TEST 6 Chapter 48/53: Diabetes Mellitus

8. The client with diabetes who is just starting on insulin therapy wants to know why more than one injection of insulin each day will be required. What is the nurse's best response? a. "A regimen of a single dose of insulin injected each day would require that you could eat no more than one meal each day." b. "You need to start with multiple injections until you become more proficient at self-injection." c. "A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock." d. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough."

ANS. D single dose therapy are usually combined with an oral therapy. With the multiple injections, the patient is better able to duplicate the normal insulin release patter from the pancreas as you eat and take in sugar.

12. The client tells the nurse that he enjoys having a glass of wine on Saturdays when dining out with friends. He asks if having type 1 diabetes will prohibit him from this activity. What is the nurse's best response? a. "You may have a glass of wine as long as you make sure you eat your meal with it and monitor your glucose." b. "Insulin activity is dramatically reduced under the influence of alcohol and drinking even one glass of wine will increase your insulin requirements." c. "You shouldn't drink any alcohol because it is likely to increase your sense of hunger and make you overeat." d. "Diabetics have decreased kidney function and should avoid ingesting alcohol in all forms at all times."

ANS: A

15. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 9:00 AM b. 8:00 PM c. 1:30 PM d. 1:00 AM

ANS: A A - The rapid-acting insulins peak in 30 min to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

25. Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. Do you feel bloated after eating? b. Have you seen any skin changes? c. Do you need to increase your insulin dosage when you are stressed? d. Have you noticed any painful new ulcerations or sores on your feet?

ANS: A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy. Page 1316 12th ed The 2 major categories of DM-related neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. Autonomic Neuropathy Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemia unawareness, bowel incontinence and diarrhea, and urinary retention. Gastroparesis (delayed gastric emptying) is a complication of autonomic neuropathy that can cause anorexia, nausea, vomiting, gastroesophageal reflux, and persistent feelings of fullness. Gastroparesis can trigger hypoglycemia by delaying food absorption. Cardiovascular problems from autonomic neuropathy include postural hypotension, resting tachycardia, and painless MI. Assess for postural hypotension to determine if the patient is at risk for falls. Teach the patient with postural hypotension to change from a lying or sitting position slowly. DM can affect sexual function. Erectile dysfunction (ED) in men with DM is common. It is often the first manifestation of autonomic neuropathy. ED is associated with other factors, including vascular disease, high glucose levels, endocrine problems, psychogenic factors, and other drugs. Decreased libido is a problem for some women with DM. Candida and nonspecific vaginitis are common. ED and sexual problems require sensitive counseling for both the patient and the patient's partner. See Chapter 59 for more about ED. A neurogenic bladder may develop as the sensation in the inner bladder wall decreases, causing urinary retention. A patient with retention has infrequent voiding, difficulty voiding, and a weak stream of urine. Emptying the bladder every 3 hours in a sitting position helps prevent stasis and infection. Tightening the abdominal muscles during voiding and using the Credé maneuver (mild massage downward over the lower abdomen and bladder) may help with complete bladder emptying. Cholinergic agonist drugs, such as bethanechol (Urecholine), may be used. Sensory Neuropathy The most common form of sensory neuropathy is

9. In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. Remind the patient that exercise will improve self-esteem. c. Teach the patient about the effects of exercise on glucose level. d. Give the patient a list of activities that are moderate in intensity.

ANS: A Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance.

45. Which nursing action can the nurse delegate to experienced assistive personnel (AP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.

ANS: A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by AP who have been trained in the procedure. The other assessments should be done by the registered nurse (RN).

11. What intervention should the nurse suggest to the diabetic client who self-injects insulin to prevent or limit local irritation at the injection site? a. "Allow the insulin to warm to room temperature before injection." b. "Remove the needle immediately after instilling the insulin." c. "Try to make the injection deep enough to enter muscle." d. "Massage the site for 1 full minute after injection."

ANS: A Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

1. Which statement regarding diabetes mellitus is true? a. Diabetes increases the risk for development of cardiovascular disease. b. The cure for diabetes is the administration of insulin. c. Diabetes increases the risk for development of epilepsy. d. Carbohydrate metabolism is disturbed in diabetes, but protein and lipid metabolism are normal.

ANS: A DM is associated with a reduced life span, largely as a result of cardiovascular disease (CVD)

34. A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse takefirst? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.

ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patients care.

13. Which patient action indicates a good understanding of the nurses teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.

ANS: A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day. Page 1294 12th ed Insulin pump An insulin pump delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or under clothing.14 Insulin pumps use rapid-acting insulin. It is loaded into a reservoir or cartridge and connected via plastic tubing to a catheter inserted into the subcutaneous tissue. Insulet Corporation has an insulin pump that is a tubing-free system (Fig. 53.7). All insulin pumps are programmed to deliver a continuous infusion of rapid-acting insulin 24 hours a day, known as the basal rate. Basal insulin can be temporarily increased or decreased based on carbohydrate intake, activity, or illness. Pump users need different basal rates at different times of the day. At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested and an additional amount, if needed, to bring down or "correct" high preprandial glucose. The infusion set is changed every 2 to 3 days and placed in a new site to avoid infection and promote good insulin absorption. Insulin pump users check their glucose level at least 4 times per day and/or use a CGM system. Monitoring 8 times or more per day is common. A major advantage of the insulin pump is the potential for keeping glucose levels in a tighter range with the goal of eliminating both high and low glucose. With careful programming and constant monitoring, this is possible because insulin delivery is similar to the normal physiologic pattern. Pumps offer users more flexibility with meals and activities. Potential challenges of pump therapy include infection at the insertion site, an increased risk for DKA if the infusion is disrupted, the cost of the pump and supplies, and being attached to a device. Hybrid closed-loop insulin pumps deliver insulin automatically by adjusting basal doses constantly

37. A female patient is scheduled for an oral glucose tolerance test. Which information from the patients health history is most important for the nurse to communicate to the health care provider? a. The patient uses oral contraceptives. b. The patient runs several days a week. c. The patient has been pregnant three times. d. The patient has a family history of diabetes.

ANS: A Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance, but will not lead to misleading information from the OGTT.

14. A 32- year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)

ANS: A Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

10. Which statement by the patient indicates a need for additional instruction in administering insulin? a. I need to rotate injection sites among my arms, legs, and abdomen each day. b. I can buy the 0.5 mL syringes because the line markings will be easier to see. c. I should draw up the regular insulin first after injecting air into the NPH bottle. d. I do not need to aspirate the plunger to check for blood before injecting insulin.

