Metabolic_Diabetes

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at:

1. 12 pm to 1 pm (1200 to 1300 hours) 2. 9am and 5pm (0900 and 1700 hours) 3. 10 am and 10 pm (1000 and 2200 hours) 4. 8am and 11 am (0800 and 1100 hours0 Rationale: (2) Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 9 am and 5 pm (0900 to 1700 hours). (Lewis, Dirksen, Heitkemper et al, 8 ed., p. 1224.)

A client is learning to inject his own insulin. Which of the following nursing observations would indicate to the nurse that the client needs further teaching?

1. Wipes the top of the insulin vial with alcohol 2. Withdraws the prescribed amount of insulin within 0.2 mL 3. Refers to the abdominal injection chart and chooses a previously unused site 4. Keeps the insulin in the refrigerator and prepares and injects it immediately Rationale: (4) Cold insulin increases the risk of lipodystrophy. All extra unopened bottles may be stored in the refrigerator, but the bottle currently being used should remain at room temperature, and the insulin should be injected at room temperature. Insulin should not be subjected to extreme temperatures, but it is stable at room temperature. (Lehne, 7 ed., p. 670; Lewis, et al, 8 ed., pp. 1226, 1227.)

The nurse is administering metformin (Glucophage) to a client. Which observation indicates a therapeutic response to this medication?

1. Blood sugar level maintained at 90 to 100 mg/dL 2. Decrease in the serum uric acid levels 3. Urine output increased to 60 ml/hr 4. Blood pressure increased to 120/80 mm HG Rationales (1) This is an oral hypoglycemic medication used for the control of adult-onset (type 2) diabetes. The desired response is a normal blood sugar level, which is 70 to 120 mg/dL. (Lehne, 7 ed., p. 674; Lewis, 8 ed., p. 1219.)

A client with type 1 diabetes calls the nurse because of nausea and not feeling well. What would be important for the nurse to tell the client?

1. "Hold the oral hypoglycemics until he can begin eating again." 2. "Take the insulin as scheduled, increase water intake, and continue to monitor the blood glucose." 3. "Take his regular dose of insulin, replace food with fruit juices, and monitor his blood glucose." 4. "Do not take any insulin as long as he is nauseous and cannot maintain intake." Rationale: (3) This client is on insulin for his diabetic control. He should continue taking the regularly scheduled dose of insulin and eating the prescribed diet, as well as increasing the amount of low-calorie fluids (e.g., broth, water, decaffeinated tea). If the client is unable to consume solid foods or keep food down, then he can increase his caloric intake by drinking carbohydrate fluids (e.g., juices and soups). It is important for the client to check his blood glucose levels every 4 hours. Additionally, for the type 1 diabetic client with blood glucose levels greater than 240 mg/dL, urine testing for ketones every 3 to 4 hours is required, and findings should be reported to the healthcare provider. The blood sugar may continue to rise because of the illness, which is why it is important to continue medication. (Lewis, et al, 8 ed., p. 1236-1238.)

If dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should plan to administer intermediate-acting insulin (Humulin N), 40 units, subcutaneously to a client between:

1. 5:00 and 5:30 am 2. 6:30 and 7:00 am 3. 9:30 and 10:30 am 4. 11:00 and 11:30 am Rationale: (2) Intermediate-acting insulin, such as Humulin N, should be given 60 to 90 minutes before a meal. Therefore, if the breakfast tray arrived at 8:00 am, a client would need to receive the insulin between 6:30 and 7:30 am. Regular insulin usually is administered 30 minutes before a meal, and insulin lispro is given immediately (15 minutes) before or after meals. (Lehne, 7 ed., pp. 666-667.)

The nurse is discussing with a child and family the various sites used for insulin injections. The nurse would explain that the following site has the fastest rate of absorption:

1. Abdomen 2. Thigh 3. Buttock 4. Arm Rationale: (1) The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration. (Hockenberry, Wilson, 9 ed., p. 1610.)

What is important to teach a client with adrenal insufficiency who has a prescription for prednisone?

