Patho: Chapter 33
When educating a patient about glargine (Lantus), the nurse should explain that this medication:
Has a prolonged absorption rate and provides a relatively constant concentration for 12-24 hours.
A 62-year-old man who is overweight has just been diagnosed with type 2 diabetes. The nurse educator is instructing him in the ways his diabetes can be controlled. The nurse should initially prioritize which action?
Helping the client make meaningful changes to his diet and activity level.
A 15 year-old boy with type 1 diabetes is exasperated by his regimen of blood sugar monitoring and insulin administration, and has told his mother that he wants to scale both back. Which of the following responses by his mother is most accurate?
"Even though it's hard to do, you need to continue so you don't go blind or need a kidney transplant down the road."
The health care provider has prescribed Repaglinide 2 mg for a client diagnosed with type 2 diabetes. The most important information for the nurse to give the client would be:
"Take the medication 15 to 30 minutes before each meal."
Which manifestation indicates a client is at risk for developing diabetes mellitus?
2 hour oral GTT 175 mg/dl Explanation: Laboratory values that are considered normal are hemoglobin A1c less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dl or less than 140 mg/dl 2 hours after an oral glucose tolerance test (GTT). A hemoglobin A1c value that is greater than or equal to 6.5 percent, a fasting blood glucose greater than 126mg/dl, or a blood glucose level greater than 200 mg/dl 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus. Potassium levels do not directly correlate with a diagnosis of diabetes mellitus. Page 805
The nurse is reviewing assessment data on four clients. Select the client at highest risk for developing type 2 diabetes.
A 45-year-old obese female with a sedentary lifestyle
A 48-year-old male client diagnosed with type 2 diabetes presents with the following: • Blood glucose level of 46 mg/dL • Very lethargic • Has cool, clammy skin. Select the most appropriate intervention.
Administer injectable glucagon
The pancreas is an endocrine organ that is composed of the acini and the islets of Langerhans. The islets of Langerhans have alpha, beta, and delta cells as well as the PP cell. Which cells secrete insulin?
Beta cells
The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. Which of these effects on blood glucose levels does the nurse teach the student epinephrine will cause?
Blood glucose will elevate. Explanation: Epinephrine, a catecholamine, helps to maintain blood glucose levels during periods of stress. Epinephrine causes glycogenolysis in the liver, thus causing large quantities of glucose to be released into the blood. Page 798
When caring for the client with diabetic ketoacidosis, the nurse recognizes that fatty acids and ketones may be used for energy by most organs. Which of these organs does the nurse recognize is reliant on glucose as the major energy source?
Brain
Which of the following criteria about insulin would prompt a diagnosis of type 1 diabetes?
Complete failure of insulin secretion
A pancreatitis patient is admitted with weight loss, nausea, and vomiting. To maintain nutrition, the physician orders parental nutrition to be started. Knowing that a major side effect of parenteral nutrition is a hyperosmolar hyperglycemic state, the nurse should assess the patient for which clinical manifestations (listed below)?
Dry lips, excess urine output, and seizures.
A 23-year-old man is admitted to the hospital. He is experiencing polyphagia, polyuria, and polydipsia. He states that the condition has come on very suddenly. This client is likely to require what treatment?
Exogenous insulin injections
A patient with diabetes asks the nurse for advice in controlling between-meal blood glucose levels. Which of the following might the nurse suggest as a long-acting insulin to provide a consistent basal level?
Glargine (Lantus)
A client is diagnosed with type 2 diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome?
Glycosylated hemoglobin 5.2% Explanation: The goals of the nutritional plan for type 2 diabetes mellitus include normal glucose levels, normal lipid levels, weight loss to ideal body weight (or at least 5-10 percent of total body weight) and regulating blood pressure. HDL cholesterol should be above 60 mg/dl. Page 805
During periods of fasting and starvation, the glucocorticoid and other corticosteroid hormones are critical for survival because of their stimulation of gluconeogenesis by the liver. When the glucocorticoid hormones remain elevated for extended periods of time, what can occur?
