Ch. 64 Diabetes Mellitus

A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? "Keep up the good work." "This is not good at all." "Have you been doing something differently? "You need an increase in your insulin dose."

"Have you been doing something differently? **The most appropriate response by the nurse is telling the client that the level is high and then assessing the client's regimen or changes he or she may have made. This is the best format to formulate interventions to gain control of blood glucose. HbA1C levels for diabetic clients need to be less than 7%. A value of 9.4% shows poor control over the past 3 months.Telling the client to "keep up the good work" is incorrect. A(HbA1C) level of 9.4% is too high. Scolding the client by saying "this is not good," although true, does not take into account problems the client may be having with the regimen or an undiagnosed illness. Although it may be true that the client needs more insulin, an assessment of the client's regimen is needed before decisions are made about medications.

The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? "I can break in my shoes by wearing them all day." "I need to monitor my feet daily for blisters or skin breaks." "I will never go barefoot." "I need to quit smoking."

"I can break in my shoes by wearing them all day." **Further teaching about injury prevention is needed when the client with diabetic peripheral neuropathy says that "I can break in my shoes by wearing them all day." Shoes need to be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated because if the client has diabetic neuropathy, stepping on something sharp or harmful would not be felt. Tobacco use further decreases peripheral circulation increasing the risk for vascular complications.

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

"I must inspect my shoes for foreign objects before putting them on." **The statement by the diabetic client that indicates that teaching was effective is, "I must inspect my shoes for foreign objects before putting them on." To avoid injury or trauma to the feet, shoes need to be checked for foreign objects before the feet are inserted in them.Clients with diabetes would not go barefoot because foot injuries can occur in those clients who lack sensation. To avoid injury or trauma, a callus needs to be removed by a podiatrist, not by the client. To prevent injury, the client with diabetes must wear protective shoes for support and not canvas shoes.

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

"I will begin exercising for at least an hour a day." **Further teaching is needed when the client says that "I will begin exercising for at least an hour a day." The goal of weight control for Type 2 diabetes is to change sedentary behavior to active behavior. This is begun by starting low-intensity activities in short sessions (less than 10 minutes). The client may increase sessions to moderate or vigorous aerobic physical activity to lose and or sustain weight loss.Monitoring the diet and avoiding empty calories is essential to managing type 2 diabetes. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis due to osmotic diuresis.

The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? "I will drink a glass of water." "I will eat three graham crackers." "I will give myself 1 mg of glucagon." "I will sit down and rest."

"I will eat three graham crackers." **Correct understanding of what the client needs to do if the client feels hungry and shaky is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.

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

"If I become hypoglycemic, I could become unconscious." **The statement by the client that indicates a correct understanding about the need to wear a MedicAlert bracelet is, "If I become hypoglycemic, I could become unconscious." Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.Hyperglycemia does not pose the same type of acute medical emergency as hypoglycemia unless it is severe and acidosis develops. Insurance information does not appear on a MedicAlert bracelet. Information on the MedicAlert bracelet may be helpful if a sudden hospitalization occurs when the client cannot communicate. However, it is standard procedure to assess blood glucose in that instance.

A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? 7:30 a.m. 11:00 a.m. 2:00 p.m. 7:30 p.m.

11:00 a.m. **Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2-4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m.The other options for peak times for regular insulin are incorrect.

A 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? "It is overwhelming, isn't it?" "Let's see how much you can learn today, so you are less nervous." "Let's tackle it piece by piece. What is most scary to you?" "Many people live with diabetes and do it just fine."

"Let's tackle it piece by piece. What is most scary to you?" **The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client centered response, and acknowledges the client's concern, letting the client master survival skills first.Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in one day may add to his anxiety by overwhelming him with information and the need to "do it all" in one day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.

The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? Add 20 mEq of KCl to each liter of IV fluid IV regular insulin at 2 units/hr IV normal saline at 100 mL/hr 1 ampule Sodium Bicarbonate IV now

1 ampule Sodium Bicarbonate IV now **Sodium Bicarbonate is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state that presents with hyperglycemia and absence of ketosis/acidosis.Insulin puts potassium into the cell. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from osmotic diuresis and electrolyte shifts. IV regular insulin at 2 units/hr will help correct hyperglycemia. IV normal saline at 100 mL/hr will help correct dehydration.

Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A client with sensory neuropathy who needs teaching about foot care A client with diabetic ketoacidosis who has an IV running at 250 mL/hr A client who needs blood glucose monitoring and insulin before each meal A client who was admitted with fatigue and shortness of breath

A client who needs blood glucose monitoring and insulin before each meal **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.The clients with sensory neuropathy, diabetic ketoacidosis, and the client with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for adults with diabetes-related complications.

Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? American Diabetes Association (ADA) Centers for Disease Control and Prevention Primary health care provider office Pharmaceutical representative

American Diabetes Association (ADA) **The American Diabetes Association is the best agency to refer the diabetic client to. The ADA provides national and regional support and resources to clients with diabetes and their families.The Centers for Disease Control and Prevention does not specifically focus on diabetes. The client's primary health care provider's office is limited in the resources available to the client with diabetes. A pharmaceutical representative is not an appropriate resource for diabetes information and support.

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 (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? Instruct the client to continue with the current diet and metformin use. Discuss the need to check blood glucose several times every day. Talk about the possibility of adding rapid-acting insulin to the regimen. Ask the client about current dietary intake and medication use.

Ask the client about current dietary intake and medication use. **The nurse's next action would be to assess the client's adherence to the currently prescribed diet and medications. The nurse would also check for any stressors or undocumented illnesses. Glycosylated hemoglobin (HbA1C) levels >8% indicate poor diabetes control and need for adherence to regimen or changes in therapy.Instructing the client to continue with current diet and metformin use is inappropriate without further assessment. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is higher than the target range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse would not assume that adding insulin, which must be prescribed by the primary health care provider, is the answer without assessing the underlying reason for the treatment failure.

Hemoglobin A1c

Assess for indications of adherence to prescribed regimens and their effectiveness

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

Assist the client with washing the feet and applying moisturizing lotion. **The nursing action that the home health nurse can delegate to a home health aide who is making daily visits to a newly diagnosed type 2 diabetic client is assisting with personal hygiene. This action is included in the role of home health aides.Assisting with appropriate dietary selections, evaluating the effectiveness of teaching, and performing assessments are complex actions that would be performed by licensed nurses.

A client newly diagnosed with diabetes is not ready 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? Select all that apply. Pathophysiology of diabetes Causes and treatment of hypoglycemia Dietary control of blood glucose Insulin administration Physical activity and exercise

Causes and treatment of hypoglycemia Insulin administration **The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay.

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

Check the blood glucose. **The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis.Based on the oxygen saturation, oxygen administration is not indicated. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.

The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? Client taking repaglinide (Prandin) who has nausea and back pain Client taking glyburide (Diabeta) who is dizzy and sweaty Client taking metformin (Glucophage) who has abdominal cramps Client taking pioglitazone (Actos) who has bilateral ankle swelling

Client taking glyburide (Diabeta) who is dizzy and sweaty **The nurse needs to first assess the client taking glyburide (Diabeta) who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.

The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? Client with type 1 diabetes whose insulin pump is beeping "occlusion" Newly diagnosed client with type 1 diabetes who is reporting thirst Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) Client with type 2 diabetes with a blood pressure of 150/90 mm Hg

Client with type 1 diabetes whose insulin pump is beeping "occlusion" **The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.

Metformin

Symptoms of lactic acidosis: fatigue dizziness, difficulty breathing, stomach discomfort, irregular heart beat)

The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes.Physical AssessmentDiagnostic FindingsProvider PrescriptionsLungs clearGlucose 179 mg/dL (9.9 mmol/L)Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L)Right great toe mottled and cold to touchHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L)Client states wears eyeglasses to readAfter completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? Poor glucose control Visual changes Respiratory distress Decreased peripheral perfusion

Decreased peripheral perfusion **A cold, mottled right great toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization. This must be reported to the primary health care provider to avoid potential gangrene and amputation.Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.