1. Be sure to include foods that are low in potassium in the diet. 2. Slowly change positions to avoid dizziness and fainting. 3. Watch for signs of low blood sugar: headache, shakiness, and diaphoresis. 4. Signs of fluid retention may occur while taking this drug. Rationale (4) Report any excessive weight gain or swelling to the health care provider, because they may indicate an adverse effect of the medication. The client taking prednisone needs to consume a high potassium diet, as prednisone causes hypokalemia. Hypertension, not orthostatic hypotension, is a side effect of taking glucocortocoids. Hyperglycemia can occur with prednisone use, not hypoglycemia. (Lehne, 7 ed., pp. 854-855.)

A nurse is caring for a client with type 1 diabetes mellitus. With a blood glucose level of 200 mg/dL, how many units of regular insulin will the nurse administer according to the sliding scale?

1. Blood glucose at 200 mg/dL or less = no insulin 2. Blood glucose 201 to 229 mg/dL = 2 units of insulin 3. Blood glucose 230 to 259 mg/dL = 4 units of insulin 4. Blood glucose 260 to 300 mg/dL = 6 units of insulin Rationale: (1) With the blood sugar level at 200 mg/dL, no additional regular insulin must be given. Sliding scale insulin dosage is determined by the amount of glucose in the blood, which is based on glucometer readings. The sliding scale enables the client to receive appropriate amounts of insulin as the blood glucose level fluctuates throughout a 24-hour period. (Potter, Perry, 7 ed., p. 743.)

Glipizide (Glucotrol) 10 mg bid PO has been ordered for an adult client with type 2 diabetes. The nurse would explain to the client that the medication reduces the blood sugar level by what process?

1. Delays the cellular uptake of potassium and insulin 2. Stimulates insulin release from the pancreas 3. Decreases the body's need for and utilization of insulin at the cellular level 4. Interferes with the absorption and metabolism of fats and carbohydrates Rationales (2) The sulfonylureas reduce the blood glucose level by stimulating insulin release from the pancreas. Over a long period of time, sulfonylureas may actually increase insulin effects at the cellular level and decrease glucose production by the liver. This is the reason that sulfonylureas are prescribed for clients with type 2 diabetes who still have a functioning pancreas. (Lehne, 7 ed., pp. 675-676.)

A client is scheduled for a routine glycosylated hemoglobin (HbA1C) test. What is important for the nurse to tell the client before this test?

1. Drink only water after midnight and come to the clinic early in the morning. 2. Eat a normal breakfast and be at the clinic 2 hours later. 3. Expect to be at the clinic for several hours because of the multiple blood draws. 4. Come to the clinic at the earliest convenience to have blood drawn. Rationale: (4) Glucose attaches to the hemoglobin molecule of the red blood cell. A glycosylated hemoglobin test gives an average of blood glucose over the past 3 to 4 months, and a blood sample can be obtained at any time during the day. It is not used in the diagnosis of diabetes and does not need to be a fasting specimen. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1223.)

The nurse is teaching a client about taking a thyroid replacement hormone. Which should be included as symptoms to watch for associated with overdose?

1. Dry skin, tremors, and weight gain 2. Sneezing, coughing, and insomnia 3. Tachycardia, angina, and nervousness 4. Bradycardia, somnolence, and sweating Rationale: (3) The client should be taught signs of thyroid hormone overdose, which are tachycardia, chest pain, nervousness, insomnia, diaphoresis, tremor, and weight loss. If the dosage is especially large, then a thyrotoxic crisis may occur. (Lewis, et al, 8 ed., p. 1265.)

What will the nurse teach the client with diabetes regarding exercise in the treatment program? Select all that apply.

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. 2. With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required. 3. Exercise increases the HDL and decreases the chance of stroke and heart disease. 4. The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake. 5. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin. Rationale:(1, 3) As carboyhdrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation. Increased HDLs have been associated with a decrease in syndrome x (Metabolic Syndrome). (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 959, 1219, 1223.)

What is the primary action of insulin in the body?

