204 PrepU Chapter 51: Assessment and Management of Patients With Diabetes

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

3 AM During the dawn phenomenon, the patient has a relatively normal blood glucose level until about 3 AM, when the level begins to rise.

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

50-60% One half to two thirds of the patient's usual morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery. The remainder is then administered after surgery.

Which would be included in the teaching plan for a client diagnosed with diabetes mellitus?

An elevated blood glucose concentration contributes to complications of diabetes, such as diminished vision. Diabetic retinopathy is the leading cause of blindness among people between 20 and 74 years of age in the United States; it occurs in both type 1 and type 2 diabetes. When blood glucose is well controlled, the potential for complications of diabetes is reduced. Several types of foods contain sugar, including cereals, sauces, salad dressings, fruits, and fruit juices. It is not feasible, nor advisable, to remove all sources of sugar from the diet. If the diabetes had been well controlled without insulin before the period of acute stress causing the need for insulin, the client may be able to resume previous methods for control of diabetes when the stress is resolved.

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. Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.

Which of the following is an age-related change that may affect diabetes? Select all that apply.

Decreased renal function Taste changes Decreased vision Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.

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. Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death. Polydipsia, polyuria, and polyphagia are symptoms associated with hyperglycemia.

Which is the primary dietary consideration for a client receiving insulin isophane suspension (NPH) at breakfast?

encourage midday snack Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 12 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.

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 Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).

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 The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?

Sensory neuropathy Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

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 continuous subcutaneous insulin regimen uses a basal rate and boluses of rapid-acting insulin. Multiple daily injection therapy uses a combination of rapid-acting and intermediate- or long-acting insulins.

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. The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

Which of the following insulins are used for basal dosage?

Glarginet (Lantus) Lantus is used for basal dosage. NPH is an intermediate acting insulin, usually taken after food. Humalog and Novolog are rapid-acting insulins.

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10-15 minutes The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

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

Hypoglycemia. The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.

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). The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Increased urine osmolarity In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

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 Type 1 diabetes usually (but not always) develops in people younger than 20. In older adults, an onset of type 2 is far more common. A significant number of older adults develops type 2 diabetes.

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

Weight loss Weight loss is the focus of nutrition intervention for clients with type 2 diabetes. A low-calorie diet may improve clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action. Consistency in the total amount of carbohydrates consumed is considered an important factor that influences blood glucose level. Protein metabolism is not the focus of nutrition intervention for clients with type 2 diabetes.

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." The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?

3 months Glycosylated hemoglobin is a blood test that reflects average blood glucose concentrations over a period of 3 months.

A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?

"Your child will need less blood work as his glucose levels stabilize." Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician if he can reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective?

1/2 cup fruit juice or regular soft drink In a client with hypoglycemia, the nurse uses the rule of 15: give 15 g of rapidly absorbed carbohydrate, wait 15 minutes, recheck the blood sugar, and administer another 15 g of glucose if the blood sugar is not above 70 mg/dL. One-half cup fruit juice or regular soft drink is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Eight ounces of skim milk is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. One tablespoon of honey or syrup is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Six to eight LifeSavers candies is equivalent to the recommended 15 g of rapidly absorbed carbohydrate.

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:

10:30 AM Serum insulin levels return to baseline within 2 to 3 hours.

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 Insulin is given intravenously. Insulin reduces the production of ketones by making glucose available for oxidation by the tissues and by restoring the liver's supply of glycogen. As insulin begins to lower the blood glucose level, the IV solution is changed to include one with glucose. Periodic monitoring of serum electrolytes and blood glucose levels is necessary. Isotonic fluid is instilled at a high volume, for example, 250 to 500 mL/hour for several hours. The rate is adjusted once the client becomes rehydrated and diuresis is less acute. Potassium replacements are given despite elevated serum levels to raise intracellular stores.

Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)?

Blood glucose can be controlled through diet and exercise Oral hypoglycemic agents may improve blood glucose concentrations if dietary modification and exercise are unsuccessful. Individuals with type 2 diabetes are usually obese at diagnosis. Individuals with type 2 diabetes rarely demonstrate ketosis, except with stress or infection. Individuals with type 2 diabetes do not demonstrate islet cell antibodies.

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 HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

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 With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.

Which factors will cause hypoglycemia in a client with diabetes? Select all that apply.

Client has not consumed food and continues to take insulin or oral antidiabetic medications. Client has not consumed sufficient calories. Client has been exercising more than usual. Hypoglycemia can occur when a client with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications, is not eating sufficient calories to compensate for glucose-lowering medications, or is exercising more than usual. Excessive sleep and aging are not factors in the onset of hypoglycemia.

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes DKA is characterized by an elevated BUN and creatinine, rapid onset, and it is more common in type 1 diabetes. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by the absence of urine and serum ketones and a normal arterial pH level.

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

Fruity breath The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.

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. The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

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 Hyperglycemic hyperosmolar syndrome (HHS) occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes (Reynolds, 2012). The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis).

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 enhanced the transport of glucose across the cell membrane Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose.

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

Ketosis-prone Little endogenous insulin Younger than 30 years of age Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent.

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 The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

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 This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

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 (Hb A1c) Hb A1c is the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.

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 Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

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

Sulfonylureas A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate the action of insulin on peripheral receptor sites. Alpha-glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

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 Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

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. "Peakless" basal or very long-acting insulins are approved by the U.S. Food and Drug Administration for use as a basal insulin; that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. It has is no peak action.

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?

be sure to apply moisture to feet daily The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water not hot water to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic or vinyl which would cause the feet to perspire.

A type 2 diabetic is ordered metformin (Glucophage) as part of the management regime. Which is the best nursing explanation for the action of this drug in controlling glucose levels?

helps tissue use insulin more effectively Glucophage improves the use of insulin in type 2 diabetes. Alpha-glucosidase inhibitors work by delaying digestion of carbohydrates. Meglitinides stimulates insulin release and/or reduce the production of glucose by the liver.

A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first?

infuse 0.9% normal saline solution 1L/hour for 2 hours In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated clients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.

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

promote absorption Subcutaneous injection sites require rotation to avoid breakdown and/or buildup of subcutaneous fat, either of which can interfere with insulin absorption in the tissue. Infection and discomfort are risks involved with injection site but not the primary reason for rotation of sites. Insulin is not injected into the muscle.

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. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.

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 Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.