Hyperglycemia
Which interventions are important for the nurse to teach a client diagnosed with distal symmetric neuropathy caused by diabetes? Select all that apply.
Inspect the feet daily for blisters. Wear well-fitted shoes. A patient with neuropathy is at risk for damage to their feet, such as blisters or ulcers, as they are unable to detect injuries. Patients need to inspect their feet daily, wear foot coverings (such as well-fitted closed-toe shoes) to prevent injuries, and continue exercise to improve circulation and glucose use. Insulin injection sites must be rotated for each administration. Page 817
Which interventions are important for the nurse to teach a client diagnosed with distal symmetric neuropathy caused by diabetes? Select all that apply.
Inspect the feet for blisters daily Explanation: A client with neuropathy is at risk for damage to his or her feet, such as blisters or ulcers, as the clients are unable to feel this damage. Clients need to inspect their feet daily, where foot coverings (such as closed-toe shoes) to prevent injuries, and continue the exercise patterns to promote improved circulation. Page 817
The diagnosis of type 1 diabetes would be confirmed by:
Insulin is not available for use by the body.
A client with severe hypoglycemia is unconscious. Which method of providing glucose should be avoided?
Orange juice orally
A client has been experiencing elevated blood glucose levels. The nurse anticipates that which assessment data correlates with hyperglycemia?
Polydipsia Explanation: Polyuria, polyphagia, and polydipsia are three classic signs of diabetes. Thirst (polydipsia) results from the intracellular dehydration that occurs as blood glucose levels rise and water is pulled out of body cells, including those in the hypothalamic thirst center. Hypotension and dry skin and mucous membranes are signs of hypovolemia that may accompany increased blood glucose levels. FBS of 120 mg/dL is normal. Page 805
Select the most common symptoms of diabetes. Select all that apply.
Polydipsia Polyuria Polyphagia Explanation: The most commonly identified signs and symptoms of diabetes are often referred to as the three polys: (1) polyuria (i.e., excessive urination), (2) polydipsia (i.e., excessive thirst), and (3) polyphagia (i.e., excessive hunger). Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. Polycythemia is a condition of increased red blood cells. Page 805
A woman in her 28th week of pregnancy tests positive for gestational diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome?
Random blood glucose 85 mg/dl
A client with diabetes carries insulin with him at all times. At 11:35, he obtains a blood glucose reading of 12.1 mmol/l and self-administers a dose of insulin in anticipation of eating lunch at noon. What type of insulin did he most likely inject?
Short acting
Research has identified a cycle of insulin-induced posthypoglycemic episodes. What is this phenomenon called?
Somogyi effect
The nurse is teaching a client with diabetes and the family about the signs and symptoms of hypoglycemia. The client asks what produces signs and symptoms of headache, disturbed behavior, coma, and seizures. The best response would be:
The brain relies on blood glucose as its main energy source.
A patient is managing his type 2 diabetes with exercise and diet. He has a fasting blood sugar level (FBS) of 80 mg/dL and a hemoglobin A1C of 5%. Based on these findings, which of the following can the nurse assume?
The patient is achieving normal glycemic control.
The nurse is caring for a client with diabetes who has developed gastroparesis. Which of these symptoms does the nurse expect the client to report?
Vomiting after eating
The nurse is caring for a client with diabetes who has developed gastroparesis. Which of these symptoms does the nurse expect the client to report?
Vomiting after eating Explanation: Gastroparesis (delayed emptying of stomach) is characterized by complaints of epigastric discomfort, nausea, postprandial vomiting, bloating, and early satiety. Page 815
The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which of these risk factors in the teaching?
Woman with a family history of diabetes
For which conditions is diabetes mellitus a risk factor? Select all that apply.
