Med surg chapter 37

5. The nurse counsels the 30-year-old woman with type 2 diabetes who is overweight and noncompliant that control of diabetes would most improve if she were to: a. lose weight. b. take more Glucophage. c. eat a high-protein diet. d. take insulin.

ANS: A Type 2 diabetes is prevalent in the obese. Of the known cases, 80% of them are overweight. Loss of weight decreases hyperglycemia.

11. The nurse would anticipate laboratory values from a patient in ketoacidosis to reveal: a. increased blood urea nitrogen (BUN). b. normal or decreased CO2. c. increased arterial pH. d. decreased glucose.

ANS: A Diabetic ketoacidosis results when the body attempts to metabolize protein and fats, which results in high BUN readings. The CO2 should be normal or low depending on the effectiveness of Kussmauls respirations. The arterial pH will be low, and there will be high glucose, which the diabetic patient cannot use.

28. The nurse is caring for a patient suspected of having ketoacidosis. What early manifestation(s) may be noted with this condition? (Select all that apply.) a. Fruity breath b. Polyuria c. Nausea d. Thirst e. Sunken eyes

ANS: A, B, D Ketoacidosis is a complication associated with type 1 diabetes. Some of the earliest symptoms may be polyuria, fatigue, anorexia, abdominal pain, and a fruity smell to the breath. Later signs and symptoms will include sunken eyes as a result of excessive dehydration. Nausea is not associated with ketoacidosis.

18. The nurse is discussing insulin administration with an assigned patient. The patient reports that she prefers to use only certain sites for insulin injections. The patient questions why rotation of the sites is important. What response by the nurse is most appropriate? a. Rotating your injection sites will help to reduce your risk of infection. b. If you do not rotate injection sites you are at risk for an erratic absorption of your medication. c. Unsightly fatty tumors can develop when you do not adequately rotate injection sites. d. Failing to rotate injection sites will improve your ability prevent an insulin reaction.

. ANS: B Insulin injections are rotated within one body area to enhance absorption. Patients are given charts showing the places on the arms, legs, buttocks, and abdomen where insulin can be injected. Patients should be encouraged to keep a daily record of injection sites to help remember which sites have been used and to avoid the problem of altered or erratic absorption, which is a complication associated with overuse of a single site. The most important way to reduce the incidence of infection is to wash the hands before insulin administration and to avoid reusing syringes. Fatty tumors are not complications of overuse of a single injection site. The term insulin reaction refers to hypoglycemia. Hypoglycemia is not directly associated with the failure to rotate injection sites.

The nurse associates the type of diabetes with the characteristics that may be seen with the specific disease. Match the type of diabetes with the symptoms that are associated with it. (The options may be used once, more than once, or not at all.) a.Type 1 b.Type 2 c.Gestational d. Prediabetes 31. Weight loss and exercise can delay onset of diabetes 32. Occurs during pregnancy 33. Adult onset 34. Little or no endogenous insulin 35. Threat of renal, retinal, and neurologic complications 36. Rarely develops ketosis

31. ANS: D 32. ANS: C 33. ANS: B 34. ANS: A 35. ANS: A 36. ANS: B

30. The nurse explains that the three cardinal signs of type 1 diabetes mellitus are __________, __________, and __________.

ANS: polydipsia, polyphagia, polyuria The three Ps polydipsia, polyphagia, and polyuria are the cardinal signs of diabetes

6. The patient inquires about the significance of islet cell antibodies. The nurses most informative response is that islet cell antibodies: a. will cause beta cells to quit producing insulin, resulting in diabetes mellitus (DM). b. protect beta cells from viral attack. c. increase production of insulin from beta cells. d. decrease the size of the pancreas.

ANS: A

20. The nurse is caring for a patient who is experiencing problems with maintaining glycemic control at night and during the early morning hours. The nurse correctly recognizes that: a. hyperglycemia is produced from counterregulatory hormones. b. hyperglycemia of dawn phenomenon does not react to insulin. c. hypoglycemia quickly follows the dawn phenomenon. d. hyperglycemia of dawn phenomenon is not changed by food intake.

ANS: A Dawn phenomenon is produced in the morning by the circadian release of growth hormones, epinephrine, and glucagon during the night.

