Ch. 48 Diabetes Mellitus

Which patient with type 1 diabetes would be at the highest risk for developing hypoglycemic unawareness? A 58-yr-old patient with diabetic retinopathy A 73-yr-old patient who takes propranolol (Inderal) A 19-yr-old patient who is on the school track team A 24-yr-old patient with a hemoglobin A1C of 8.9%

A 73-yr-old patient who takes propranolol (Inderal) Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness

The nurse is assigned to care for a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in managing diabetes, what should be the nurse's initial intervention? Assess patient's perception of what it means to have diabetes. Ask the patient to write down current knowledge about diabetes. Set goals for the patient to actively participate in managing his diabetes. Assume responsibility for all of the patient's care to decrease stress level.

Assess patient's perception of what it means to have diabetes. For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise the patient to take? Eat a piece of pizza. Drink some diet pop. Eat 15 g of simple carbohydrates. Take an extra dose of rapid-acting insulin.

Eat 15 g of simple carbohydrates. When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.

The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis? Excessive thirst Gradual weight gain Overwhelming fatigue Recurrent blurred vision

Excessive thirst The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? Central apnea Hypoventilation Kussmaul respirations Cheyne-Stokes respirations

Kussmaul respirations In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease. Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.

Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

A patient with diabetes is scheduled for a fasting blood glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time? 6:00 PM on the evening before the test Midnight before the test 4:00 AM on the day of the test 7:00 AM on the day of the test

Midnight before the test Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

6. The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)? a. Maintain a healthy weight. b. Exercise for 60 minutes each day. c. Have blood pressure checked regularly. d. Assess for visual changes on monthly basis. e. Monitor for polyuria, polyphagia, and polydipsia.

a, e. To reduce the risk of developing diabetes, the patient with prediabetes should learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, maintain a healthy weight, exercise regularly, and eat a healthy diet.

Betty, an 18-year-old type 1 diabetic patient, is unconscious when admitted to the hospital. Her daily dose of insulin has been 32 units of NPH each morning. 1. On the basis of the knowledge of hypoglycemia, the nurse would expect that Betty's serum glucose level on admission is approximately: a. 50 mg/dL. b. 70 mg/dL. c. 90 mg/dL. d. 110 mg/dL.

a

30. What are manifestations of diabetic ketoacidosis (DKA) (select all that apply)? a. Thirst b. Ketonuria c. Dehydration d. Metabolic acidosis e. Kussmaul respirations f. Sweet, fruity breath odor

a, b, c, d, e, f. In DKA, ketosis leads to ketonuria in trying to decrease the blood glucose and ketonemia. The metabolic acidosis leads to the Kussmaul respirations trying to decrease the acid in the system. The sweet, fruity breath odor is from DKA. Thirst and dehydration are found with both DKA and hyperosmolar hyperglycemic syndrome (HHS).

4. What characterizes type 2 diaterm-27betes (select all that apply)? a. β-Cell exhaustion b. Insulin resistance c. Genetic predisposition d. Altered production of adipokines e. Inherited defect in insulin receptors f. Inappropriate glucose production by the liver

a, b, c, d, e, f. Type 2 diabetes is characterized by insulin resistance, β-cell exhaustion, altered production of adipokines, genetic predisposition, inherited defect in insulin receptors, and inappropriate glucose production by the liver.

21. The patient with type 2 diabetes is being put on acarbose (Precose) and wants to know why she is taking it. What should the nurse include in this patient's teaching (select all that apply)? a. Take it with the first bite of each meal. b. It is not used in patients with heart failure. c. Endogenous glucose production is decreased. d. Effectiveness is measured by 2-hour postprandial glucose. e. It delays glucose absorption from the gastrointestinal (GI) tract.

a, d, e. Acarbose (Precose) is an α-glucosidase inhibitor that is taken with the first bite of each meal. The effectiveness is measured with 2-hour postprandial blood glucose testing, as it delays glucose absorption from the GI tract. The other options describe thiazolidinediones.

9. Priority Decision: When caring for a patient with metabolic syndrome, what should the nurse give the highest priority to teaching the patient about? a. Achieving a normal weight b. Performing daily aerobic exercise c. Eliminating red meat from the diet d. Monitoring the blood glucose periodically

a. Metabolic syndrome is a cluster of abnormalities that include elevated glucose levels, abdominal obesity, elevated blood pressure, high levels of triglycerides, and low levels of high-density lipoproteins (HDLs). Overweight individuals with metabolic syndrome can prevent or delay the onset of diabetes through a program of weight loss. Exercise is also important but normal weight is most important.

23. Individualized nutrition therapy for patients using conventional, fixed insulin regimens should include teaching the patient to a. eat regular meals at regular times. b. restrict calories to promote moderate weight loss. c. eliminate sucrose and other simple sugars from the diet. d. limit saturated fat intake to 30% of dietary calorie intake.

a. The body requires food at regularly spaced intervals throughout the day and omission or delay of meals can result in hypoglycemia, especially for the patient using conventional insulin therapy or oral hypoglycemic agents. Weight loss may be recommended in type 2 diabetes if the individual is overweight but many patients with type 1 diabetes are thin and do not require a decrease in caloric intake. Fewer than 7% of total calories should be from saturated fats and simple sugar should be limited but moderate amounts can be used if counted as a part of total carbohydrate intake.

