MedSurg II - PrepU - Chapter 51

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.

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.

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.

Which of the following would be considered a "free" item from the exchange list?

Diet soda Free items include unsweetened iced tea, diet soda, and ice water with lemon. A green salad is exchanged for 1 vegetable. A medium apple is 1 fruit; 1 tsp of olive oil is 1 fat.

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.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Serum glucose level of 52 mg/dl Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

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

Younger than 30 years of age Ketosis-prone Little endogenous insulin 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.

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

at least three times per week. Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.

What is the duration of regular insulin?

4 to 6 hours The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.

Which type of insulin acts most quickly?

Lispro The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.

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.

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.

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.

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

The client has not eaten but continues to take insulin or oral antidiabetic medications. Hypoglycemia occurs when a client with diabetes is not eating and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the client has not been compliant with the prescribed treatment regimen. If the client has eaten and has not taken or received insulin, diabetic ketoacidosis is more likely to develop.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer?

NPH Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting.

A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:

138 mg/dL, 2 hours postprandial. The goals for a 2-hour, postprandial blood glucose level are less than 120 mg/dL in a patient who might develop gestational diabetes.

Lispro (Humalog) is an example of which type of insulin?

Rapid-acting Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

Regular Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.

Which instruction about insulin administration should a nurse give to a client?

"Always follow the same order when drawing the different insulins into the syringe." The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it?

"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." The client stating that he'll remain hydrated and pay attention to his eating, drinking, and voiding needs indicates understanding of HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of non-diet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.

A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

"I'm going to give your son some insulin. Then I'll be happy to talk with you." Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs. By informing the mother that she's going to administer the insulin and will then make time to talk with her, the nurse recognizes the mother's needs as legitimate. She provides a reasonable response while attending to the priority of administering insulin as soon as possible. Telling the mother that she can't talk with her or telling her to wait for the physician could increase the mother's fear and anxiety. The nurse shouldn't tell the mother that everything will be fine; the nurse doesn't know that everything will be fine.

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

"Ketones will tell us if your body is using other tissues for energy." The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

10 to 15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

15 g of carbohydrates. The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

15 to 20 g of a fast-acting carbohydrate such as orange juice. This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Administering 1 ampule of 50% dextrose solution, per physician's order The nurse should administer 50% dextrose solution to restore the client's physiological integrity. Feeding through a feeding tube isn't appropriate for this client. A bolus of normal saline solution doesn't provide the client with the much-needed glucose. Observing the client for 1 hour delays treatment. The client's blood glucose level could drop further during this time, placing him at risk for irreversible brain damage.

Which information should be included in the teaching plan for a client receiving glargine, a "peakless" basal 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. 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.

During a follow-up visit 3 months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure?

Glycosylated hemoglobin level Glycosylated hemoglobin is a blood test that reflects the average blood glucose concentration over a period of approximately 2 to 3 months. When blood glucose is elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycosylated hemoglobin level becomes.

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which symptom when caring for this client?

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.

The nurse is educating the client with diabetes on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?

Increase frequency of glucose self-monitoring. Minor illnesses such as influenza can present a special challenge to a diabetic client. The body's need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis.

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

A patient who is diagnosed with type 1 diabetes would be expected to:

Need exogenous insulin. Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.

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?

Presence of autoantibodies against islet cells There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?

Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.

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.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

The short-acting insulin is withdrawn before the intermediate-acting insulin. When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy."

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

glycosylated hemoglobin level. Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:

polyphagia. While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose.

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes." The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury.

A client with diabetes mellitus must learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

"Rotate injection sites within the same anatomic region, not among different regions." The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours." The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well-controlled?

6.5% Normally the level of glycosylated hemoglobin is less than 7%. Thus a level of 6.5% would indicate that the client's blood glucose level is well-controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dL. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?

100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

A female patient with diabetes who weighs 150 pounds has an ideal body weight of 118 pounds. She can lose 1 pound per week and drop her extra 32 pounds in approximately 8 months. To meet this goal, the nurse advises the patient to decrease her calories by:

3,500 per week. A person needs to decrease caloric intake by 3,500 for each lb of weight that is lost. To lose 1 lb per week, a person would decrease his or her daily caloric intake by 500 calories (500 calories × 7 days = 3,500 calories = 1 lb).

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?

Albumin Albumin is one of the most important blood proteins that leak into the urine. Although small amounts may leak undetected for years, its leakage into the urine is among the earliest signs that can be detected. Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria but in fewer than 5% of people without microalbuminuria. The urine should be checked annually for the presence of microalbumin.

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation?

Ask the physician to delay the discharge because the client requires further teaching. The nurse's primary concern should be the safety of the client after discharge. She should provide succinct information to the physician concerning the client's needs, express her concern about ensuring the client's safety, and ask the physician to delay the client's discharge. The nurse shouldn't suggest that the client rely on a friend or family member because she doesn't know if a friend or family member will be available to help. Refusing to rush and telling the charge nurse she isn't sure the client will be safe demonstrate appropriate intentions, but these actions don't alleviate the pressure to discharge the client. Asking a physician to refer the client to a diabetic nurse-educator addresses the client's needs, but isn't the best response because there's no guarantee a diabetic nurse-educator will be available on such short notice.

Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?

Blurred vision Blurred vision occurs when blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mf/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

Crying whenever diabetes is mentioned A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

Deficient fluid volume related to osmotic diuresis A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and fluid volume deficit, making Deficient fluid volume related to osmotic diuresis the highest priority. In this client, tachycardia is more likely to result from fluid volume deficit than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition: Less than body requirements isn't appropriate. A temperature of 100.6° F isn't life-threatening, eliminating Ineffective thermoregulation as the top priority.

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.

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.

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

Glucagon During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn't effective in reversing hypoglycemia.

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

Increased urine output Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin. If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than usual.

A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible?

To restore liver glycogen and prevent secondary hypoglycemia A client with type 1 diabetes who requires glucagon should be given a complex carbohydrate snack as soon as possible to restore the liver glycogen and prevent secondary hypoglycemia. A complex carbohydrate snack doesn't decrease the possibility of nausea and vomiting or stimulate the appetite, and it increases the amount of glycogen in the system.

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.