift of fluid from the intracellular space to the vascu- lar space. The loss of intracellular water combined with the volume loss through the kidneys creates excessive thirst in the patient, or polydipsia. The lack of insulin necessary to move glucose into the cells leads to the breakdown of proteins and fat as a source of energy. This starvation of the cells leads to polyphagia, increased appetite. Despite an increased appetite lead- ing to consumption of large amounts of food, the continual breakdown of fats and proteins leads to weight loss and fatigue.

The nurse recognizes that blood glucose monitoring before meals and at bedtime is done to achieve which outcome? (Select all that apply.) A. Maintain glycemic control. B. Prevent complications of long-term hyperglycemia. C. Facilitate insulin administration that mimics the healthy pancreas. D. Provide frequent practice with the finger stick technique. E. Prevent acute complications of type 1 diabetes.

Answer: A, B, and C Rationale: Blood glucose monitoring before meals and at bedtime facilitates insulin administration that mim- ics the healthy pancreas which helps maintain glycemic control and prevents complications of long-term hyper- glycemia. The goal is not frequent practice. Acute com- plications can occur independent of glucose monitoring such as infection or stress which increase glucose needs.

The nurse correlates which laboratory values as a diagnostic for DKA? (Select all that apply.) A. Serum bicarbonate of 15 mEq/L B. Negative anion gap C. Serum glucose of 350 mg/dL D. Positive anion gap E. Arterial pH of 7.36

Answer: A, C, and D Rationale: In diabetes ketoacidosis, there is inadequate insulin for cells to obtain adequate glucose for normal metabolism. The body attempts to obtain energy by the rapid breakdown of fat stores, releasing fatty acids from adipose tissues. The liver converts the fatty acids into ketone bodies, which can serve as an energy source in the absence of glucose. The ketone bodies, however, have a low pH, resulting in a metabolic acidosis, a low serum bicarbonate, and a positive anion gap. The absence of insulin also results in an increased release of hormones such as glucagon and cortisol in response to inadequate glucose transport into the cells. This leads to gluconeogenesis and glycogenolysis, resulting in severe hyperglycemia.

The nurse understands HHS (Hyperosmolar hyperglycemic state) differs from DKA in which of the following ways? (Select all that apply.) A. HHS has a more gradual onset. B. DKA presents with higher serum glucose. C. Potassium depletion is a potential complication with HHS. D. A positive anion gap is not diagnostic for HHS. E. Ketosis is typically not present in HHS.

Answer: A, D, and E Rationale: DKA does not present with a higher glucose. Potassium depletion, a positive anion gap, and ketosis is associated with DKA.

The nurse is screening patients for the risk of developing type 2 DM. The nurse should consider which patients at risk? (Select all that apply.) A. Women with a history of gestational diabetes B. Women with a history of multiple births C. Men with a history of pancreatic cancer D. Men who are overweight or obese E. Men and women with cardiovascular disease

Answer: A, D, and E Rationale: Multiple births or a history of pancreatic cancer do not increase the risk of type 2 DM. Pancre- atic cancer may result in surgically induced type 1 DM.

The nurse documents glucose in the urine as which finding? A. Polyuria B. Glucosuria C. Hyperglycemia D. Hyperosmolarity

Answer: B Rationale: Glucosuria is glucose in the urine. Polyuria is excessive urine output. Hyperglycemia is high serum glucose and hyperosmolarity is increased body fluid osmolality or concentration.

The nurse is providing care for a patient newly diagnosed with type 1 diabetes. Which lifestyle modifications need to be included into the plan of care? A. Limit exercise, carbohydrate counting, self- monitoring of blood glucose B. Distribute carbohydrate intake throughout the day, control weight, limit alcohol C. Carbohydrate counting, self-monitoring of blood glucose, physician visits as needed D. Limit protein intake, distribute carbohydrate intake throughout the day, regular physician visits

Answer: B Rationale: Recommendations for the control of type 2 DM include aerobic training and resistance training, controlling weight which is associated with insulin re- sistance, distributing carbohydrates throughout the day in small meals and snacks, self-blood glucose monitor- ing, limiting alcohol as it contains carbohydrates, and regular physician visits.

