Pathophysiology Chap 33
A diabetic client presents to a clinic for routine visit. Blood work reveals a HbA1C of 11.0% (high)? Which response by the patient may account for this abnormal lab result? Select one: A. "My meter broke so I have not been checking my blood glucose levels for a while." B. "To tell you the truth, my blood glucose levels have been pretty normal for me." C. "I've been doing great. I haven't needed much insulin coverage before meals." D. "I've had more periods of hypoglycemia than usual over the past few months."
A. "My meter broke so I have not been checking my blood glucose levels for a while." Glycosylated hemoglobin is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cell is not insulin dependent, the rate at which glucose becomes attached to the hemoglobin molecule depends on blood glucose; the level is an index of blood glucose levels over the previous 6 to 12 weeks. If the diabetic client is not monitoring his or her blood glucose, he or she could be having more periods of hyperglycemia and just is not aware of the need for insulin coverage.
A hospital client has been complaining of increasing fatigue for several hours, and his nurse has entered his room to find him unarousable. The nurse immediately checked the client's blood glucose level (and reverified with a second blood glucose meter), which is 22 mg/dL (1.2 mmol/L). The nurse should prepare to administer which of the following? Select one: A. A 50% glucose solution intravenously B. Infusion of rapid-acting insulin C. A snack that combines simple sugars, protein, and complex carbohydrates D. An oral solution containing glucagon and simple sugars
A. A 50% glucose solution intravenously The client's presentation and low blood sugars indicate the need for aggressive treatment such as glucose (20 to 50 mL of a 50% solution) intravenously. The unconscious client cannot take anything by mouth, and glucagon can never be administered orally. Insulin would be potentially fatal.
Impaired and delayed healing in a person with diabetes is caused by long-term complications that include: Select one: A. Chronic neuropathies B. Somogyi effect C. Fluid imbalances D. Ketoacidosis
A. Chronic neuropathies Suboptimal response to infection in a person with diabetes is caused by the presence of chronic complications, such as vascular disease and neuropathies, poorly controlled hyperglycemia, and altered immune cell and neutrophil function. Sensory deficits may cause a person with diabetes to ignore minor trauma and infection, and vascular disease may impair circulation and delivery of blood cells and other substances needed to produce an adequate inflammatory response and effect healing. Somogyi effect is an acute complication of diabetes, causing hypoglycemia. Ketoacidosis is an acute complication of hyperglycemia when liver ketone production exceeds cell use.
Diabetic retinopathy, the leading cause of acquired blindness in the United States, is characterized by retinal: Select one: A. Hemorrhages B. Glaucoma C. Infections D. Dehydration
A. Hemorrhages Although people with diabetes are at increased risk for the development of cataracts and anterior chamber glaucoma, retinopathy is the most common pattern of eye disease. Diabetic retinopathy is characterized by abnormal retinal vascular permeability, microaneurysm formation, neovascularization and associated hemorrhage, scarring, and retinal detachment. In conjunction with the retinopathy, the inflammatory response causes macular edema rather than loss of vitreous fluid (dehydration). Intraocular infection is an uncommon, yet potential, complication of retinal surgery.
Which of the following pregnant women likely faces the greatest risk of developing gestational diabetes? A client who: Select one: A. Is morbidly obese defined as greater than 100 pounds over ideal weight B. Was diagnosed with placenta previa early in her pregnancy C. Has BP of 130/85 mm Hg and pulse rate of 90 beats/minute D. Is gravida five (in her fifth pregnancy)
A. Is morbidly obese defined as greater than 100 pounds over ideal weight Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.
A client's primary care provider has ordered an oral glucose tolerance test (OGTT) as a screening measure for diabetes. Which of the following instructions should the client be given? Select one: A. "You'll have to refrain from eating after midnight and then go to the lab to have your blood taken first thing in the morning." B. "The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals." C. "They'll take a blood sample and see how much sugar is attached to your red blood cells." D. "You can go to the lab at any time; just tell the technician when you last ate before they draw a blood sample."
B. "The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals." The OGTT measures the plasma glucose response to 75 g of concentrated glucose solution at selected intervals, usually 1 and 2 hours. A fasting blood glucose test requires 8 hours without food, and A1C measures glucose binding to hemoglobin. A casual blood glucose test is administered without regard for time or last meal.
The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which of the following pathophysiologic processes underlies the client's new diagnosis? Select one: A. Destruction of beta cells that is not attributable to autoimmunity B. Beta cell exhaustion due to long-standing insulin resistance C. T-lymphocyte-mediated hypersensitivity reactions D. Actions of insulin autoantibodies (IAAs) and islet cell autoantibodies (ICAs)
B. Beta cell exhaustion due to long-standing insulin resistance Exhaustion of the beta cells arising from insulin resistance is characteristic of type 2 diabetes. Beta cell destruction in the absence of an autoimmune reaction is associated with type 1b diabetes, while autoimmune processes contribute to type 1a diabetes.