15. A patient with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. The nurse determines that additional teaching is needed when the patient does what? a. Withdraws the NPH dose into the syringe first b. Injects air equal to the NPH dose into the NPH vial first c. Removes any air bubbles after withdrawing the first insulin d. Adds air equal to the insulin dose into the regular vial and withdraws the dose

a. When mixing regular and intermediate-acting insulin, regular insulin should always be drawn into the syringe first to prevent contamination of the regular insulin vial with intermediate-acting insulin additives. Air is added to the neutral protamine Hagedorn (NPH) vial. Then air is added to the regular vial and the regular insulin is withdrawn, bubbles are removed, and the dose of NPH is withdrawn.

1. Glucose intolerance increases with age. The incidence in those older than 65 years is: a. 20% b. 50% c. 65% d. 80%

b

2. The ethnic group with the lowest incidence of diabetes mellitus in the United States is: a. African Americans. b. Caucasians. c. Hispanics. d. Native Americans

b

3. Albert refuses his bedtime snack. This should alert the nurse to assess for: a. an elevated serum bicarbonate and a decreased blood pH. b. signs of hypoglycemia earlier than expected. c. symptoms of hyperglycemia during the peak time of NPH insulin. d. sugar in the urine.

b

5. Christine is started on low-dose intravenous insulin therapy. Nursing assessment includes all of the following except frequent: a. blood pressure measurements to monitor the degree of hypotension. b. estimates of serum potassium, because increased blood glucose levels are correlated with elevated potassium levels. c. evaluation of blood glucose levels, because glucose levels should decline as insulin levels increase. d. elevation of serum ketones to monitor the course of ketosis.

b

Albert, a 35-year-old insulin-dependent diabetic patient, is admitted to the hospital with a diagnosis of pneumonia. He has been febrile since admission. His daily insulin requirement is 24 units of NPH. 1. Every morning Albert is given NPH insulin at 7:30 AM. Meals are served at 8:30 AM, 12:30 PM, and 6:30 PM. The nurse expects that the NPH insulin will reach its maximum effect (peak) between the hours of: a. 11:30 AM and 1:30 PM. b. 11:30 AM and 7:30 PM. c. 3:30 PM and 9:30 PM. d. 5:30 PM and 11:30 PM.

b

20. Which class of oral glucose-lowering agents is most commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose? a. Insulin b. Biguanide c. Meglitinide d. Sulfonylurea

b. Biguanides (e.g., metformin [Glucophage]) are most commonly used with type 2 diabetes. They reduce glucose production by the liver and increase insulin sensitivity at the tissue level that improves glucose transport into the cells. Insulin is not taken orally, as it is ineffective. Meglitinides and sulfonylureas increase insulin production from the pancreas

11. There seems to be a strong positive correlation between type 2 diabetes mellitus and: a. hypotension. b. kidney dysfunction. c. obesity. d. sex.

c

12. The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is: a. 90 mg/dL. b. 115 mg/dL. c. 126 mg/dL. d. 180 mg/dL.

c

18. The nurse knows that an intermediate-acting insulin should reach its "peak" in: a. 1 to 2 hours. b. 3 to 4 hours. c. 4 to 12 hours. d. 16 to 20 hours.

c

2. A bedtime snack is provided for Albert. This is based on the knowledge that intermediate-acting insulins are effective for an approximate duration of: a. 6 to 8 hours. b. 10 to 14 hours. c. 16 to 20 hours. d. 24 to 28 hours.

c

28. The major electrolyte of concern in the treatment of diabetic ketoacidosis is: a. calcium. b. magnesium. c. potassium. d. sodium.

c

29. Mortality rates for patients with diabetes are positively correlated with atherosclerotic complications, especially in the coronary arteries, which account for about what percentage of all deaths in these patients? a. 10% b. 30% c. 40% d. 60%

c

3. As a cause of death by disease in the United States, diabetes mellitus ranks: a. first. b. second. c. third. d. fourth.

c

36. Nursing care for a diabetic patient with peripheral neuropathy includes: a. assessing pain patterns to rule out peripheral vascular insufficiency. b. inspecting the feet for breaks in skin integrity. c. palpating the lower extremities for temperature variations. d. all of the above.

c

4. A patient is diagnosed with type 1 diabetes. The nurse knows that all of the following are probable clinical characteristics except: a. ketosis-prone. b. little endogenous insulin. c. obesity at diagnoses. d. younger than 30 years.

c

5. A patient who is diagnosed with type 1 diabetes mellitus would be expected to: a. be restricted to an American Diabetic Association diet. b. have no damage to the islet cells of the pancreas. c. need exogenous insulin. d. need to receive daily doses of a hypoglycemic agent.

c

32. The patient with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech. What should the nurse suspect is happening? a. DKA b. HHS c. Hypoglycemia d. Hyperglycemia

c. Hypoglycemia causes epinephrine release that contributes to shakiness and irritability from nervousness and anxiety. Without glucose in the brain, the patient may have difficulty speaking, visual disturbances, stupor, confusion, or coma. It is better to treat for hypoglycemia when unsure of the actual blood glucose level.

40. Following the teaching of foot care to a diabetic patient, the nurse determines that additional instruction is needed when the patient makes which statement? a. "I should wash my feet daily with soap and warm water." b. "I should always wear shoes to protect my feet from injury." c. "If my feet are cold, I should wear socks instead of using a heating pad." d. "I'll know if I have sores or lesions on my feet because they will be painful."

d. Complete or partial loss of sensitivity of the feet is common with peripheral neuropathy of diabetes and patients with diabetes may suffer foot injury and ulceration without ever having pain. Feet must be inspected during daily care for any cuts, blisters, swelling, or reddened areas.

1. In addition to promoting the transport of glucose from the blood into the cell, what does insulin do? a. Enhances the breakdown of adipose tissue for energy b. Stimulates hepatic glycogenolysis and gluconeogenesis c. Prevents the transport of triglycerides into adipose tissue d. Accelerates the transport of amino acids into cells and their synthesis into protein

d. Insulin is an anabolic hormone that is responsible for growth, repair, and storage. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Glucagon is responsible for hepatic glycogenolysis and gluconeogenesis. Fat is used for energy when glucose levels are depleted.

14. Lispro insulin (Humalog) with NPH insulin is ordered for a patient with newly diagnosed type 1 diabetes. The nurse knows that when lispro insulin is used, when should it be administered? a. Only once a day b. 1 hour before meals c. 30 to 45 minutes before meals d. At mealtime or within 15 minutes of meals

d. Lispro is a rapid-acting insulin that has an onset of action of approximately 15 minutes and should be injected at the time of the meal to within 15 minutes of eating. Regular insulin is short acting with an onset of action in 30 to 60 minutes following administration and should be given 30 to 45 minutes before meals

5. Which laboratory results would indicate that the patient has prediabetes? a. Glucose tolerance result of 132 mg/dL b. Glucose tolerance result of 240 mg/dL c. Fasting blood glucose result of 80 mg/dL d. Fasting blood glucose result of 120 mg/dL

d. Prediabetes is defined as impaired glucose tolerance and impaired fasting glucose or both. Fasting blood glucose results between 100 mg/dL (5.56 mmol/L) and 125 mg/dL (6.9 mmol/L) indicate prediabetes. A diagnosis of impaired glucose tolerance is made if the 2-hour oral glucose tolerance test (OGTT) results are between 140 mg/dL (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L).

10. A nurse is assigned to care for a patient who is suspected of having type 2 diabetes mellitus. Clinical manifestations for which the nurse should assess include: a. blurred or deteriorating vision. b. fatigue and muscle cramping. c. wounds that heal slowly or respond poorly to treatment. d. all of the above.

d

15. The nurse should encourage exercise in the management of diabetes, because it: a. decreases total triglyceride levels. b. improves insulin utilization. c. lowers blood glucose. d. accomplishes all of the above.

d

30. Macrovascular disease has a direct link with: a. hypertension. b. increased triglyceride levels. c. obesity. d. all of the above.

d

32. With nonproliferative (background) retinopathy, examination of the retina may reveal: a. leakage of fluid or serum (exudates). b. microaneurysms. c. focal capillary single closure. d. all of the above pathologic changes.

d

9. Knowing that gluconeogenesis helps to maintain blood levels, a nurse should: a. document weight changes because of fatty acid mobilization. b. evaluate the patient's sensitivity to low room temperatures because of decreased adipose tissue insulation. c. protect the patient from sources of infection because of decreased cellular protein deposits. d. do all of the above.

d

Christine, a 64-year-old woman, is admitted to the clinical area with a diagnosis of diabetic ketoacidosis. On admission, she is drowsy yet responsive. 1. Nursing actions for a diagnosis of ketoacidosis include: a. monitoring urinary output by means of an indwelling catheter. b. evaluating serum electrolytes. c. testing for glucosuria and acetonuria. d. all of the above.

d

18. When teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantage of using an insulin pump? a. Tight glycemic control can be maintained. b. Errors in insulin dosing are less likely to occur. c. Complications of insulin therapy are prevented. d. Frequent blood glucose monitoring is unnecessary.

a. Insulin pumps provide tight glycemic control by continuous subcutaneous insulin infusion based on the patient's basal profile, with bolus doses at mealtime at the patient's discretion and related to blood glucose monitoring. Errors in insulin dosing and complications of insulin therapy are still potential risks with insulin pumps.

26. A clinical feature that distinguishes a hypoglycemic reaction from a ketoacidosis reaction is: a. blurred vision. b. diaphoresis. c. nausea. d. weakness.

b

38. The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively? a. 10% to 20% b. 25% to 40% c. 50% to 60% d. 85% to 90%

c

22. Priority Decision: The nurse is assessing a newly admitted diabetic patient. Which observation should be addressed as the priority by the nurse? a. Bilateral numbness of both hands b. Stage II pressure ulcer on the right heel c. Rapid respirations with deep inspiration d. Areas of lumps and dents on the abdomen

c. Rapid deep respirations are symptoms of diabetic ketoacidosis (DKA), so this is the priority of care. Stage II pressure ulcers and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate a need to teach the patient about site rotation.