• Coronary artery disease • Cerebrovascular accident • Chronic kidney disease
A client with diabetes mellitus has sudden onset of slurred speech, incoordination, and cool, clammy skin. What will the nurse do first?
check blood glucose Explanation: Hypoglycemia is a medical emergency. Because other conditions can also cause these symptoms, the blood glucose level should be checked first. Then glucose should be given. The client should follow this with a protein and complex carbohydrate to avoid a recurrence of hypoglycemia. Blood glucose should be tested about 15 minutes after the glucose is given to monitor progress. Page 812
A diabetic patient's most recent blood work indicated a decreased glomerular filtration rate, and urine testing revealed microalbuminuria. Which of the following self-care measures should the nurse suggest to the patient? Select all that apply.
• Stop smoking. • Maintain systolic pressure below 130 mm Hg. • Restrict protein consumption.
A client diagnosed with type 2 diabetes has been instructed about managing his condition with diet. The nurse determines further teaching is necessary when the client states:
"I must avoid all candies and cookies, but can eat unlimited amounts of pasta and breads."
Hypoglycemia has a sudden onset with a progression of symptoms. What are the signs and symptoms of hypoglycemia?
Altered cerebral function and headache
A nurse educator is conducting a course for newly diagnosed diabetes clients. Which statement by participants should the nurse follow up first?
"I've had a little sore on the sole of my foot for a few days, but I'm sure it will eventually heal."
The mother of a 2-year-old newly diagnosed with type 1 diabetes asks why insulin has to be given by injection. The best response by the nurse is:
"Insulin is destroyed by the stomach contents and has to be administered by injection." Insulin is destroyed by the gastrointestinal tract and needs to be administered via injection or inhalation. Type 1 diabetes is not treated with oral medications at this time. Insulin is administered subcutaneously rather than in the vein, and the final statement does not address the mother's concerns. Page 807
What are the hallmark signs of diabetes mellitus?
Polyuria, polydipsia, and polyphagia
Infections are common in people with diabetes. Which infection is thought to be related to a neurogenic bladder?
Pyelonephritis
A three year-old girl has just been diagnosed with type 1A diabetes. Her parents are currently receiving education from the diabetes education nurse. How can the nurse best explain to the parents the etiology (cause) of their daughter's diabetes?
"The problem that underlies her diabetes is that her own body has destroyed the cells in her pancreas that produce insulin."
A three year-old girl has just been diagnosed with type 1A diabetes. Her parents are currently receiving education from the diabetes education nurse. How can the nurse best explain to the parents the etiology (cause) of their daughter's diabetes?
"The problem that underlies her diabetes is that her own body has destroyed the cells in her pancreas that produce insulin." Explanation: Type 1A, or immune-mediated, diabetes involves the autoimmune destruction of pancreatic beta cells and a consequent absolute lack of insulin. Exogenous insulin is required as dietary control alone is insufficient. The central problem is an absolute lack of insulin production rather than deranged release. Page 801
Following an oral glucose tolerance, a 36 year-old mother of 4 has been diagnosed with gestational diabetes mellitus (GDM), a problem that was not present in any of her previous pregnancies. What should her primary care provider tell her about this new health problem?
"Your baby could become too large or have low blood sugars if we're not vigilant about controlling your sugars."
The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. Which of these effects on blood glucose levels does the nurse teach the student epinephrine will cause?
Blood glucose will elevate.
A 60 year-old man has long managed his type 1 diabetes effectively with a combination of vigilant blood sugar monitoring, subcutaneous insulin administration and conscientious eating habits. This morning, however, his wife has noted that he appears pale and clammy and appears to be in a stupor, though he is responsive. She suspects that he has made an error in his insulin administration and that he is experiencing a hypoglycemic episode. Which of the following actions should be the wife's first choice?
Administration of 15 to 20 g of glucose in a concentrated carbohydrate source. Explanation: An insulin reaction necessitates intervention in addition to careful observation. The ideal response to an insulin reaction in a still conscious client is the administration of 15 to 20 g of glucose in a concentrated carbohydrate source. Glucagon or D50 would be indicated if the client is unconscious or unable to swallow. Page 812
The critical care nurse has just admitted a client with diabetic ketoacidosis (DKA) whose blood glucose level is 877 mg/dL. The client's breath has a fruity odor and the client is confused. Which of these does the nurse set as the priority at this time?
