102 - E3

A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patient's ability to prepare and self-administer insulin? A) Ask the patient to describe the process in detail. B) Observe the patient drawing up and administering the insulin. C) Provide a health education session reviewing the main points of insulin delivery. D) Review the patient's first hemoglobin A1C result after discharge.

Ans: B Feedback: Nurses should assess the patient's ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the patient performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the patient about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.

A medical nurse is caring for a patient with type 1 diabetes. The patient's medication administration record includes the administration of regular insulin three times daily. Knowing that the patient's lunch tray will arrive at 11:45, when should the nurse administer the patient's insulin? A) 10:45 B) 11:15 C) 11:45 D) 11:50

Ans: B Feedback: Regular insulin is usually administered 20-30 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A diabetes nurse is assessing a patient's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient's knowledge of nutritional therapy in diabetes? A) Ask the patient to describe an optimally healthy meal. B) Ask the patient to keep a food diary and review it with the nurse. C) Ask the patient's family what he typically eats. D) Ask the patient to describe a typical day's food intake.

Ans: B Feedback: Reviewing the patient's actual food intake is the most accurate method of gauging the patient's diet.

A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient? A) A sulfonylurea B) A biguanide C) A thiazolidinedione D) An alpha glucosidase inhibitor

Ans: B Feedback: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient? A) An elderly patient with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy. B) Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. C) Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. D) Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities.

Ans: B Feedback: The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs administered for diabetes.

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

Ans: B, C, D, E Feedback: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class? A) Low fat generally indicates low sugar. B) Protein should constitute 30% to 40% of caloric intake. C) Most calories should be derived from carbohydrates. D) Animal fats should be eliminated from the diet.

Ans: C Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body's need for insulin? A) Adequate sleep B) Low stimulation C) Exercise D) Low-fat diet

Ans: C Feedback: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low fat intake and low levels of stimulation do not reduce a patient's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient? A) Examine feet weekly for redness, blisters, and abrasions. B) Avoid the use of moisturizing lotions. C) Avoid hot-water bottles and heating pads. D) Dry feet vigorously after each bath.

Ans: C Feedback: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury.

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A) A combination of protein and carbohydrates, such as a small cup of yogurt B) Two teaspoons of sugar dissolved in a cup of apple juice C) Half of a cup of juice, followed by cheese and crackers D) Half a sandwich with a protein-based filling

Ans: C Feedback: Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.

A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what? A) "I read that a pancreas transplant will provide a cure for my diabetes." B) "I will take my oral antidiabetic agents when my morning blood sugar is high." C) "I will make sure to follow the weight loss plan designed by the dietitian." D) "I will make sure I call the diabetes educator when I have questions about my insulin."

Ans: C Feedback: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? A) The patient should withhold his next scheduled dose of insulin. B) The patient should promptly eat some protein and carbohydrates. C) The patient's insulin levels are inadequate. D) The patient would benefit from a dose of metformin (Glucophage).

Ans: C Feedback: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patient's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse's best response? A) "Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years." B) "The cause is not known for sure but it is thought to have something to do with ketoacidosis." C) "The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years." D) "Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels."

Ans: C Feedback: The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugars (rather than fluctuations or variations in blood sugars) are thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.

Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control? A) A patient who skips breakfast when his glucose reading is greater than 220 mg/dL B) A patient who never deviates from her prescribed dose of insulin C) A patient who adheres closely to a meal plan and meal schedule D) A patient who eliminates carbohydrates from his daily intake

Ans: C Feedback: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual's risk for developing diabetes? A) Have blood glucose levels checked annually. B) Stop using tobacco in any form. C) Undergo eye examinations regularly. D) Lose weight, if obese.

Ans: D Feedback: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent the diabetes.

A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy? A) Persistently cold feet B) Pain that does not respond to analgesia C) Acute pain, unrelieved by rest D) The presence of a tingling sensation

Ans: D Feedback: Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication.

A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA's recommendations include? A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

Ans: D Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? A) Patients who are obese and who have no known history of diabetes B) Patients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

Ans: D Feedback: HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.

A nurse is teaching basic "survival skills" to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address? A) Signs and symptoms of diabetic nephropathy B) Management of diabetic ketoacidosis C) Effects of surgery and pregnancy on blood sugar levels D) Recognition of hypoglycemia and hyperglycemia

Ans: D Feedback: It is imperative that newly diagnosed patients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for education, but are not components of the patient's immediate "survival skills" following a new diagnosis.

