CH48: DKA, HHS, HYPOGLYCEMIA

*2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

ANS: C Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention

* 9. An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema.

ANS: C Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

* 37. A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate the infusion of 5% dextrose in water. b. Teach the patient how to use desmopressin (DDAVP) nasal spray. c. Assess the patients hydration status every 8 hours. d. Administer subcutaneous DDAVP.

ANS: D

*38. Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.

ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

Health Promotion and Maintenance 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.

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. DIF: Cognitive Level: Apply (application) REF: 1128 TOP: Nursing Process: Evaluation MSC:

Health Promotion and Maintenance 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.

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. DIF: Cognitive Level: Apply (application) REF: 1145 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1153 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity s 10e 624 45. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) 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.

A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Physiological Integrity 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. s 10e 609 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.

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. DIF: Cognitive Level: Apply (application) REF: 1127 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 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 s 10e 621 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

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. DIF: Cognitive Level: Apply (application) REF: 1121 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Safe and Effective Care Environment MULTIPLE RESPONSE 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

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 diabetic patient presents with symptoms of respiratory or infectious problems but are not routinely included in screening. DIF: Cognitive Level: Apply (application) REF: 1128 TOP: Nursing Process: Planning MSC:

The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH. A. high, low B. absent, absent C. low, high D. low, low

C

Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? A. Polyuria B. Polydipsia C. Polyphagia D. Extreme thirst

C

Physiological Integrity 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.

C s 10e 618 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. DIF: Cognitive Level: Apply (application) REF: 1127 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 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 s 10e 607

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. DIF: Cognitive Level: Apply (application) REF: 1124 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1125 TOP: Nursing Process: Evaluation MSC:

* 8. A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) a. elevated hematocrit. b. decreased serum sodium. c. low urine specific gravity. d. increased serum chloride.

ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

After several diagnostic tests, a client is diagnosed with diabetes insipidus (DI). The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder?1.fatigue 2.diarrhea 3.polydipsia 4.weight gain

3. DI is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms of DI. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur.

Physiological Integrity 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?

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. DIF: Cognitive Level: Apply (application) REF: 1150 TOP: Nursing Process: Assessment MSC:

Health Promotion and Maintenance 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)

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. DIF: Cognitive Level: Apply (application) REF: 1125 TOP: Nursing Process: Planning MSC:

* 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.

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. s 10e 608 DIF: Cognitive Level: Apply (application) REF: 1135 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1124 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1144 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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.

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. s 10e 616 DIF: Cognitive Level: Apply (application) REF: 1151 TOP: Nursing Process: Implementation MSC:

* 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 s 10e 610

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. DIF: Cognitive Level: Understand (comprehension) REF: 1126 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 44. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should 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.

A The rule of 15 indicates that administration of quickly acting carbohydrates should be done 2 to 3 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 once the glucose has stabilized. Glucagon should be used if the patients level of consciousness decreases so that oral carbohydrates can no longer be given. DIF: Cognitive Level: Apply (application) REF: 1146 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with?*A. SIADHB. Diabetes InsipidusC. Addison's DiseaseD. Fluid Volume Deficient

A

Physiological Integrity OTHER 1. In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). s 10e 626 a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.

A, D, E, B, C When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin.

** 7. The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following? a. I need to shop for foods low in sodium and avoid adding salt to food. b. I should weigh myself daily and report any sudden weight loss or gain. c. I need to limit my fluid intake to no more than 1 quart of liquids a day. d. I will eat foods high in potassium because diuretics cause potassium loss.

ANS: A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other

* 32. The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? a. The patient is confused and lethargic. b. The patient reports a recent head injury. c. The patient has a urine output of 400 mL/hr. d. The patients urine specific gravity is 1.003.

ANS: A The patients confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

Physiological Integrity 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.

B s 10e 613 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. DIF: Cognitive Level: Apply (application) REF: 1136 TOP: Nursing Process: Evaluation MSC:

* 32. Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a. Intracranial pressure is 16 mm Hg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.

ANS: B The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

* 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. s 10e 615 d. Administer a continuous infusion of 5% dextrose for 24 hours.