ANS: A Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed. Page 1293 12 ed Teach patients to rotate the injection within and between sites. This allows for better insulin absorption. It may be helpful to think of the abdomen as a checkerboard, with each -in square representing an injection site. Injections are rotated systematically across the board, with each injection site at least 1/2 to 1 inch away from the previous injection site. It can be helpful to inject fast-acting insulin into faster-absorbing sites and slow-acting insulin into slower absorbing sites. Page 1294 12th ed Most commercial insulin is available as U100. This means that 1 mL contains 100 U of insulin. U100 insulin must be used with a U100-marked syringe. Disposable plastic insulin syringes are available in a variety of sizes, including 1.0, 0.5, and 0.3 mL. The 0.5-mL size is for doses of 50 U or less. The 0.3-mL syringe is for doses of 30 U or less. The 0.5- and 0.3-mL syringes are in 1-unit increments. This provides more accurate delivery when the dose is an odd number. The 1.0-mL syringe is necessary for patients who inject more than 50 U of insulin. The 1.0-mL syringe is in 2-unit increments. When patients change from a 0.3- or a 0.5-mL to a 1.0-mL syringe, tell them of the dose increment difference.

44. The nurse has administered 4 oz of orange juice to an alert patient whose glucose was 62 mg/dL. Fifteen minutes later, the glucose is 67 mg/dL. Which action would the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

ANS: A The "rule of 15" indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used after the glucose has stabilized. Glucagon should be used if the patient's level of consciousness decreases so that oral carbohydrates can no longer be given. TABLE 53.21 Emergency Management Hypoglycemia Interventions: Initial • Check glucose. • Determine cause of hypoglycemia (after correcting condition). Management Conscious Patient • Have patient eat or drink 15-20 g of quick-acting carbohydrate (4-6 oz of regular soda, 5-8 LifeSavers, 1 Tbsp syrup or honey, 4 tsp jelly, 4-6 oz orange juice, commercial dextrose products [per label instructions]). • Wait 15 min. Check glucose level. • If glucose is still <70 mg/dL, have patient eat or drink another 15-20 g of carbohydrate. • Once the glucose level is stable, give patient additional food of carbohydrate plus protein or fat (e.g., crackers with peanut butter or cheese) if the next meal is more than 1 h away or patient is engaged in physical activity. • Immediately notify HCP or emergency service (if patient outside hospital) if symptoms do not subside after 2 or 3 doses of quick-acting carbohydrate. Worsening Symptoms or Unconscious Patient • 1 mg glucagon subcutaneous or IM or IV administration of 20-50 mL of 50% glucose. • Turn the patient on the side to prevent aspiration.

7. A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.

ANS: A The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.

6. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.

ANS: A The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.

35. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.

ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

18. Which of these laboratory values, noted by the nurse when reviewing the chart of a hospitalized diabetic patient, indicates the need for rapid assessment of the patient? a. Noon blood glucose of 52 mg/dL b. Triglyceride's 220 mg/dl c. Fasting blood glucose of 180 mg/dL d. Hgb A1C of 7.8%

ANS: A The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.

26. Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

ANS: A The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems. Page 1318 12th ed Table 53.23 PATIENT & CAREGIVER TEACHING Foot Care Include the following instructions when teaching the patient and caregiver about foot care: 1. Wash feet daily with mild soap and warm water. First, test water temperature with elbow. 2. Pat feet dry gently, especially between toes. 3. Examine feet daily for cuts, blisters, swelling, and red, tender areas. Do not depend on feeling sores. If eyesight is poor, have others inspect feet. 4. Use lanolin on feet to prevent skin from drying and cracking. Do not apply between toes. 5. Use mild foot powder on sweaty feet. 6. Do not use commercial remedies to remove calluses or corns. 7. Cleanse cuts with warm water and mild soap, covering with clean dressing. Do not use iodine, rubbing alcohol, or strong adhesives. 8. Report skin infections or nonhealing sores to HCP at once. 9. Cut toenails evenly with rounded contour of toes. Do not cut down corners. The best time to trim nails is after a shower or bath. 10. Separate overlapping toes with cotton or lamb's wool. 11. Avoid open-toe, open-heel, and high-heel shoes. Leather shoes are preferred to plastic ones. Wear slippers with soles. Do not go barefoot. Inspect feet, socks, and shoes for foreign objects before putting on. 12. Wear clean, absorbent (cotton or wool) socks or stockings that have not been mended. Colored socks must be colorfast. 13. Do not wear clothing that leaves impressions, hindering circulation. 14. Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth. 15. Guard against frostbite. 16. Exercise feet daily either by walking or by flexing and extending feet in suspended position. Avoid prolonged sitting, standing, and crossing of legs.

12. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM

ANS: A The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

47. After change-of-shift report, which patient would the nurse assess first? a. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12% b. A 23-yr-old patient with type 1 diabetes who has a glucose of 40 mg/dL c. A 50-yr-old patient who uses exenatide and is reporting acute abdominal pain d. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low glucose. The other patients also have symptoms that require assessments or interventions, but they are not at immediate risk for life-threatening complications.

20. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patients family to participate in the diabetes education program. b. Assess the patients perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management.

ANS: B Before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

11. Which patient action indicates good understanding of the nurses teaching about administration of aspart (NovoLog) insulin? a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration. c. The patient stores the insulin in the freezer after administering the prescribed dose. d. The patient pushes the plunger down while removing the syringe from the injection site.

ANS: B Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.

21. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.

ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patients blood glucose and would be contraindicated.

16. The health care provider suspects the Somogyi effect in a patient whose 7:00 AM blood glucose is 220 mg/dL. Which action will the nurse plan to take? a. Remind the patient about the need to avoid snacking at bedtime. b. Check the patient's blood glucose at 3:00 AM. c. Administer a larger dose of long-acting insulin. d. Educate about the need to increase the rapid-acting insulin dose.