16. Self-monitoring of blood glucose is recommended for patients with: a. abnormal renal glucose thresholds. b. hypoglycemia without warning symptoms. c. unstable diabetes. d. all of the above conditions.

d

19. Insulin pumps in use today: a. can deliver a premeal dose (bolus) of insulin before each meal. b. deliver a continuous basal rate of insulin at 0.5 to 2.0 units/h. c. prevent unexpected savings in blood glucose measurements. d. are capable of doing all of the above.

d

2. Betty is given 1 mg of glucagon hydrochloride, subcutaneously, in the emergency department. Knowledge about the action of this drug alerts the nurse to observe for latent symptoms associated with: a. glucosuria. b. hyperglycemia. c. ketoacidosis. d. rebound hypoglycemia.

d

20. A probable candidate for diabetic management with oral antidiabetic agents is the patient who is: a. non-insulin-dependent. b. stable and not prone to ketosis. c. unable to be managed by diet alone. d. characterized by all of the above.

d

21. An example of a first-generation sulfonylurea used in type 2 diabetes is: a. Dia-Beta b. Glyset c. Starlix d. Tolinase

d

22. The nurse should expect that insulin therapy will be temporarily substituted for oral antidiabetic therapy if the diabetic patient: a. develops an infection with fever. b. suffers trauma. c. undergoes major surgery. d. develops any or all of the above.

d

27. The nurse knows that treatment modalities for diabetic ketoacidosis should focus on management of: a. acidosis. b. dehydration. c. hyperglycemia. d. all of the above.

d

3. After Betty is medically stabilized, she is admitted to the clinical area for observation and health teaching. The nurse should make sure that Betty is aware of warning symptoms associated with hypoglycemia, such as: a. emotional changes. b. slurred speech and double vision. c. staggering gait and incoordination. d. all of the above.

d

3. In evaluating the laboratory results, the nurse expects all of the following to indicate ketoacidosis except: a. a decreased serum bicarbonate level. b. an elevated blood glucose. c. an increased blood urea. d. an increased blood pH.

d

31. Clinical nursing assessment for a patient with microangiopathy who has manifested impaired peripheral arterial circulation includes all of the following except: a. integumentary inspection for the presence of brown spots on the lower extremities. b. observation for paleness of the lower extremities. c. observation for blanching of the feet after the legs are elevated for 60 seconds. d. palpation for increased pulse volume in the arteries of the lower extremities.

d

33. A diagnostic manifestation of proliferative retinopathy is: a. decreased capillary permeability. b. microaneurysm formation. c. neovascularization into the vitreous humor. d. the leakage of capillary wall fragments into surrounding areas.

d

35. With peripheral neuropathy, a diabetic patient has limited sensitivity to: a. heat. b. pain. c. pressure. d. all of the above.

d

37. During surgery, glucose levels will rise, because there is an increased secretion of: a. cortisol. b. epinephrine. c. glucagon. d. all of the above.

d

4. Betty should also be taught that hypoglycemia may be prevented by: a. eating regularly scheduled meals. b. eating snacks to cover the peak time of insulin. c. increasing food intake when engaging in increased levels of physical exercise. d. doing all of the above.

d

6. As blood glucose levels approach normal, the nurse should assess for signs of electrolyte imbalance associated with: a. hypernatremia. b. hypercapnia. c. hypocalcemia. d. hypokalemia.

d

6. Possible risk factors associated with type 1 diabetes mellitus include: a. an autoimmune susceptibility to diabetogenic viruses. b. environmental factors. c. the presence of human leukocyte antigen (HLA). d. all of the above.

d

8. The nurse is asked to assess a patient for glucosuria. The nurse would secure a specimen of: a. blood. b. sputum. c. stool. d. urine.

d

13. The most sensitive test for diabetes mellitus is the: a. fasting plasma glucose. b. 2-hour postload glucose. c. intravenous glucose. d. urine glucose.

a

24. Rotation sites for insulin injection should be separated from one another by 2.5 cm (1 in) and should be used only once every: a. third day. b. week. c. 2 to 3 weeks. d. 2 to 4 weeks.

c

26. The nurse assesses the diabetic patient's technique of self-monitoring of blood glucose (SMBG) 3 months after initial instruction. Which error in the performance of SMBG noted by the nurse requires intervention? a. Doing the SMBG before and after exercising b. Puncturing the finger on the side of the finger pad c. Cleaning the puncture site with alcohol before the puncture d. Holding the hand down for a few minutes before the puncture

c. Cleaning the puncture site with alcohol is not necessary and may interfere with test results and lead to drying and splitting of the fingertips. Washing the hands with warm water is adequate cleaning and promotes blood flow to the fingers. Blood flow is also increased by holding the hand down. Punctures on the side of the finger pad are less painful. Self-monitored blood glucose (SMBG) should be performed before and after exercise.

A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? "With type 2 diabetes, the body of the pancreas becomes inflamed." "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

"With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes

The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? "Smokeless tobacco products decrease the risk of kidney damage." "I can help control my blood pressure by avoiding foods high in salt." "I should have yearly dilated eye examinations by an ophthalmologist." "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."

"I can help control my blood pressure by avoiding foods high in salt." Patients with type 2 diabetes to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment of retinopathy.

The nurse teaches a patient with diabetes about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? "I plan to lose 25 pounds this year by following a high-protein diet." "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." "I should include more fiber in my diet than a person who does not have diabetes." "If I use an insulin pump, I will not need to limit foods with saturated fat in my diet."

