Ch 46 Diabetes (The Point)
A 1200-calorie diet and exercise are prescribed for a client with newly diagnosed type 2 diabetes. The nurse is teaching the client about meal planning using exchange lists. The teaching is determined to be effective based on which statement by the client? "For dinner I ate 4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion; 1 ounce low-fat cheese; 1 tablespoon mayonnaise; 1 cup fresh strawberry shortcake; and unsweetened iced tea." "For dinner I ate 2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda." "For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." "For dinner I ate 2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas in a garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon."
"For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. For example, 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1 cup watermelon; "free" items like diet soda are optional.
A client with type 2 diabetes has recently been prescribed acarbose, and the nurse is explaining how to take this medication. The teaching is determined to be effective based on which statement by the client? "I will take this medication in the morning, 15 minutes before breakfast." "I will take this medication in the morning, with my first bite of breakfast." "It does not matter what time of day I take this medication." "This medication needs to be taken after the midday meal."
"I will take this medication in the morning, with my first bite of breakfast." Alpha-glucosidase inhibitors such as acarbose and miglitol, delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response? "Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood." "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." "Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid." "When the body does not have enough insulin, hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic by-products to be released."
"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.
A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition? "You may be having undiagnosed infections, causing you to lose extra weight." "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism." "Your body is using protein and fat for energy instead of glucose." "I will refer you to a dietician who can help you with your weight."
"Your body is using protein and fat for energy instead of glucose." Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.
The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection? 1 to 2 hours 30 to 40 minutes 3 hours 10 to 15 minutes
10 to 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.
Once digested, what percentage of carbohydrates is converted to glucose? 70 100 80 90
100 Once digested, 100% of carbohydrates are converted to glucose. However, approximately 50% of protein foods are also converted to glucose, but this has minimal effect on blood glucose concentration.
A client newly diagnosed with type 1 diabetes has an unusual increase in blood glucose from bedtime to morning. The physician suspects the client is experiencing insulin waning. Based on this diagnosis, the nurse expects which change to the client's medication regimen? Changing the time of evening injection of intermediate-acting insulin from dinnertime to bedtime Increasing morning dose of long-acting insulin Administering a dose of intermediate-acting insulin before the evening meal Decreasing evening bedtime dose of intermediate-acting insulin and administering a bedtime snack
Administering a dose of intermediate-acting insulin before the evening meal Insulin waning is a progressive rise in blood glucose form bedtime to morning. Treatment includes increasing the evening (before dinner or bedtime) dose of intermediate-acting or long-acting insulin or instituting a dose of insulin before the evening meal if that is not already part of the treatment regimen.
A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the client's symptoms to be those of diabetic ketoacidosis (DKA). Which action will help the nurse confirm the diagnosis? Assess the client's ability to take a deep breath Assess the client's breath odor Assess the client's ability to move all extremities Assess for excessive sweating
Assess the client's breath odor DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue, with eventual stupor and coma if not treated. The breath has a characteristic fruity odor due to the presence of ketoacids. Checking the client's breath will help the nurse confirm the diagnosis.
Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high? Blurred vision Increased energy Oliguria Hyperactivity
Blurred vision
Which information should be included in the teaching plan for a client receiving glargine, which is "peakless" basal insulin? Administer the total daily dosage in 2 doses. Glargine is rapidly absorbed and has a fast onset of action. Do not mix with other insulins. Draw up the drug first, then add regular insulin.
Do not mix with other insulins. Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. Glargine is a "peakless" basal insulin that is absorbed very slowly over a 24-hour period and can be given once a day. When administering glargine insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.
A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which condition when caring for this client? Hypoglycemia Blurred vision Polydipsia Polyuria
Hypoglycemia The nurse should observe the client receiving an oral antidiabetic agent for signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.
A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first? Infuse 0.9% normal saline solution 1 L/hr for 2 hours. Administer regular insulin 30 U IV push. Start an infusion of regular insulin at 50 U/hr. Administer sodium bicarbonate 50 mEq IV push.