ANS: B If the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2 and 4 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

7. Which therapy for diabetes mellitus is the client not at risk for hypoglycemia? a. Sulfonylureas b. Biguanides c. Lispro insulin d. Regular insulin

ANS: B Page 1296 12th ed Biguanides The most widely used OA is metformin. It is the only drug in the biguanide class available in the United States. Metformin is the most effective first-line treatment for type 2 DM. Forms of metformin include Glucophage (immediate-release), Glucophage XR (extended-release), Fortamet (extended-release), and Riomet (liquid). The primary action of metformin is to reduce glucose production by the liver. It enhances insulin sensitivity at the tissue level and improves glucose transport into the cells. It has beneficial effects on lipid levels. Because it may cause moderate weight loss, metformin may be useful for people with type 2 DM and prediabetes who are overweight or obese. It may prevent type 2 DM in those with prediabetes who are younger than age 60 and have risk factors, such as hypertension or a history of gestational DM. Patients who are having surgery or radiologic procedures that involve the use of a contrast medium need to temporarily discontinue metformin before surgery or the procedure. This reduces the risk of contrast-induced kidney injury (CIN) (see Chapter 49). They should not resume the metformin until 48 hours afterward once their serum creatinine has been checked and is normal.

33. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide teaching about an increased risk for fetal problems with gestational diabetes.

ANS: B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. The other actions may also be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take. Page 1288 12th ed Gestational Diabetes Gestational diabetes develops during pregnancy and occurs in about 2% to 10% of pregnancies in the United States.9 Women with gestational DM have a higher risk for cesarean delivery. Their babies are at increased risk for perinatal death, birth injury, and neonatal complications. Women who are at high risk for gestational DM are screened at the first prenatal visit. Those at high risk include women who are obese, are of advanced maternal age, or have a family history of DM. We screen women with an average risk for gestational DM using an OGTT at 24 to 28 weeks of gestation. Most women with gestational DM have normal glucose levels within 6 weeks postpartum. Women with a history of gestational DM have up to a 63% chance of developing type 2 DM within 16 years. Gestational DM and managing the pregnant patient with DM are specialized areas not covered in detail here. Consult an obstetric text for more information.

24. Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.

ANS: B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

13. Which action should the nurse suggest to reduce insulin needs in the client with diabetes mellitus? a. Eating animal organ meats high in insulin b. Walking 1 mile each day c. Reducing intake of water and other liquids to no more than 2 L/day d. Taking two 1-hour naps daily

ANS: B Regular exercise such as walking, helps regulate blood glucose levels on a daily basis and results in lower insulin requirements in type 1 diabetics

43. A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy, the home health nurse makes a visit. Which finding would the nurse promptly discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Glomerular filtration rate is decreased. c. Last eye examination was 18 months ago. d. Patient has questions about the prescribed diet.

ANS: B The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan to schedule the patient for an eye examination and address the questions about diet, but the area for prompt intervention is the patient's decreased renal function.

4. The client is a 28-year-old man newly diagnosed with type 1 diabetes mellitus. He wears glasses for myopia and asks the nurse how frequently he should see his ophthalmologist now. What is the nurse's best answer? a. "See your ophthalmologist whenever you have a vision problem and yearly after you are 40 years old." b. "The disease increases your risk for cataracts, glaucoma, and retinal blood vessel changes, so you should see the ophthalmologist yearly, even when you do not have a new vision problem." c. "At your age, you do not need to change your usual patterns for visiting the ophthalmologist." d. "Your vision will change more quickly now, and you should see the ophthalmologist whenever you find that your glasses are not strong enough to allow you to read comfortably."

ANS: B The disease increases your risk for cataracts, glaucoma, and retinal blood vessel changes, so you should see your ophthalmologist yearly, even when you do not have a new vision problem Diabetic retinopathy is a leading cause of blindness.

38. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurses assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

ANS: B The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient.

19. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.

ANS: B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

15. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

ANS: B The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

9. The client on an intensified insulin regimen consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which statement below is true. a. The client is at increased risk for developing hypoglycemia. b. The client is demonstrating good control of blood glucose. c. The client is at increased risk for developing hyperglycemia. d. The client is demonstrating signs of insulin resistance.

ANS: B These are all WNL HbA1C (<6.5%), postprandial (less than 200), fasting (<100)

28. A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

ANS: B Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclic antidepressants. Page 1316 12th ed Sensory Neuropathy The most common form of sensory neuropathy is distal symmetric polyneuropathy. It affects the hands and/or feet bilaterally. We sometimes call this stocking-glove neuropathy. Characteristics include loss of sensation, abnormal sensations, pain, and paresthesias. Patients describe the pain as burning, cramping, crushing, or tearing. It is usually worse at night and may occur only at that time. The paresthesias may be associated with tingling, burning, and itching sensations. The patient may report a feeling of walking on pillows or numb feet. The skin can become so sensitive (hyperesthesia) that the patient cannot tolerate even light pressure from bed sheets. Complete or partial loss of sensitivity to touch and temperature is common. Foot injury and ulcerations can occur without the patient ever having pain (Fig. 53.15). Neuropathy can cause atrophy of the small muscles of the hands and feet, causing deformity and limiting fine movement. Managing glucose is the only treatment for DM-related neuropathy. It is effective in many, but not all, cases. Drug therapy may be used to treat neuropathic symptoms, especially pain. At the start of therapy, symptoms usually increase, followed by relief of pain in 2 to 3 weeks. Common drugs used include topical creams (e.g., capsaicin), tricyclic antidepressants (e.g., amitriptyline), selective serotonin and norepinephrine reuptake inhibitors (e.g., duloxetine), and antiseizure drugs (e.g., gabapentin). Capsaicin is a moderately effective topical cream made from chili peppers. It depletes the accumulation of pain-mediating chemicals in the peripheral sensory neurons. The cream is applied 3 or 4 times a day. Tricyclic antidepressants are moderately effective in treating DM-related neuropathy. They inhibit the reuptake of norepinephrine and serotonin, which are neurotransmitters thoug

1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that apply.) a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

ANS: B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

42. Which patient statement indicates that the nurse's teaching about exenatide (Byetta) has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning."

ANS: C Because exenatide slows gastric emptying, oral medications would be taken at least 1 hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.

41. A 30-yr-old patient has a new diagnosis of type 2 diabetes. When would the nurse recommend the patient schedule a dilated eye examination? a. Every 2 years b. Every 6 months c. As soon as available d. At the age of 39 years

ANS: C Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter. Page 1315 12th ed The earliest and most treatable stages of DM-related retinopathy often cause no changes in the vision. Teach patients with type 2 DM to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Those with type 1 DM need to have a dilated eye examination within 5 years after the onset of DM and then annually.

14. The client getting ready to engage in a 30-minute, moderate-intensity exercise program performs a self-assessment. Which data indicate that exercise should be avoided at this time? a. Weighs 1 pound higher than the week before b. Pulse rate of 66 beats/min c. Ketone bodies in the urine d. Blood sugar level of 155 mg/dL

ANS: C Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency.

