PrepU Ch. 50: Diabetes Mellitus and the Metabolic Syndrome
A diabetic client presents to a clinic for routine visit. Blood work reveals a HbA1C of 11.0% (high). Which response by the patient may account for this abnormal lab result? "I've had more periods of hypoglycemia than usual over the past few months." "I've been doing great. I haven't needed much insulin coverage before meals." "To tell you the truth, my blood glucose levels have been pretty normal for me." "My meter broke so I have not been checking my blood glucose levels for a while."
"My meter broke so I have not been checking my blood glucose levels for a while." Explanation: Glycosylated hemoglobin is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cell is not insulin dependent, the rate at which glucose becomes attached to the hemoglobin molecule depends on blood glucose; the level is an index of blood glucose levels over the previous 6 to 12 weeks. If the diabetic client is not monitoring his or her blood glucose, he or she could be having more periods of hyperglycemia and just is not aware of the need for insulin coverage.
A client with a new diagnosis of type 2 diabetes mellitus states, "I am really worried that I might need to take injections. Is there something I can do to avoid that?" What is the best response by the nurse? "Diabetes management is complicated; you can't avoid injections." "If you exercise weekly, you won't need injections." "A support group could help you cope with stress and learn helpful tips." "You could regulate your diet, exercise regularly, and lose weight."
"You could regulate your diet, exercise regularly, and lose weight." Explanation: Diabetes management is based on dietary regulation, exercise, and medications. Many clients with type 2 diabetes mellitus can avoid injections if they exercise regularly, follow dietary guidelines, and manage their weight.
Which manifestation indicates a client is at risk for developing diabetes mellitus? Fasting blood glucose level 75 mg/dL Hemoglobin A1c 5.0% 2 hour oral GTT 175 mg/dL Serum potassium 4.2 mEq/dL
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.
A nurse is evaluating patients for the risk of developing type 2 diabetes. Which of the following patients has the highest risk? A 40-year-old man who has an active lifestyle A 45-year-old obese woman with a sedentary lifestyle A 10-year-old boy whose grandmother has type 2 diabetes A 60-year-old woman with a history of gestational diabetes
A 45-year-old obese woman with a sedentary lifestyle The person most at risk for developing type 2 diabetes is the 45-year-old obese woman with a sedentary lifestyle. Other risk factors include family history, age older than 40, and history of gestational diabetes. The 10-year-old boy, despite family history, would be at low risk as long as obesity and sedentary lifestyle are avoided. The 60-year-old woman most likely would have developed type 2 diabetes within 20 years after the pregnancy.
Which of the following clients would be considered to be exhibiting manifestations of "prediabetes"? A retired female registered nurse with a fasting plasma glucose level of 92 mg/dL. A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. A school-aged child who had a blood glucose level of 115 following lunch. An elderly client who got "light-headed" when he skipped his lunch. Blood glucose level was 60 mg/dL at this time.
A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. Explanation: Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.
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? Monitoring for fever Orienting the client to the events surrounding his admission Education related to prevention of DKA Administration of intravenous fluids
Administration of intravenous fluids Explanation: Goals of care for clients with DKA include administration of insulin and intravenous fluid and electrolyte replacement solutions. A common reason for development of DKA is an infection; monitoring for a fever should not take priority over administration of insulin and fluid replacement.
The nurse knows that type 1 diabetes mellitus results from destruction of the pancreatic beta cells by two mechanisms. The mechanism for type 1A diabetes is _______ destruction. Genetic Resistant Idiopathic Autoimmune
Autoimmune Explanation: Type 1 diabetes is subdivided type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes involves autoimmune destruction of beta cells. The pathophysiology of type 2 diabetes has both genetic and acquired factors.