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. DIF: Cognitive Level: Apply (application) REF: 1146 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1124 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1143 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1129 TOP: Nursing Process: Evaluation MSC:

3. The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

ANS: B After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

* 6. The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patients a. weight has increased. b. urinary output is increased. c. peripheral edema is decreased. d. urine specific gravity is increased.

ANS: B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder

* 29. Which intervention will the nurse include in the plan of care for a 52-year-old male patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Monitor for peripheral edema. b. Offer patient hard candies to suck on. c. Encourage fluids to 2 to 3 liters per day. d. Keep head of bed elevated to 30 degrees.

ANS: B Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

** 2. Which statement by a 50-year-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? a. I notice my breasts are tender lately. b. I am so thirsty that I drink all day long. c. I get up several times at night to urinate. d. I feel a lump in my throat when I swallow.

ANS: D Difficulty in swallowing can occur with a goiter. Nocturia is associated with diseases such as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.

Physiological Integrity 41. A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.

B Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye exams starting 5 years after they are diagnosed and then annually. DIF: Cognitive Level: Apply (application) REF: 1149 TOP: Nursing Process: Planning MSC:

* 47. After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% s 10e 625 b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain•

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 blood glucose. The other patients also have symptoms that require assessments and/or interventions, but they are not at immediate risk for lifethreatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 1146 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC:

Health Promotion and Maintenance 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.

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. DIF: Cognitive Level: Apply (application) REF: 1139 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1124 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning s 10e 619 MSC:

* 15. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes s 10e 611 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.

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. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 40. An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a. Hemoglobin A1C level 6.2% b. Blood pressure 146/88 mmHg c. Heart rate at rest 58 beats/minute s 10e 622 d. High density lipoprotein (HDL) level 65 mg/dL

B To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80. 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 patients diabetes and risk factors for vascular disease are well controlled. DIF: Cognitive Level: Apply (application) REF: 1148 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1150 TOP: Nursing Process: Implementation MSC:

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.

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. DIF: Cognitive Level: Understand (comprehension) REF: 1133 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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. s 10e 612 c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.

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. DIF: Cognitive Level: Apply (application) REF: 1142 TOP: Nursing Process: Planning MSC:

* 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.

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. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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 s 10e 614 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%.

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 testing is not used to evaluate short-term alterations in blood glucose. DIF: Cognitive Level: Apply (application) REF: 1138 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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/LVN)? a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for the use of 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.

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. DIF: Cognitive Level: Apply (application) REF: 1152 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

* 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.

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. DIF: Cognitive Level: Apply (application) REF: 1132 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 42. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching 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.

C Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication. s 10e 623 DIF: Cognitive Level: Apply (application) REF: 1132 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 43. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

C 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 on scheduling the patient for an eye exam and addressing the questions about diet, but the biggest concern is the patients decreased renal function. DIF: Cognitive Level: Apply (application) REF: 1153 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

* 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 s 10e 620 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.

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. DIF: Cognitive Level: Apply (application) REF: 1146 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

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

C The patients 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. DIF: Cognitive Level: Analyze (analysis) REF: 1145 OBJ: Special Questions: Multiple Patients; Prioritization TOP: Nursing Process: Planning MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1123 TOP: Nursing Process: Planning MSC:

Physiological Integrity 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%. s 10e 617 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.

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. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 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?

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. DIF: Cognitive Level: Apply (application) REF: 1123 TOP: Nursing Process: Assessment MSC:

"Excessive thirst and volume of very dilute urine may be symptoms of:"A. Urinary tract infectionB. Diabetes insipidusC. Viral gastroenteritisD.Hypoglycemia"

Correct answer: B Diabetes insipidus is a condition in which the kidneys are unable to conserve water, often because there is insufficient antidiuretic hormone (ADH) or the kidneys are unable to respond to ADH. Although diabetes mellitus may present with similar symptoms, the disorders are different. Diabetes insipidus does not involve hyperglycemia."

* 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.

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. DIF: Cognitive Level: Apply (application) REF: 1133 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1127 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 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.

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. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 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? s 10e 606 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.

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. DIF: Cognitive Level: Apply (application) REF: 1134 TOP: Nursing Process: Assessment MSC: