Chronic Care Exam 2 (PrepU & ATI)

During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse?

"After menopause, the body's bone density declines, resulting in a gradual loss of height."

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."

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session?

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."

Which of the following is an age-related change that may affect diabetes? Select all that apply.

-Decreased renal function -Taste changes -Decreased vision Rationale: Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective?

1/2 cup fruit juice or regular soft drink.

A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:

138 mg/dL, 2 hours postprandial.

What is the duration of regular insulin?

4 to 6 hours

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well-controlled?

6.5%

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:45 AM. Rationale: Insulin lispro has an onset of 5 to 15 minutes. Therefore, the nurse would need to ensure that the client has his breakfast by 7:45 AM at the latest. Otherwise, the client may experience hypoglycemia.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure?

Administering large doses of I.V. antibiotics as ordered

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given?

Alendronate

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?

Fruity breath

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. Rationale: 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 Rationale: 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.

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

A nurse understands that a major concern with type 2 diabetes is:

Insulin resistance. Rationale: A major concern with type 2 diabetes is insulin resistance, which refers to decreased tissue sensitivity to insulin. Age and body weight contribute to the diagnosis.

NPH is an example of which type of insulin?

Intermediate-acting

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes?

Lower lumbar

Which of the following presents with an onset of heel pain with the first steps of the morning?

Plantar fasciitis

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize?

Quadriceps

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

Rapid-acting

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?

Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.

A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following?

Staphylococcus aureus

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort?

Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation?

Surgical debridement

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

Sweating, tremors, and tachycardia Rationale: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin.

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

The client has not eaten but continues to take insulin or oral antidiabetic medications. Rationale: Hypoglycemia occurs when a client with diabetes is not eating and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the client has not been compliant with the prescribed treatment regimen. If the client has eaten and has not taken or received insulin, diabetic ketoacidosis is more likely to develop.

To help minimize calcium loss from a hospitalized client's bones, the nurse should:

encourage the client to walk in the hall.

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.

Lifestyle risk factors for osteoporosis include

lack of exposure to sunshine.

The nurse is educating a client with low back pain on proper lifting techniques. The nurse recognizes that the education was effective when the client

places the load close to the body.

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. Rationale: 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.

Which instruction about insulin administration should a nurse give to a client?

"Always follow the same order when drawing the different insulins into the syringe."

After teaching a client with type 1 diabetes who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching?

"I might need insulin later on but probably not as much or as often." Rationale: Transplanted islet cells tend to lose their ability to function over time, and approximately 70% of recipients resume insulin administration in 2 years. However, the amount of insulin and the frequency of its administration are reduced because of improved control of blood glucose levels. Thus, this type of transplant doesn't cure diabetes. It requires the use of two human pancreases to obtain sufficient numbers of islet cells for transplantation. A whole organ transplant requires a means for exocrine enzyme drainage and venous absorption of insulin.

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes." Rationale: The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours." Rationale: The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

A client has gained 55 lb in the last 3 years and is concerned about developing type 2 diabetes mellitus. Additionally, the client's healthcare provider has diagnosed metabolic syndrome. What are the conditions which contribute to developing metabolic syndrome? Select all that apply.

-abdominal obesity -elevated blood glucose levels Rationale: Metabolic syndrome includes obesity, especially in the abdominal area; high blood pressure (BP); elevated triglyceride, low-density lipoprotein (LDL), and blood glucose levels; and a low high-density lipoprotein (HDL) level.

The nurse is preparing to administer IV fluids for a patient with ketoacidosis who has a history of hypertension and congestive heart failure. What order for fluids would the nurse anticipate infusing for this patient?

0.45 normal saline Rationale: Half-strength NS (0.45%) solution (also known as hypotonic saline solution) may be used for rehydration of patients with hypertension or hypernatremia and those at risk for heart failure.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

10 to 15 g of a simple carbohydrate.

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

15 g of carbohydrates.

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

15 to 20 g of a fast-acting carbohydrate such as orange juice. Rationale: This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

8:30 AM. Rationale: Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.

A client with type 1 diabetes is to receive a short-acting insulin and an intermediate-acting insulin subcutaneously before breakfast. The nurse would administer the insulin at which site as the preferred site?

Abdomen Rationale: Although the arms, thighs, and lower back can be used, the preferred site insulin administration is the abdomen which allows more rapid absorption.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage

Which medication classification is prescribed when allergy is a factor causing the skin disorder?

Antihistamines

Insulin is secreted by which of the following types of cells?

Beta cells Rationale: Insulin is secreted by the beta cells, in the islets of Langerhans of the pancreas. In diabetes, cells may stop responding to insulin, or the pancreas may decrease insulin secretion or stop insulin production completely. Melanocytes are what give the skin its pigment. Neural cells transmit impulses in the brain and spinal cord. Basal cells are a type of skin cell.

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl Rationale: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker?

Dietitian Rationale: The client should be referred to a dietitian, who will help him gain better control of his blood glucose levels. The client can care for himself, so a home health agency isn't necessary. The client shows no signs of needing a psychiatric referral, and referring the client to a psychiatrist isn't in the nurse's scope of practice. Social workers help clients with financial concerns; the scenario doesn't indicate that the client has a financial concern warranting a social worker at this time.

Which information should be included in the teaching plan for a client receiving glargine, which is "peakless" basal insulin?

Do not mix with other insulins. Rationale: Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. Glargine is a "peakless" basal insulin that is absorbed very slowly over a 24-hour period and can be given once a day. When administering glargine insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

Glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

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. Rationale: Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?

It enhances transport of glucose across the cell wall. Rationale: Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose.

Which type of insulin acts most quickly?

Lispro Rationale: The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.

A client with diabetes is receiving an oral anti diabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin Rationale: Metformin is a biguanide and, along with the thiazolidinediones (rosiglitazone and pioglitazone), are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide, which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

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

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

Which of the following would the nurse use to determine that a client is exhibiting signs and symptoms of chronic osteomyelitis?

Persistent draining sinus

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. Rationale: 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.

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Presence of islet cell antibodies. Rationale: Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?

Sensory neuropathy Rationale: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates. Rationale: While assessing a client, it is important to note the client's consumption of carbohydrates because he has high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client's to be noted in a client with high blood sugar.

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance. Rationale: Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.