A client with a new diagnosis of diabetes mellitus receives education about the diabetic diet plan. Which menu selection indicates the client understood the instruction? Oatmeal, bagel with jam, orange juice Green salad without dressing, an apple, and tea Baked chicken breast, coleslaw, and milk Cheeseburger, French fries, milk shake
Baked chicken breast, coleslaw, and milk Diet is a cornerstone of diabetes control. Meals and snacks should be eaten at regular intervals. Initial recommendations are for carbohydrates to make up between 45 percent and 60 percent, fats to be between 20 and 35 percent, and for protein to comprise about 10 to 20 percent of each meal. The cheeseburger meal contains too large an amount of fat. The salad and oatmeal menus are too high in carbohydrates without sufficient fat and protein.
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. Hypoglycemia will occur. An unusable form of glucose will be released. Gluconeogenesis will occur.
Blood glucose will elevate. 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.
A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increase risks associated with exercise, the health care provider should encourage the client to: Carry a snack with carbs to prevent profound hypoglycemia Watch for too rapid weight loss Be careful that he or she is not experiencing a rebound hyperglycemia Monitor for respiratory disorders
Carry a snack with carbs to prevent profound hypoglycemia Explanation: People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia. Respiratory disorders are associated with preexisting pulmonary or vascular problems exacerbated by the period of exercise.
The diagnosis of type 1 diabetes would be confirmed by: Insulin is produced but unavailable for use in the body. Insulin is not available for use by the body. Small amounts of insulin are produced daily. Insulin is present in large amounts for use by the body.
Insulin is not available for use by the body. Explanation: Type 1 diabetes is a catabolic disorder characterized by an absolute lack of insulin. In type 2 diabetes, some insulin is produced.
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 Regular NPH Glargine
Lispro Explanation: There are four principal types of insulin: short acting, rapid acting, intermediate acting, and long acting. Regular insulin is short-acting insulin whose effects begin within 30 minutes after subcutaneous injection and generally last for 5 to 8 hours. The rapid-acting insulins (lispro, aspart, and glulisine) have a more rapid onset, peak, and duration of action than short-acting regular insulin and are administered immediately before a meal. Intermediate- to long-acting insulins include NPH, glargine, and detemir. These insulins have slower onsets and a longer duration of action.
A client with diabetes mellitus arrives at the hospital with a blood glucose level of 639 mg/dl. What assessment data would indicate type 2 diabetes mellitus rather than type 1? Negative ketones in urine Kussmaul's respirations Metabolic acidosis Weight loss
Negative ketones in urine Explanation: Hyperosmolar hyperglycemic state (HHS) occurs most commonly in clients with type 2 diabetes mellitus that is out of control. The elevated glucose level leads to dehydration. But because the client is able to make some insulin, there is no ketoacidosis or compensatory hyperventilation. Weight loss occurs with both diabetic ketoacidosis and HHS because of dehydration.
Select the most common symptoms of diabetes. Select all that apply. Polyphagia Polyuria Polydipsia Polycythemia Polyhydramnios
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.
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 at risk for an insulin reaction. The patient is at risk for developing hyperglycemia. The patient needs to modify his diet related to the low readings. The patient is achieving normal glycemic control.
The patient is achieving normal glycemic control. The reading for the FBS is appropriate (<100 mg/dL is normal) and the hemoglobin A1C level (<6.5) shows good control of glucose levels over a 6- to 12-week period. This patient should continue his current exercise and diet routine, which is working well for him.
A client with long-standing type 2 diabetes is surprised at his high blood sugar readings while recovering from an emergency surgery. Which of the following factors may have contributed to the client's inordinately elevated blood glucose levels? The stress of the event caused the release of cortisol. The tissue trauma of surgery resulted in gluconeogenesis. Sleep disruption in the hospital precipitated the dawn effect. Illness inhibited the release and uptake of glucagon.
The stress of the event caused the release of cortisol. Explanation: Elevation of glucocorticoid levels, such as during stressful events, can lead to hyperglycemia. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels.
