Diabetes & Thyroid
The home health nurse is visiting a client newly diagnosed with type 1 diabetes mellitus. The client reports nausea and abdominal pain. The nurse observes dehydration and dry skin. What question should the nurse ask the client?
"Are you taking your insulin daily?" The nurse should ask if the client is taking their insulin, as a common cause of DKA is missed insulin. Classic symptoms of diabetic ketoacidosis (DKA) include polyuria, weight loss, nausea and vomiting, altered mental status, abdominal pain, and Kussmaul's respirations. The nurse should also check a blood glucose level. Asking the client what he drank, if he weighed himself, and when he had a check-up will not help identify the cause of the current symptoms.
A client with diabetes mellitus is admitted with hypoglycemia. Which information should the nurse include in her client teaching? Select all that apply.
"Strenuous activity may result in hypoglycemia." "Hypoglycemia can result from excessive alcohol consumption." "Skipping meals can cause hypoglycemia." "Symptoms of hypoglycemia include shakiness, confusion, and headache." Alcohol consumption, missed meals, and strenuous activity may lead to hypoglycemia. Symptoms of hypoglycemia include shakiness, confusion, headache, sweating, and tingling sensations around the mouth. Thirst and excessive urination are symptoms of hyperglycemia. Hypoglycemia can become a life-threatening disorder involving seizures and death to brain cells; the client shouldn't be told that the condition is relatively harmless.
A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl (2.2 mmol/L). His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?
Administering 1 ampule of 50% dextrose solution, per physician's order The nurse should administer 50% dextrose solution to restore the client's physiological integrity. Feeding through a feeding tube isn't appropriate for this client. A bolus of normal saline solution doesn't provide the client with the much-needed glucose. Observing the client for 1 hour delays treatment. The client's blood glucose level could drop further during this time, placing him at risk for irreversible brain damage.
The nurse is preparing to administer IV insulin to a client diagnosed with diabetic ketoacidosis (DKA). What will the nurse monitor while the client is receiving this intervention?
Hypokalemia and hypoglycemia The nurse should monitor for decreased potassium and decreased glucose. Hypoglycemia might occur if too much insulin is administered, or insulin is administered too quickly. Intravenous insulin forces potassium into cells, thereby lowering plasma levels of potassium. The client may have hyperkalemia prior to starting the insulin therapy, but hypokalemia will occur with insulin administration. Calcium and sodium levels should not be affected.
A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to:
consult a health care provider (HCP) about removing the corns. A client with diabetes should be advised to consult a HCP or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a HCP or podiatrist.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatest effect on fluid loss?
rapid, deep respirations Due to the rapid, deep respirations, the client is losing fluid from vaporization from the lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through vaporization. Decreased serum potassium level has no effect on insensible fluid loss. Hypotension occurs due to polyuria and inadequate fluid intake. It may decrease the flow of blood to the skin, causing the skin to be warm and dry.
When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:
"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." The nurse should make the client aware that diabetes affects sensation in the feet and that he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it?
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Stating the need to remain hydrated and pay attention to eating, drinking, and voiding needs indicates that the client understands HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. Limiting fluids will exacerbate the development of HHNS; limiting food might be acceptable, but it may lead to ketosis. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
The laboratory comes to draw an Hgb AIc. The client asks the nurse what this test represents. Which statement would be correct?
"This test reflects the average blood glucose over a period of approximately 2-3 months." HbG AIc is a measurement of blood glucose over the life of a red blood cell. It measures the percentage of glycated hemoglobin in the blood All the other choices do not accurately represent the purpose of the test.
A client with diabetic ketoacidosis (DKA) has asked the unlicensed nursing assistant for another pitcher of water. It is the third such request over the past 4 hours. The nurse would recognize this request as which of the following manifestations?
An occurrence of the excess loss of fluid associated with osmotic diuresis Due to the DKA and fluid shift, the client would present with the 3 Ps: polyuria, polyphagia, and polydipsia. Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency. The other choices are part of the problem but not the main manifestation of the disease process.
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Below-normal serum potassium level A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
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 (61.05 mmol/L) 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 (33.33 mmol/L) 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.