Nurse presenting info about nutrition habits that prevent type 2 diabetes. Which of the following should the nurse include?

Eat less meat and processed foods Decrease intake of sat. fats Increase daily fiber intake Include omega-3 fatty acids in diet

The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? Current lifestyle Educational and literacy level Sexual orientation Current energy level

Educational and literacy level **The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.

DKA Assessment priorites

First assess the airway, LOC, hydration status, electrolytes, and blood glucose level of any pt with DKA

Sulfonylurea drugs

Increased risk for hypoglycemic reactions

Peripheral Neuropathy Teaching

Instruct pt to use a bath thermometer to test water for bathing, to avoid walking barefoot, and inspect feet daily

The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? Perform a blood glucose check on a client who requires insulin. Verify the infusion rate on a continuous infusion insulin pump. Assess a client who reports tremors and irritability. Monitor a client who is reporting palpitations and anxiety.

Perform a blood glucose check on a client who requires insulin. **Performing bedside glucose monitoring is a task that may be delegated to UAPs because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for UAPs. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for UAPs. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.

Nurse teaching about foot care to DM pt. Which of the following should nurse in include in the teaching?

Perform nail care after bathing Trim toenails straight across Wear closed-toe shoes

An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? Urine output 12-lead electrocardiogram (ECG) Potassium level Rate of IV fluids

Potassium level **After DKA therapy starts, serum potassium levels drop quickly. An ECG shows conduction changes and ectopy related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the ectopy is essential.Ectopy is not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause, which is most likely hypokalemia. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.

A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? "Your diabetes is getting worse, so you will need to take insulin." "You can't take your metformin while in the hospital." Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." "You must take insulin from now on because the surgery will affect your diabetes."

Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." **The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.

DM pt fasting glucose 82 mg/dL and HgB A1C of 5.9%. What is the nurse's interpretation of these findings?

The values indicate that the client has managed his or her disease well

The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? Most clients with type 1 diabetes are born with it. People with type 1 diabetes are often obese. Those with type 2 diabetes make insulin, but in inadequate amounts. People with type 2 diabetes do not develop typical diabetic complications.

Those with type 2 diabetes make insulin, but in inadequate amounts. **The explanation by the students that indicate understanding of the type of diabetes is "Those with type 2 diabetes make insulin, but in inadequate amounts." People with type 2 diabetes may also have resistance to existing insulin.Most clients with type 1 diabetes are not born with it. Although type 1 diabetes may occur early in life, it is considered an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person. Risk for type 1 DM is determined by inheritance of genes coding for the HLA-DR and HLA-DQA and DQB tissue types (McCance et al., 2014). However, inheritance of these genes only increases the risk, and most people with these genes do not develop type 1 DM. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for typical diabetic complications, especially cardiovascular diseases.

Teach back strategies

Use return demonstration when teaching pt about drug regimen, insulin injection, blood glucose monitoring, and foot assessment

Diabetic Teaching

Wear medical alert bracelet Rotate injection sites within one area Instruct always to carry a glucose source Teach those who exercise to test urine for ketone bodies of blood glucose levels greater than 250 mg/dL before engaging in exercise Avoid becoming dehydrated and drink at least 2L of water each day unless from another condition Remind to have yearly eye exams

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

While performing the test in the hospital **Teaching the client about the operation of the machine while performing the test in the hospital is the best time for the nurse to introduce the client to SMBG. The teaching can be reinforced each time testing is performed on the client and again before discharge.Instructing the client on the day of admission or the day of discharge would not allow time for redemonstration and correction of the skill if needed. Other time-consuming activities are done on those days and could distract the client and make the client feel overwhelmed. Also, waiting for the client to state readiness may postpone the instructions too long.

Type 2 DM

a risk factor independent of other risk factors is exposure to main component of agent orange , dioxin, which was used in military conflicts risk for type 2 diabetes appears higher among US military personal/veterans deployed in those geographic areas