Chapter 51: Caring for Clients with Diabetes Mellitus

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

B Regular insulin is usually given 20 to 30 minutes before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker? A. Home health nurse B. Dietitian C. Psychiatrist D. Social worker

B The client should be referred to a dietitian, who will help him gain better control of his blood glucose levels. The client can care for himself, so a home health agency isn't necessary. The client shows no signs of needing a psychiatric referral, and referring the client to a psychiatrist isn't in the nurse's scope of practice. Social workers help clients with financial concerns; the scenario doesn't indicate that the client has a financial concern warranting a social worker at this time.

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by: a. 8:30 AM. b. 10:30 AM. c. 12:30 PM. d. 2:30 PM.

a Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.

Lispro (Humalog) is an example of which type of insulin? a. Rapid-acting b. Intermediate-acting c. Short-acting d. Long-acting

a Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client 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."

C 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 clients may require insulin on an ongoing 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 nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites? A. Insulin is absorbed more slowly at abdominal injection sites than at other sites. B. Insulin is absorbed rapidly regardless of the injection site. C. Insulin is absorbed more rapidly at abdominal injection sites than at other sites. D. Insulin is absorbed unpredictably at all injection sites.

C Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis? a. Hypokalemia and hypoglycemia b. Hypocalcemia and hyperkalemia c. Hyperkalemia and hyperglycemia d. Hypernatremia and hypercalcemia

a Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective? a. 1/2 cup fruit juice or regular soft drink b. 4 oz of skim milk c. 1/2 tbsp honey or syrup d. three to six LifeSavers candies

a In a client with hypoglycemia, the nurse uses the rule of 15: give 15 g of rapidly absorbed carbohydrate, wait 15 minutes, recheck the blood sugar, and administer another 15 g of glucose if the blood sugar is not above 70 mg/dL. One-half cup fruit juice or regular soft drink is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Eight ounces of skim milk is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. One tablespoon of honey or syrup is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Six to eight LifeSavers candies is equivalent to the recommended 15 g of rapidly absorbed carbohydrate.

A client has been diagnosed with prediabetes. How can the client delay or avoid type 2 diabetes? a. weight loss b. increased physical activity c. decreased sleep d. hydrotherapy e. Increased vitamins

a, b A significant number of those with prediabetes will develop the disease; however, many can delay or avoid type 2 diabetes with increased physical activity and weight reduction.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? a. Coma, anxiety, confusion, headache, and cool, moist skin b. Kussmaul respirations, dry skin, hypotension, and bradycardia c. Polyuria, polydipsia, hypotension, and hypernatremia d. Polyuria, polydipsia, polyphagia, and weight loss

a Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mg/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply. a. Ketosis-prone b. Little or no endogenous insulin c. Obesity at diagnoses d. Younger than 30 years of age e. Older than 65 years of age

a, b, d Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: a. 2 to 5 g of a simple carbohydrate. b. 10 to 15 g of a simple carbohydrate. c. 18 to 20 g of a simple carbohydrate. d. 25 to 30 g of a simple carbohydrate.

b To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

A client with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which factor should the nurse monitor when caring for the client? a. Polyuria b. Hypertonicity c. Low blood glucose concentration d. Allergic reactions

c Clients who switch from animal to synthesized human insulin should initially be monitored for low blood glucose concentrations because the human form of insulin is used more effectively. Human insulin causes fewer allergic reactions than insulin obtained from animal sources. Polyuria and hypertonicity are symptoms of diabetes mellitus.

Which type of insulin acts most quickly? a. Regular b. NPH c. Lispro d. Glargine

c The onset of action of rapid-acting lispro is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate-acting NPH insulin is 3 to 4 hours. The onset of action of very long-acting glargine is ~6 hours.

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan? a. Making sure that the patient is aware that quantity of foods will be limited b. Ensuring that the patient understands that some favorite foods may not be allowed on the meal plan and substitutes will need to be found c. Determining whether the patient is on insulin or taking oral antidiabetic medication d. Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns

d The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? A. Do not eliminate insulin when nauseated and vomiting. B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). C. Eat three substantial meals a day, if possible. D. Reduce food intake and insulin doses in times of illness.

A The most important issue to teach clients 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 carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

A client has been brought to the emergency department by paramedics after being found unconscious. The client's Medic Alert bracelet indicates that the client has type 1 diabetes and the client'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

a In hospitals and emergency departments, for clients 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 client's condition.