A patient has just been prescribed furosemide (Lasix). After reviewing the patient's medication history, what drug would cause the nurse concern when taken with furosemide (Lasix)? A) Acetaminophen B) Ferrous sulfate (Feosol) C) Naproxen sodium (Naprosyn) D) Ampicillin

Ans: D Feedback: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient's renal function. This drug does not typically affect patients' neutrophils, liver function, or cognition.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

Ans: D Feedback: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

A patient has been brought to the emergency department by paramedics after being found unconscious. The patient's Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaCl

Ans: A Feedback: In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patient's condition.

A patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following? A) Participation in a support group for persons with diabetes B) Regular consultation of websites that address diabetes management C) Weekly telephone "check-ins" with an endocrinologist D) Participation in clinical trials relating to antihyperglycemics

Ans: A Feedback: Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on patients' circumstances.

A diabetes nurse educator is teaching a group of patients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic patient? A) Do not eliminate insulin when nauseated and vomiting. B) Report elevated glucose levels greater than 150 mg/dL. C) Eat three substantial meals a day, if possible. D) Reduce food intake and insulin doses in times of illness.

Ans: A Feedback: The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe? A) "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase." B) "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it." C) "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." D) "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."

Ans: D Feedback: Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose.

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what? A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." B) "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." C) "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea." D) "I will call the doctor if my blood sugar is over 300 mg/dL or if I have ketones in my urine."

Ans: A Feedback: The nurse must explanation the "sick day rules" again to the patient who plans to stop taking insulin when sick. The nurse should emphasize that the patient should take insulin agents as usual and test one's blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the patient should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following? A) Avoid using the same injection site more than once in 2 to 3 weeks. B) Avoid mixing more than one type of insulin in a syringe. C) Cleanse the injection site thoroughly with alcohol prior to injecting. D) Inject at a 45º angle.

Ans: A Feedback: To prevent lipodystrophy, the patient should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable, within specific guidelines, and the needle is usually inserted at a 90º angle. Cleansing the injection site with alcohol is optional.

The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue? A) The need for frequent eye examinations for patients with diabetes B) The fact that patients with diabetes have an elevated risk of myocardial infarction C) The relationship between kidney function and blood glucose levels D) The need to monitor urine for the presence of albumin

Ans: B Feedback: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and renal function are considered to be microvascular.

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes? A) "I've always been a fan of sweet foods, but lately I'm turned off by them." B) "Lately, I drink and drink and can't seem to quench my thirst." C) "No matter how much sleep I get, it seems to take me hours to wake up." D) "When I went to the washroom the last few days, my urine smelled odd."

Ans: B Feedback: Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.

A patient with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment? A) Alterations in bile metabolism and release have likely caused hyperglycemia. B) Stress has likely caused an increase in the patient's blood sugar levels. C) The patient has likely overestimated her ability to control her diabetes using nonpharmacologic measures. D) The patient's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

Ans: B Feedback: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The patient's need for insulin is unrelated to the action of bile, the patient's overestimation of previous blood sugar control, or fluid imbalance.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patient's fluid balance C) Assessing the patient's level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

Ans: B Feedback: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

The diabetic Nurse Educator is teaching a class for newly diagnosed diabetics and their families. In this class the Nurse Educator is teaching about "sick day rules." What guideline applies to periods of illness ("sick day rules") in a diabetic patient? A. If nauseated, do not eat solid foods. B. Do not eliminate insulin when nauseated and vomiting. C. Report elevated glucose levels greater than 150 mg/dL. D. Eat three meals a day.

B. Do not eliminate insulin when nauseated and vomiting. The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent small portions of food. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

An adolescent patient tells the nurse at school that he is feeling nervous and hungry. The school nurse assesses the patient and finds he has tachycardia and is diaphoretic. What should the school nurse administer? A. Honey, 1 tsp B. Fruit juice, 4 to 6 oz C. Three hard candies (eg, Life Savers) D. Non-diet soda, 1 oz

B. Fruit juice, 4 to 6 oz The usual recommendation for treatment of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally, such as three or four commercially prepared glucose tablets; 4 to 6 oz of fruit juice or regular soda; 6 to 10 Life Savers or other hard candies; or 2 to 3 tsp of sugar or honey. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.