What information will the nurse include in the preoperative education for a client scheduled for thyroid lobectomy?
Daily neck exercises Surgical clients should be taught specific and general postoperative care. Following thyroid surgery, clients should perform neck exercises to maintain range of motion. All surgical clients should observe for common surgical complications such as bleeding or infection and how to provide postoperative wound care. After partial thyroidectomy for an early-stage cancer, the client will not need a tracheostomy or replacement medications. If a calcium imbalance develops, it will be hypocalcemia resulting from removal or damage to the parathyroid glands.
A client has a foot ulcer that has not shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing? Select all that apply.
Diabetes Peripheral vascular disease Peripheral vascular disease causes cellular damage that leads to decreased blood supply to the extremities. When blood supply is deficient, wound healing cannot take place. A history of diabetes may cause a delay in wound healing. Multiple myeloma, hepatitis, and Parkinson's disease do not interfere with wound healing.
A nurse records a client's history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control?
Diabetes, hypercholesterolemia, and hypertension Controllable risk factors for CAD include hypertension, hypercholesterolemia, obesity, lack of exercise, smoking, diabetes mellitus, stress, alcohol abuse, and use of hormonal contraceptives. Uncontrollable risk factors for CAD include gender, age, and heredity.
A client with diabetes exhibits polyphagia, polydipsia, and oliguria; and also reports headache, malaise, and some vision changes with signs of dehydration present. Which condition does the nurse determine correlates with these symptoms?
Diabetic ketoacidosis Early manifestations of diabetic ketoacidosis include polydipsia, polyphagia, and polyuria. As the client dehydrates and loses electrolytes, this condition often leads to oliguria, malaise, and visual changes. Diabetes insipidus may result in dehydration but not polyphagia and polydipsia. Symptoms of hypoglycemia include diaphoresis, tachycardia, and nervousness. A client with SIADH is unable to excrete a dilute urine, causing hyponatremia.
A client with diabetes mellitus who is in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath. What do these findings suggest?
Diabetic ketoacidosis Signs and symptoms of diabetic ketoacidosis include nausea and vomiting, a fruity or acetone breath odor, signs of dehydration (such as flushed, dry skin), hyperglycemia, ketonuria, hypotension, deep and rapid respirations, and a decreased level of consciousness. In contrast, hypoglycemia causes sweating, tremors, palpitations, and behavioral changes. Infection causes a fever. Transition to the active phase of labor is signaled by cervical dilation of up to 7 cm and contractions every 2 to 5 minutes.
A young adult client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next?
Inform the HCP that the client has not received any subcutaneous insulin yet. Because subcutaneous administration of insulin has a slower rate of absorption than IV insulin, there must be an adequate level of insulin in the bloodstream before discontinuing the insulin drip; otherwise, the glucose level will rise. Adding an IV antibiotic has no influence on the insulin drip; it should not be piggy-backed into the insulin drip. Glargine cannot be administered IV and should not be mixed with other insulins or solutions.
A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?
Initiate fluid replacement therapy. The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.
The nurse is admitting a client diagnosed with diabetic ketoacidosis (DKA). What is the nurse's priority intervention?
Intravenous insulin A client with DKA should receive IV insulin to lower glucose and IV fluids to correct hypotension. Glucagon is given to treat hypoglycemia and is not appropriate for DKA. Blood products aren't needed to correct DKA. Glucocorticoids are not used to treat DKA, and may aggravate the hyperglycemia.
The nurse understands that the difference between diabetic coma and hyperosmolar hyperglycemic coma is that clients in diabetic coma can experience which of the following?
Kussmaul respirations Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). It affects clients with type 2 diabetes who still have some insulin production because insulin prevents the breakdown of fats into ketones. This type of breathing is the only difference. All the other choices can occur in both types of coma.
When obtaining the nursing history of a client who has type 1 diabetes mellitus, the nurse should assess the client for which early symptom of diabetic nephropathy?
Microalbuminuria In early diabetic nephropathy, a microvascular complication associated with damage to the small blood vessels that supply the glomeruli in the kidneys, begin to leak albumin into the urine through the damaged blood vessels. Clients with diabetes should be screened for nephropathy annually with a random spot urine collection. Oliguria occurs later. Flank pain and hematuria are not associated with diabetic nephropathy.