The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer? a. NPH b. Iletin II c. Lispro (Humalog) d. Glargine (Lantus)

a Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting.

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition? a. ketoacidosis b. hyperosmolar hyperglycemic nonketotic syndrome c. hepatic disorder d. All options are correct.

a Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.

A characteristic of type 2 diabetes includes which of the following? a. No islet cell antibodies b. Often have islet antibodies c. Little insulin d. Ketosis-prone when insulin absent

a Type 2 diabetes is characterized by no islet cell antibodies or a decrease in endogenous insulin or increase with insulin resistance. Type 1 diabetes is characterized by production of little or no insulin; the patient is ketosis-prone when insulin is absent and often has islet cell antibodies.

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate? a. Albumin b. Bacteria c. Red blood cells d. White blood cells

a Nephropathy, or kidney disease secondary to diabetic microvascular changes in the kidney, is a common complication of diabetes. Consistent elevation of blood glucose levels stresses the kidney's filtration mechanism, allowing blood proteins to leak into the urine and thus increasing the pressure in the blood vessels of the kidney. Albumin is one of the most important blood proteins that leak into the urine, and its leakage is among the earliest signs that can be detected. Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria but in fewer than 5% of people without microalbuminuria. The urine should be checked annually for the presence of proteins, which would include microalbumin.

Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)? a. Blood glucose can be controlled through diet and exercise b. Client is usually thin at diagnosis c. Client is prone to ketosis d. Clients demonstrate islet cell antibodies

a Oral hypoglycemic agents may improve blood glucose concentrations if dietary modification and exercise are unsuccessful. Individuals with type 2 diabetes are usually obese at diagnosis. Individuals with type 2 diabetes rarely demonstrate ketosis, except with stress or infection. Individuals with type 2 diabetes do not demonstrate islet cell antibodies.

A client has been living with type 2 diabetes for several years, and the nurse realizes that the client is likely to have minimal contact with the health care system. In order to ensure that the client maintains adequate blood sugar control over the long term, what should the nurse recommend? 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

a Participation in support groups is encouraged for clients 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 clients' circumstances.

Which of the following medications is considered a glitazone? a. pioglitazone b. metformin c. metformin with glyburide d. dapagliflozin

a Pioglitazone and rosiglitazone are classified as a glitazone or thiazolidinedione. Metformin and metformin with glyburide are classified as biguanides. Dapagliflozin is classified as a sodium-glucose co-transporter 2 (SGL-2) inhibitor.

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? a. Sweating, tremors, and tachycardia b. Dry skin, bradycardia, and somnolence c. Bradycardia, thirst, and anxiety d. Polyuria, polydipsia, and polyphagia

a Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of: a. hypoglycemia b. polyuria c. blurred vision d. polydipsia

a The nurse should observe the client receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes? a. increased thirst, hunger, and urination b. Increased weight loss, dehydration, and fatigue c. Loss of appetite, increased urination, and dehydration d. Increased weight gain, appetite, and thirst

a The three classic symptoms of both types of diabetes mellitus are polyuria, polydipsia, and polyphagia. Weight loss, dehydration, and fatigue are additional symptoms.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes? a. Presence of autoantibodies against islet cells b. Obesity c. Rare ketosis d. Altered glucose metabolism

a There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

A nurse is caring for a client newly diagnosed with type 1 diabetes. The nurse is educating the client about self-administration of insulin in the home setting. The nurse should teach the client to do what action? 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 45 degree angle.

a To prevent lipodystrophy, the client 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 90 degree angle. Cleansing the injection site with alcohol is optional.

A nurse educator been invited to local seniors center to discuss health-maintaining strategies for older adults. The nurse addresses the subject of diabetes mellitus, its symptoms, and consequences. What should the educator teach the participants about type 1 diabetes? a. The participants are unlikely to develop a new onset of type 1 diabetes. b. New cases of diabetes are highly uncommon in older adults. c. New cases of diabetes will be split roughly evenly between type 1 and type 2. d. Type 1 diabetes always develops before the age of 20.

a Type 1 diabetes usually (but not always) develops in people younger than 20. In older adults, an onset of type 2 is far more common. A significant number of older adults develops type 2 diabetes.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication? a. The short-acting insulin is withdrawn before the intermediate-acting insulin. b. The intermediate-acting insulin is withdrawn before the short-acting insulin. c. Different types of insulin are not to be mixed in the same syringe. d. If administered immediately, there is no requirement for withdrawing one type of insulin before another.

a When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy."