1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

ANS: C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

17. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.

ANS: C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.

6. Which action should the nurse teach the diabetic client as being most beneficial in delaying the onset of microvascular and macrovascular complications? a. Restricting fluid intake b. Preventing hypoglycemia c. Controlling hyperglycemia d. Controlling body weight

ANS: C Hyperglycemia is a critical factor for long-term complications in patients, keeping glucose levels stable and within range delays the onset of these changes.

23. The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.

ANS: C If the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night. Page 1295 12th ed Somogyi effect and dawn phenomenon Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin causes a decline in glucose levels during the night. As a result, counterregulatory hormones (e.g., glucagon, epinephrine, GH, cortisol) are released. They stimulate lipolysis, gluconeogenesis, and glycogenolysis, which in turn cause rebound hyperglycemia. The danger of this effect is that when glucose levels are measured in the morning, hyperglycemia is present, and the patient (or the HCP) may increase the insulin dose. If a patient has morning hyperglycemia, checking glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. The patient may report headaches on awakening and recall having night sweats or nightmares. The dawn phenomenon is also characterized by hyperglycemia that is present on awakening. Two counterregulatory hormones (GH and cortisol), which are excreted in increased amounts in the early morning hours, may be the cause of this phenomenon. The dawn phenomenon affects many people with DM. It tends to be most severe when GH is at its peak in adolescence and young adulthood. Careful assessment is needed to diagnose the Somogyi effect or dawn phenomenon because the treatment for each differs. The treatment for Somogyi effect is a bedtime snack, reducing the dose of insulin, or both. The treatment for dawn phenomenon is an increase in insulin or an adjustment in administration time. Your assessment must include insulin dose, injection sites, and variability in the time of meals or insulin administration. Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM glucose i

22. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

ANS: C Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin (A1C) testing is not used to evaluate short-term alterations in blood glucose. Page 1305 12th ed Acute illness and surgery Emotional and physical stress can increase the glucose level and cause hyperglycemia. Because stress is unavoidable, certain situations may require more intense treatment, such as extra insulin and more frequent BGM, to maintain glycemic goals and avoid hyperglycemia. Acute illness, injury, and surgery may evoke a counterregulatory hormone response, causing hyperglycemia. Even common illnesses, such as an upper respiratory tract infection or the flu, can cause this response. Encourage patients to check glucose at least every 4 hours when they are ill. Teach acutely ill patients with type 1 DM and glucose greater than 240 mg/dL (13.3 mmol/L) to check urine for ketones every 3 to 4 hours. Teach patients to contact the HCP when glucose levels are over 300 mg/dL twice in a row, or urine ketone levels are moderate to high. A patient with type 1 DM may need an increase in insulin to prevent DKA. High glucose levels can lead to poor healing and infection. A patient with type 2 DM may need insulin therapy to prevent or treat hyperglycemia symptoms and avoid an acute hyperglycemia emergency. In critically ill patients, insulin therapy may be started if the glucose is persistently greater than 180 mg/dL. These patients have a higher targeted glucose goal, which is usually 140 to 180 mg/dL. Food intake is important during times of stress and illness when the body needs extra energy. If patients can eat normally, they can continue with their regular meal plan while increasing the intake of noncaloric fluids, such as water, sugar-free gelatin, and other decaffeinated beverages, and continue taking OAs, nonins

39. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Communicate the glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for insulin therapy during the immediate postoperative period. c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

ANS: C LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

8. The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. I can have an occasional alcoholic drink if I include it in my meal plan. b. I will need a bedtime snack because I take an evening dose of NPH insulin. c. I can choose any foods, as long as I use enough insulin to cover the calories. d. I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.

ANS: C Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

31. A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.

ANS: C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

36. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.

ANS: C The patients clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patients glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patients symptoms become worse or if the patient is unconscious.

2. A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

ANS: C The patients impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

29. Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patients most recent HbA1C was 6.5%. b. The patients admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.

ANS: C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

40. An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider? a. Hemoglobin A1C level of 6.2% b. Heart rate at rest of 58 beats/min c. Blood pressure of 140/88 mmHg d. High-density lipoprotein (HDL) level of 65 mg/dL

ANS: C To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the blood pressure should be kept in normal range. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient's diabetes and risk factors for vascular disease are well controlled.

4. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. Are you anorexic? b. Is your urine dark colored? c. Have you lost weight lately? d. Do you crave sugary drinks?

ANS: C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

18. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patients later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

ANS: D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

3. A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? a. Early-stage renal failure causes a loss of urine concentrating capacity b. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine c. Inadequate secretion of antidiuretic hormone (ADH) d. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia

ANS: D Hyperosmolarity of the extracellular fluids secondary to hyperglycemia: The hyperosmolarity of the extracellular fluids causes fluid to leak out of the cells in order to return the body to an isotonic state; hence there is increased intravascular fluid the kidneys must excrete.

30. Which action by a patient indicates that the home health nurses teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patients family prefills the syringes with the mix of insulins weekly. c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

ANS: D Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily.

32. The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patients blood pressure is 154/92. b. The patient has a history of emphysema. c. The patients blood glucose is 86 mg/dL. d. The patient has chest pressure when walking.

ANS: D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider. Page 1298 12th ed Thiazolidinediones Thiazolidinediones, sometimes called "insulin sensitizers," include pioglitazone (Actos) and rosiglitazone (Avandia). They are most effective for people who have insulin resistance. These drugs improve insulin sensitivity, transport, and use at target tissues. Because they do not increase insulin production, they do not cause hypoglycemia when used alone. These drugs are rarely used because of their adverse effects. Rosiglitazone can cause cardiovascular events (e.g., myocardial infarction [MI]). It can be obtained only through restricted access programs. Pioglitazone can worsen heart failure (HF). Use is associated with an increased risk for bladder cancer.

27. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patients blood glucose level is 174 mg/dL. b. The patient has gained 2 lb (0.9 kg) since yesterday. c. The patient is scheduled for a chest x-ray in an hour. d. The patients blood urea nitrogen (BUN) level is 52 mg/dL.

ANS: D The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

5. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level

ANS: D The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.

17. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral arterial disease. Which information will the nurse include in patient teaching? a. Buy callus remover for corns or calluses. b. Soak the feet in warm water for an hour every day. c. Set heating pads on a low temperature. d. Choose flat-soled leather shoes.