A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin lispro. The last meal was lunch, 2 hours ago. Place the nursing actions in the order in which the nurse should perform them. All options must be used.
Obtain a fingerstick test for blood glucose. Notify the health care provider (HCP). Start an IV infusion with normal saline solution. Administer insulin lispro. The client is experiencing ketoacidosis. The nurse should first obtain the blood glucose level and then notify the HCP who will then prescribe the appropriate dose of insulin. Dehydration should be addressed next by the nurse starting the IV saline infusion prior to administering the insulin.
A nurse obtains a fingerstick glucose level of 45 mg/dl (2.47 mmol/L) on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?
Obtain a repeat fingerstick glucose level. The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.
The nurse might expect to see which of these manifestations in the client who is hypocalcemic? Select all that apply.
Prolonged Q-T interval Irritability Tetany Hypocalcemia will cause a prolonged Q-T interval, irritability, and tetany. Fatigue and syncope would be signs of hypoglycemia.
Which information should the nurse include about hypoglycemia when teaching a client newly diagnosed with type 2 diabetes mellitus? Select all that apply.
Regular meals and a bedtime snack will decrease the incidence of hypoglycemia. Symptoms of hypoglycemia can include irritability, hunger, shaking, and sweating. A carbohydrate food source should be available during strenuous exercise. Alcohol consumption can increase the incidence of hypoglycemia. Regular meals and snacks are encouraged to prevent hypoglycemia. Strenuous exercise can increase the likelihood of hypoglycemia. Therefore, monitoring blood glucose and dietary intake is suggested in these situations. Alcohol consumption can increase the likelihood of hypoglycemia and should be avoided. Hypoglycemia can occur with oral diabetic agents even when the client is not taking insulin. Symptoms of hypoglycemia vary but include irritability, hunger, shaking, sweating, confusion, and headache.
Which nursing intervention should be done first when managing a pediatric client admitted to the emergency department with severe diabetic ketoacidosis (DKA)?
Secure the client's airway to ensure adequate ventilation. Treating pediatric clients with severe DKA is a medical emergency; therefore, attending to the airway, breathing, and circulation is the first priority. Once the airway is secured, the healthcare team should estimate the level of dehydration and begin replacement fluids of normal saline. An insulin drip should be started after the initial 1 to 2 hours of treatment at a rate of 0.1 units/kg/hr. Blood glucose should be tested every 1 to 2 hours until the client is stable, then it should be every 6 hours. Additionally, serum electrolytes should be drawn every 1 to 2 hours until the client is stable, then every 4 to 6 hours.
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, tolbutamide. Which laboratory test is the most important for confirming this disorder?
Serum osmolarity 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.
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?
Serum potassium level The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.
A client is being discharged after undergoing a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply.
Take thyroid replacement medication as ordered. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician. A thyroidectomy is the surgical removal of all or part of the thyroid. After removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy, restlessness, cold sensitivity, and dry skin, which may indicate the need for a higher dosage of medication. The thyroid gland does not regulate blood glucose level; therefore, signs and symptoms of hypoglycemia are not relevant for this client. Injectable dexamethasone is not needed for this client. Some OTC medications (such as non-aspirin products) are allowable.
A 56-year-old female client is being discharged after having a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply.
Take thyroid replacement medication, as ordered. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician. After removal of the thyroid gland, the client needs to take thyroid replacement medication. The client needs to report to the physician changes in body functioning, such as lethargy, restlessness, cold sensitivity, and dry skin. These changes may indicate the need to increase the medication dose. The thyroid gland does not regulate the serum glucose level; therefore, the client would not need to recognize the signs and symptoms of hypoglycemia. Dehydration is seen in diabetes insipidus. A client with Addison's disease should avoid over-the-counter medications and carry injectable dexamethasone.
Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome?
The client is severely dehydrated and needs 2 to 3 L of I.V. fluid rapidly. Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly ordered fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution. The client has severely elevated serum glucose levels and does not need more dextrose. The client is dehydrated, not fluid overloaded.