34. A 35 year old female patient with Type 1 diabetes has come to the clinic because she just doesn't feel well. The patient confides in the nurse that she is going through a divorce and a custody battle for her children ages 2and 4. She has started drinking and has lost her job. What would the nurse suspect is causing this patient to feel poorly? A. Hypoglycemia B. Ketoacidosis C. Hypernatremia D. Fluid overload

B. Ketoacidosis Patients with type 1 diabetes also risk developing ketoacidosis during periods of stress. The scenario describes a very stressful time in this patient's life. Hypoglycemia is a concern when the patient is undergoing surgery. Hypernatremia and fluid overload would not be a concern with a diabetic patient under stress.

31. The nurse is teaching a class for people newly diagnosed with diabetes and is going over complications of diabetes. Signs and symptoms of macrovascular complications of diabetes will be reviewed. A macrovascular complication of diabetes is: A. Retinopathy B. Stroke C. Nephropathy D. Renal failure

B. Stroke Myocardial infarction and stroke are considered macrovascular complications of diabetes mellitus, while peripheral neuropathy is related to the effects of elevated blood glucose levels over a period of years directly affecting the nerves. Microvascular complications include diabetic retinopathy and nephropathy.

A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. The nurse is explaining to the patient the etiology of type 1 diabetes. Which of the following explanations is appropriate? A. "The secretion of placental hormones causes the body to be resistant to insulin." B. "The formation of an acidic substance when the liver breaks down fatty acids because of the lack of insulin in the body." C. "Destruction of special cells in the pancreas causes a decrease in insulin production and the level of glucose (sugar) in the bloodstream increases because the body lacks insulin to break down the glucose." D. "The tissues in the body are resistant to the action of insulin, making insulin less effective in the body."

C. "Destruction of special cells in the pancreas causes a decrease in insulin production and the level of glucose (sugar) in the bloodstream increases because the body lacks insulin to break down the glucose." Type 1 diabetes is characterized by the destruction of pancreatic beta cells resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood and leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. Gestational diabetes is defined as any degree of glucose intolerance with its onset during pregnancy and is caused by the secretion of placental hormones. Ketosis is the formation of a highly acidic substance when the liver breaks down free fatty acids in the absence of insulin.

You are caring for four patients, all diagnosed with type 1 diabetes. Based upon components of managing diabetes, which patient will likely have the greatest success in maintaining tight glucose control of type 1 diabetes? A. A patient who skips breakfast when his or her morning fingerstick glucose reading is greater than 220 mg/dL B. A patient who never deviates from his or her prescribed dose of insulin C. A patient who adheres to a meal plan and meal schedule D. A patient who eliminates carbohydrates from his or her daily intake.

C. A patient who adheres to a meal plan and meal schedule The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for an insulin-dependent diabetic.

A patient newly diagnosed with type 2 diabetes is attending a nutrition class specifically designed for type 2 diabetics. What general guideline would it be important to teach the patients at this class? A. Dietary fat should be eliminated from the diet. B. Protein should constitute 35% of dietary intake. C. Control calorie intake to attain a reasonable body weight. D. Low fat generally indicates low sugar.

C. Control calorie intake to attain a reasonable body weight. In general, calorie distribution recommended is higher in carbohydrates than in fat and protein, and all carbohydrates should be eaten in moderation to avoid high postprandial blood glucose levels. The most important objective in the dietary management of diabetes is control of total calorie intake to attain or maintain reasonable body weight. Low fat does not automatically mean low sugar. Dietary fat does not need to be eliminated from the diet. Protein intake needs to keep calories within a reasonable amount.

39. An adolescent patient tells the nurse at school that he is feeling nervous and hungry. The school nurse assesses the patient and finds he has tachycardia and is diaphoretic. What should the school nurse administer? A. Non-diet soda, one ounce B. Three hard candies (life-Savers) C. Fruit-juice, 4-6 ounces D. Honey, one teaspoon

C. Fruit juice, 4 to 6 oz The usual recommendation for treatment of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally, such as three or four commercially prepared glucose tablets; 4 to 6 oz of fruit juice or regular soda; 6 to 10 Life Savers or other hard candies; or 2 to 3 tsp of sugar or honey. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.C.