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? Select one: A. Initiation of glycogenolysis B. Promotion of glucose uptake by target cells C. Promotion of fat breakdown D. Promotion of gluconeogenesis
B. 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 young child develops type 1A diabetes. The parents ask, "They tell us this is genetic. Does that mean our other children will get diabetes?" The best response by the health care provider would be: Select one: A. "Probably not since genetically your other children have a different cellular makeup, they just might not become diabetic." B. "If you put all your children on a low-carbohydrate diet, maybe they won't get diabetes." C. "This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes." D. "We don't know what causes diabetes, so we will just have to wait and see."
C. "This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes." Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes.
A client tells his health care provider that his body is changing. It used to be normal for his blood glucose to be higher during the latter part of the morning. However, now his fasting blood glucose level is elevated in the early AM (07:00). The health care provider recognizes the client may be experiencing: Select one: A. Somogyi effect B. Hyperglycemic hyperosmolar state (HHS) C. Dawn phenomenon D. Possible stress-related hypoglycemia
C. Dawn phenomenon A change in the normal circadian rhythm for glucose tolerance, which usually is higher during the later part of the morning, is altered in people with diabetes, with abnormal nighttime growth hormone secretion as a possible factor. The dawn phenomenon is characterized by increased levels of fasting blood glucose or insulin requirements, or both, between 5 AM and 9 AM without preceding hypoglycemia. The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. The cycle begins when the increase in blood glucose and insulin resistance is treated with larger insulin doses. The insulin-induced hypoglycemia produces a compensatory increase in blood levels of catecholamines, glucagon, cortisol, and growth hormone, leading to increased blood glucose with some insulin resistance.
Which of the following assessment findings of a male client constitutes a criterion for a diagnosis of metabolic syndrome? The client: Select one: A. States that he does less than 30 minutes of strenuous physical activity each week B. Has a fasting triglyceride level of 100 mg/dL C. Has blood pressure that is consistently in the range of 150/92 mm Hg D. Has a resting heart rate between 85 and 95 beats/minute
C. Has blood pressure that is consistently in the range of 150/92 mm Hg Diagnostic criteria for metabolic syndrome include blood pressure of greater than 130/85 mm Hg. A triglyceride level below 150 mg/dL is within normal range. Sedentary lifestyle, high resting heart rate, and a family history of type 2 diabetes are associated with other health problems, including diabetes, but these are not diagnostic criteria for metabolic syndrome.
A diabetic client was visiting the endocrinologist for annual checkup. The client's blood work reveals an increased level of which lab result that reveals early signs of diabetic nephropathy? Select one: A. Hypokalemia B. Hyperlipidemia C. Microalbuminuria D. Oliguria
C. Microalbuminuria One of the first manifestations of diabetic nephropathy is increased urinary albumin excretion (i.e., microalbuminuria). Risk factors, rather than renal manifestations, include glycosylated hemoglobin levels greater than 8.1%, genetic and familial predisposition, hypertension, poor glycemic control, smoking, and hyperlipidemia. Usually, serum potassium levels are elevated (hyperkalemia) in diabetic nephropathy. The presence of ketones in the urine is a sign of ketoacidosis and severe hyperglycemia rather than nephropathy.
A client with long-standing type 2 diabetes is surprised at his high blood sugar readings while recovering from an emergency surgery. Which of the following factors may have contributed to the client's inordinately elevated blood glucose levels? Select one: A. The tissue trauma of surgery resulted in gluconeogenesis. B. Sleep disruption in the hospital precipitated the dawn effect. C. The stress of the event caused the release of cortisol. D. Illness inhibited the release and uptake of glucagon.
C. The stress of the event caused the release of cortisol. Elevation of glucocorticoid levels, such as during stressful events, can lead to hyperglycemia. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels.
A client with a history of diabetes presents to the emergency department following several days of polyuria and polydipsia with nausea/vomiting. On admission, the client labs show a blood glucose level of 480 mg/dL and bicarbonate level of 7.8 mEq/dL. The nurse suspects the client has diabetic ketoacidosis (DKA). The priority intervention should include: Select one: A. Limit fluid intake to only 250 mL/4 hours. B. Push a stat dose of bicarbonate followed by a double-dose (loading) of metformin. C. Give at least 50 units of regular insulin IV stat and recheck blood glucose in 2 hours. D. Begin a loading dose of IV regular insulin followed by a continuous insulin infusion.
D. Begin a loading dose of IV regular insulin followed by a continuous insulin infusion. The goals in treating DKA are to improve circulatory volume and tissue perfusion, decrease blood glucose, and correct the acidosis and electrolyte imbalances. These objectives usually are accomplished through the administration of insulin and intravenous fluid and electrolyte replacement solutions. An initial loading dose of short-acting (i.e., regular) or rapid-acting insulin often is given intravenously, followed by continuous low-dose short-acting insulin infusion. Frequent laboratory tests are used to monitor blood glucose. The fluids need to be replaced, not withheld. Too rapid a drop in blood glucose may cause hypoglycemia that can occur with a large dose of regular insulin. The client may require bicarbonate, but glucose levels are lowered with insulin in this emergency situation, not by oral medication.