The nurse is administering an insulin infusion for a client diagnosed with diabetic ketoacidosis (DKA). Which outcome indicates that treatment has been effective?
The replacement of fluids during the first 24 hours The goal of treatment for DKA is to lower the blood glucose level gradually while replacing fluids during the first 24 hours of treatment. Lowering blood glucose levels too quickly will result in complications, and is not a desirable outcome. The anion gap should be decreased with treatment.
A client with type 2 diabetes mellitus needs instruction on proper foot care. Which instructions should the nurse include in client teaching? Select all that apply.
Wear cotton socks. Apply foot powder after bathing. See a podiatrist regularly to have your feet checked. Foot care for a client with diabetes mellitus includes keeping the feet dry with the application of foot powder and wearing cotton socks to absorb moisture. The client should have a podiatrist check the feet regularly to detect problems early. To prevent injury to the feet, the client should be instructed not to cut the toenails with scissors, walk barefoot, or wear loose-fitting shoes.
The student nurse asks why a client is receiving an IV of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse?
With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and IV lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.
An elderly client with type 2 diabetes had hyperglycemic hyperosmolar syndrome (HHS). The nurse should monitor the infusion for too rapid correction of the blood glucose in order to prevent:
cerebral edema. HHS can be caused by acute illness, such as an infection like pneumonia or sepsis. In HHS, there is a residual amount of insulin that suppresses ketosis but cannot control hyperglycemia. This leads to severe dehydration and impaired renal function. Ketone bodies are usually absent in HHS, and they do not form as a result of too rapid correction of blood glucose. The nurse should assess the client for a major vascular accident in the elderly as an etiology for a hyperglycemic crisis. Volume depletion must be treated first in HHS. Cerebral edema is a risk with too rapid correction of blood glucose.
A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action?
deep, rapid respirations with long expirations Deep, rapid respirations with long expirations are indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.
A client with diabetes who takes insulin has a blood glucose level of 40 mg/dL (2.22 mmol/L). What should the nurse offer the client to begin to raise the blood glucose level? Select all that apply.
one-half cup (120 mL) of orange juice one cup (240 mL) of milk one slice of bread one-half cup (120 mL) of regular soda To treat a low blood glucose level, the nurse should provide the client with approximately 15 g of carbohydrate and monitor the blood glucose level within 15 minutes. The orange juice, milk, bread, or soda would provide approximately 15 g of carbohydrate. Meat or fish, such as tuna, do not contain carbohydrate. Processed peanut butter may contain small amounts of carbohydrate, but it is also high in fat and protein. Peanut butter is not a good option to raise a blood glucose level in a timely manner.
A 58-year-old homeless person is brought to the emergency department by the police after being found unconscious on the street. Following examination and evaluation of laboratory test results, a diagnosis of diabetic ketoacidosis is confirmed. Which information is most crucial to document on the client's medical record? Select all that apply.
size of pupils and reaction of pupils to light blood pressure hourly urine output response to verbal and painful stimuli skin condition and presence of any rashes, lesions, or ulcers Diabetic ketoacidosis is a potentially life-threatening problem. The state of unconsciousness requires very astute monitoring of the neurologic condition. Frequent assessments of neurologic status (including the client's ability to respond to stimuli), blood pressure, and urinary output need to be documented. Assessment of skin condition for the presence of lesions, bruises, ulcers, or bumps is documented to assess for possible injuries, such as falls associated with head injury or internal injuries. Although it would be helpful to know how long the client has had diabetes, this information is not essential to document.
A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply.
type 2 diabetes mellitus advancing age smoking Advancing age, type 2 diabetes mellitus, and smoking are risk factors for delayed healing. Advanced age slows collagen synthesis by fibroblasts, impairs circulation, and requires a longer time for epithelialization of skin. Type 2 diabetes mellitus reduces the supply of oxygen and nutrients secondary to vascular complications. Nicotine is a potent vasoconstrictor and impedes blood flow, which reduces the supply of oxygen and nutrients necessary for healing. Atrial fibrillation causes venous stasis in the atria but does not have an effect on wound healing. Hypertension does not have an effect on healing.