When caring for the client with diabetes, the nurse emphasizes the risk of kidney disease. Which of these tests does the nurse encourage the client to have performed annually for early detection of renal disease? Lipid levels Urine test for microalbuminuria Hemoglobin A1C Renal angiogram
Urine test for microalbuminuria Explanation: One of the first manifestations of diabetic nephropathy is an increase in urinary albumin excretion (i.e., microalbuminuria), which is easily assessed by laboratory methods. A spot urine test to detect microalbumin should be done annually for all persons with diabetes. Hemoglobin A1C determines average blood glucose over 6-12 weeks.
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: "Keep the medication refrigerated until used." "Use a different injection site for each injection." "Take the medication 15 to 30 minutes before each meal." "Adjust the dosing based on recent blood glucose readings."
"Take the medication 15 to 30 minutes before each meal." Explanation: To avoid hypoglycemia, Repaglinide is taken 15 to 30 minutes before each meal. This is an oral medication, so there is not injection site and does not need to be refrigerated. The dosing is not based on glucose levels.
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? Alpha cells Beta cells Delta cells PP cells
Beta cells Each islet is composed of beta cells that secrete insulin and amylin, alpha cells that secrete glucagon, and delta cells that secrete somatostatin. In addition, at least one other type of cell, the PP cell, is present in small numbers in the islets and secrets a hormone of uncertain function called pancreatic polypeptide.
Impaired and delayed healing in a person with diabetes is caused by long-term complications that include: Chronic neuropathies Ketoacidosis Somogyi effect Fluid imbalances
Chronic neuropathies Explanation: Suboptimal response to infection in a person with diabetes is caused by the presence of chronic complications, such as vascular disease and neuropathies, poorly controlled hyperglycemia, and altered immune cell and neutrophil function. Sensory deficits may cause a person with diabetes to ignore minor trauma and infection, and vascular disease may impair circulation and delivery of blood cells and other substances needed to produce an adequate inflammatory response and effect healing. Somogyi effect is an acute complication of diabetes, causing hypoglycemia. Ketoacidosis is an acute complication of hyperglycemia when liver ketone production exceeds cell use.
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 Sulfonylureas Biguanides
Exogenous insulin injections Type 1 diabetes is the best diagnosis as the client has no other symptoms and the disease presented so rapidly. Insulin will likely be necessary and oral antihyperglycemics will not be sufficient.
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? Aspart (Novolog) Glargine (Lantus) Glulisine (Apidra) Regular
Glargine (Lantus) Explanation: Glargine is a long-acting peakless insulin that provides consistent basal levels over a 20- to 24-hour period. Regular insulin has a duration of 5 to 7 hours . Aspart and glulisine have the most rapid onset and shortest duration of action, making them optimal for postprandial glucose control.
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% Blood pressure 148/90 HDL 35 mg/dL Fasting blood glucose 155 mg/dL
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.
Which characteristics in a pregnant woman increase the risk of gestational diabetes mellitus? Select all that apply. Gravida 5 BMI 35 Asian ancestry History of bronchitis Sister has diabetes mellitus type 2
Gravida 5 BMI 35 Sister has diabetes mellitus type 2 Explanation: African American, Latino American, or American Indian women with obesity (BMI greater than 25), five or more pregnancies, a family history of diabetes mellitus, a previous child born large for gestational age, and history of stillbirth or fetal anomalies have greater risk of gestational diabetes.
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? Hepatomegaly Portal hypertension Hyperglycemia Adrenal hyperplasia
Hyperglycemia Explanation: In predisposed persons, the prolonged elevation of glucocorticoid hormones can lead to hyperglycemia and the development of diabetes mellitus and starvation. They stimulate gluconeogenesis by the liver, sometimes producing a 6- to 10-fold increase in hepatic glucose production. A prolonged increase in glucocorticoid hormones does not cause hepatomegaly, portal hypertension, or adrenal hyperplasia.
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 Hyperglycemia Hyponatremia Hypernatremia
Hypoglycemia Explanation: Alcohol decreases liver gluconeogenesis, and people with diabetes need to be cautioned about its potential for causing hypoglycemia, especially if alcohol is consumed in large amounts or on an empty stomach.