Administration of intravenous fluids
While reviewing the role of glucagon in regards to regulation of blood glucose, the nurse knows which of the following situations could lead to an inhibition of glucagon release?
An increase in glucose levels. Explanation: Low blood sugar, intake of protein and strenuous physical activity are associated with glucagon release. Lowered cellular metabolic needs and/or increased glucose levels would inhibit glucagon release. Page 798
Which complications may be experienced by a client with diabetic neuropathies? Select all that apply.
Foot ulcers Gastroparesis Erectile dysfunction Urinary retention Explanation: Neuropathies may be distal or autonomic. People with peripheral neuropathies lose perception of pain, vibration, and temperature usually in the distal extremities. This leads to injuries and foot ulcers. Autonomic neuropathies lead to gastroparesis, urinary retention, altered bowel patterns, and orthostatic hypotension. Page 815
A young adult has been experiencing some extreme fatigue, changes in vision, and unexpected weight loss, leading the healthcare provider to suspect hyperglycemia. Which clinical manifestations correlate with a diagnosis of diabetes? Select all that apply.
Frequent thirst Excess urination Ravaging hunger Explanation: The most commonly identified signs and symptoms of diabetes are often referred to as the three polys: (1) polyuria (i.e., excessive urination), (2) polydipsia (i.e., excessive thirst), and (3) polyphagia (i.e., excessive hunger). These three symptoms are closely related to the hyperglycemia and glycosuria of diabetes. Fruity breath and honey-sweat are not commonly associated with diabetes. Page 805
Type 1A diabetes is now considered an autoimmune disorder. What factors are considered necessary for type 1A diabetes to occur?
Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen
The nurse is caring for a client who received regular insulin at 7 am. Four hours later the nurse finds the client diaphoretic, cool, and clammy. Which of these interventions is the priority?
Give the client a concentrated carbohydrate.
The family of a client in the hospital with diabetes mellitus out of control asks the nurse to explain the client's recent weight loss while eating more than usual. How will the nurse respond?
Glucose is unused without insulin, so body fats are used for energy. Explanation: Most of these options are true statements, but they do not answer the question asked by the family. Normally, nutrients are metabolized in a number of ways. Glucose is transported into cells by insulin and then is broken down to carbon dioxide and water. When there is surplus glucose present, it is metabolized and stored as glycogen in the liver and skeletal muscles. Further surplus is converted by the liver to fatty acids and stored as triglycerides. When triglycerides are metabolized the glycerol molecule enters the glycolytic pathway to release energy. Excess proteins are also converted to fatty acids for storage. Insulin is needed to transport glucose into cells, prevent fat breakdown, and inhibit gluconeogenesis. When diabetes is out of control there is lack of insulin. Weight loss occurs as the cells break down fats to use fatty acids for energy. Page 805
Which of the following statements best describes an aspect of the normal process of glucose metabolism?
Glucose that exceeds metabolic needs is converted and stored by the liver. Explanation: Approximately two thirds of the glucose that is ingested with a meal is removed from the blood and stored in the liver as glycogen. Between meals, the liver releases glucose as a means of maintaining blood glucose within its normal range. Normal glucose metabolism does not involve large variations in blood glucose levels in response to food intake, and excess glucose does not normally remain in circulation. Glucose levels are not primarily maintained by the kidneys. Page 794
A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes .The best diagnostic indicator that would support the client's response would be:
Glycosylated hemoglobin, hemoglobin A1C (HbA1C)
A patient has been admitted with diabetic ketoacidosis. The Emergency Department starts an IV to improve circulatory volume. If there is a sudden change in extracellular fluid osmolality which results in a too rapid blood glucose lowering, the nurse will likely observe which of the following clinical manifestations?