ANS: D The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

16. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. If I overeat at a meal, I will still take the usual dose of medication. b. Other medications besides the Glucotrol may affect my blood sugar. c. When I am ill, I may have to take insulin to control my blood sugar. d. My diabetes wont cause complications because I dont need insulin.

ANS: D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

46. After change-of-shift report, which patient will the nurse assess first? a. A 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon b. A 60-yr-old patient with type 1 diabetes whose most recent glucose reading was 230 mg/dL c. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain d. A 35-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

ANS: D The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

3. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.

ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.

10. Which statement made by the client newly diagnosed with type 2 diabetes mellitus indicates a need for clarification regarding diet therapy? a. "My intake of saturated fats should be no more than 10% of my total calorie intake." b. "I should increase my intake of vegetables with moderate to high amounts of dietary fiber." c. "My intake of plain water each day is not restricted." d. "I should try to keep my diet free from carbohydrates."

ANS: D carbs should be 45-65% of calories

5. While assessing the client who has had diabetes for 15 years, the nurse notes that the client has decreased tactile sensation in both feet. What is the nurse's best first action? a. Document the finding as the only action. b. Test sensory perception in the client's hands. c. Teach the importance of wearing shoes at all times. d. Examine the client's feet for signs of injury.

ANS: D diabetic foot, asses the foot for abnormal skin and nail conditions.

2. How does glucagon assist in maintaining blood glucose levels? a. Glucagon enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. b. Glucagon is a storage form of glucose and can be broken down for energy when blood glucose levels are low. c. Glucagon converts the excess glucose into glycogen, lowering blood glucose levels in times of excess. d. Glucagon prevents hypoglycemia by promoting glucose release from liver storage sites.

ANS: D it is a counter regulatory hormone that has the opposite effects of insulin. It prevents hypoglycemia (low blood glucose levels) by triggering the release of glucose from cell storage sites.

What assessment findings occur with diabetic ketoacidosis (DKA) (select all that apply)? a. Thirst b. Ketonuria c. Dehydration d. Metabolic acidosis e. Kussmaul respirations f. Sweet, fruity breath odor

a, b, c, d, e, f. In DKA, thirst occurs to replace fluid used to eliminate ketones in the urine in trying to decrease the blood glucose and ketonemia. The metabolic acidosis leads to the Kussmaul respirations trying to decrease the acid in the system. The sweet, fruity breath odor is from acetone. Thirst and dehydration are found with both DKA and hyperosmolar hyperglycemic syndrome (HHS).

What characterizes type 2 diabetes (select all that apply)? a. β-cell exhaustion b. Insulin resistance c. Genetic predisposition d. Altered production of adipokines e. Inherited defect in insulin receptors f. Inappropriate glucose production by the liver

a, b, c, d, e, f. Type 2 diabetes is characterized by β-cell exhaustion, insulin resistance, genetic predisposition, altered production of adipokines, inherited defect in insulin receptors, and inappropriate glucose production by the liver. The roles of the brain, kidneys, and gut in type 2 diabetes development are being studied.

The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)? a. Exercise regularly. b. Maintain a healthy weight. c. Have BP checked regularly. d. Assess for visual changes on a monthly basis. e. Monitor for polyuria, polyphagia, and polydipsia.

a, b, e. To reduce the risk of developing diabetes, the patient with prediabetes should maintain a healthy weight, learn to monitor for symptoms of diabetes, have blood glucose and glycosylated hemoglobin (A1C) tested regularly, exercise regularly, and eat a healthy diet.

The patient with diabetes has a blood glucose level of 248 mg/dL. Which assessment findings would be related to this blood glucose level (select all that apply)? a. Headache b. Unsteady gait c. Abdominal cramps d. Emotional changes e. Increase in urination f. Weakness and fatigue

a, c, e, f. Manifestations of hyperglycemia include abdominal cramps, polyuria, weakness, fatigue, and headache. The headache may also be seen with hypoglycemia that is manifested by the remaining options.

During routine health screening, a patient is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). At a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)? a. A1C of 7.5% b. Glycosuria of 3 + c. FPG ≥ 127 mg/dL (7.0 mmol/L). d. Random blood glucose of 126 mg/dL (7.0 mmol/L) e. A 2-hour oral glucose tolerance test (OGTT) of 190 mg/dL (10.5 mmol/L)

a, c. The patient has 1 prior test result of fasting plasma glucose (FPG) ≥ to 126 mg/dL (7.0 mmol/L) that meets criteria for a diagnosis of diabetes, and the result is confirmed on this follow-up visit. The A1C is 7.5% and greater than diagnostic criteria of 6.5% or higher. The other diagnostic criteria include a 2-hour OGTT level ≥ 200 mg/dL (11.1 mmol/L), or a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.0 mmol/L).

SKIP DO NOT NEED TO KNOW FOR NOW. The patient with type 2 diabetes is being put on acarbose (Precose) and wants to know about taking it. What should the nurse include in this patient's teaching (select all that apply)? a. Take it with the first bite of each meal. b. It is not used in patients with heart failure. c. Endogenous glucose production is decreased. d. Effectiveness is measured by 2-hour postprandial glucose. e. It delays glucose absorption from the gastrointestinal (GI) tract.

a, d, e. Acarbose (Precose) is an α-glucosidase inhibitor that is taken with the first bite of each meal. The effectiveness is measured with 2-hour postprandial blood glucose testing, as it delays glucose absorption from the gastrointestinal (GI) tract. The other options describe rarely used thiazolidinediones.

A patient with diabetes calls the clinic because she has nausea and flu-like symptoms. Which advice from the nurse will be the best for this patient? a. Administer the usual insulin dosage. b. Hold fluid intake until the nausea subsides. c. Come to the clinic immediately for evaluation and treatment. d. Monitor the blood glucose every 1 to 2 hours and call if it rises over 150 mg/dL (8.3 mmol/L).

a. During minor illnesses, the patient with diabetes should continue drug therapy and fluid and food intake. Insulin is important because counter regulatory hormones may increase blood glucose during the stress of illness. Food or a carbohydrate liquid substitution is important because during illness the body requires extra energy to deal with the stress of the illness. Blood glucose monitoring should be done every 4 hours, and the HCP should be notified if the level is >300 mg/dL (13.9 mmol/L) twice in a row, or urine ketone levels are moderate to high.

When teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantage of using an insulin pump? a. Tight glycemic control can be maintained. b. Errors in insulin dosing are less likely to occur. c. Complications of insulin therapy are prevented. d. Frequent blood glucose monitoring is unnecessary.

a. Insulin pumps provide tight glycemic control by continuous subcutaneous insulin infusion based on the patient's basal profile, with bolus doses at mealtime at the patient's discretion and related to blood glucose monitoring. Errors in insulin dosing and complications of insulin therapy are still potential risks with insulin pumps.

