NURS 401: Ch. 33 (Porth): Diabetes & Metabolic Syndrome

A client has been admitted with diabetic ketoacidosis. The emergency department starts an IV to improve circulatory volume. If there is a sudden change in extracellular fluid osmolality which results in a too rapid blood glucose lowering, the nurse will likely observe which clinical manifestations? Rapid, deep respirations, palpitations, low BP. Increase urine output, thirst, vomiting. Chills, profuse sweating, weakness. Headaches, dizziness, change in level of consciousness.

Headaches, dizziness, change in level of consciousness. Explanation: A sudden change in osmolality of extracellular fluid can also occur when blood glucose levels are lowered too rapidly, and this can cause cerebral edema, more common in children than adults. The other responses all have some component of signs/symptoms of DKA rather than cerebral edema signs and symptoms.

The nurse has just completed teaching a client, newly diagnosed with type 1 diabetes, about the treatment options. Which response by the client leads the nurse to conclude that addidtional teaching is needed? "An exercise plan will be helpful for prevention of long-term complications." "If I forget my insulin in the morning, I should take it as soon as I can to prevent hyperglycemia." "If I work on losing some weight, that might help prevent complications later." "So I can stop my insulin if I start an exercise program."

"So I can stop my insulin if I start an exercise program." Explanation: Clients with type 1 diabetes require insulin therapy from the time of diagnosis. Weight loss and dietary management may be sufficient to control blood glucose levels. Treatments which involve medical nutrition therapy, exercise, and insulin will help prevent complications later on as the client ages.

A 3-year-old girl has just been diagnosed with type 1A diabetes. Her parents are currently receiving education from the diabetes education nurse. How can the nurse best explain to the parents the etiology (cause) of their daughter's diabetes? "The problem that underlies her diabetes is that her own body has destroyed the cells in her pancreas that produce insulin." "It's not known exactly why your daughter has completely stopped making insulin, and treatment will consist of your rigidly controlling her diet." "This tendency to produce insufficient amounts of insulin is likely something that she inherited." "Environmental and lifestyle factors are known to play a part in the fact that her pancreas secretes and withholds insulin at the wrong times."

"The problem that underlies her diabetes is that her own body has destroyed the cells in her pancreas that produce insulin." Explanation: Type 1A, or immune-mediated, diabetes involves the autoimmune destruction of pancreatic beta cells and a consequent absolute lack of insulin. Exogenous insulin is required as dietary control alone is insufficient. The central problem is an absolute lack of insulin production rather than deranged release.

A client with a new diagnosis of type 2 diabetes mellitus states, "I am really worried that I might need to take injections. Is there something I can do to avoid that?" What is the best response by the nurse? "Diabetes management is complicated; you can't avoid injections." "You could regulate your diet, exercise regularly, and lose weight." "A support group could help you cope with stress and learn helpful tips." "If you exercise weekly, you won't need injections."

"You could regulate your diet, exercise regularly, and lose weight." Explanation: Diabetes management is based on dietary regulation, exercise, and medications. Many clients with type 2 diabetes mellitus can avoid injections if they exercise regularly, follow dietary guidelines, and manage their weight.

Which manifestation indicates a client is at risk for developing diabetes mellitus? Fasting blood glucose level 75 mg/dL (4.16 mmol/L) Hemoglobin A1 5.0% (.05) 2 hour oral GTT 175 mg/dL (9.7 mmol/L) Serum potassium 4.2 mEq/L (4.2 mmol/L)

2 hour oral GTT 175 mg/dL (9.7 mmol/L) Explanation: Laboratory values that are considered normal are hemoglobin A1C less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dL or less than 140 mg/dL 2 hours after an oral glucose tolerance test (GTT). A hemoglobin A1C value that is greater than or equal to 6.5 percent; a fasting blood glucose greater than 126 mg/dL, or a blood glucose level greater than 200 mg/dL 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus. Potassium levels do not directly correlate with a diagnosis of diabetes mellitus.

A 60 year-old man has long managed his type 1 diabetes effectively with a combination of vigilant blood sugar monitoring, subcutaneous insulin administration, and conscientious eating habits. This morning, however, his wife has noted that he appears pale and clammy and appears to be in a stupor, though he is responsive. She suspects that he has made an error in his insulin administration and that he is experiencing a hypoglycemic episode. Which action should be the wife's first choice? Administration of 15 to 20 g of glucose in a concentrated carbohydrate source. IV infusion of 50% dextrose and water solution. Careful monitoring for level of consciousness and resolution of hypoglycemia. Administration of subcutaneous glucagon.

