11) Chapter 67: Care of Patients with Diabetes Mellitus

The nurse is providing discharge teaching to the client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching? A. "I can break in my shoes by wearing them all day." B. "I need to monitor my feet daily for blisters or skin breaks." C. "I should never go barefoot." D. "I should quit smoking."

A. "I can break in my shoes by wearing them all day." Rationale A. Shoes should be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering. B. People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. C. People with diabetes have decreased sensation to the lower extremities and a higher risk for increased injury. Going barefoot is contraindicated. D. Tobacco use further decreases peripheral circulation in the diabetic client.

Which is the best referral that the nurse can suggest to a client newly diagnosed with diabetes? A. American Diabetes Association B. Centers for Disease Control and Prevention C. Health care provider office D. Pharmaceutical representative

A. American Diabetes Association Rationale A. The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families. B. The Centers for Disease Control and Prevention does not focus on diabetes. C. The client's health care provider's office is not the best resource for diabetes information and support. D. A pharmaceutical representative is not an appropriate resource for diabetes information and support.

The nurse is teaching the client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A. "I should go barefoot in my house so that my feet are exposed to air." B. "I must inspect my shoes for foreign objects before putting them on." C. "I will soak my feet in warm water to soften calluses before trying to remove them." D. "I must wear canvas shoes as much as possible to decrease pressure on my feet."

B. "I must inspect my shoes for foreign objects before putting them on." Rationale A. Diabetic clients should not go barefoot. Foot injuries can occur. B. To avoid injury or trauma to the feet, shoes should be inspected for foreign objects before they are put on. C. To avoid injury or trauma, a callus should be removed by a podiatrist, not by the client. D. The diabetic client must wear firm support shoes.

When preparing a mixed insulin injection, which action does the nurse perform first? A. Draws up the longer-acting insulin B. Draws up the short-acting insulin C. Puts air in the longer-acting insulin vial D. Puts air in the shorter-acting insulin vial

C. Puts air in the longer-acting insulin vial Rationale A. Drawing up the longer-acting insulin is the fourth step in preparing a mixed insulin injection. B. Drawing up the short-acting insulin is the third step in preparing a mixed insulin injection. C. Putting air in the longer-acting insulin vial is the first step in preparing a mixed insulin injection. D. Putting air in the shorter-acting insulin vial is the second step in preparing a mixed insulin injection.

The nurse is teaching the client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A. "I should begin exercising for at least an hour a day." B. "I should monitor my diet." C. "If I lose weight, I may not need to use the insulin anymore." D. "Weight loss can be a sign of diabetic ketoacidosis."

A. "I should begin exercising for at least an hour a day." Rationale A. For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly. B. Monitoring the diet is key to type 2 diabetes management. C. Weight loss can minimize the need for insulin. D. Weight loss can be a sign of diabetic ketoacidosis.

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." These are the client's vital signs: T 98.4° F (36.9º C), P 112, R 38, BP 91/54, and O2 saturation 99% on room air. Which action should the nurse take first? A. Check the blood glucose. B. Administer oxygen. C. Offer reassurance. D. Attach a cardiac monitor.

A. Check the blood glucose. Rationale A. The client's clinical presentation is consistent with diabetic ketoacidosis, and the nurse should initially check the client's glucose level. B. Based on the oxygen saturation, oxygen administration is not necessary. C. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. D. Reassurance and cardiac monitoring may be implemented, but the first action should be to obtain the glucose level.

Why is controlling blood glucose levels important? A. High blood glucose levels increase the risk for heart disease, strokes, blindness, and kidney failure. B. High blood glucose levels increase the risk for seizure disorders, arthritis, osteoporosis, and bone fractures. C. Low blood glucose levels increase the risk for peripheral neuropathy, Alzheimer's disease, and premature aging. D. Low blood glucose levels increase the risk for obesity, pancreatitis, dehydration, and certain types of cancer.

