Diabetes Mellitus Complications (HHNS and DKA) NCLEX

What is the best teaching for a patient who is newly diagnosed with diabetes mellitus type 2? A. Read a Snellen chart yearly. B. Be checked out for presbycusis. C. Notify the doctor if your vision has color distortion. D. See an ophthalmologist for a dilated eye examination yearly.

D. See an ophthalmologist for a dilated eye examination yearly. The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Because of this, the patient with type 2 diabetes should have a dilated eye examination by an ophthalmologist at the time of diagnosis and annually thereafter for early detection and treatment.

The patient with HHS presented with a glucose level of 800 mg/dL and is started on IV fluids and insulin. What action do you anticipate when the patient's glucose reaches 250 mg/dL? A. Administer an intravenous (IV) solution with 5% dextrose. B. Administer sodium polystyrene sulfate (Kayexalate). C. Slow the IV infusion rate to 40 mL/hour. D. Assess cardiac monitoring for peaked T waves.

A. Administer an intravenous (IV) solution with 5% dextrose. When blood glucose levels fall to approximately 250 mg/dL, IV fluids containing glucose are administered to prevent hypoglycemia. Kayexalate (for cation exchange) is used in the treatment of hyperkalemia, which causes peaked T waves on cardiac monitoring. In HHS hypokalemia may result from insulin moving the potassium intracellularly. Fluid replacement remains a priority, but it is given with dextrose. The infusion rate of 40 mL/hour keeps the vein open, but it is not the appropriate replacement rate.

The elderly patient with type 2 diabetes mellitus presents to the clinic with a fever and productive cough. The diagnosis of pneumonia is made. You notice tenting skin, deep tongue furrows, and vital signs of 110/80 mm Hg, 120 beats/minute, and 24 breaths/minute. What assessment is important for you to obtain? A. Blood glucose B. Orthostatic blood pressures C. Urine ketones D. Temperature

A. Blood glucose HHS is typically seen in patients with type 2 diabetes and infection, such as pneumonia. The main presenting sign is a glucose level above 600 mg/dL. Enough evidence of dehydration already exists that orthostatic vital sign assessments are not a priority, and they are often inaccurate in the elderly due to poor vascular tone. Patients with HHS do not have elevated ketone levels, which is a key distinction between HHS and DKA. Temperature will eventually be taken but is often blunted in the elderly and diabetics. An infectious diagnosis has already been made. The glucose level for appropriate fluid and insulin treatment is the priority.

Laboratory results are available for a 54-year-old patient with a 15-year history of diabetes. Which result follows the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Decreased low-density lipoprotein levels C. Increased high-density lipoprotein levels D. Decreased very-low-density lipoprotein levels

A. Increased triglyceride levels Macrovascular complications of diabetes include changes in medium- and large-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. For this reason, the patient should limit the amount of fat in the diet.

The patient with diabetes and shortness of breath is brought from the nursing home to the hospital emergency department. The electrocardiogram (ECG) shows evidence of a myocardial infarction (MI), but the patient denied ever having chest pain. Which is the best explanation of what happened? A. The patient had a "silent" MI related to autonomic neuropathy. B. The patient had chest pain but forgot because of dementia. C. The patient minimized the chest pain because he was worried about costs. D. The patient has the psychologic defense mechanism of denial.

A. The patient had a "silent" MI related to autonomic neuropathy. Cardiovascular abnormalities associated with autonomic neuropathy include painless myocardial infarction. Shortness of breath related to decreased cardiac functioning can be the first overt sign or symptom.

What therapies are appropriate for patients with diabetes mellitus (select all that apply)? A. Use of statins to treat dyslipidemia B. Use of diuretics to treat nephropathy C. Use of angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy D. Use of laser photocoagulation to treat retinopathy E. Use of protein restriction in patients with early signs of nephropathy

A. Use of statins to treat dyslipidemia C. Use of angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy D. Use of laser photocoagulation to treat retinopathy In patients with diabetes who have microalbuminuria or macroalbuminuria, ACE inhibitors (-prils) or angiotensin II receptor antagonists (ARBs) (-sartans) should be used. Both of these drug classes are used to treat hypertension. The statin drugs are the most widely used lipid-lowering drugs. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, macular edema, and in some cases of nonproliferative retinopathy.

The patient presents to the emergency department with a glucose level of 400 mg/dL, ketone result of 2+, and rapid respirations with a fruity odor. What finding do you anticipate? A. pH below 7.30 B. Urine specific gravity below 1.005 C. High sodium bicarbonate levels D. Low blood urea nitrogen (BUN) level

A. pH below 7.30 The patient is in metabolic acidosis, which is a pH below 7.35. Dehydration results in a high urine specific gravity (at the upper end of the normal range, or above 1.025 to 1.030). Sodium bicarbonate levels are low in metabolic acidosis. The dehydration that occurs with DKA elevates the BUN level.