Administration of 15 to 20 g of glucose in a concentrated carbohydrate source. Explanation: An insulin reaction necessitates intervention in addition to careful observation. The ideal response to an insulin reaction in a still conscious client is the administration of 15 to 20 g of glucose in a concentrated carbohydrate source. Glucagon or D50 would be indicated if the client is unconscious or unable to swallow.

The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. The nurse teaches the student that epinephrine will cause which effect on blood glucose levels? An unusable form of glucose will be released. Hypoglycemia will occur. Gluconeogenesis will occur. Blood glucose will elevate.

Blood glucose will elevate. Explanation: Epinephrine, a catecholamine, helps to maintain blood glucose levels during periods of stress. Epinephrine causes glycogenolysis in the liver, thus causing large quantities of glucose to be released into the blood.

Which clinical manifestations would the nurse identify as indications of increased blood glucose levels? Select all that apply. Fatigue Hypertension Blurred vision Thirst Skin infections

Blurred vision Thirst Fatigue Skin infections Explanation: Polyuria, polyphagia, and polydipsia are three classic signs of diabetes. Hypotension and fatigue are signs of hypovolemia that may accompany increased blood glucose levels. Skin infections occur frequently in type 2 diabetes. Blurred vision results from exposure of the lens and retina to hyperosmotic fluids.

A client with diabetes mellitus has sudden onset of slurred speech, incoordination, and cool, clammy skin. What will the nurse do first? Check blood glucose Notify the physician Provide cheese and crackers Administer glucose

Check blood glucose Explanation: Hypoglycemia is a medical emergency. Because other conditions can also cause these symptoms, the blood glucose level should be checked first. Then glucose should be given. The client should follow this with a protein and complex carbohydrate to avoid a recurrence of hypoglycemia. Blood glucose should be tested about 15 minutes after the glucose is given to monitor progress.

The nurse and nursing student are performing medication reconciliation. Which medications taken by the client with diabetes does the nurse teach the student are implicated in causing hyperglycemia? Select all that apply. Antidepressants Loop diuretics Glucocorticoids Intravenous fluid Oral contraceptives

Correct response: Loop diuretics Glucocorticoids Oral contraceptives Explanation: Diuretics, specifically thiazide and loop diuretics, can elevate blood glucose. These diuretics increase potassium loss, which is thought to impair beta cell release of insulin. Other drugs and therapies known to cause hyperglycemia include diazoxide, glucocorticoids, oral contraceptives, antipsychotic agents, and total parenteral nutrition.

Which metabolic abnormalities can cause type 2 diabetes? Select all that apply. Deranged secretion of insulin Decreased glucose production by the pancreas Hypersensitivity to insulin Increased glucose production by the liver Insulin resistance

Deranged secretion of insulin Insulin resistance Increased glucose production by the liver Explanation: The metabolic abnormalities that lead to type 2 diabetes include (1) insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver.

A 23-year-old man is admitted to the hospital. He is experiencing polyphagia, polyuria, and polydipsia. He states that the condition has come on very suddenly. This client is likely to require what treatment? Biguanides Exogenous insulin injections Meglitinides Sulfonylureas

Exogenous insulin injections Explanation: Type 1 diabetes is the best diagnosis as the client has no other symptoms and the disease presented so rapidly. Insulin will likely be necessary and oral antihyperglycemics will not be sufficient. Meglitinides treat type 2 diabetes.

A 40-year-old man who is morbidly obese and leads a sedentary lifestyle has recently been diagnosed with type 2 diabetes. Which aspects of the man's obesity likely contributed to his new health problem? Fat tissue initiates glycogenolysis and reliance on glycogen release rather than metabolism of free glucose. Free fatty acids contribute to problems such as beta cell dysfunction and insulin resistance. The low metabolic needs of adipose tissue mimic a hypoglycemic state and suppress insulin secretion. Triglyceride deposits in the pancreas result in damage to beta cells.

Free fatty acids contribute to problems such as beta cell dysfunction and insulin resistance. Explanation: Type 2 diabetes in obese people is thought to link to the actions of free fatty acids, which include beta cell dysfunction (lipotoxicity), insulin resistance, glucose underutilization, and the accumulation of FFAs and triglycerides to reduce hepatic insulin sensitivity.