A diabetic patient calls the clinic complaining of having a "flu bug." The nurse tells him to take his regular dose of insulin. What else would the nurse tell the patient? A. Eat as you regularly would. B. Check your urine ketones every 8 hours. C. Try drinking juice, regular soda, and eating gelatin frequently and in small portions. D. Check your blood glucose every hour.

C. Try drinking juice, regular soda, and eating gelatin frequently and in small portions. For prevention of DKA related to illness, "sick day" rules for managing diabetes when ill (Chart 41-9) should be reviewed. The most important concept in this is to never eliminate insulin doses when nausea and vomiting occur. Instead, the patient should take the usual insulin dose (or previously prescribed special "sick day" doses) and then attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

The nursing instructor is teaching his students about foot care for the diabetic patient. The instructor teaches the students what general guidelines regarding foot care? A. Do not wear socks to bed. B. Walk barefoot only at the beach. C. Wash feet in warm water. D. Rub a thin coat of lotion between the toes.

C. Wash feet in warm water. Feet should be washed in warm water, and lotion should be applied to the tops and bottoms of the feet, but not between the toes. The patient should never walk barefoot. Patient may wear socks to bed if the feet are cold.

A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor? A) Increased caloric intake during the first trimester B) Changes in osmolality and fluid balance C) The effects of hormonal changes during pregnancy D) Overconsumption of carbohydrates during the first two trimesters

C. the effects of hormonal changes during pregnancy rationale Hyperglycemia and eventual gestational diabetes develops during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality.

43. A client is to receive Lispro insulin at breakfast. The nurse correctly administers the insulin: A. 30 minutes before breakfast B. 5 minutes before breakfast C. Immediately after breakfast D. Before breakfast

B. 5 minutes before breakfast

42. In NUR 102 the instructor is explaining the action of sulfonylureas. You understand that the action of sulfonylureas is to A. Stimulate the beta cells to secrete more insulin B. Stimulate the adrenal medulla to secrete more epinephrine C. Stimulate the release of glycogen D. Treat clients who have Type 1 diabetes.

A. Stimulate the beta cells to secrete more insulin

44. Which of the following statement is accurate about Type 1 diabetes? (Select all that apply) A. Destruction of the pancreatic beta cells due to autoimmune response B. There is slight genetic predisposition to Type 1 diabetes C. Signs and symptoms develop gradually over a long period of time D. A person with Type 1 diabetes must use insulin

A B D

The nurse teaches a 38-year-old man who was recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse? A. "I will discard any insulin bottle that is cloudy in appearance." B. "The best injection site for insulin administration is in my abdomen." C. "I can wash the site with soap and water before insulin administration." D. "I may keep my insulin at room temperature (75o F) for up to a month."

A. "I will discard any insulin bottle that is cloudy in appearance." Rationale. Intermediate-acting insulin and combination premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (less than 32° F [0° C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

36. The diabetic educator is teaching a class on complications of diabetes for newly diagnosed diabetic children and their parents. The diabetic educator would define hypoglycemia as what blood glucose level? A. Below 60 mg/dL B. Between 60-120 mg/dL C. Between 120-180 mg/dL D. Above 180 mg/dL

A. Below 60 mg/dL Hypoglycemia occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L), because of too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity.

The nurse is teaching a newly diagnosed diabetic about his insulin regimen. When administering Humalog insulin the nurse should teach the patient what? A. Have the patient's meal tray available. B. Feed the patient prior to administering the dose of insulin. C. Have the patient begin the meal tray 30 minutes following the injection. D. Watch for symptoms of hyperglycemia.

A. Have the patient's meal tray available. Humalog's onset of action is 10 to 15 minutes. Because of its rapid action, patients should be instructed not to wait the usual 30 minutes after injection to eat. You do not feed a patient before administering insulin. You always assess for symptoms of hyperglycemia.

The nursing instructor is quizzing one of her students who is caring for a diabetic in the clinical area. The instructor asks the student what is a contributing cause of ulcers to the foot in the diabetic patient. What should the student answer? A. Insensitive feet B. Arterial insufficiency C. Gout D. Smoking

A. Insensitive feet Patients with an insensitive foot do not feel injuries, which may be thermal (eg, from using heating pads, walking barefoot on hot concrete, testing bath water with the foot), chemical (eg, burning the foot while using caustic agents on calluses, corns, or bunions), or traumatic (eg, injuring skin while cutting nails, walking with an undetected foreign object in the shoe, or wearing ill-fitting shoes and socks). Arterial insufficiency, gout and smoking are not considered contributing causes of foot ulcers in the diabetic patient.