Infuse 0.9% normal saline solution 1 L/hr 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. CORRECT FLUID STATUS FIRST, THEN RECHECK BLOOD GLUCOSE, TREAT WITH INSULIN
Which term refers to the progressive increase in blood glucose from bedtime to morning? Diabetic ketoacidosis (DKA) Somogyi effect Dawn phenomenon Insulin waning
Insulin waning Insulin waning is a progressive rise in blood glucose from bedtime to morning. The dawn phenomenon occurs when blood glucose is relatively normal until about 3 a.m., when the level begins to rise. The Somogyi effect occurs when blood glucose is normal or elevated at bedtime, decreases at 2 to 3 a.m. to hypoglycemia levels, and subsequently increases as a result of the production of counter-regulatory hormones. DKA is caused by an absence or markedly inadequate amount of insulin. This insulin deficit results in disorders in the metabolism of carbohydrates, proteins, and fats. The primary clinical features of DKA are hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis.
Which statement is correct regarding glargine insulin? It cannot be mixed with any other type of insulin. It is given twice daily. It is absorbed rapidly. Its peak action occurs in 2 to 3 hours.
It cannot be mixed with any other type of insulin.
A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which factor should the nurse monitor when caring for the client? Hypertonicity Polyuria Low blood glucose concentration Allergic reactions
Low blood glucose concentration Clients who switch from animal to synthesized human insulin should initially be monitored for low blood glucose concentrations because the human form of insulin is used more effectively. Human insulin causes fewer allergic reactions than insulin obtained from animal sources. Polyuria and hypertonicity are symptoms of diabetes mellitus.
A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom? Muscle wasting and tissue loss Altered mental state Dehydration Weight gain
Muscle wasting and tissue loss Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although clients with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.
A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes? Rare ketosis Presence of autoantibodies against islet cells Obesity Altered glucose metabolism
Presence of autoantibodies against islet cells
Which category of oral antidiabetic agents exerts the primary action by directly stimulating the pancreas to secrete insulin? Alpha-glucosidase inhibitors Sulfonylureas Thiazolidinediones Biguanides
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 receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction? Between 8:00 and 10:00 a.m. This insulin has no peak action and does not cause a hypoglycemic reaction. Between 7:00 and 9:00 p.m. Between 4:00 and 6:00 p.m.
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.
A client with type 1 diabetes mellitus is being taught about self-injection of insulin. Which fact about site rotation should the nurse include in the teaching? Choose a different site at random for each injection. Rotate sites from area to area every other day. Use all available injection sites within one area. Avoid the abdomen because absorption there is irregular.
Use all available injection sites within one area. Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the client should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.
A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan? An eye examination every 2 years until age 50 Weight reduction through diet and exercise Maintenance of blood glucose levels between 180 and 200 mg/dl Smoking reduction but not complete cessation
Weight reduction through diet and exercise
The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan? If two different types of insulin are ordered, they need to be given in separate injections. There is no need to inject air into the bottle of insulin before withdrawing the insulin. When mixing insulin, the regular insulin is drawn up into the syringe first. When mixing insulin, the NPH insulin is drawn up into the syringe first.
When mixing insulin, the regular insulin is drawn up into the syringe first. When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before being drawn into the syringe. The American Diabetic Association recommends that the regular insulin be drawn up first. The most important issues are that patients (1) are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) do not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.
A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to skip the evening neutral protamine Hagedorn insulin dose on days when exercising and skipping meals. eat a complex carbohydrate snack in the evening before bed. check blood glucose at 3:00 a.m. administer an increased dose of neutral protamine Hagedorn insulin in the evening.
check blood glucose at 3:00 a.m. In the Somogyi effect, the client has a normal or elevated blood glucose concentration at bedtime, which decreases to hypoglycemic levels at 2 to 3 a.m., and subsequently increases as a result of the production of counter-regulatory hormones. It is important to check blood glucose in the early morning hours to detect the initial hypoglycemia.