When caring for a patient with metabolic syndrome, the nurse should give the highest priority to teaching the patient about which treatment plan? a. Achieving a normal weight b. Performing daily aerobic exercise c. Eliminating red meat from the diet d. Monitoring the blood glucose periodically

a. Metabolic syndrome is a cluster of abnormalities that include elevated glucose levels, abdominal obesity, elevated BP, high levels of triglycerides, and low levels of high-density lipoproteins (HDLs). Overweight persons with metabolic syndrome can prevent or delay the onset of diabetes through a program of weight loss. Regular physical activity is also important, but normal weight is most important.

Individualized nutrition therapy for patients using conventional, fixed insulin regimens should include teaching the patient to a. eat regular meals at regular times. b. restrict calories to promote moderate weight loss. c. eliminate sucrose and other simple sugars from the diet. d. limit saturated fat intake to 30% of dietary calorie intake.

a. The body needs food at regularly spaced intervals throughout the day. Omission or delay of meals can result in hypoglycemia, especially for the patient using conventional insulin therapy or OAs. Weight loss may be recommended in type 2 diabetes if the person is overweight, but many patients with type 1 diabetes are thin and do not require a decrease in caloric intake. Fewer than 7% of total calories should be from saturated fats and simple sugar should be limited, but moderate amounts can be used if counted as a part of total carbohydrate intake.

To prevent hyperglycemia or hypoglycemia related to exercise, what should the nurse teach the patient using glucose-lowering agents about the best time for exercise? a. Plan activity and food intake related to blood glucose levels b. When blood glucose is greater than 250 mg/dL and ketones are present c. When glucose monitoring reveals that the blood glucose is in the normal range d. When blood glucose levels are high, because exercise always has a hypoglycemic effect

a. To plan for exercise, a person with diabetes must monitor blood glucose and make adjustments to insulin dose (if taken) and food intake to prevent exercise-induced hypoglycemia. Exercise is delayed if blood glucose is ≥ 250 mg/dL with ketones. Before exercise if blood glucose is ≤ 100 mg/dL a 15-g carbohydrate snack is eaten. Blood glucose levels should be monitored before, during, and after exercise to determine the effect of exercise on the levels.

A patient with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. The nurse determines that additional teaching is needed when the patient does what? a. Withdraws the NPH dose into the syringe first b. Injects air equal to the NPH dose into the NPH vial first c. Removes any air bubbles after withdrawing the first insulin d. Adds air equal to the insulin dose into the regular vial and withdraws the dose

a. When mixing regular and intermediate-acting insulin, regular insulin should always be drawn into the syringe first to prevent contamination of the regular insulin vial with intermediate-acting insulin additives. Air is added to the NPH vial first. Then air is added to the regular vial and the regular insulin is withdrawn, bubbles are removed, and then the dose of NPH is withdrawn.

A patient with type 1 diabetes uses 20 U of Novolin 70/30 (NPH/regular) in the morning and at 6:00 pm. When teaching the patient about this regimen, what should the nurse emphasize? a. Hypoglycemia is most likely to occur before the noon meal. b. A set meal pattern with a bedtime snack is necessary to prevent hypoglycemia. c. Flexibility in food intake is possible because insulin is available 24 hours a day. d. Premeal glucose checks are required to determine needed changes in daily dosing.

b. A split-mixed dose of insulin requires that the patient adhere to a set meal pattern to provide glucose for the peak action of the insulin, and a bedtime snack is usually required when patients take an intermediate-acting insulin late in the day to prevent nocturnal hypoglycemia. Hypoglycemia is most likely to occur with this dose late in the afternoon and during the night. When premixed formulas are used, flexible dosing based on glucose levels is not recommended.

Which class of oral glucose-lowering agents (OA) is most commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose? a. Insulin b. Biguanide c. Meglitinide d. Sulfonylurea

b. Biguanides (e.g., metformin [Glucophage]) are most commonly used with type 2 diabetes. They reduce glucose production by the liver and increase insulin sensitivity at the tissue level that improves glucose transport into the cells. Insulin is not taken orally, as it is ineffective. Meglitinides and sulfonylureas increase insulin production from the pancreas.

The following interventions are planned for a patient with diabetes. Which intervention can the nurse delegate to unlicensed assistive personnel (UAP)? a. Discuss complications of diabetes. b. Check that the bath water is not too hot. c. Check the patient's technique for drawing up insulin. d. Teach the patient to use a meter for self-monitoring of blood glucose.

b. Checking the temperature of the bath water is part of assisting with activities of daily living (ADLs) and within the scope of care for the UAP. This is important for the patient with neuropathy. Discussing complications, teaching, and assessing learning are appropriate for RNs.

When teaching the patient with diabetes about insulin administration, the nurse should include which instruction? a. Pull back on the plunger after inserting the needle to check for blood. b. Consistently use the same size of insulin syringe to avoid dosing errors. c. Clean the skin at the injection site with an alcohol swab before each injection. d. Rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies.

b. Patients should consistently use the same size of insulin syringe to avoid dosing errors. Errors can be made if patients switch back and forth between different sizes of syringes. Aspiration before injection of the insulin is no longer recommended, nor is the use of alcohol to clean the skin. Because the rate of peak serum concentration varies with the site selected for injection, injections should be rotated within a particular area, such as the abdomen, before changing to another area. Lipodystrophies are rare with the use of human insulin.

In type 1 diabetes, glucose has an osmotic effect when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose? a. Fatigue b. Polydipsia c. Polyphagia d. Recurrent infections

b. Polydipsia is caused by fluid loss from polyuria when high glucose levels cause osmotic diuresis. Cellular starvation from lack of glucose and the use of body fat and protein for energy contribute to fatigue, weight loss, and polyphagia in type 1 diabetes. Page 1289 12th ed The osmotic effect of excess glucose in the bloodstream causes polydipsia and polyuria.

The nurse is assessing a newly admitted patient with diabetes. Which observation should be addressed as the priority by the nurse? a. Bilateral numbness of both hands b. Rapid respirations with deep inspiration c. Stage II pressure injury on the right heel d. Areas of lumps and dents on the abdomen

b. Rapid deep respirations are symptoms of diabetic ketoacidosis (DKA), so this is the priority of care. Stage II pressure injuries and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate the patient has lipodystrophy and may need to learn about site rotation of insulin injections.