14. The nurse notes that the HbA1c level of an assigned patient demonstrated a drop from 9.4% to 5.4%. What inference can best be made about this patient? a. The patient is demonstrating improved control of hyperglycemia over the last several months. b. The patient has been less compliant with the prescribed treatment regimen. c. The patient is experiencing a reduction in insulin sensitivity. d. The patient has less need for insulin.

ANS: A HbA1c is a diagnostic assessment used to review blood glucose levels retrospectively. A reduction in the value indicates improved glucose control by the patient. There is no evidence of insulin sensitivity. The need for insulin is not decreased in this patient.

22. The nurse is reviewing the patients prescribed insulin regimen. The nurse notes that the physician has ordered a long-lasting insulin. Which medication will best meet this criteria? a. Lantus b. NovoLog c. Humalog d. Regular

ANS: A Lantus is a long-lasting insulin. It may be administered only one time per day. NovoLog and Humalog are both rapid-onset insulin preparations. Regular insulin is classified as a short-acting insulin.

19. A long-term diabetic patient reports that the physician has told him he has the early symptoms of cardiovascular disease. The nurse correctly understands that diabetes predisposes the patient to cardiovascular complications for which reason? a. The periods of hyperglycemia that result in diabetes damage the basement membrane causing atherosclerosis. b. Hypoglycemic periods result in increased release of cortisol resulting in hypertension. c. Insulin constricts the cardiovascular vessels. d. Diabetes causes a decrease in the bodys ability to digest fats by the pancreas.

ANS: A Periods of hyperglycemia cause thickening of the vessels, chiefly the basement membrane (thin layer of connective tissue under the epithelium). The vessels of the retina, renal glomeruli, peripheral nerves, muscles, and skin are affected. Larger vessels also are affected, predisposing the patient to atherosclerosis and vascular occlusion. Two out of three people with diabetes die prematurely from heart attack or stroke

7. The nurse reinforces the American Diabetes Associations recommendation that all people over age 45, especially if overweight, monitor themselves for diabetes by: a.having regularly scheduled fasting blood glucose level testing. b.adhering to weight reduction diets. c.exercising regularly. d.using stress reduction techniques.

ANS: A The ADA recommends screening with a fasting blood glucose. The other options are helpful with controlling diabetes but do not monitor for diabetes.

16. The diet of the diabetic is geared toward adequate nutrition and: a. control of weight. b. exclusion of all sweets. c. increase in fats for energy. d. avoidance of all fast foods.

ANS: A The much less stringent diet of the diabetic is focused on adequate nutrition and weight and cholesterol control. The newer diets allow for some sweets and some fast foods. Fats are not adequate sources of energy. Fat intake should be limited to reduce complications related to weight gain and cardiovascular concerns

25. The nurse is aware that the weight loss experienced by type 1 diabetics is attributed to: (Select all that apply.) a. loss of body fluid. b. insulin intolerance. c. metabolization of body fats. d. stress of disease. e. altered diet.

ANS: A, C Weight loss in type 1 diabetics can be attributed to loss of body fluids and metabolization of fats.

27. When discussing exercise programs with the diabetic, the nurse should stress that the patient should: (Select all that apply.) a. delay the exercise program until glucose is under control. b. check glucose after exercise. c. have a quick source of glucose available while exercising. d. begin slowly and build up to 30 to 45 minutes. e. use abdomen only for injection site for insulin.

ANS: A, C, D, E All options should be observed by the diabetic who exercises except the patient should check the glucose level before exercise rather than after

23. The nurse explains that genetic factor(s) that increase(s) the risk of a person developing diabetes mellitus include: (Select all that apply.) a. the number of relatives who have diabetes mellitus. b. whether the relatives are related on the maternal side. c. whether the relatives are male. d. the genetic closeness of the relatives. e. severity of the relatives disease.

ANS: A, D, E Neither the gender nor the family side of the relationship is significant.

12. The patient comes to the emergency room with dry hot skin, fruity breath, and deep respirations and is complaining of abdominal pain. The nurse interprets these signs and symptoms as: a. an insulin reaction. b. ketoacidosis. c. rebound hyperglycemia. d. hypoglycemia.