A. High blood glucose levels increase the risk for heart disease, strokes, blindness, and kidney failure. Rationale Persistent high blood glucose levels cause major changes in blood vessels that lead to organ damage, serious health problems, and early death. The long-term complications of diabetes include heart attacks, strokes, and kidney failure. In addition, diabetes is the main cause of foot and leg amputations and new-onset blindness.

The nurse caring for four diabetic clients has the following activities to perform. Which of these is appropriate to delegate to the nursing assistant? A. Perform hourly bedside blood glucose checks for a client with hyperglycemia. B. Verify the infusion rate on a continuous infusion insulin pump. C. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability. D. Check on a client who is reporting palpitations and anxiety.

A. Perform hourly bedside blood glucose checks for a client with hyperglycemia. Rationale A. Performing bedside glucose monitoring is an activity that may be delegated because it does not require extensive clinical judgment to perform; the nurse follows up with the results. B. Intravenous therapy and medication administration are not within the scope of practice for the nursing assistant. C. This client will need further monitoring, assessment, and intervention; these are not within the scope of practice for the nursing assistant. D. This client may have hypoglycemia, requiring further intervention. He should be assessed by licensed nursing staff.

You have just received change-of-shift report on the endocrine unit. Which client should you see first? A. The type 1 diabetic client whose insulin pump is beeping "occlusion" B. The newly diagnosed type 1 diabetic client who is reporting thirst C. The type 2 diabetic client with a blood glucose of 150 mg/dL D. The type 2 diabetic client with a blood pressure of 150/90

A. The type 1 diabetic client whose insulin pump is beeping "occlusion" Rationale A. Because glucose levels will increase quickly in clients who use continuous insulin pumps, the nurse should assess this client and the insulin pump first to avoid DKA. B. Thirst is a symptom of hyperglycemia and although important, is not a priority; the nurse could delegate finger stick blood glucose to unlicensed personnel while assessing Client A. C. Although mildly elevated, this is not an emergency. D. Mild hypertension is not an emergency; Client A should be seen first.

The nurse is teaching the client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates correct understanding of hypoglycemia management? A. "I should drink a glass of water." B. "I should eat three graham crackers." C. "I should give myself 1 mg of glucagon." D. "I should sit down and rest."

B. "I should eat three graham crackers." Rationale A. Water does not remedy hypoglycemia. B. Eating three graham crackers is a correct management tactic for mild hypoglycemia. C. Glucagon should be administered only in cases of severe hypoglycemia. D. Resting does not relieve hypoglycemia.

Which statement made by the client during nutritional counseling indicates to the nurse that the client with diabetes type 1 correctly understands his or her nutritional needs? A. "If I completely eliminate carbohydrates from my diet, I will not need to take insulin." B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." C. "My intake of protein in terms of grams and calories should be the same as my intake of carbohydrate." D. "My intake of unsaturated fats in terms of grams and calories should be the same as my intake of protein."

B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." Rationale Carbohydrates are the main fuel for the human cellular engine and the substance most commonly used to make ATP. Clients who have diabetes should never consume less than 130 g of carbohydrate per day (the percentage of total calories needed is determined for each client). Protein intake should range between 15% and 30% of total caloric intake per day.

The nurse is providing discharge teaching to the client with newly diagnosed diabetes. Which statement by the client indicates correct understanding about the need to wear a medical alert bracelet? A. "If I become hyperglycemic, it is a medical emergency." B. "If I become hypoglycemic, I could become unconscious." C. "Medical personnel may need confirmation of my insurance." D. "I may need to be admitted to the hospital suddenly."

B. "If I become hypoglycemic, I could become unconscious." Rationale A. Hyperglycemia is not a medical emergency unless it is acidosis. People with diabetes tolerate mild hyperglycemia routinely. B. Hypoglycemia is the most common cause of medical emergency. A medical alert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. C. Insurance information does not appear on a medical bracelet. D. Information needed for hospital admission does not appear on a medical alert bracelet.