Headaches, dizziness, change in level of consciousness. Explanation: A sudden change in osmolality of extracellular fluid can also occur when blood glucose levels are lowered too rapidly, and this can cause cerebral edema, more common in children than adults. Answers A, B, C all have some component of signs/symptoms of DKA rather than cerebral edema s/s (answer B). Page 812
Diabetics are at higher risk than are the majority of the population for injury to organ systems in the body. Which organs are most at risk?
Kidneys and eyes
A man is brought into the emergency department by paramedics who state that the client passed out on the street. The man smells of alcohol, and when roused says he has not eaten since yesterday. He is wearing a medic alert bracelet that says he is a diabetic. What would the nurse suspect as a diagnosis?
Hypoglycemia
Select the most appropriate intervention for the nurse to teach a client diagnosed with distal symmetric neuropathy related to diabetes.
Inspect the feet for blisters daily
The nurse has just completed teaching a client newly diagnosed with type 1 diabetes about rapid-acting insulin. The nurse determines that teaching was effective when the client selects:
Lispro
A patient with distal symmetric polyneuropathy usually begins by complaining of:
Loss of feeling or touch in the feet.
A client with diabetic retinopathy develops a retinal bleed and asks the nurse, "How can I prevent this from happening again?" What response provides the most effective information?
Maintain healthy blood pressure and blood sugar levels. Diabetic retinopathy occurs when blood vessels have increased permeability, develop microaneurysms, vascular proliferation, scarring, and retinal detachment. These conditions are worsened when the client has poor glycemic control, poorly controlled hypertension, and hyperlipidemia. Laser photocoagulation can be used to stop vessel proliferation and bleeding. An annual examination will evaluate the disease, but does not prevent recurrence. Eye use patterns do not change retinopathy. Page 816
The nurse screening for diabetes mellitus at a health fair obtains these results. Which client should be referred to a primary healthcare provider for further evaluation?
Random blood glucose 195 mg/dl Explanation: Laboratory values that are considered normal are hemoglobin A1c less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dl or less than 140 mg/dl 2 hours after an oral glucose tolerance test (GTT). Urine should be free of ketones. A hemoglobin A1c value that is greater than or equal to 6.5 percent, a fasting blood glucose greater than 126mg/dl, or a blood glucose level greater than 200 mg/dl 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus and require further evaluation. A random blood glucose should is expected to correlate with the two-hour GTT results and should be below 200 mg/dl. Page 805
The nurse is teaching a client with diabetes about the signs and symptoms of hypoglycemia. The client asks, "Why do you get headache, disturbed behavior, coma, and seizures if it's my pancreas that's impaired?" Which response is the best explanation?
The brain relies on blood glucose as its main energy source. Explanation: Because the brain relies on blood glucose as its main energy source, hypoglycemia produces behaviors related to altered cerebral function. Headache, difficulty in problem solving, disturbed or altered behavior, coma, and seizures may occur. Hyperglycemia causes ketone breakdown. Hepatic glycogenolysis. is stimulated by epinephrine, resulting in the raising of the level of blood glucose. However, that process is generally initiated by the fight-or-flight response, as opposed to the physiological drop in blood glucose levels that stimulates glucagon secretion. Somogyi phenomenon is also known as rebound hyperglycemia. The Somogyi phenomenon describes a rebound high blood glucose level in response to low blood glucose. Page 812
A client with type 1 diabetes mellitus wishes to stop taking insulin injections. What option is appropriate?
Using an insulin infusion pump
An obese adult has recently been diagnosed with type 2 diabetes.The nurse knows that the most likely treatment plan for this client will include which topics?
Weight loss, glucose monitoring and oral antihyperglycemic medications Persons with type 2 diabetes would be unlikely to require insulin initially and oral medications are likely to be of benefit as an addition to weight loss and glucose monitoring. Page 807
A young adult has been experiencing some extreme fatigue, changes in vision and unexpected weight loss. At the health clinic, the healthcare provider is assessing for hyperglycemia. Which would be considered the most commonly identifiable signs/symptoms of diabetes? Select all that apply.
• Frequent thirst • Excess urination • Ravaging hunger