ANS: B All the signs and symptoms mentioned are characteristics of ketoacidosis. An insulin reaction may be referred to as hypoglycemia. The symptoms of hypoglycemia: tremulousness, hunger, headache, pallor, sweating, palpitations, blurred vision, and weakness. Rebound hyperglycemia, also known as the Somogyi effect, follows a period of hypoglycemia, often during sleep. When hypoglycemia occurs, the body secretes glucagon, epinephrine, growth hormone, and cortisol to counteract the effects of low blood sugar. The patient may report nightmares and night sweats along with morning elevated serum glucose; if the patient increases the insulin dose, it worsens the problem.

13. The nurse is aware that diabetics are prone to infection, which can be attributed to: a. high glucose levels. b. atherosclerotic vascular changes. c. deficient protein reserve. d. inadequacy of blood cell production.

ANS: B People with diabetes are prone to infection, delayed healing, and vascular diseases. Poor control of diabetes makes the person prone to develop an infection. The propensity for infection is thought to be partly a result of decreased normal function of leukocytes and abnormal phagocyte function. Another contributing factor to infection and delayed healing probably is decreased blood supply to the tissues because of atherosclerotic changes in the blood vessels. An impaired blood supply means a deficit in the protective cells brought by the blood to a site of injury.

9. The nurse is caring for a patient who was hospitalized with ketosis. The nurse recognizes that the patient correctly understands the phenomenon when she reports what about the condition? a. I had taken too much insulin to decrease my bodys levels of glucose. b. The condition resulted when my body tried to break down and use my stores of fats. c. When my blood glucose goes over 150 mg/dL, I am at risk for this condition. d. I was exercising too much and had too sharp reductions in my blood glucose level.

ANS: B Persons with type 1 diabetes are more prone to a serious complication, ketosis, associated with an excess production of ketone bodies, leading to ketoacidosis (metabolic acidosis). When the glucose level gets too high the body attempts to metabolize fats for energy, and the result is a buildup of ketone bodies.

8. A patient recently diagnosed with type 1 diabetes mellitus questions the nurse about her increased thirst level. What should be included in the response by the nurse? a. Diabetes results in a lack of protein absorption causing reduced amino acids, resulting in thirst. b. Elevated levels of blood glucose pull cellular water into circulating volume. c. Thirst results from the bodys increased loss of fluids through polyuria. d. Appetites of both food and water signal the changes of diabetes.

ANS: B Polydipsia is stimulated by cellular dehydration from the hyperglycemia pulling intracellular fluid into the circulating volume.

4. A patient asks the nurse if stress can be a potential cause of type 2 diabetes. What should be included in the response provided by the nurse? a. Stress decreases the number of alpha cells in the pancreas, thus increasing the workload on the beta cells. b. Periods of stress cause increases in glycogen production by the adrenal cortex. c. Stress is directly associated with decreased insulin tolerance. d. The inhibition of beta cells to glucose is increased in periods of stress.

ANS: B Stress stimulates the adrenal cortex to release glucocorticoids, which can cause hyperglycemia.

26. The nurse outlines the criteria for tight control of hyperglycemia as: (Select all that apply.) a. glucose testing two times a day. b. insulin injections three times a day based on glucometer readings. c. fasting glucose remaining within normal limits. d. maintaining normal weight for height and age. e. maintaining cholesterol within normal limits.

ANS: B, C, D, E Patients attempting tight control follow an intensive therapy plan of blood glucose testing and insulin injections, three or more times a day, or they use an insulin pump. The protocol for control of diabetes mellitus is highly individualized and depends on the type of diabetes a person has, age, general state of health, ability to follow the prescribed regimen, and acceptance of responsibility for managing the illness, along with a host of other factors.

24. The nurse is aware that among the microbiologic factor(s) that may cause diabetes mellitus are: (Select all that apply.) a. hepatitis B. b. coxsackievirus. c. influenza virus. d. chickenpox. e. mumps.

ANS: B, C, E Coxsackievirus, mumps, and influenza are suspected to be the virus-related causes of diabetes mellitus.

17. The patient takes his NovoLog 70-30 at 7:00 AM. The nurse suggests the best time to schedule exercise would be at: a. 7:30 AM before peak action of insulin. b. 10:00 AM at peak action of insulin. c. 1:00 PM after peak action of insulin. d. any time after injection.