40. The Diabetic Nurse Educator is teaching a class for newly diagnosed diabetics and their families. The nurse educator is talking about "sick day" kits. What would the Nurse Educator tell the people attending the class to put in their "sick day" kits? (Select all that apply) A. Concentrated proteins B. Urine test strips C. Nutritious pastries D. Baby orange juice E. Blood glucose test strips

ANS: B, D, E Patients are taught to have foods available for use on sick days. In addition, a supply of urine test strips (for ketone testing) and blood glucose test strips should be available. The patient must know how to contact his or her physician 24 hours a day. These materials should be assembled in a "sick day" kit. Concentrated proteins would not be included in the kit. Nutritious pastries is an oxymoron and would not be included in the kit.

A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer? A) "If you are going to use up the vial within 1 month it can be kept at room temperature." B) "If a vial of insulin will be used up within 21 days, it may be kept at room temperature." C) "If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature." D) "If a vial of insulin will be used up within 1 week, it may be kept at room temperature."

Ans: A Feedback: If a vial of insulin will be used up within 1 month, it may be kept at room temperature.

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A) Always carry a form of fast-acting sugar. B) Perform exercise prior to eating whenever possible. C) Eat a meal or snack every 8 hours. D) Check blood sugar at least every 24 hours.

Ans: A Feedback: The following teaching points should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.

41. A patient is placed on 4 injections of regular insulin in addition to insulin glargine (Lantus) at bedtime. About how many hours after each injection of regular insulin should the patient be alert to symptoms of hypoglycemia? A. ½ hour B. 3 hours C. 6 hours D. 12 hours

B. 3 hours

You are beginning to teach a diabetic patient about the vascular complications of diabetes. Which information is appropriate for you to include? A. Macroangiopathy does not occur in type 1 diabetes but does affect type 2 diabetics who have severe disease. B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. C. Renal damage resulting from changes in large and medium-sized blood vessels can be prevented by careful glucose control. D. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.

B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Rationale. Microangiopathy occurs in type 1 and type 2 diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Sexual impotency and slowed gastric emptying result from microangiopathy.

The nursing instructor is discussing diabetes mellitus with the nursing class. What would the instructor tell the class may develop in the patient when ketone bodies accumulate in excessive amounts? A. Hypovolemia B. Polyuria C. Diabetic Ketoacidosis D. Blurred vision

C. Diabetic Ketoacidosis Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. This will result in diabetic ketoacidosis. Signs and symptoms are abdominal pain, nausea, vomiting hyperventilation, fruity odor of breath, and if left untreated, possible death. Excessive amounts of ketone bodies do not cause hypovolemia, polyuria or blurred vision.

38. In nursing theory the student nurses are learning about oral antidiabetic agents. What category of oral antidiabetic agents would the students learn enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas? A. Sulfonylureas B. Biguanides C. Thiazolidinediones D. Alpha glucosidase inhibitors

C. Thiazolidinediones Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides facilitate insulin's action on peripheral receptor sites. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

35. An adolescent, newly diagnosed with type 1 diabetes, asks the nurse what caused the diabetes. What would be the nurse's best response? A. Type I diabetes has a variety of causes that work together to cause the disease B. It is thought to be caused by environmental factors like a virus C. Part of the cause of diabetes is immunologic. That means your body is destroying itself D. The causes of Type 1 diabetes are genetic, immunologic, and environmental

D. "The causes of type 1 diabetes are genetic, immunologic, and environmental." The etiology of type 1 diabetes mellitus includes genetic, immunologic, and environmental factors (eg, virus). Option C is not something you would say to a patient without further explanation. Options A and B are not complete answers to the patient's question.

A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin (Glucophage). Following an ordered increase in the patient's daily dose of metformin, the nurse should prioritize which of the following assessments? A) Monitoring the patient's neutrophil levels B) Assessing the patient for signs of impaired liver function C) Monitoring the patient's level of consciousness and behavior D) Reviewing the patient's creatinine and BUN levels

D. Reviewing the patient's creatinine and BUN levels Feedback: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient's renal function. This drug does not typically affect patients' neutrophils, liver function, or cognition.