The client with type 1 diabetes mellitus received regular insulin at 7 AM. The client should be monitored for hypoglycemia at which time? A. 7:30 AM B. 11 AM C. 2 PM D. 7:30 PM

B. 11 AM Rationale A. Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours. B. Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours. Therefore 11 AM is the anticipated onset time for regular insulin received at 7 AM. C. 2 PM is not the anticipated peak time for regular insulin received at 7 AM. Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours. D. Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours.

The client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? A. Causes and treatment of hyperglycemia B. Causes and treatment of hypoglycemia C. Dietary control D. Insulin administration

B. Causes and treatment of hypoglycemia Rationale A. The causes and treatment of hyperglycemia is a topic for secondary teaching and is not the priority for the client with hypoglycemia. B. The causes and treatment of hypoglycemia must be understood by the client and family to manage the client's diabetes effectively. C. Dietary control is important but is not the priority in this situation. D. Insulin administration is important but is not the priority in this situation.

The client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction about the disease and its management? A. Current lifestyle B. Educational and literacy level C. Sexual orientation D. Current energy level

B. Educational and literacy level Rationale A. Although lifestyle should be taken into account, it is not the priority. B. A large amount of information must be synthesized; typically written instructions are given. This is essential information. C. Sexual orientation will have no bearing on the ability of the client to provide self-care. D. Although energy level will influence the ability to exercise, it is not essential.

You have just taken change-of-shift report on a group of clients on the medical unit. Which client should you assess first? A. The client taking repaglinide (Prandin) who has nausea and back pain B. The client taking glyburide (Diabeta) who is dizzy and sweaty C. The client taking metformin (Glucophage) who has abdominal cramps D. The client taking pioglitazone (Actos) who has bilateral ankle swelling

B. The client taking glyburide (Diabeta) who is dizzy and sweaty Rationale A. Although this client requires assessment, Client B has clear signs of hypoglycemia and needs treatment. B. This client has symptoms consistent with hypoglycemia and should be assessed first because he displays the most serious adverse effect of antidiabetic medications. C. Metformin may cause abdominal cramping and diarrhea; this client does not require immediate assessment. D. Ankle swelling is an expected side effect of pioglitazone.

The client newly diagnosed with type 1 diabetes asks why insulin is given only by injection and not as an oral drug. What is the nurse's best response? A. "Injected insulin works faster than oral drugs to lower blood glucose levels." B. "Oral insulin is so weak that it would require very high dosages to be effective." C. "Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes." D. "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."

C. "Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes." Rationale Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.

The client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? A. "It is overwhelming, isn't it?" B. "Let's see how much you can learn today, so you are less nervous." C. "Let's tackle it piece by piece. What is most scary to you?" D. "Other people do it just fine."

C. "Let's tackle it piece by piece. What is most scary to you?" Rationale A. This statement is supportive but is not therapeutic or helpful to the client. B. This statement may actually cause the client to become more nervous. An overload of information is overwhelming. C. This approach will allow the client to have a sense of mastery with acceptance. D. This statement is belittling and dismisses the client's concerns.

The client newly diagnosed with diabetes asks why he is always so thirsty. What is the nurse's best response? A. "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." B. "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." C. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." D. "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost."

C. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." Rationale: The movement of glucose into cells is impaired, and the resulting high blood glucose levels increase the osmolarity of the blood. This increased osmolarity stimulates the osmoreceptors in the hypothalamus, triggering the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.

The diabetic client has a hemoglobin (Hb)A1c level of 9.4. What does the nurse say to the client regarding this finding? A. "Keep up the good work." B. "This is not good at all." C. "What are you doing differently?" D. "You need more insulin."

C. "What are you doing differently?" Rationale A. HbA1C levels for diabetic people should be less than 7; a value of 9.4 shows poor control over the past 3 months. B. This statement, although true, does not take into account problems that the client may be having with the regimen and sounds like scolding. C. Assessing the client's regimen or changes he may have made is the basis for formulating interventions to gain control of blood glucose. D. Although this may be true, an assessment of his regimen is needed before decisions are made about medications.