ANS: C Exercise should occur after peak action time to prevent hypoglycemia. NovoLog is a rapid-acting insulin that peaks 1 to 3 hours after administration

10. At 2:00 AM, the CNA reports that a patient with type 1 diabetes is extremely wet with perspiration, is cool to the touch, and is complaining of hunger. The nurse should: a. give insulin by sliding scale based on glucometer reading. b. notify the night supervisor of the patients deteriorating condition. c. give 6 ounces of orange juice. d. ambulate the patient in the hall to use up excess glucose with exercise.

ANS: C Hypoglycemia is a common complication of type 1 diabetes mellitus. Most often it is a response to either too large a dose of insulin or too much exercise in relation to the amount of food eaten. Symptoms of hypoglycemia include tremulousness, hunger, headache, pallor, sweating, palpitations, blurred vision, and weakness. Management includes providing a source of quick-acting carbohydrate/glucose. Insulin is used to manage hyperglycemia, not hypoglycemia. The patients condition is likely easily managed by the interventions noted and will not warrant notification of the supervisor. The patient will not benefit from exercise as he has limited serum glucose.

15. The nurse cautions that the technique of tight control of hyperglycemia is not recommended for the older adult because the older adult: a. may not be able to test and administer sliding-scale insulin. b. is at a lower risk for hyperglycemia. c. is prone to cardiovascular problems resultant from hypoglycemia. d. has an unstable metabolic rate.

ANS: C Hypoglycemia is a complication of the tight control method of controlling hyperglycemia. Older adults experience hypoglycemia more quickly than do younger people, and the elderly are more prone to hypoglycemic episodes. The older adult may progress to dangerously low levels of blood glucose before signs and symptoms are obvious. Severe hypoglycemia in the older adult can precipitate myocardial infarction, angina, stroke, or seizures. For this reason, tight control may not be the best thing for the older adult.

3. The nurse recognizes a need for further information when a young woman with gestational diabetes says: a. Gestational diabetes results from the hormonal changes of pregnancy. b. I will need to exercise regularly and lose weight to reduce my risk of becoming a diabetic. c. Ill be free of diabetes when this baby is born. d. The baby will have to be monitored for hypoglycemia during my pregnancy.

ANS: C Of the women who have gestational diabetes, 5% to 10% go on to develop type 2 diabetes.

29. The nurse is observing a patient administer insulin. Which observation indicates the need for further instruction? (Select all that apply.) a. The patient uses a 90-degree angle to administer the injection. b. The patient cleans the injection site with alcohol before the injection. c. The patient rubs the injection site after administration of the insulin injection. d. The patient draws up the cloudy insulin and then the clear insulin. e. The patient shakes the insulin bottle before administration.

ANS: C, D, E When administering insulin the site is cleaned with alcohol before the injection but not after. Rubbing will alter the rate of absorption. When mixing two types of insulin the clear should be drawn into the syringe first. This prevents contamination of the second vial. Shaking the bottle can damage the solution. The bottle should be gently rolled between the palms of the hands.

21. A patient with type 1 diabetes mellitus is preparing for a moderate 30-minute exercise period. Which action best indicates understanding of condition management? a. The patient reduces insulin use during days when exercise periods are planned. b. The patient administers insulin after exercise rather than before exercise. c. The patient eats a high-carbohydrate snack before the exercise period. d. The patient consumes a simple carbohydrate snack after 30 minutes of activity.

ANS: D During moderate exercise (such as brisk walking, bowling, or vacuuming), 5 g of simple carbohydrate should be consumed at the end of 30 minutes and at 30-minute intervals during the continued activity. (A food example with 5 g of simple carbohydrate is 1 tsp honey.)

1. The nurse explains to a newly diagnosed type 1 diabetic that the beta cells can no longer produce adequate insulin because: a.they are inhibited by pituitary disorder. b.an allergic response has altered their response to hyperglycemia. c.alpha cells have proliferated in the islets of Langerhans. d.the bodys immune system has destroyed them.

ANS: D In type 1 diabetes mellitus (DM), the beta cells on the islets of Langerhans are destroyed by an autoimmune reaction.

2. The nurse uses a visual aid to demonstrate that among diabetics, type 2 diabetics comprise up to _____% of all known cases. a. 70 b. 75 c. 80 d. 95

ANS: D Type 2 diabetics comprise 90% to 95% of all known cases.