Type 1A diabetes is now considered an autoimmune disorder. What factors are considered necessary for type 1A diabetes to occur? Diabetogenic gene from both parents, physiologic triggering event, and an allergic reaction to pancreatic delta cells Genetic predisposition, physiologic triggering event, allergic reaction to pancreatic alpha cells Diabetogenic gene from both parents, environmental triggering event, and a B-lymphocyte reaction to alpha cell antigens Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen

Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen Explanation: Type 1A diabetes is thought to be an autoimmune disorder resulting from a genetic predisposition (i.e., diabetogenic genes); an environmental triggering event, such as an infection; and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen.

The nurse is caring for a client who received regular insulin at 7 am. Four hours later the nurse finds the client diaphoretic, cool, and clammy. Which of these interventions is the priority? Place the client in the supine position. Bathe the client with tepid water. Repeat the dose of insulin. Give the client a concentrated carbohydrate.

Give the client a concentrated carbohydrate. Explanation: The client is displaying symptoms of hypoglycemia, which include headache, difficulty in problem solving, altered behavior, coma, and seizures. Hunger may occur. Activation of the sympathetic nervous system may cause anxiety, tachycardia, sweating, and cool and clammy skin.

A client is diagnosed with type 2 diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome? Glycosylated hemoglobin 5.2% (0.52) High-density cholesterol 35 mg/dL (0.91 mmol/L) Blood pressure 148/90 mm Hg Fasting blood glucose 155 mg/dL (8.60 mmol/L)

Glycosylated hemoglobin 5.2% (0.52) Explanation: The goals of the nutritional plan for type 2 diabetes mellitus include normal glucose levels, normal lipid levels, weight loss to ideal body weight (or at least 5% to 10% of total body weight) and regulating blood pressure. High-density cholesterol should be above 60 mg/dL (1.55 mmol/L).

During periods of fasting and starvation, the glucocorticoid and other corticosteroid hormones are critical for survival because of their stimulation of gluconeogenesis by the liver. When the glucocorticoid hormones remain elevated for extended periods of time, what can occur? Adrenal hyperplasia Portal hypertension Hyperglycemia Hepatomegaly

Hyperglycemia Explanation: In predisposed persons, the prolonged elevation of glucocorticoid hormones can lead to hyperglycemia and the development of diabetes mellitus and starvation. They stimulate gluconeogenesis by the liver, sometimes producing a 6- to 10-fold increase in hepatic glucose production. A prolonged increase in glucocorticoid hormones does not cause hepatomegaly, portal hypertension, or adrenal hyperplasia.

A client with diabetes asks the nurse for advice in controlling between-meal blood glucose levels. Which of these might the nurse suggest as a long-acting insulin to provide a consistent basal level? Insulin aspart Insulin glulisine Regular insulin Insulin glargine

Insulin glargine Explanation: Glargine is a long-acting peakless insulin that provides consistent basal levels over a 20- to 24-hour period. Regular insulin has a duration of 5 to 7 hours. Aspart and glulisine have the most rapid onset and shortest duration of action, making them optimal for postprandial glucose control.

A client is brought to the emergency department with a suspected diagnosis of DKA (diabetic ketoacidosis). Select the assessment data (or diagnostic data) to confirm the diagnosis. Select all that apply. Negative serum ketones Hypoglycemia Low serum bicarbonate High arterial pH Positive urine ketones

Low serum bicarbonate Positive urine ketones Explanation: The definitive diagnosis of DKA consists of hyperglycemia (blood glucose levels >250 mg/dL [13.8 mmol/L]), low serum bicarbonate, low arterial pH, and positive urine and serum ketones.

The nurse screening for diabetes mellitus at a health fair obtains these results. Which client should be referred to a primary health care provider for further evaluation? Fasting blood glucose 89 mg/dL (4.94 mmol/L) Urine ketones 0 Hemoglogin A1C 6.0% (.06) Random blood glucose 195 mg/dL (10.82 mmol/L)

Random blood glucose 195 mg/dL (10.82 mmol/L) Explanation: Laboratory values that are considered normal are hemoglobin A1C less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dL or less than 140 mg/dL 2 hours after an oral glucose tolerance test (GTT). Urine should be free of ketones. A hemoglobin A1C value that is greater than or equal to 6.5 percent, a fasting blood glucose greater than 126mg/dL, or a blood glucose level greater than 200 mg/dL 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus and require further evaluation. A random blood glucose level is expected to correlate with the two-hour GTT results and should be below 200 mg/dL.