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: Select one: A. Be careful that you're not experiencing a rebound hyperglycemia B. Watch for too rapid weight loss C. Monitor for respiratory disorders D. Carry a snack with carbs to prevent profound hypoglycemia
D. 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.
A diabetic client's most recent blood work indicated a decreased glomerular filtration rate and urine testing revealed + microalbuminuria. Which priority self-care measures should the client's care team prescribe for this client? Select one: A. Decreased oral sugar intake to less than 5 tsp/day B. Increased fluid intake to at least 2000 mL/day C. Use of over-the-counter herbal products for natural diuretic properties D. Diet, exercise, and prescriptions to lower blood pressure below 140/80 mm Hg
D. Diet, exercise, and prescriptions to lower blood pressure below 140/80 mm Hg Both systolic hypertension and diastolic hypertension accelerate the progression of diabetic nephropathy. Even moderate lowering of blood pressure can decrease the risk of chronic kidney disease. Diuretics may exacerbate diabetes, and neither increased fluid intake nor decreased sugar intake will necessarily mitigate the potential for further kidney damage.
While working on the med-surg floor, the nurse has a client who is experiencing an insulin reaction. The client is conscious and can follow directions. The most appropriate intervention would be: Select one: A. Start pushing 50% glucose solution slowly and do not stop pushing until the client's repeat blood glucose level is above 100 mg/dL. B. Skip the oral glucose tablets and go directly to giving intramuscular glucagon. Repeat the glucagon in 15 minutes if the blood glucose level is not within a normal range. C. Call the physician and wait for him or her to respond to give you orders of what he or she prefers you do for this client. D. Immediately administer 15 g of glucose (preferably via oral route if the client is alert enough to swallow) and wait for 15 minutes. Then repeat this if necessary
D. Immediately administer 15 g of glucose (preferably via oral route if the client is alert enough to swallow) and wait for 15 minutes. Then repeat this if necessary The most effective treatment of an insulin reaction is the immediate administration of 15 g of glucose in a concentrated carbohydrate source. According to the so-called rule of 15, this 15 g of glucose can be repeated every 15 minutes for up to three doses. Alternative methods for increasing blood glucose may be required when the person having the reaction is unconscious or unable to swallow. Glucagon may be given intramuscularly or subcutaneously. Glucagon acts by hepatic glycogenolysis to raise blood glucose. In situations of severe or life-threatening hypoglycemia, administer glucose (20 to 50 mL of a 50% solution) intravenously.
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? Select one: A. They have increased predisposition to other autoimmune disorders such as Graves disease, rheumatoid arthritis, and Addison disease. B. The destruction of beta cells and absolute lack of insulin in people with type 2 diabetes means that they are particularly prone to the development of diabetic complication. C. Because of the loss of insulin response, all people with type 2 diabetes require exogenous insulin replacement to control blood glucose levels. D. In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Following meals (postprandial), glucose levels are higher due to diminished efficiency of glucose clearance.
D. 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.
A newly diagnosed type 2 diabetic client has been prescribed metformin. When explaining the actions of this medication, the nurse should include which statement? This medication: Select one: A. Blocks the action of intestinal brush border enzymes that break down complex carbohydrates B. Acts like a hormone released into the circulation by the gastrointestinal tract after a meal, especially one high in carbohydrates, which amplify the glucose-induced release of insulin C. Increases insulin sensitivity in the insulin-responsive tissues—liver, skeletal muscle, and fat—allowing the tissues to respond to endogenous insulin more efficiently D. Inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin
D. Inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin Metformin, the only currently available biguanide, inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin. Secondary benefits of metformin therapy include weight loss and improved lipid profiles. This medication does not stimulate insulin secretion; therefore, it does not produce hypoglycemia. Distractor B relates to α-glucosidase inhibitors; distractor C relates to thiazolidinediones; and distractor D relates to incretin-based agents.
Which of the following insulin administration regimens is most likely to result in stable blood glucose levels for a client with a diagnosis of type 1 diabetes? Select one: A. Six to eight small doses of rapid-acting insulin each day, with capillary monitoring before each B. One large dose of long-acting insulin each day before breakfast C. Long-acting insulin twice daily (breakfast and bedtime), with intermediate-acting insulin in the afternoon D. Intermediate-acting insulin at 8:00 AM and 8:00 PM with rapid-acting insulin before each meal
D. Intermediate-acting insulin at 8:00 AM and 8:00 PM with rapid-acting insulin before each meal With multiple daily injections (MDIs), the basal insulin requirements are met by an intermediate- or long-acting insulin administered once or twice daily. Boluses of rapid- or short-acting insulin are used before meals. Serial injections of short- or rapid-acting insulin are not typically used.