"I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes. High-protein diets are not recommended for weight loss.

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement? "I should only walk barefoot in nice dry weather." "I should look at the condition of my feet every day." "I will need to cut back the number of times I shower per week." "My shoes should fit nice and tight because they will give me firm support."

"I should look at the condition of my feet every day." Patients with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.

The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which statement by the patient requires an intervention by the nurse? "I will discard any insulin bottle that is cloudy in appearance." "The best injection site for insulin administration is in my abdomen." "I can wash the site with soap and water before insulin administration." "I may keep my insulin at room temperature (75° F) for up to 1 month."

"I will discard any insulin bottle that is cloudy in appearance." Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

The nurse is teaching a patient with type 2 diabetes about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? "I will go running when my blood sugar is too high to lower it." "I will go fishing frequently and pack a healthy lunch with plenty of water." "I do not need to increase my exercise routine since I am on my feet all day at work." "I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week."

"I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week." The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.

33. The patient with diabetes has a blood glucose level of 248 mg/dL. Which manifestations in the patient would the nurse understand as being related to this blood glucose level (select all that apply)? a. Headache b. Unsteady gait c. Abdominal cramps d. Emotional changes e. Increase in urination f. Weakness and fatigue

. a, c, e, f. Manifestations of hyperglycemia include abdominal cramps, polyuria, weakness, fatigue, and headache. The headache can also be seen with hypoglycemia that is manifested by the remaining options.

16. Delegation Decision: The following interventions are planned for a diabetic patient. Which intervention can the nurse delegate to unlicensed assistive personnel (UAP)? a. Discuss complications of diabetes. b. Check that the bath water is not too hot. c. Check the patient's technique for drawing up insulin. d. Teach the patient to use a meter for self-monitoring of blood glucose.

. b. Checking the temperature of the bath water is part of assisting with activities of daily living (ADLs) and within the scope of care for unlicensed assistive personnel (UAP). This is important for the patient with neuropathy. Discussion of complications, teaching, and assessing learning are appropriate for RNs.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? 8:40 PM to 9:00 PM 9:00 PM to 11:30 PM 10:30 PM to 1:30 AM 12:30 AM to 8:30 AM

10:30 PM to 1:30 AM Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes? A 48-yr-old woman with a hemoglobin A1C of 8.4% A 58-yr-old man with a fasting blood glucose of 111 mg/dL A 68-yr-old woman with a random plasma glucose of 190 mg/dL A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A 48-yr-old woman with a hemoglobin A1C of 8.4% Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.

17. An example of a commonly administered intermediate-acting insulin is: a. NHP. b. Iletin II. c. Humalog. d. Humulin U.

a

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? Routine insulin therapy and exercise Administer a different antibiotic for the UTI Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration

Cardiac monitoring to detect potassium changes This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? Cheese Broccoli Chicken Oranges

Cheese Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

The nurse has been teaching a patient with diabetes how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Chooses a puncture site in the center of the finger pad. Washes hands with soap and water to cleanse the site to be used. Warms the finger before puncturing the finger to obtain a drop of blood. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

Chooses a puncture site in the center of the finger pad. The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

The nurse caring for a patient hospitalized with diabetes would look for which laboratory test result to obtain information on the patient's past glucose control? Prealbumin level Urine ketone level Fasting glucose level Glycosylated hemoglobin level

Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased triglyceride levels Increased high-density lipoproteins (HDL) Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL)

Increased triglyceride levels Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Avoid sick people and wash hands. Obtain comprehensive dental care. Maintain hemoglobin A1C below 7%. Coughing and deep breathing with splinting

Obtain comprehensive dental care. A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to explain how this medication works? Increases insulin production from the pancreas. Slows the absorption of carbohydrate in the small intestine. Reduces glucose production by the liver and enhances insulin sensitivity. Increases insulin release from the pancreas and inhibits glucagon secretion.

Reduces glucose production by the liver and enhances insulin sensitivity. Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

2. The nurse should expect that the rehydrating intravenous solution used will be: a. 0.9% saline solution. b. 5% dextrose in water. c. 10% dextrose in water. d. sterile water.

a

23. The tissue area that provides the fastest absorption rate for regular insulin is believed to be the: a. abdominal area. b. anterior thigh. c. deltoid area. d. gluteal site.

a

25. Hypoglycemia, an abnormally low blood glucose concentration, occurs with a glucose level that is: a. lower than 50 to 60 mg/dL. b. between 60 and 80 mg/dL. c. between 75 and 90 mg/dL. d. 95 mg/dL.

a

34. A nurse caring for a diabetic patient with a diagnosis of nephropathy would expect the urinalysis report to indicate: a. albumin. b. bacteria. c. red blood cells. d. white blood cells.

a

4. The physician notes a change in Christine's respirations. Her breathing is described as Kussmaul respirations. The nurse knows that these respirations are: a. deep. b. labored. c. rapid. d. shallow.

a

A patient is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.) The level is consistent with renal insufficiency from renal nephropathy. The level may be high because of dehydration that accompanies hyperglycemia. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. The patient may be excreting sodium and retaining potassium from malnutrition. This level shows adequate treatment of the cellulitis and acceptable glucose control.