1. Enhances the transport of glucose across cell walls 2. Aids in the process of gluconeogenesis 3. Stimulates the pancreatic beta cells 4. Decreases the intestinal absorption of glucose Rationale: (1) Insulin acts to lower the blood sugar level, primarily by improving the transport of glucose into the cells. It is the principal regulator of the metabolism and storage of fats, carbohydrates, and proteins. It is a hormone produced in the beta cells in the islets of Langerhans of the pancreas. The rise in insulin after a meal stimulates the conversion of glucose to glycogen, inhibits gluconeogenesis, enhances fat deposition, and increases protein synthesis. It does not decrease intestinal absorption of glucose but works in the bloodstream to promote glucose transport across the cell membrane to the cytoplasm of the cell. (Lehne, 7 ed., p. 664.)

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently asleep. How would the nurse know whether the client was having a hypoglycemic reaction?

1. Feel the client and bed for dampness. 2. Observe the client for Kussmaul respirations. 3. Smell the client's breath for acetone odor. 4. Note if the client is incontinent of urine. Rationale: (1) When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated with hyperglycemia. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1245.)

The nurse is administering metformin (Glucophage) to a client. What nursing observations would cause the nurse concern regarding side effects of the medication?

1. Gastrointestinal upset 2. Photophobia 3. Hyperglycemia 4. Skin eruptions Rationale (1) Anorexia, nausea, and a metallic taste in the mouth are common side effects, but can contribute to the client not taking the medication if unaware of the expected side effects. Over time, the gastrointestinal symptoms subside and can be relieved by taking the medication with food or by starting at a lower dose. (Lehne, 7 ed., p. 674.)

The nurse is conducting discharge teaching for a client with Addison disease. What would the nurse advise the client to carry at all times? Select all that apply.

1. Hydrocortisone 2. Epinephrine 3. An injectable diuretic agent 4. The physician's phone number 5. The client's medication schedule 6. Documentation of the client's diagnosis Rationale (1, 4, 5, 6) A client with Addison disease should always wear a medical alert ID bracelet and should carry an emergency kit, which should include 100 mg of IM hydrocortisone and directions for its injection, the physician's phone number, and the client's diagnosis and medication schedule. (Lewis, et al, 8 ed, p. 1282.)

The nurse is teaching the parents of a child who is experiencing difficulty with control of his diabetes. Which of the following agents should the nurse teach the parents to administer if their child loses consciousness and has a severe hypoglycemic reaction?

1. IV dextrose 2. Subcutaneous insulin 3. Subcutaneous glucagon 4. Oral fast-acting carbohydrate Rationale: (3) If the child has a severe hypoglycemic episode, he frequently is neurologically compromised. It is important to administer subcutaneous or intramuscular glucagon. Subcutaneous insulin would further worsen the child's condition. IV dextrose would be given in the hospital. Oral administration of fast-acting carbohydrates is reserved for the conscious child who is not having a severe hypoglycemic reaction. (Lehne, 7 ed., p. 672.)

A client with an acute exacerbation of ulcerative colitis has type 2 diabetes that is controlled with diet and metformin (Glucophage). The health care provider orders prednisone to reduce inflammation in the colon. What would the nurse anticipate as part of the client's plan of care?

1. Increase in fiber and calories in daily diet 2. Increase in adverse side effects caused by the combination drug therapy 3. Add insulin therapy while on prednisone 4. More frequent monitoring of glycosolated hemoglobin levels Rationale: (3) The addition of insulin to the client's diabetic medication regime would be required because of prednisone, which in high doses increases the blood sugar. More frequent monitoring of glycosolated hemoglobin is unnecessary, but rather more frequent glucose monitoring while on the insulin. Taking the two medications together should not increase the likelihood of adverse effects. Prednisone will increase the appetite, so calories and fluids should be monitored to avoid weight gain and fluid retention. (Lewis, et al, 8 ed., p. 1222.)

A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritic pain. An expected change that requires close monitoring by the nurse is.

1. Increased blood glucose level 2. Increased platelet aggregation 3. Increased creatinine clearance 4. Decreased white blood cell count Rationales: (1) An adverse reaction to corticosteroids is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Creatinine clearance measures renal function. Platelet aggregation is associated with hematologic disorders. Clients taking corticosteroids are at increased risk for infection due to suppressed immune response and not a decrease in WBCs.

The physician orders hydrocortisone daily for a client with Addison disease. The nurse explains to the client that the dosage may need to be adjusted because of which concern?