A nurse is observing a newly diagnosed client with diabetes mellitus administer an insulin injection. Which site will the nurse advise the client to predominantly use? a. abdomen b. upper arms c. thighs d. buttocks

a Clients with diabetes are taught to use the abdomen for self-administration of insulin.

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection? a. 10 to 15 minutes b. 30 to 40 minutes c. 1 to 2 hours d. 3 hours

a The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

A nurse educator has been invited to a local senior center to discuss health-maintaining strategies for older adults. The nurse discusses diabetes mellitus, its symptoms, and consequences. What is the prevalence of Type I diabetes? a. 5% to 10% of all diagnosed cases b. 0% to 5% of all diagnosed cases c. 10% to 15% of all diagnosed cases d. 15% to 20% of all diagnosed cases

a Type 1 diabetes accounts for approximately 5% to 10% of all diagnosed cases of diabetes (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2008).

An adult client has gained 55 lbs in the last 3 years. During client education, the nurse should educate the client about: a. the risk of type 2 diabetes. b. the risk of type 1 diabetes. c. insulin resistance. d. the benefits of a low-sugar diet.

a Weight gain creates a significant risk for type 2 diabetes. Insulin resistance is a small component of this larger risk. Dietary and lifestyle modifications go beyond simply reducing sugar intake.

The nurse is assessing a patient with nonproliferative (background) retinopathy. When examining the retina, what would the nurse expect to assess? Select all that apply. a. Leakage of fluid or serum (exudates) b. Microaneurysms c. Focal capillary single closure d. Detachment e. Blurred optic discs

a, b, c Almost all patients with type 1 diabetes and the majority of patients with type 2 diabetes have some degree of retinopathy after 20 years (ADA, 2013). Changes in the microvasculature include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure.

A nurse is educating a client about the benefits of fruit versus fruit juice in the diabetic diet. The client states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What are the best responses by the nurse? Select all that apply. a. "Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." b. "Eating the fruit is more satisfying than drinking the juice. You will get full faster." c. "Eating the fruit will give you more vitamins and minerals than the juice will." d. "Eating the fruit will lead to hyperglycemia and the fruit juice will not lead to hyperglycemia." e. "The fruit has less sugar than the juice."

a, e Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption. A serving of juice has more sugar than a serving of fruit. Whether a fruit is more satisfying and has more vitamins and minerals than the fruit's juice are dependent on the types of fruit and juices. Eating fruit does not lead to hyperglycemia.

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being 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."

b 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.

Which statement is correct regarding glargine insulin? a. Its peak action occurs in 2 to 3 hours. b. It cannot be mixed with any other type of insulin. c. It is absorbed rapidly. d. It is given twice daily.

b Because this insulin is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. There is no peak in action. It is approved to give once daily.

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true? a. Nearly two-thirds of clients with diabetes mellitus are older than age 60. b. Diabetes mellitus is more common in Hispanics and Blacks than in Whites. c. Type 2 diabetes mellitus is less common than type 1 diabetes mellitus. d. Approximately one-half of the clients diagnosed with type 2 diabetes are obese.

b Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client 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 client's blood sugar levels. c. The client has likely overestimated her ability to control her diabetes using nonpharmacologic measures. d. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

b 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 client's need for insulin is unrelated to the action of bile, the client's overestimation of previous blood sugar control, or fluid imbalance.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? a. Serum glucose level of 450 mg/dl b. Serum glucose level of 52 mg/dl c. Serum calcium level of 8.9 mg/dl d. Serum calcium level of 10.2 mg/dl

b Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing? a. Systemic inflammatory response syndrome b. Hyperglycemic hyperosmolar syndrome c. Multiple-organ dysfunction syndrome d. Diabetic ketoacidosis

b Hyperglycemic hyperosmolar syndrome (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 (Reynolds, 2012). The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis).