A nurse working in an outpatient clinic plans a screening program for diabetes. What recommendations for screening should be included? a. OGTT for all minority populations every year b. FPG for all persons at age 45 years and then every 3 years c. Testing people under the age of 21 years for islet cell antibodies d. Testing for type 2 diabetes in all overweight or obese persons

b. The American Diabetes Association recommends that testing for type 2 diabetes with a FPG, A1C, or 2-hour OGTT should be considered for all persons at the age of 45 years and above and, if normal, repeated every 3 years. Testing for immune markers of type 1 diabetes is not recommended. Testing at a younger age or more frequently should be done for members of a high-risk ethnic population, including blacks, Hispanics, Native Americans, Asian Americans, and Pacific Islanders. Overweight adults with additional risk factors should be tested.

Cortisol, glucagon, epinephrine, and growth hormone are referred to as counterregulatory hormones because they a. Decrease glucose production b. Stimulate glucose output by the liver c. Increase glucose transport into the cells d. Independently regulate glucose level in the blood

b. The counter regulatory hormones have the opposite effect of insulin by stimulating glucose production and output by the liver and by decreasing glucose transport into the cells. The counter regulatory hormones and insulin together regulate the blood glucose level.

What should the goals of nutrition therapy for the patient with type 2 diabetes include? a. Ideal body weight b. Normal serum glucose and lipid levels c. A special diabetic diet using dietetic foods d. Five small meals per day with a bedtime snack

b. The specific goals of nutrition therapy for people with diabetes include maintaining near-normal blood glucose levels and achievement of optimal serum lipid levels and BP. Dietary modifications are believed to be important factors in preventing both short- and long-term complications of diabetes. Loss of weight, which may or may not be to ideal body weight, may improve insulin resistance. There is no longer a specific "diabetic diet," and use of dietetic foods is not necessary for glucose control. Most patients with diabetes eat 3 meals a day, and some require a bedtime snack for control of nighttime hypoglycemia. The other goals of nutrition therapy include prevention of chronic complications of diabetes, attention to individual nutritional needs, and maintenance of the pleasure of eating.

Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)? a. Liver b. Brain c. Adipose d. Blood cells e. Skeletal muscle

c, e. Adipose tissue and skeletal muscle require insulin to allow the transport of glucose into the cells. Brain, liver, and blood cells require adequate glucose supply for normal function but do not depend directly on insulin for glucose transport. Page 1286 12th ed Skeletal muscle and adipose tissue have specific receptors for insulin and are considered insulin-dependent tissues. Insulin is required to "unlock" these receptor sites, allowing the transport of glucose into the cells to be used for energy. Other tissues (e.g., brain, liver, blood cells) do not directly depend on insulin for glucose transport but require an adequate glucose supply for normal function. Although liver cells are not insulin-dependent tissue, insulin receptor sites on the liver facilitate uptake of glucose and its conversion to glycogen.

A patient taking insulin has recorded fasting glucose levels above 200 mg/dL (11.1 mmol/L) on awakening for the last 5 mornings. What should the nurse have the patient to do first? a. Increase the evening insulin dose to prevent the dawn phenomenon. b. Use a single-dose insulin regimen with an intermediate-acting insulin. c. Monitor the glucose level at bedtime, between 2:00 am and 4:00 am, and on arising. d. Decrease the evening insulin dosage to prevent night hypoglycemia and the Somogyi effect.

c. The patient's high glucose on arising may be the result of either dawn phenomenon or Somogyi effect. The best way to determine whether the patient needs more or less insulin is by monitoring the glucose at bedtime, between 2:00 am and 4:00 am, and on arising. If the 2:00 am to 4:00 am blood glucose levels are below 60 mg/dL, the insulin dose should be reduced to prevent Somogyi effect; if it is high, the insulin should be increased to prevent dawn phenomenon.

The nurse assesses the technique of the patient with diabetes for self-monitoring of blood glucose (SMBG) 3 months after initial instruction. Which error in the performance of SMBG noted by the nurse requires intervention? a. Doing the SMBG before and after exercising b. Puncturing the finger on the side of the finger pad c. Cleaning the puncture site with alcohol before the puncture d. Holding the hand down for a few minutes before the puncture

c. Cleaning the puncture site with alcohol is not necessary and may interfere with test results and lead to drying and splitting of the fingertips. Washing the hands with warm water is adequate cleaning and promotes blood flow to the fingers. Blood flow is also increased by holding the hand down. Punctures on the side of the finger pad are less painful. Self-monitored blood glucose (SMBG) should be performed before and after exercise.

What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)? a. DKA requires administration of bicarbonate to correct acidosis. b. Potassium replacement is not necessary in management of HHS. c. HHS requires greater fluid replacement to correct the dehydration. d. Glucose is withheld in HHS until the blood glucose reaches a normal level.

c. The management of DKA is similar to that of HHS except that HHS requires greater fluid replacement because of the severe hyperosmolar state. Bicarbonate is not usually given in DKA to correct acidosis unless the pH is < 7.0 because administration of insulin will reverse the abnormal fat metabolism. Total body potassium deficit is possible in both conditions, requiring monitoring and possibly potassium administration, and in both conditions glucose is added to IV fluids when blood glucose levels fall to 250 mg/dL (13.9 mmol/L).

Which patient should the nurse plan to teach how to prevent or delay the development of diabetes? a. An obese 40-year-old Hispanic woman b. A 20-year-old man whose father has type 1 diabetes c. A 34-year-old woman whose parents both have type 2 diabetes d. A 12-year-old boy whose father has Maturity-Onset Diabetes of the Young (MODY)

c. Type 2 diabetes has a strong genetic influence (8% to 14% risk for offspring) and offspring of parents who both have type 2 diabetes have an increased chance of developing it. In contrast, type 1 diabetes is associated with a genetic susceptibility that is related to human leukocyte antigens (HLAs). Offspring of a mother with type 1 diabetes have a 1% to 4% chance of developing the disease, while offspring of a father with diabetes have 5% to 6% risk. Other risk factors for type 2 diabetes include obesity; Native American, Hispanic, or African ancestry; and age of 55 years or older. Although 50% of people with a parent with maturity-onset diabetes of the young (MODY) will develop MODY, it is autosomal dominant, and treatment depends on which genetic mutation caused it. It is not associated with obesity or hypertension and is not currently considered preventable.