The level is consistent with renal insufficiency from renal nephropathy. The level may be high because of dehydration that accompanies hyperglycemia. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient's potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.

7. Clinical manifestations associated with a diagnosis of type 1 diabetes mellitus include all of the following except: a. hypoglycemia. b. hyponatremia. c. ketonuria. d. polyphagia.

a

14. A female diabetic patient who weighs 130 lb has an ideal body weight of 116 lb. For weight reduction of 2 lb/week, her daily caloric intake should be approximately: a. 1,000 calories. b. 1,200 calories. c. 1,500 calories. d. 1,800 calories.

a

10. During routine health screening, a patient is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). At a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)? a. A1C of 7.5% b. Glycosuria of 3+ c. FPG >126 mg/dL (7.0 mmol/L). d. Random blood glucose of 126 mg/dL (7.0 mmol/L) e. A 2-hour oral glucose tolerance test (OGTT) of 190 mg/dL (10.5 mmol/L)

a, c. The patient has one prior test result that meets criteria for a diagnosis of diabetes but this test must be confirmed on a subsequent day. The A1C is greater than 6.5% so it also indicates diabetes according to criteria for diabetes diagnosis. These criteria include a fasting plasma glucose (FPG) level ≥126 mg/dL (7.0 mmol/L), A1C ≥6.5%, or a 2-hour OGTT level ≥200 mg/dL (11.1 mmol/L), or in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.0 mmol/L).

36. Priority Decision: Two days following a self-managed hypoglycemic episode at home, the patient tells the nurse that his blood glucose levels since the episode have been between 80 and 90 mg/dL. Which is the best response by the nurse? a. "That is a good range for your glucose levels." b. "You should call your health care provider because you need to have your insulin increased." c. "That level is too low in view of your recent hypoglycemia and you should increase your food intake." d. "You should take only half your insulin dosage for the next few days to get your glucose level back to normal."

a. Blood glucose levels of 80 to 90 mg/dL (4.4 to 5 mmol/L) are within the normal range and are desired in the patient with diabetes, even following a recent hypoglycemic episode. Hypoglycemia is often caused by a single event, such as skipping a meal, taking too much insulin, or vigorous exercise. Once corrected, normal glucose control should be maintained.

28. Priority Decision: A patient with diabetes calls the clinic because she is experiencing nausea and flu-like symptoms. Which advice from the nurse will be the best for this patient? a. Administer the usual insulin dosage. b. Hold fluid intake until the nausea subsides. c. Come to the clinic immediately for evaluation and treatment. d. Monitor the blood glucose every 1 to 2 hours and call if it rises over 150 mg/dL (8.3 mmol/L).

a. During minor illnesses, the patient with diabetes should continue drug therapy and food intake. Insulin is important because counter regulatory hormones may increase blood glucose during the stress of illness. Food or a carbohydrate liquid substitution is important because during illness the body requires extra energy to deal with the stress of the illness. Blood glucose monitoring should be done every 4 hours and the health care provider should be notified if the level is greater than 240 mg/dL (13.9 mmol/L) or if fever, ketonuria, or nausea and vomiting occur.

41. A 72-year-old woman is diagnosed with diabetes. What does the nurse recognize about the management of diabetes in the older adult? a. It is more difficult to achieve strict glucose control than in younger patients. b. It usually is not treated unless the patient becomes severely hyperglycemic. c. It does not include treatment with insulin because of limited dexterity and vision. d. It usually requires that a younger family member be responsible for care of the patient.

a. Older adults have more conditions that may be treated with medications that impair insulin action. Hypoglycemic unawareness is more common, so these patients are more likely to suffer adverse consequences from blood glucose- lowering therapy. Because the clinical manifestations of longterm complications of diabetes take 10 to 20 years to develop, the goals for glycemic control are not as rigid as in the younger population. Treatment is indicated and insulin may be used if the patient does not respond to oral agents. The patient's needs rather than age determine the responsibility of others in care.

38. What disorders and diseases are related to macrovascular complications of diabetes (select all that apply)? a. Chronic kidney disease b. Coronary artery disease c. Microaneurysms and destruction of retinal vessels d. Ulceration and amputation of the lower extremities e. Capillary and arteriole membrane thickening specific to diabetes

b, d. Macrovascular disease causes coronary artery disease and ulceration and results in amputation of the lower extremities. However, neuropathy may also contribute to not feeling ulcerations. The remaining options are related to microvascular complications of diabetes.

39. The patient with diabetes has been diagnosed with autonomic neuropathy. What problems should the nurse expect to find in this patient (select all that apply)? a. Painless foot ulcers b. Erectile dysfunction c. Burning foot pain at night d. Loss of fine motor control e. Vomiting undigested food f. Painless myocardial infarction

b, e, f. Autonomic neuropathy affects most body systems. Manifestations of autonomic neuropathy include erectile dysfunction in men and decreased libido, gastroparesis (nausea, vomiting, gastroesophageal reflux and feeling full), painless myocardial infarction, postural hypotension, and resting tachycardia. The remaining options would occur with sensory neuropathy

25. To prevent hyperglycemia or hypoglycemia related to exercise, what should the nurse teach the patient using glucose-lowering agents about the best time for exercise? a. Only after a 15-g carbohydrate snack is eaten b. About 1 hour after eating when blood glucose levels are rising c. When glucose monitoring reveals that the blood glucose is in the normal range d. When blood glucose levels are high, because exercise always has a hypoglycemic effect

b. During exercise, a diabetic person needs both adequate glucose to prevent exercise-induced hypoglycemia and adequate insulin, because counter regulatory hormones are produced during the stress of exercise and may cause hyperglycemia. Exercise after meals is best but a 15-g carbohydrate snack may be taken if exercise is performed before meals or is prolonged. Blood glucose levels should be monitored before, during, and after exercise to determine the effect of exercise on the levels.