1. Increased food intake 2. An increase in blood glucose levels 3. Increased stress levels 4. Stomach discomfort Rationale: (3) Stress levels in the body will cause utilization of increased amounts of cortisol. With the lack of steroids caused by adrenal insufficiency associated with Addison disease, it would be important to maintain the level of cortisone in the body to keep the body functioning appropriately. (Lewis, et al, 8 ed., p. 1281.)

The nurse is teaching a client about her medication. Which of the following will guide the nurse's explanation about glyburide (Micronase)?

1. It is thought to stimulate insulin production and release from the pancreas. 2. With prolonged use, it may decrease cellular sensitivity to insulin. 3. It is an analog of insulin and acts by directly stimulating the beta cells of Langerhans. 4. It reduces the blood sugar level by decreasing the rate of lipolysis, preventing gluconeogenesis. Rationale: (1) Glyburide is a second-generation sulfonylurea whose primary action is to stimulate the release of insulin from the pancreatic islet cells. The second-generation sulfonylureas are more potent than first-generation ones, such as tolbutamide (Orinase), and with prolonged use, may increase cellular sensitivity to insulin. (Lehne, 7 ed., pp. 675-676.)

The nurse understands the following about the correct administration of insulin lispro:

1. It needs to be taken after the meals. 2. It should be taken within 15 minutes of beginning a meal. 3. It is to be taken once daily at the noon meal. 4. It is taken only in the evenings with a snack before bedtime. Rationale: (2) Rapid-acting insulins, such as insulin lispro (Humalog) and insulin aspart (Novolog), are able to more closely mimic the body's natural rapid insulin output after consumption of a meal, which is why both medications usually are administered within 15 minutes of beginning a meal. (Lehne, 7 ed., p. 665.)

A nurse knows the clinical manifestations of a client with Addison's disease include which of the following? Select all that apply.

1. Nausea 2. Hypothermia 3. Hypertension 4. Hyperpigmentation 5. Hypotension 6. Hypernatremia Rationale: (1, 4, 5) Addison's disease is due to a hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation (melanosis) is a classic sign. This bronze coloring of the skin is seen primarily in those areas exposed to the sun, pressure points, joints, and in skin creases (especially on the palms, knuckles, and elbows). Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1280.)

A client with diabetes receives 10 units of regular insulin at 6:00 am and does not eat breakfast. About noon, what observation would the nurse expect to see?

1. Polydipsia 2. Polyphagia 3. Polyuria 4. Diaphoresis Rationale: (4) The nurse would expect symptoms of hypoglycemia, which include diaphoresis, shakiness, fatigue, hunger, and low blood sugar. The three Ps—polydipsia, polyphagia, and polyuria—are observed in hyperglycemia. (Lehne, 7 ed., p. 665.)

An 8-year-old boy with type 1 diabetes has been receiving NPH and regular insulin. His mother calls the nurse and explains that the child's morning blood glucose readings have been above 200 mg/dL. What should the nurse advise the mother to do?

1. Raise his NPH dose by two units to cover the elevation in the early morning. 2. Change the time of the night dose to 1 hour before sleep. 3. Do blood glucose checks during the night. 4. Keep a glass of water near the bed to dilute the sugar levels during the night. Rationale: (3) The child is having a rapid decrease in his blood glucose level during the night, causing a hyperglycemic rebound response. The rebound rise in the blood sugar reading is picked up in the morning blood glucose reading, which can lead to misinterpretation. This may be classified as a Somogyi effect. (Hockenberry, Wilson, 9 ed., p. 1603.)

A client receiving insulin asks if the disposable needles and syringes can be used more than once. The nurse's response should be based on what information? Needle reuse:

1. Should not be practiced because of increased rate of infection 2. Is appropriate once per day 3. Is acceptable if the client has limited financial resources 4. Is acceptable if there is no needle contamination Rationale (4) it is acceptable practice for the client to reuse their disposable needles and syringes. Increases in rates of infection have not been documented in the research, and there is a considerable cost saving. A nurse should stress the importance of vigorous handwashing before handling any equipment, in addition to the importance of capping the syringe immediately after use. The needle should not be used indefinitely. Depending on number of injections, 1 to 3 days would be an acceptable guideline for reusing the needles. (Potter, Perry, 7 ed., p. 749.)