The patient has diabetes mellitus and macroalbuminuria. The patient asks you why the physician is prescribing the angiotensin-converting enzyme (ACE) inhibitor lisinopril (Zestril) for him even though his blood pressure is well-controlled. What is your response? A. It helps prevent hypertension as diabetics are prone to it. B. ACE inhibitors delay the progression of nephropathy in patients with diabetes. C. ACE inhibitors prevent macrovascular complications. D. ACE inhibitors help prevent atherosclerosis.

B. ACE inhibitors delay the progression of nephropathy in patients with diabetes. ACE inhibitors and angiotensin II receptor antagonists (ARBs) are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. ACE inhibitors are not used prophylactically. ACE inhibitors do not affect macrovascular complications. Nephropathy is a microvascular complication.

The patient is managed with NPH and regular insulin injections before breakfast and before dinner. When is the patient most likely to have a hypoglycemic reaction? A. After breakfast B. Before lunch C. During lunch D. After lunch

B. Before lunch The regular insulin peak occurs about 2 to 3 hours with a duration of 5 to 6 hours. If too much insulin or not enough food is given, the most likely time of hypoglycemia is before lunch, when the regular insulin is still present, the NPH has its onset, and the breakfast food has been metabolized.

The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute, and 28 deep, sighing respirations/minute. What is the priority need for the patient? A. Oxygen B. Intravenous (IV) fluids C. Albuterol (Ventolin) D. Metformin (Glucophage)

B. Intravenous (IV) fluids A patient in diabetic ketoacidosis (DKA) needs IV fluids and insulin to stop the tissue breakdown resulting in ketone bodies and acidosis. The initial goal is fluid and electrolyte balance. Kussmaul respirations indicate the body is attempting to compensate by blowing off the carbon dioxide, but it is ineffective as long as the body continues to break down the ketone bodies and remains in metabolic acidosis.

You are beginning to teach a diabetic patient about the vascular complications of diabetes. Which information is appropriate for you to include? A. Macroangiopathy does not occur in type 1 diabetes but does affect type 2 diabetics who have severe disease. B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C. Renal damage resulting from changes in large and medium-sized blood vessels can be prevented by careful glucose control. D. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.

B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in type 1 and type 2 diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Sexual impotency and slowed gastric emptying result from microangiopathy.

What is a typical finding of hyperosmolar hyperglycemic syndrome (HHS)? A. Occurs in type 1 diabetes as the presenting symptom B. Slow onset resulting in a blood glucose level greater than 600 mg/dL C. Ketone bodies higher than 4+ in urine D. Signs and symptoms of diabetes insipidus

B. Slow onset resulting in a blood glucose level greater than 600 mg/dL HHS has a slower onset than diabetic ketoacidosis. HHS is often related to impaired thirst sensation, inadequate fluid intake, or functional inability to replace fluids. Because of the slower onset, the blood glucose levels can be quite high (more than 600 mg/dL) before diagnosis. HHS is seen in type 2 diabetics, and there is enough circulating insulin to prevent ketoacidosis. Diabetes insipidus is related to inadequate antidiuretic hormone secretion or kidney response with dilute, frequent urination. It is not related to HHS.

Which elevated laboratory finding is the best indication of potential diabetic nephropathy? A. Blood urea nitrogen (BUN) level B. Urine albumin-to-creatinine ratio C. Urine specific gravity D. Chloride (Cl-) level

B. Urine albumin-to-creatinine ratio Screening for nephropathy depends on the urinary albumin-to-creatinine ratio and a serum creatinine level. BUN alone, without correction to creatinine, can indicate many other issues, including dehydration and liver function. Unless there is renal failure, urine specific gravity is more indicative of dehydration.

Which symptoms reported by a patient with diabetes mellitus are most important to follow-up? A. "My vision has been getting fuzzier over the past year." B. "I cannot read the small print anymore." C. "There is something like a veil of blackness coming across my vision." D. "I have yellow discharge from one eye."

C. "There is something like a veil of blackness coming across my vision." Diabetic retinopathy, particularly proliferative retinopathy, can cause retinal detachment, which has the classic new symptom of a veil coming across the field of vision. This requires emergency treatment. Chronic blurry vision can be cataracts and is not emergent. Change in the ability to read things near to the eye (presbyopia or farsightedness) is an age-related change and not emergent. Conjunctivitis needs treatment but is not as emergent as retinal detachment.

The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority? A. Obtain a serum glucose level. B. Give hard candy under the tongue. C. Administer glucagon per standing order. D. Notify the health care provider.

C. Administer glucagon per standing order. The patient has signs and symptoms of hypoglycemia for which treatment should be the priority. Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Waiting for a serum result (up to an hour) is improper because brain cells continue to die from a lack of glucose. Nothing solid should be placed in the mouth when the patient has an altered level of consciousness and can aspirate. With obvious symptoms, emergent treatment takes priority over notifying the health care provider.