A woman in her 28th week of pregnancy tests positive for gestational diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome? Glycosylated hemoglobin 7.2% (.07) Random blood glucose 85 mg/dL (4.72 mmol/L) Gained 5 lb in one week 1% ketones present in urine

Random blood glucose 85 mg/dL (4.72 mmol/L) Explanation: The goals of the nutritional plan for gestational diabetes mellitus (GDM) include normal glucose levels, no ketosis, proper weight gain for the pregnancy, and adequate nutrition for fetal health.

A client presents to the emergency room with fatigue, weakness, dehydration, and thirst. What additional symptoms would correlate with a diagnosis of type 1 diabetes mellitus? Select all that apply. Recent weight loss Blurred vision Joint pain Insomnia Polyuria

Recent weight loss Polyuria Blurred vision Explanation: The cardinal manifestations of diabetes mellitus are the three "polys": polyuria, polydipsia, and polyphagia, and weight loss. Additional symptoms include fatigue and weakness, blurred vision, and skin infections.

The nurse is teaching a client with diabetes about the signs and symptoms of hypoglycemia. The client asks, "Why will I get headache, disturbed behavior, coma, and seizures if it's my pancreas that's impaired?" Which response is the best explanation? Hypoglycemia causes ketone breakdown. The brain relies on blood glucose as its main energy source. Insulin produces a rebound hyperglycemia. Hepatic glycogenolysis

The brain relies on blood glucose as its main energy source. Explanation: Because the brain relies on blood glucose as its main energy source, hypoglycemia produces behaviors related to altered cerebral function. Headache, difficulty in problem solving, disturbed or altered behavior, coma, and seizures may occur. Hyperglycemia causes ketone breakdown. Hepatic glycogenolysis is stimulated by epinephrine, resulting in the raising of the level of blood glucose. However, that process is generally initiated by the fight-or-flight response, as opposed to the physiologic drop in blood glucose levels that stimulates glucagon secretion. Somogyi phenomenon is also known as rebound hyperglycemia. The Somogyi phenomenon describes a rebound high blood glucose level in response to low blood glucose.

A client is managing diabetes with exercise and diet. The health care provider reviews the client's most recent laboratory results: fasting blood glucose level at 80 mg/dL (4.44 mmol/L) and a hemoglobin A1C of 5% (0.05). Select the response that best identifies the client. The client is at risk for an insulin reaction. The client needs to modify the diet related to the low readings. The client is achieving normal glycemic control. The client is at risk for developing hyperglycemia.

The client is achieving normal glycemic control. Explanation: The reading for the fasting blood glucose is appropriate, and the hemoglobin A1C level estimates good control of glucose levels over a 6- to 12-week period. This client should continue the exercise and diet routine as planned.

The nurse is teaching a client about a sulfonylurea medication. Which teaching points should be included in the discussion? Select all that apply. Hypoglycemia may result from this type of medication. Insulin is a type of sulfonylurea. A sulfonylurea is useful in type 1 diabetes. If all beta cells are destroyed, this medication is useful. These medications cause insulin to be released from the pancreas.

These medications cause insulin to be released from the pancreas. Hypoglycemia may result from this type of medication. Explanation: The sulfonylureas are used in the treatment of type 2 diabetes and cannot be substituted for insulin in people with type 1 diabetes, who have an absolute insulin deficiency. These medications reduce blood glucose by increasing insulin to be released from the pancreas and therefore can cause hypoglycemia.

A client with type 1 diabetes mellitus wishes to stop taking insulin injections. What option is appropriate? Taking metformin Using an insulin infusion pump Increasing daily aerobic activity Taking the herb chromium picolinate

Using an insulin infusion pump Explanation: Clients with type 1 diabetes mellitus require exogenous insulin because they have absolute lack of their own secretion. Insulin is a protein that would be digested if taken orally. To avoid injections, clients could use an insulin pump, which provides continuous infusion through a catheter placed under the skin that is changed every few days. While some herbal preparations may help lower blood glucose, they do not replace insulin. While aerobic activity helps mobilize glucose, it does not replace insulin. Metformin is an insulin sensitizer that enhances insulin utilization, but does not replace insulin.

ketosis

breakdown of fats for energy, resulting in an increase in ketones to be excreted from the body

Polyphagia

excessive hunger

Polydipsia

excessive thirst

Polyuria

excessive urination

What are the intermediate to long acting insulins?

glargine, detemir, and NPH

What are the rapid-acting insulins?

