CH. 51 Care for Diabetes

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

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

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

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

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include?

- "Be sure to apply a moisturizer to feet daily." Explanation: The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water, not hot water, to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic, or vinyl, which would cause the feet to perspire.

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states:

- "I will make sure to follow the weight loss plan designed by the dietitian." Explanation: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some clients may require insulin on an ongoing basis, or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

- "You'll need less insulin when you exercise or reduce your food intake." Explanation: - The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

- "Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

- 10 to 15 minutes Explanation: The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)?

- Blood glucose can be controlled through diet and exercise Explanation: Oral hypoglycemic agents may improve blood glucose concentrations if dietary modification and exercise are unsuccessful. Individuals with type 2 diabetes are usually obese at diagnosis. Individuals with type 2 diabetes rarely demonstrate ketosis, except with stress or infection. Individuals with type 2 diabetes do not demonstrate islet cell antibodies.

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client?

- Do not eliminate insulin when nauseated and vomiting. Explanation: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

A nurse is providing health education to a teenage client newly diagnosed with type 1 diabetes mellitus, as well as the client's family. The nurse teaches the client and family nonpharmacologic measures that will decrease the body's need for insulin. What measure provides the greatest impact on glucose reduction?

- Exercise Explanation: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not reduce a client's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?

- Fluid and electrolyte replacement Explanation: The overall approach to HHS includes: - fluid replacement - correction of electrolyte imbalances - insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

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

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

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

- Hypokalemia and hypoglycemia Explanation: Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?

- Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes?

- Increased thirst, hunger, and urination Explanation: The three classic symptoms of both types of diabetes mellitus are polyuria, polydipsia, and polyphagia. Weight loss, dehydration, and fatigue are additional symptoms.

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

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

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

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

NPH is an example of which type of insulin?

- Intermediate-acting Explanation: NPH is an intermediate-acting insulin.

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

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

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

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

A client has been living with type 2 diabetes for several years, and the nurse realizes that the client is likely to have minimal contact with the health care system. In order to ensure that the client maintains adequate blood sugar control over the long term, what should the nurse recommend?

- Participation in a support group for persons with diabetes Explanation: Participation in support groups is encouraged for clients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on clients' circumstances.

An older adult patient that has type 2 diabetes comes to the emergency department with second-degree burns to the bottom of both feet and states, "I didn't feel too hot but my feet must have been too close to the heater." What does the nurse understand is most likely the reason for the decrease in temperature sensation?

- Peripheral neuropathy Explanation: As the neuropathy progresses, the feet become numb. In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body) and a decreased sensation of light touch may lead to an unsteady gait. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?

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

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

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

A nurse is teaching basic "survival skills" to a client newly diagnosed with type 1 diabetes. What topic should the nurse address?

- Recognition of hypoglycemia and hyperglycemia Explanation: It is imperative that newly diagnosed clients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for education, but are not components of the client's immediate "survival skills" following a new diagnosis.

What is the only insulin that can be given intravenously?

- Regular Explanation: Insulins other than regular are in suspensions that could be harmful if administered IV.

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

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

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder?

- Serum osmolarity Explanation: Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what factor most likely caused for this short-term change in treatment?

- Stress has likely caused an increase in the client's blood sugar levels. Explanation: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The client's need for insulin is unrelated to the action of bile. The client's normal routine of nonpharmacological strategies of diet and exercise have been changed due to the client's admission to the hospital. Therefore, the client cannot overestimate what they cannot control. Electrolyte/ fluid balances may have some bearing on glucose levels, but stress is the most impactful cause of the change happening to this client.

A client with type 1 diabetes has told the nurse that the client's most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?

- The client's insulin levels are inadequate. Explanation: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A pregnant client has been diagnosed with gestational diabetes. The client is shocked by the diagnosis, stating that they are conscientious about their health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?

- The effects of hormonal changes during pregnancy Explanation: Hyperglycemia and eventual gestational diabetes develop during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality.

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

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

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

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

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

- has type 2 diabetes. Explanation: Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't ordered oral antidiabetic agents because the effect on the fetus or breast-fed infant is uncertain.

A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of:

- hypoglycemia Explanation: The nurse should observe the client receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

Which is a characteristic of type 2 diabetes?

- insulin resistance Explanation: Type 2 diabetes is characterized by either a decrease in endogenous insulin or an increase accompanied by insulin resistance. Type 1 diabetes is characterized by production of little or no insulin; the client with type 1 diabetes is ketosis-prone when insulin is absent and often has islet cell antibodies.

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

- ketoacidosis Explanation: Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.

A client with diabetes mellitus has been taking a purified insulin extract for many years. The client's health care provider has recently switched the client's insulin to a human form. What factor should the nurse monitor when caring for this client?

- low blood glucose levels Explanation: Clients who switch from animal to synthesized human insulin should be monitored for low blood glucose levels initially because the human form of insulin is used more effectively. There is a greater risk of allergic reactions when using purified insulin extracts.

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

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

Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?

3 months Explanation: Glycosylated hemoglobin is a blood test that reflects average blood glucose concentrations over a period of 3 months.

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

DKA is characterized by: - an elevated BUN and creatinine - rapid onset - it is more common in type 1 diabetes Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by: - the absence of urine - absence serum ketones - a normal arterial pH level

- The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase?

Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood

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

Type I diabetes mellitus is associated with the following characteristics: - onset any age, but usually young (<30 y) - usually thin at diagnosis, recent weight loss - etiology includes genetic, immunologic, and environmental factors (e.g., virus); - often have islet cell antibodies; often have antibodies to insulin even before insulin treatment - little or no endogenous insulin - need exogenous insulin to preserve life - ketosis prone when insulin absent.