24. What should the goals of nutrition therapy for the patient with type 2 diabetes include? a. Ideal body weight b. Normal serum glucose and lipid levels c. A special diabetic diet using dietetic foods d. Five small meals per day with a bedtime snack

b. Maintenance of near-normal blood glucose levels and achievement of optimal serum lipid levels with dietary modification are believed to be the most important factors in preventing both short- and long-term complications of diabetes. There is no longer a specific "diabetic diet" and use of dietetic foods is not necessary for diabetes control. Most diabetics eat three meals a day and some require a bedtime snack for control of nighttime hypoglycemia. Loss of weight, which may or may not be to ideal body weight, may improve insulin resistance. The other goals of nutrition therapy include prevention of chronic complications of diabetes, attention to individual nutritional needs, and maintenance of the pleasure of eating.

7. In type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose? a. Fatigue b. Polydipsia c. Polyphagia d. Recurrent infections

b. Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1 diabetes.

27. A nurse working in an outpatient clinic plans a screening program for diabetes. What recommendations for screening should be included? a. OGTT for all minority populations every year b. FPG for all individuals at age 45 and then every 3 years c. Testing people under the age of 21 for islet cell antibodies d. Testing for type 2 diabetes in all overweight or obese individuals

b. The American Diabetes Association recommends that testing for type 2 diabetes with a FPG, A1C, or 2-hour OGTT should be considered for all individuals at the age of 45 and above and, if normal, repeated every 3 years. Testing for immune markers of type 1 diabetes is not recommended. Testing at a younger age or more frequently should be done for members of a high-risk ethnic population, including African Americans, Hispanics, Native Americans, Asian Americans, and Pacific Islanders. Overweight adults with additional risk factors should be tested

3. Why are the hormones cortisol, glucagon, epinephrine, and growth hormone referred to as counter regulatory hormones? a. Decrease glucose production b. Stimulate glucose output by the liver c. Increase glucose transport into the cells d. Independently regulate glucose level in the blood

b. The counter regulatory hormones have the opposite effect of insulin by stimulating glucose production and output by the liver and by decreasing glucose transport into the cells. The counter regulatory hormones and insulin together regulate the blood glucose level.

37. Which statement best describes atherosclerotic disease affecting the cerebrovascular, cardiovascular, and peripheral vascular systems in patients with diabetes? a. It can be prevented by tight glucose control. b. It occurs with a higher frequency and earlier onset than in the nondiabetic population. c. It is caused by the hyperinsulinemia related to insulin resistance common in type 2 diabetes. d. It cannot be modified by reduction of risk factors such as smoking, obesity, and high fat intake.

b. The development of atherosclerotic vessel disease seems to be promoted by the altered lipid metabolism common in diabetes. Although tight glucose control may help to delay the process, it does not prevent it completely. Atherosclerosis in patients with diabetes does respond somewhat to a reduction in general risk factors, as it does in nondiabetics, and reduction in fat intake, control of hypertension, abstention from smoking, maintenance of normal weight, and regular exercise should be carried out by all patients

12. When teaching the patient with diabetes about insulin administration, the nurse should include which instruction for the patient? a. Pull back on the plunger after inserting the needle to check for blood. b. Consistently use the same size of insulin syringe to avoid dosing errors. c. Clean the skin at the injection site with an alcohol swab before each injection. d. Rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies.

b. U100 insulin must be used with a U100 syringe but for those using low doses of insulin, syringes that have increments of 1 unit instead of 2 units are available. Errors can be made in dosing if patients switch back and forth between different sizes of syringes. Aspiration before injection of the insulin is not recommended, nor is the use of alcohol to clean the skin. Because the rate of peak serum concentration varies with the site selected for injection, injections should be rotated within a particular area, such as the abdomen, before changing to another area.

2. Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)? a. Liver b. Brain c. Adipose d. Blood cells e. Skeletal muscle

c, e. Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend directly on insulin for glucose transport.

3. A patient with type 1 diabetes uses 20 U of 70/30 neutral protamine Hagedorn (NPH/regular) in the morning and at 6:00 pm. When teaching the patient about this regimen, what should the nurse emphasize? a. Hypoglycemia is most likely to occur before the noon meal. b. Flexibility in food intake is possible because insulin is available 24 hours a day. c. A set meal pattern with a bedtime snack is necessary to prevent hypoglycemia. d. Premeal glucose checks are required to determine needed changes in daily dosing.

c. A split-mixed dose of insulin requires that the patient adhere to a set meal pattern to provide glucose for the peak action of the insulin and a bedtime snack is usually required when patients take an intermediate-acting insulin late in the day to prevent nocturnal hypoglycemia. Hypoglycemia is most likely to occur with this dose late in the afternoon and during the night. When premixed formulas are used, flexible dosing based on glucose levels is not recommended.