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A) Fasting plasma glucose greater than or equal to 126 mg/dL B) Random plasma glucose greater than 150 mg/dL C) Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions D) Random plasma glucose greater than 126 mg/dL

Ans: A Feedback: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.

Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Increased high-density lipoproteins (HDL) C. Decreased low-density lipoproteins (LDL) D. Decreased very-low-density lipoproteins (VLDL)

A. Increased triglyceride levels Rationale. Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A) Infection B) Acute pain C) Acute confusion D) Impaired urinary elimination

Ans: A Feedback: Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function.

A diabetic patient calls the clinic complaining of having a "flu bug." The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) "Make sure to stick to your normal diet." B) "Try to eat small amounts of carbs, if possible." C) "Ensure that you check your blood glucose every hour." D) "For now, check your urine for ketones every 8 hours."

Ans: B Feedback: For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the child's pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes? A) Type 1 diabetes B) Type 2 diabetes C) Non-insulin-dependent diabetes D) Prediabetes

Ans: A Feedback: Beta cell destruction is the hallmark of type 1 diabetes. Non-insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse's most appropriate action? A) Teach the patient about actions to slow the progression of nephropathy. B) Ensure that the patient receives a comprehensive assessment of liver function. C) Determine whether the patient has been using expired insulin. D) Administer a fluid challenge and have the test repeated.

Ans: A Feedback: Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the patient's liver function is not likely affected. There is no indication for the use of a fluid challenge.

A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurse's priority action? A) Ensure that the patient understands the basic pathophysiology of diabetes. B) Identify the patient's body mass index. C) Teach the patient "survival skills" for diabetes. D) Assess the patient's readiness to learn.

Ans: D Feedback: Before initiating diabetes education, the nurse assesses the patient's (and family's) readiness to learn. This must precede other physiologic assessments (such as BMI) and providing health education.

45. Kussmaul's breathing which is often observed in person's with DKA, can be viewed as a compensatory mechanism in which the increased ventilation attempts to: A. Increase the oxygen content of the blood in an effort to burn excess glucose B. Blow off excess carbon dioxide in an effort to increase the pH C. Increase the respiratory loss of ketone bodies as a means of controlling the pH D. Increase oxygen supply to the brain.

B. Blow off excess carbon dioxide in an effort to increase the pH

You are caring for a newly diagnosed type 2 diabetic. The patient is 67 years old and has been found to have what long-term complication of diabetes mellitus? A. Retinal damage B. Cardiovascular disease C. Hypertension D. Renal disease

B. Cardiovascular disease Long-term complications are seen in both type 1 and type 2 diabetes but usually do not occur within the first 5 to 10 years after diagnosis. However, evidence of these complications may be present at the time of diagnosis of type 2 diabetes, because patients may have had undiagnosed diabetes for many years. Renal (microvascular) disease is more prevalent in patients with type 1 diabetes, and cardiovascular (macrovascular) complications are more prevalent in older patients with type 2 diabetes.

A student nurse is caring for a patient with type 1 diabetes who also has glycosuria. The nursing instructor asks this student nurse what the patient's urine should look like. What would be the student's best response? A. Concentrated urine B. Dilute urine C. Elevated specific gravity D. Cloudy urine

B. Dilute urine When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. The urine will be dilute due to the osmotic diuresis. While the urine may be cloudy if the patient has a urinary tract infection, the best answer related to glycosuria is the excretion of dilute urine. A concentrated urine or urine with an elevated specific gravity occurs when the body is conserving fluid and is the opposite of diuresis.

The Diabetic Educator is assessing a hospitalized patient to see if it is necessary to reinforce parts of the patient's knowledge of basic diabetic self-care skills. What would be an appropriate way for the Diabetic Educator to assess the patient's knowledge of nutritional therapy in diabetes mellitus? A. Ask the patient's family what they eat at home. B. Monitor the patient's daily food menus. C. Ask the patient's roommate. D. Ask the nursing staff what the patient is eating.

B. Monitor the patient's daily food menus. The patient's knowledge about diet can be assessed with the help of a dietitian through direct questioning and review of the patient's menu choices.