The client with type 2 diabetes has been admitted for surgery, and the physician has placed her on insulin. The client wants to know why she should have to take this. What is your best response? A. "Your diabetes is worse, so you will need to take insulin." B. "You can't take your metformin while in the hospital." C. "Your body is under more stress, so you will need to have insulin to support your medication." D. "You will have to take insulin from now on because the surgery will affect your diabetes."

C. "Your body is under more stress, so you will need to have insulin to support your medication." Rationale A. No evidence suggests that the client's diabetes has worsened; however, surgery is stressful and may increase insulin requirements. B. Metformin may be taken in the hospital, however not on days when the client is NPO for surgery. C. Because of the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for the client who uses oral agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides. D. When the client returns to the previous health state, oral agents will be resumed.

Which of these clients with diabetes should the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A. A 58-year-old with sensory neuropathy who needs teaching about foot care B. A 68-year-old with diabetic ketoacidosis who has an IV running at 250 mL/hr C. A 70-year-old who needs blood glucose monitoring and insulin before each meal D. A 76-year-old who was admitted with fatigue and shortness of breath

C. A 70-year-old who needs blood glucose monitoring and insulin before each meal Rationale A. This client has teaching needs or is at risk for complications that would be more familiar to nurses who usually care for older adults with diabetes. B. This client has teaching needs or is at risk for complications that would be more familiar to nurses who usually care for older adults with diabetes. C. A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit. D. This client has needs for assessment of complications more familiar to nurses who usually care for older adults with diabetes.

A client with type 2 diabetes who also has heart failure is prescribed metformin extended-release (Glucophage XR) once daily. On assessment, the nurse finds that the client now has muscle aches, drowsiness, low blood pressure, and a slow, irregular heartbeat. What is the nurse's best action? A. Assess the client's blood glucose level and prepare to administer IV glucose. B. Reassure the client that these symptoms are normal effects of this drug. C. Hold the dose and notify the prescriber immediately. D. Administer the drug at bedtime to prevent falls.

C. Hold the dose and notify the prescriber immediately. Rationale Muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat are symptoms of lactic acidosis, an adverse reaction to metformin. The drug should be stopped and the prescriber notified so steps can be taken to reduce the client's acidosis.

The intensive care client with ketoacidosis (DKA) is receiving insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make? A. Urine output B. 12-lead electrocardiogram (ECG) C. Potassium level D. Rate of IV fluids

C. Potassium level Rationale A. Insulin treats symptoms of diabetes by putting glucose into the cell as well as potassium. Ectopy, indicative of cardiac irritability, is not associated with changes in urine output. B. A 12-lead ECG can verify the ectopy; the priority is to detect and fix the underlying cause. C. With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential. D. Increased fluids treat the symptoms of dehydration secondary to DKA but do not treat the cause.

Which explanation best assists the client in differentiating type 1 diabetes from type 2 diabetes? A. Most clients with type 1 diabetes are born with it. B. People with type 1 diabetes are often obese. C. Those with type 2 diabetes make insulin, but in inadequate amounts. D. People with type 2 diabetes do not develop typical diabetic complications.

C. Those with type 2 diabetes make insulin, but in inadequate amounts. Rationale A. Although type 1 diabetes may occur early in life, it may be caused by immune responses. B. Obesity is typically associated with type 2 diabetes. C. People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin. D. People with type 2 diabetes are at risk for complications, especially cardiovascular complications.

The client newly diagnosed with type 2 diabetes asks how diabetes type 1 and diabetes type 2 are different. What is the nurse's best response? A. "Diabetes type 1 develops in people younger than 40 years and diabetes type 2 develops only in older people." B. "Diabetes type 2 develops in people younger than 40 years and diabetes type 1 develops only in older people." C. "Patients with type 1 diabetes are at higher risk for obesity and heart disease, whereas patients with type 2 diabetes are at higher risk for strokes." D. "Patients with type 1 diabetes produce no insulin and patients with type 2 diabetes produce insulin but their insulin receptors are not very sensitive to it."