The patient had a hypoglycemic episode and is treated with a concentrated glucose oral tablet. Fifteen minutes later the capillary glucose level (Accu-Check) is 150 mg/dL. What action should you take? A. Administer a second bolus of glucose solution. B. Administer regular insulin per sliding scale. C. Have the patient eat peanut butter and toast. D. Obtain a serum glucose level.

C. Have the patient eat peanut butter and toast. The patient has had an appropriate response to the glucose. Now a complex carbohydrate is needed to prevent hypoglycemia from reoccurring. There is no need for a second bolus of glucose because the result is within normal range. Insulin is not given, even though the glucose level is slightly elevated. The short-acting glucose is metabolized and insulin administration can increase the risk of a second hypoglycemic reaction. A serum confirmation of the level can be obtained but is not the priority.

Which lower extremity or foot finding is a sign of sensory neuropathy in a patient with diabetes mellitus? A. Dusky when legs are dependent B. Pitting pedal edema C. Intermittent claudication D. Strong pedal pulse

C. Intermittent claudication Peripheral arterial disease (PAD) is caused by a reduction of blood flow to the lower extremities. Classic signs include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor. Dusky legs when they are dependent, pitting pedal edema, and a strong pedal pulse are signs of peripheral venous disease.

The male patient with diabetes and heart disease confides to you that he can no longer have an erection. What is the reason for these changes? A. It is a normal part of aging and is relieved with sildenafil (Viagra). B. It usually is related to emotions and is a temporary problem. C. It is often the first sign of diabetic autonomic neuropathy. D. It indicates that the patient has developed a neurogenic bladder.

C. It is often the first sign of diabetic autonomic neuropathy. Erectile dysfunction (ED) is common and often is the first manifestation of autonomic failure. ED is a common long-term complication of diabetes. Neurogenic bladder is related to urinary retention.

The patient with diabetes reports tingling and burning in the lower extremities at night. The patient asks you why the primary health care provider prescribed the selective serotonin reuptake inhibitor (SSRI) duloxetine (Cymbalta). What is the best response? A. The doctor thought the discomfort was causing the patient to be depressed. B. The drug is known to improve patients' moods and enhance coping. C. It regulates pain by affecting neurotransmitters that transmit pain through the spine. D. It deadens the sensitivity to peripheral nerve endings.

C. It regulates pain by affecting neurotransmitters that transmit pain through the spine. SSRI drugs work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters that are believed to play a role in the transmission of pain through the spinal cord. Duloxetine is thought to relieve pain by increasing the levels of serotonin and norepinephrine, which improves the body's ability to regulate pain.

What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)? A. Glucose level above 400 mg/dL B. Hyperkalemia C. Ketones in blood D. Urine output of 30 mL/hr

C. Ketones in blood The main difference between the two conditions is that ketone bodies are absent or minimal in HHS because the body has enough insulin to prevent ketoacidosis. Both have high glucose levels, although the level in HHS tends to be higher (above 600 mg/dL). Hypokalemia is possible in both, although it is more likely and serious in DKA. Urine output of 30 mL/hr is normal obligatory output; both conditions are likely to have dehydration and decreased output.

A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessment of the patient, you suspect DKA rather than HHS based on the finding of A. polyuria. B. severe dehydration. C. rapid, deep respirations. D. decreased serum potassium.

C. rapid, deep respirations. Rapid, deep respirations are Kussmaul's and are are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Acetone is detected on the breath as a sweet, fruity odor.

Which assessment is the most sensitive indicator that the IV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease? A. Pedal edema B. Tachypnea C. Urine output of 40 mL/hour D. Change in the level of consciousness

D. Change in the level of consciousness Too rapid fluid replacement can lead to hyponatremia and cerebral edema. Pedal edema is a later and relatively insignificant sign. In a bedridden patient, edema is more evident in the sacral area. The Kussmaul respirations are expected; crackles auscultated in the lungs are a more sensitive indicator. The desired urine output for adequate hydration is 30 to 60 mL/hr.

The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor? A. Magnesium (Mg) B. Hemoglobin (Hb) C. White blood cells (WBCs) D. Potassium (K)

D. Potassium (K) Even if the patient has normal potassium levels, there can be significant hypokalemia when insulin is administered as it pushes the serum potassium intracellularly. This can lead to life-threatening hypokalemia. The other options are not as significant.

What is most helpful in the prevention of nephropathy in a patient with diabetes mellitus? A. Acid-ash diet B. Ensuring adequate fluid intake for renal perfusion C. Preventing obstruction from benign prostatic hyperplasia (BPH) D. Stopping smoking

D. Stopping smoking Risk factors for diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Diabetic nephropathy is an intrarenal microvascular complication in which the glomeruli of the kidney are damaged. The kidney receives about 25% of the cardiac output, and inadequate fluids or shock resulting in adequate perfusion is a prerenal cause. BPH is a postrenal cause of kidney pathology.