lispro, aspart, glulisine

glycosuria

presence of glucose in the urine

A client admitted to the hospital with elevated blood glucose is diagnosed with type 2 diabetes mellitus. What characteristics commonly differentiate type 2 diabetes mellitus from type 1 diabetes mellitus? Select all that apply. HgbA1C 7.5% (.07) Onset after age 35 Overweight Insulin required for management Abrupt onset of symptoms

Correct response: Onset after age 35 Overweight Explanation: Diabetes mellitus (DM) type 1 commonly occurs before age 20 with abrupt onset of polyuria, polyphagia, and polydipsia, and is the result of autoimmune destruction of beta cells, which causes the necessity of exogenous insulin to regulate blood sugar. Glycosylated hemoglobin, also called hemoglobin A1C, will be elevated in uncontrolled diabetes mellitus of any type. Diabetes mellitus type 2 generally occurs after age 35 to clients who are overweight. The symptoms develop over a longer period of time. Often clients who lose weight or implement diet changes do not need insulin to control blood glucose because the beta cells are not destroyed.

Select the most common symptoms of diabetes. Select all that apply. Polyphagia Polyhydramnios Polycythemia Polyuria Polydipsia

Correct response: Polydipsia Polyuria Polyphagia Explanation: The most commonly identified signs and symptoms of diabetes are often referred to as the three polys: (1) polyuria (i.e., excessive urination), (2) polydipsia (i.e., excessive thirst), and (3) polyphagia (i.e., excessive hunger). Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. Polycythemia is a condition of increased red blood cells.

How does insulin participate in cellular metabolism? Select all that apply. Increases amino acid conversion to glucose Promotes triglyceride synthesis in the liver Increases use of fatty acids as fuel Promotes glycogen conversion to glucose Transports glucose into skeletal muscle

Correct response: Transports glucose into skeletal muscle Promotes triglyceride synthesis in the liver Increases use of fatty acids as fuel Explanation: Insulin is needed to transport glucose into cells, prevent fat breakdown, and inhibit gluconeogenesis. Glucagon works to raise blood glucose levels by converting amino acids to glucose, activating lipase to release fatty acids for energy, and to promote glycogenolysis, breaking down glycogen to glucose.

A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes. The best diagnostic indicator that would support the client's response would be: Urine test Glycosylated hemoglobin, hemoglobin A1C (HbA1C) Capillary blood glucose sample Fasting blood glucose level

Glycosylated hemoglobin, hemoglobin A1C (HbA1C) Explanation: Glycosylated hemoglobin, hemoglobin A1C (HbA1C), and A1C are terms used to describe hemoglobin into which glucose has been incorporated. Glycosylation is essentially irreversible, and the level of A1C present in the blood provides an index of blood glucose levels over the previous 6 to 12 weeks. In uncontrolled diabetes or diabetes with hyperglycemia, there is an increase in the level of A1C. The other options would not reflect the 2-month period.

A client with diabetes carries insulin with him at all times. At 11:35, he obtains a blood glucose reading of 218 mg/dL (12.1 mmol/L) and self-administers a dose of insulin in anticipation of eating lunch at noon. What type of insulin did he most likely inject? Intermediate acting Premixed Short acting Long acting

Short acting Explanation: Short-acting (regular) insulin is used to facilitate metabolism of the food that is being eaten. Premixed insulin is possible, but is not used as commonly. Intermediate- and long-acting insulin would have too distant an onset.

An obese adult has recently been diagnosed with type 2 diabetes. The nurse knows that the most likely treatment plan for this client will include which topics? Weight loss, glucose monitoring, and oral antihyperglycemic medications Continuous subcutaneous insulin infusion (CSII) and nutrition management Daily monitoring for urine ketones and weight loss measures. Injectable insulin, nutrition management, and adequate hydration

Weight loss, glucose monitoring, and oral antihyperglycemic medications Explanation: Persons with type 2 diabetes would be unlikely to require insulin initially and oral medications are likely to be of benefit as an addition to weight loss and glucose monitoring.

The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which risk factor in the teaching? First pregnancy Woman with a family history of diabetes First birth occurring during the teenage years Woman who has had a child under 5 lb (2.2 kg)

Woman with a family history of diabetes Explanation: Gestational diabetes occurs most commonly in black, Hispanic/Latino and Native American/First Nation women. It most frequently affects women with a family history of diabetes; a history of stillbirth or spontaneous abortion; women who previously gave birth to a newborn with fetal anomaly or had a previous large-for-gestational-age infant; those who are obese; those of advanced maternal age; or those who have had five or more pregnancies.