An extremely lethargic patient arrives by ambulance at the emergency department. His blood glucose level is 32 mg/dL. The nurse will anticipate that this patient will be diagnosed with which of the following? Hypoglycemia Dawn phenomenon Autonomic neuropathy Diabetic ketoacidosis
Hypoglycemia Explanation: Hypoglycemia is a blood glucose level of less than 60 mg/dL. Blood glucose levels would be elevated in diabetic ketoacidosis and in the dawn phenomenon. Autonomic neuropathy causes disorders of autonomic (for example, cardiovascular) function.
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 Decrease daily walking activity Rotate insulin injection sites once a week Wear comfortable, open-toe shoes
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.
The nurse knows that metabolic abnormalities that lead to type 2 diabetes include which physiologic problems? Select all that apply. Hepatic glycogenolysis Chronic overeating Acute pancreatitis Insulin resistance Beta cell failure
Insulin resistance Beta cell failure Hepatic glycogenolysis Explanation: The metabolic abnormalities that lead to type 2 diabetes include peripheral insulin resistance, deranged secretion of insulin by the pancreatic beta cells, and increased glucose production by the liver. Obese persons have increased insulin resistance and impaired suppression of glucose production by the liver, resulting in both hyperglycemia and hyperinsulinemia leading to beta cell failure. Lifestyle and overeating may be triggering events (rather than metabolic abnormalities). Acute pancreatitis is a reversible impairment of alpha and beta cell function, with hypoinsulinemia as a complication.
Which of the following pregnant women likely faces the greatest risk of developing gestational diabetes? A client who: Was diagnosed with placenta previa early in her pregnancy Is gravida five (in her fifth pregnancy) Has BP of 130/85 mm Hg and pulse rate of 90 beats/minute Is morbidly obese (defined as greater than 100 pounds over ideal weight)
Is morbidly obese (defined as greater than 100 pounds over ideal weight) Explanation: Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.
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? Visit your eye health professional for annual exams. Maintain healthy blood pressure and blood sugar levels. Control stress and monitor vision changes. Wear glasses when reading and limit computer time.
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.
What are the hallmark signs of diabetes mellitus? Polyuria, polydipsia, and pheochromocytoma Polyuria, polyphagia, and polycythemia Polyuria, polydipsia, and polyphagia Polycythemia, polydipsia, and pheochromocytoma
Polyuria, polydipsia, and polyphagia The most commonly identified signs and symptoms of diabetes are 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). Pheochromocytoma and polycythemia are not hallmark signs of diabetes mellitus.
A hospital client with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin? Promotion of fat breakdown Promotion of gluconeogenesis Promotion of glucose uptake by target cells Initiation of glycogenolysis
Promotion of glucose uptake by target cells Explanation: The actions of insulin are threefold (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.
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? Gained 5 pounds in one week Random blood glucose 85 mg/dl Glycosylated hemoglobin 7.2% 1% ketones present in urine
Random blood glucose 85 mg/dl Explanation: The goals of the nutritional plan for gestational diabetes mellitus (GDM) include normal glucose levels, no ketosis, proper weight gain for the pregnancy, and adequate nutrition for fetal health.
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 Premixed Long acting Intermediate acting
Short acting Short acting (regular) insulin is used to facilitate metabolism of the food that is being eaten. Premixed insulin is possible, but is not used as commonly. Intermediate- and long-acting insulin would have too distant an onset.
Research has identified a cycle of insulin-induced posthypoglycemic episodes. What is this phenomenon called? Dawn phenomenon Joslin phenomenon Somogyi effect Sunset effect
Somogyi effect Explanation: The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. In 1924, Joslin and associates noticed that hypoglycemia was associated with alternate episodes of hyperglycemia. The other answers are not correct.
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 Weight gain Diarrhea Intolerance to fats
Vomiting after eating Explanation: Gastroparesis (delayed emptying of stomach) is characterized by complaints of epigastric discomfort, nausea, postprandial vomiting, bloating, and early satiety.