D. "Patients with type 1 diabetes produce no insulin and patients with type 2 diabetes produce insulin but their insulin receptors are not very sensitive to it." Rationale The main problem with type 1 diabetes is that the person can no longer make insulin. Without insulin, the client's blood glucose level becomes very high, but glucose cannot enter many cells. Clients with type 1 diabetes must use insulin daily for the rest of their lives or receive a pancreas transplant. With type 2 diabetes, the person still has beta cells that make some insulin. In fact, some people with type 2 diabetes have normal levels of insulin; however, the insulin receptors are not very sensitive to it. As a result, insulin does not bind as tightly to its receptors as it should, and less glucose moves from the blood into the cells.

In reviewing the physician admission requests for the client admitted with hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis? A. 20 mEq KCl for each liter of IV fluid B. IV regular insulin at 2 units/hr C. IV normal saline at 100 mL/hr D. 1 ampule NaHCO3 IV now

D. 1 ampule NaHCO3 IV now Rationale A. 20 mEq KCl for each liter of IV fluid will correct hypokalemia from diuresis. B. IV regular insulin at 2 units/hr will correct hyperglycemia. C. IV normal saline at 100 mL/hr will correct dehydration. D. NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis.

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1c) is 8.2%. Which action will the nurse plan to take next? A. Instruct the client to continue with the current diet and Glucophage use. B. Discuss the need to check blood glucose several times every day. C. Talk about the possibility of adding rapid-acting insulin to the regimen. D. Ask the client about current dietary intake and medication use.

D. Ask the client about current dietary intake and medication use. Rationale A. The HbA1c indicates that the client's average glucose level is not in the desired range. B. This option assumes that the client is not compliant with the therapy and glucose monitoring. C. The nurse should not assume that adding insulin, which must be prescribed by the provider, is the answer without assessing the underlying reason for the treatment failure. D. The nurse's first action should be to assess whether the client is adherent to the currently prescribed diet and medications. The client's current diet and medication use have not been successful in keeping glucose in the desired range. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data.

Which of these nursing actions can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A. Assist the client's spouse in choosing appropriate dietary items. B. Evaluate the client's use of a home blood glucose monitor. C. Inspect the extremities for evidence of poor circulation. D. Assist the client with washing his feet and applying moisturizing lotion.

D. Assist the client with washing his feet and applying moisturizing lotion. Rationale A. Dietary education is the role of the professional nurse. B. The assistant can verify that the client has a monitor, but evaluating effectiveness of teaching is within the scope of practice of the RN. C. Assessment is the function of the professional nurse. D. Assisting with personal hygiene is included in the role of home health aides. Assisting with dietary choices, evaluating the effectiveness of teaching, and performing assessments are complex actions that should be implemented by licensed nurses.

Which complication of diabetes should the nurse report to the provider? The nurse receives report on a 52-year-old client with type 2 diabetes. CHART EXHIBIT Assessment Diagnostics Prescriptions Lungs clear Glucose 179 Regular insulin 8 units if blood glucose 250 to 275 and cold to touch Right great toe mottled Hemoglobin A1C 6.9 Regular insulin 10 units if glucose 275 to 300 Client states wears eyeglasses to read. A. Poor glucose control B. Visual changes C. Respiratory distress D. Peripheral tissue perfusion

D. Peripheral tissue perfusion Rationale A. Although one glucose reading is elevated, the hemoglobin A1C indicates successful glucose control over the past 3 months. B. After the age of 40, reading glasses may be needed owing to difficulty in accommodating to close objects. C. Lungs are clear, and no evidence of distress is noted. D. A cold, mottled toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization; this must be reported to avoid potential gangrene and amputation.

The client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine? A. Day of discharge B. On admission C. When the client states readiness D. While performing the test in the hospital

D. While performing the test in the hospital Rationale A. Instructing the client about operation of the machine on the day of discharge would be overwhelming to the client because of all the other activities taking place that day. B. Instructing the client about operation of the machine on the day of admission would be overwhelming to the client because of all the other activities taking place that day. C. The client may never feel ready to learn this daunting task. The nurse must be more proactive. D. Teaching the client about the operation of the machine while performing the test in the hospital is the best way for the client to learn. The teaching can be reinforced before discharge.