An adult with a diagnosis of hypothyroidism has been prescribed thyroid replacement therapy with levothyroxine (Synthroid). After 1 week, she calls to complain that she feels no better. The nurse's response should be based on the fact that:

1. The client may require a different preparation of the medication 2. The client did not take her medication as instructed 3. Synthroid does not reach peak effect for at least a month 4. The client's diet may be causing absorption problems Rationale: (3) Clients should understand that it takes at least a month for thyroid replacement medication to cause plasma levels to reach a plateau and have therapeutic effects. This is because the hormone, levothyroxine, has a half-life of approximately 7 days. Because of the long half-life of the hormone, levels remain steady between doses, which makes this medication well suited for lifelong therapy with once-a-day dosing. (Lehne, 7 ed., p. 693.)

What would be important for the nurse to include in the teaching plan for clients who are taking insulin?

1. The client should use only the injection sites that are most accessible. 2. During times of illness, clients should increase their insulin dosage by 25%. 3. When mixing insulins, the NPH insulin should be drawn up into the syringe first. 4. When mixing insulins, regular insulin should be drawn up into the syringe first. Rationale: (4) If mixing insulins, the regular insulin should always be drawn up into the syringe first. Remember: clear to cloudy; regular insulin first, followed by cloudy ones, such as NPH and Ultralente. Clients should always rotate injection sites (preferably in the abdomen) and should notify their physicians if they become ill. (Lehne, 7 ed., pp. 668, 685.)

A client who is planning a trip to the beach is taking glipizide (Glucotrol). What would be important for the nurse to discuss with the client?

1. The importance of eating night-time and between-meal snacks 2. The problems associated with fluid retention in a warm climate 3. Skin sensitivity resulting from exposure to saltwater 4. Wearing sunscreen and avoiding direct sunlight Rationale: (4) Orally hypoglycemic agents, such as the sulfonylureas, may increase sensitivity to sunlight, resulting in sunburn (photosensitivity). The nurse must teach the client to wear sunscreen and to avoid excessive exposure to sunlight. Fluid retention is a prominent side effect of the "glitazones," or oral hypoglycemic medications, such as rosiglitazone (Avandia). (Lehne, 7 ed., p. 1026.)

A child with newly diagnosed diabetes is in the emergency room and is unconscious. Glucagon has been prescribed for treatment of hypoglycemia. What would be important nursing management? Select all that apply.

1. Watch for side effects of hypoglycemia 2. Child usually awakens within 20 minutes of receiving glucagon. 3. Vomiting may occur after administration, so aspiration precautions should be taken. 4. Do not rotate sites for administration, because even absorption in the abdomen is best. 5. Give PO glucagon once the client has consciousness. 6. Monitor blood values for increasing blood sugar. Rationale: (1, 2, 3, 6) Glucagon is the medication of choice used to elevate blood sugar levels after insulin overdose. It does not correct hypoglycemia resulting from starvation. Rebound hypoglycemia is a potential adverse effect, which is why it is important for the client to have carbohydrates once consciousness returns. No significant side effects exist. If unconscious when administered, the child usually awakens in 5 to 20 minutes after receiving glucagon. Vomiting may occur after administration, so aspiration precautions should be taken by placing the child on the side. Blood work to monitor an increase in blood sugar (desired outcome) would be collected. IV is the preferred method of glucagon administration, although the medication is able to be given subQ and IM, not PO. When client is conscious, oral carbohydrates and protein should be given. (Lehne, 7 ed., p. 683.)

It is important for the nurse to teach the client which of the following about metformin (Glucophage)?

1. it may cause constipation 2. it should be taken at night 3. it should be taken with meals 4. it may increase the effects of aspirin (3) Metformin (Glucophage) is administered with meals to minimize gastrointestinal effects. These adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste. Metformin interacts with alcohol and cimetidine and is contraindicated in heart failure and liver disease and in clients with compromised renal function. (Lehne, 7 ed., pp. 674-675.)`