31. What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)? a. DKA requires administration of bicarbonate to correct acidosis. b. Potassium replacement is not necessary in management of HHS. c. HHS requires greater fluid replacement to correct the dehydration. d. Administration of glucose is withheld in HHS until the blood glucose reaches a normal level.

c. The management of DKA is similar to that of HHS except that HHS requires greater fluid replacement because of the severe hyperosmolar state. Bicarbonate is not usually given in DKA to correct acidosis unless the pH is <7.0 because administration of insulin will reverse the abnormal fat metabolism. Total body potassium deficit is possible in both conditions, requiring potassium administration, and in both conditions glucose is added to IV fluids when blood glucose levels fall to 250 mg/dL (13.9 mmol/L).

19. Priority Decision: A patient taking insulin has recorded fasting glucose levels above 200 mg/dL (11.1 mmol/L) on awakening for the last five mornings. What should the nurse advise the patient to do first? a. Increase the evening insulin dose to prevent the dawn phenomenon. b. Use a single-dose insulin regimen with an intermediate-acting insulin. c. Monitor the glucose level at bedtime, between 2:00 am and 4:00 am, and on arising. d. Decrease the evening insulin dosage to prevent night hypoglycemia and the Somogyi effect

c. The patient's elevated glucose on arising may be the result of either dawn phenomenon or Somogyi effect. The best way to determine whether the patient needs more or less insulin is by monitoring the glucose at bedtime, between 2:00 am and 4:00 am, and on arising. If predawn levels are below 60 mg/dL, the insulin dose should be reduced. If the 2:00 am to 4:00 am blood glucose is high, the insulin should be increased.

8. Which patient should the nurse plan to teach how to prevent or delay the development of diabetes? a. An obese 50-year-old Hispanic woman b. A child whose father has type 1 diabetes c. A 34-year-old woman whose parents both have type 2 diabetes d. A 12-year-old boy whose father has maturity onset diabetes of the young (MODY)

c. Type 2 diabetes has a strong genetic influence and offspring of parents who both have type 2 diabetes have an increased chance of developing it. In contrast, type 1 diabetes is associated with a genetic susceptibility that is related to human leukocyte antigens (HLAs). Offspring of parents who both have type 1 diabetes have a 1% to 4% chance of developing the disease. Other risk factors for type 2 diabetes include obesity; being a Native American, Hispanic, or African American; and being 55 years or older. Although 50% of people with a parent with maturity-onset diabetes of the young (MODY) will develop MODY, it is autosomal dominant and treatment depends on which genetic mutation caused it. It is not associated with obesity or hypertension and is not currently considered preventable

29. The nurse should observe the patient for symptoms of ketoacidosis when a. illnesses causing nausea and vomiting lead to bicarbonate loss with body fluids. b. glucose levels become so high that osmotic diuresis promotes fluid and electrolyte loss. c. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy. d. the patient skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy.

c. When insulin is insufficient and glucose cannot be used for cellular energy, the body releases and breaks down stored fats and protein to meet energy needs. Free fatty acids from stored triglycerides are released and metabolized in the liver in such large quantities that ketones are formed. Ketones are acidic and alter the pH of the blood, causing acidosis. Osmotic diuresis occurs as a result of elimination of both glucose and ketones in the urine

34. A diabetic patient is found unconscious at home and a family member calls the clinic. After determining that a glucometer is not available, what should the nurse advise the family member to do? a. Have the patient drink some orange juice. b. Administer 10 U of regular insulin subcutaneously. c. Call for an ambulance to transport the patient to a medical facility. d. Administer glucagon 1 mg intramuscularly (IM) or subcutaneously.

d. If a diabetic patient is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage and IM or subcutaneous administration of 1 mg of glucagon should be done. If the unconsciousness has another cause, such as ketosis, the rise in glucose caused by the glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Insulin is contraindicated without knowledge of the patient's glucose level and oral carbohydrates cannot be given when patients are unconscious.

11. The nurse determines that a patient with a 2-hour OGTT of 152 mg/dL has a. diabetes. b. elevated A1C. c. impaired fasting glucose. d. impaired glucose tolerance.

d. Impaired glucose tolerance exists when a 2-hour OGTT level is higher than normal but lower than the level diagnostic for diabetes (i.e., >200). Impaired fasting glucose exists when fasting glucose levels are greater than the normal of 100 mg/dL but less than the 126 mg/dL diagnostic of diabetes. Both abnormal values are diagnostic for a condition known as prediabetes.

17. The home care nurse should intervene to correct a patient whose insulin administration includes a. warming a prefilled refrigerated syringe in the hands before administration. b. storing syringes prefilled with NPH and regular insulin needle-up in the refrigerator. c. placing the insulin bottle currently in use in a small container on the bathroom countertop. d. mixing an evening dose of regular insulin with insulin glargine in one syringe for administration.

d. Insulin glargine (Lantus), a long-acting insulin that is continuously released with no peak of action, cannot be diluted or mixed with any other insulin or solution. Mixed insulins should be stored needle-up in the refrigerator and warmed before administration. Currently used bottles of insulin can be kept at room temperature out of sunlight.