Which are considered clinical manifestations of type 2 diabetes? (Select all that apply.) A. Decreased appetite B. Poor wound healing C. Fatigue D. Hyperactivity E. Visual disturbances

Answer: B, C, and E Rationale: Decreased appetite and hyperactivity are not associated with type 2 DM. Poor wound healing is due to decreased peripheral circulation. Visual disturbances are due to microvascular effects of DM and fatigue is due to the breakdown of fats and proteins for energy needs.

In a diabetic patient, numbness, tingling, and pain in the hands and feet are all symptoms of which complication? A. Autonomic neuropathy B. Hyperosmolar hyperglycemic syndrome C. Diabetic peripheral neuropathy D. Diabetic ketoacidosis

Answer: C Rationale: Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Autonomic neuropathy results when there is dam- age to the nerves of the autonomic nervous system. In DKA the initial patient presentation is one of polyuria, polydipsia, and polyphagia. The patient becomes dehydrated, and electrolyte imbalance such as hyperkalemia or hypokalemia may result (see Safety Alert). The increased serum osmolarity also results in a shift of fluid from the intracellular to the extracellular space, causing a dilutional hypona- tremia. The patient is also at risk for hypovolemia secondary to the osmotic diuresis. Hyperosmolar hyperglycemic syndrome is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis.

Which statement by Mrs. Simpson, who was has diabetes and a recent ripple cardiac bypass, indicates that teaching has been effective? A. "I don't have to worry about my blood pressure now that I've had heart surgery." B. "My diabetes is separate from my heart problems." C. "My blood glucose may go up if I get another infection." D. "I can take two of my glucose pills to make up for a missed dose as long as I check my blood glucose."

Answer: C Rationale: Infection or stress may lead to increases in blood glucose. Heart surgery does not cure hypertension. DM is associated with heart disease. Patients should not take two pills together to make up for a missed dose.

The nurse is caring for a patient who just finished breakfast. The nurse understands is released from the cells of the pancreas to maintain the blood sugar within normal range. A. glucagon, B. insulin, C. glucagon, D. insulin

Answer: D

The nurse recognizes the action of insulin is to: A. Transport glucose to the cell B. Metabolize glucose within the cell C. Transport glucose to the liver for storage D. Transport glucose across the cell membrane

Answer: D

The nurse includes which information in the teaching plan for Mrs. Simpson with diagnosis of diabetes? A. Insulin administration B. Once-a-day blood glucose monitoring C. Carbohydrate counting D. Monitoring for infection

Answer: D Rationale: Infection may increase Mrs. Simpson's insulin needs. She should not go home on insulin and should monitor her glucose levels more than once/day. Carbohydrate counting is more typically done with type I DM.

The nurse is assigned to care for 3 patients on a general medical unit. Patient A - known alcoholic with a finger stick of 60 Patient B - diabetic patient complaining of 6/10 abdominal pain, nausea, and vomiting Patient C - an elderly patient with type 2 diabetes Which patient should the nurse see first?

Answer: Patient C Rationale: Hypoglycemia is more severe when the early signs of low blood sugar are blunted, as in the elderly or those who have a change in mental status.

The nurse has received report on three patients: John Johnson is a 37-year-old male brought into the ED by police because of disorderly contact and public intoxication. He is a history of type 2 diabetes. Vitals are: T- 98.4, R- 20, P- 65, Spo2- 97%, BP- 120/60, BS- 60 Steve Smith is a 75-year-old male brought to the ED by his family presenting with confusion. He has a history of type 2 diabetes. Vital signs are: Temp 98.8 Pulse 102 Resp 22 SpO2 95% BP 110//55 BS unknown Helen Wilson is a 24-year-old female with a history of type 1 diabetes. She presents to the ED complaining of 7/10 abdominal pain, nausea, and vomiting. Vital signs are: Temp 99.8 Pulse 110 Resp 24 SpO2 95% BP 130/65 BS 130 Pain rating 7/10 The nurse should see what patient first, second and third?

Answer: See Mr. Smith first, Mr. Johnson second, and Helen Wilson third. Rationale: See Mr. Smith first—Hypoglycemia is more severe when the early signs of low blood sugar are blunted, as in the elderly or those who have a change in mental status. The nurse should see Mr. Johnson second because alcohol depresses the release of glucose from the liver and rapid treatment of hypoglycemia may be necessary to avoid serious neurological seque- lae. The nurse should see Helen Wilson third—she is presenting with serious but common issues with r/t diabetes - gastroparesis