The nurse should observe the patient for symptoms of ketoacidosis when a. illnesses causing nausea and vomiting lead to bicarbonate loss with body fluids. b. glucose levels become so high that osmotic diuresis promotes fluid and electrolyte loss. c. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy. d. the patient skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy.

c. When insulin is insufficient and glucose cannot be used for cellular energy, the body uses stored fats to meet energy needs. Free fatty acids from stored triglycerides are metabolized in the liver in such large quantities that ketones are formed. Ketones are acidic and alter the pH of the blood, causing acidosis. Osmotic diuresis from the elimination of both glucose and ketones in the urine causes dehydration, not ketosis. The loss of bicarbonate and skipping a meal after insulin administration do not cause ketosis.

A patient with diabetes is found unconscious at home, and a family member calls the clinic. After determining that a glucometer is not available, what should the nurse advise the family member to do? a. Have the patient drink some orange juice. b. Administer 10 U of regular insulin subcutaneously. c. Call for an ambulance to transport the patient to a medical facility. d. Administer glucagon 1 mg intramuscularly (IM) or subcutaneously.

d. If a patient with diabetes is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage, and IM or subcutaneous administration of 1 mg of glucagon should be done. If the unconsciousness has another cause, such as ketosis, the rise in glucose caused by the glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Oral carbohydrates cannot be given when patients are unconscious, and insulin is contraindicated without knowledge of the patient's glucose level.

The nurse determines that a patient with a 2-hour OGTT of 152 mg/dL has a. diabetes. b. elevated A1C. c. impaired fasting glucose. d. impaired glucose tolerance.

d. Impaired glucose tolerance exists when a 2-hour OGTT level is higher than normal but lower than the level diagnostic for diabetes (i.e., > 200 mg/dL). Impaired fasting glucose exists when fasting glucose levels are greater than the normal of 100 mg/dL but < the 126 mg/dL diagnostic of diabetes. Both abnormal values indicate prediabetes.

The home care nurse should intervene to correct a patient whose insulin administration includes a. warming a prefilled refrigerated syringe in the hands before administration. b. storing syringes prefilled with NPH and regular insulin needle-up in the refrigerator. c. placing the insulin bottle currently in use in a small container on the bathroom countertop. d. mixing an evening dose of regular insulin with insulin glargine in 1 syringe for administration.

d. Insulin glargine (Lantus), a long-acting insulin that is continuously released with no peak of action, cannot be diluted or mixed with any other insulin or solution. Mixed insulins should be stored needle-up in the refrigerator and warmed before administration. Currently used bottles of insulin may be kept at room temperature out of sunlight for 4 weeks.

In addition to promoting the transport of glucose from the blood into the cell, what does insulin do? a. Enhances the breakdown of adipose tissue for energy b. Stimulates hepatic glycogenolysis and gluconeogenesis c. Prevents the transport of triglycerides into adipose tissue d. Increases amino acid transport into cells and protein synthesis

d. Insulin is an anabolic hormone that is responsible for growth, repair, and storage. It facilitates movement of amino acids into cells, synthesis of protein, storage of glucose as glycogen, and deposition of triglycerides and lipids as fat into adipose tissue. Fat is used for energy when glucose levels are depleted. Glucagon is responsible for hepatic glycogenolysis and gluconeogenesis. Page 1271 12th ed Insulin Insulin is the main regulator of metabolism and storage of ingested carbohydrates, fats, and proteins. Insulin facilitates glucose transport into cells, transport of amino acids across muscle membranes, and the synthesis of amino acids into protein in the peripheral tissues. However, the brain, nerves, lens of the eye, hepatocytes, erythrocytes, and cells in the intestinal mucosa and kidney tubules are not dependent on insulin for glucose uptake. After a meal, insulin is responsible for how we use and store nutrients (anabolism). An increased blood glucose level is the major stimulus for insulin synthesis and secretion. Low blood glucose levels, glucagon, somatostatin, hypokalemia, and catecholamines usually inhibit insulin secretion.

Lispro insulin (Humalog) with NPH (Humulin N) insulin is ordered for a patient with newly diagnosed type 1 diabetes. When should the nurse administer lispro insulin? a. Only once a day b. 1 hour before meals c. 30 to 45 minutes before meals d. At mealtime or within 15 minutes of meals

d. Lispro is a rapid-acting insulin that has an onset of action of approximately 15 minutes and should be injected at the time of the meal to within 15 minutes of eating. Regular insulin is short acting with an onset of action in 30 to 60 minutes following administration and should be given 30 to 45 minutes before meals.

Which laboratory results indicate the patient has prediabetes? a. Glucose tolerance result of 132 mg/dL (7.3 mmol/L) b. Glucose tolerance result of 240 mg/dL (13.3 mmol/L) c. Fasting blood glucose result of 80 mg/dL (4.4 mmol/L) d. Fasting blood glucose result of 120 mg/dL (6.7 mmol/L)

d. Prediabetes is defined as impaired glucose tolerance and impaired fasting glucose or both. Fasting blood glucose results between 100 mg/dL (5.56 mmol/L) and 125 mg/dL (6.9 mmol/L) indicate prediabetes. A diagnosis of impaired glucose tolerance is made if the 2-hour oral glucose tolerance test (OGTT) results are between 140 mg/dL (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L).

SKIP DO NOT NEED TO KNOW FOR NOW. The patient with type 2 diabetes has had trouble controlling his blood glucose with several OAs but wants to avoid the risks of insulin. The health care provider (HCP) told him a medication will be prescribed that will increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and slow gastric emptying. Which medication will have to be injected? a. Dopamine receptor agonist, bromocriptine (Cycloset) b. Dipeptidyl peptidase-4 (DPP-4) inhibitor, sitagliptin (Januvia) c. Sodium-glucose co-transporter 2 (SGLT2) inhibitor, canagliflozin (Invokana) d. Glucagon-like peptide-1 receptor agonist, exenatide extended release (Bydureon)

d. This glucagon-like peptide-1 (GLP-1) receptor agonist stimulates GLP-1 to increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, slow gastric emptying, and must be injected subcutaneously once every 7 days. The other medications are oral agents (OAs). The mechanism of action for glycemic control for the dopamine receptor agonist is unknown. Dipeptidyl peptidase-4 (DPP-4) inhibitors block the action of the DPP-4 enzyme that inactivates incretin so there is increased insulin release, decreased glucagon secretion, and decreased hepatic glucose production. Sodium-glucose co-transporter 2 (SGLT2) inhibitors block the reabsorption of glucose by the kidney and increase urinary glucose excretion.