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously? a. NPH b. Regular c. Lispro d. Lantus

b Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline? a. "You'll need more insulin when you exercise or increase your food intake." b. "You'll need less insulin when you exercise or reduce your food intake." c. "You'll need less insulin when you increase your food intake." d. "You'll need more insulin when you exercise or decrease your food intake."

b The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

A client with diabetes mellitus must learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? a. "Inject insulin into healthy tissue with large blood vessels and nerves." b. "Rotate injection sites within the same anatomic region, not among different regions." c. "Administer insulin into areas of scar tissue or hypertrophy whenever possible." d. "Administer insulin into sites above muscles that you plan to exercise heavily later that day."

b The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond? a. "The spleen releases ketones when your body can't use glucose." b. "Ketones will tell us if your body is using other tissues for energy." c. "Ketones can damage your kidneys and eyes." d. "Ketones help the physician determine how serious your diabetes is."

b The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition? a. "I will refer you to a dietician who can help you with your weight." b. "You may be having undiagnosed infections, causing you to lose extra weight." c. "Your body is using protein and fat for energy instead of glucose." d. "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism."

c Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the client and family that what nonpharmacologic measures will decrease the body's need for insulin? a. Adequate sleep b. Low stimulation c. Exercise d. Low-fat diet

c 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 client'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 client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? a. Arterial pH 7.25 b. Plasma bicarbonate 12 mEq/L c. Blood glucose level 1,100 mg/dl d. Blood urea nitrogen (BUN) 15 mg/dl

c HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use? a. Fasting blood glucose test b. 6-hour glucose tolerance test c. Serum glycosylated hemoglobin (Hb A1c) d. Urine ketones

c Hb A1c is the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.

A pregnant woman has been diagnosed with gestational diabetes. The client 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 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.

A client 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 client should withhold his next scheduled dose of insulin. b. The client should promptly eat some protein and carbohydrates. c. The client's insulin levels are inadequate. d. The client would benefit from a dose of metformin.

c 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 client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be: a. monitoring blood glucose every 4 hours and as needed. b. checking for the presence of ketones with each void. c. providing client education at every opportunity. d. administering insulin routinely and as needed via a sliding scale.

c The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? a. A client who skips breakfast when his glucose reading is greater than 220 mg/dL (12.3 mmol/L) b. A client who never deviates from her prescribed dose of insulin c. A client who adheres closely to a meal plan and meal schedule d. A client who eliminates carbohydrates from his daily intake

c 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 clients. For clients 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, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

NPH is an example of which type of insulin? a. Rapid-acting b. Short-acting c. Intermediate-acting d. Long-acting

c NPH is an intermediate-acting insulin.

A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction? a. Between 8:00 and 10:00 a.m. b. Between 4:00 and 6:00 p.m. c. Between 7:00 and 9:00 p.m. d. This insulin has no peak action and does not cause a hypoglycemic reaction.

d "Peakless" basal or very long-acting insulins are approved by the U.S. Food and Drug Administration for use as a basal insulin; that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. It has is no peak action.

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client 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

d Although approximately half of clients 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.

Which information should be included in the teaching plan for a client receiving glargine, a "peakless" basal insulin? a. Administer the total daily dosage in two doses. b. Draw up the drug first, then add regular insulin. c. It is rapidly absorbed and has a fast onset of action. d. Do not mix with other insulins.

d Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine insulin, it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: a. urine glucose level. b. fasting blood glucose level. c. serum fructosamine level. d. glycosylated hemoglobin level.

d Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

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

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

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What should the nurse describe? 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

d 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. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder? a. Serum potassium level b. Serum sodium level c. Arterial blood gas (ABG) values d. Serum osmolarity

d Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia? a. Polyuria, headache, and fatigue b. Polyphagia and flushed, dry skin c. Polydipsia, pallor, and irritability d. Nervousness, diaphoresis, and confusion

d Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death. Polydipsia, polyuria, and polyphagia are symptoms associated with hyperglycemia.

A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease? a. "I always carry hard candy to eat in case my blood sugar level drops." b. "I avoid exposure to the sun as much as possible." c. "I always wear my medical identification bracelet." d. "I skip lunch when I don't feel hungry."

d The client requires further teaching if he states that he skips meals. A client who is receiving an oral antidiabetic agent should eat meals on a regular schedule because skipping a meal increases the risk of hypoglycemia. Carrying hard candy, avoiding exposure to the sun, and always wearing a medical identification bracelet indicate effective teaching.

An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client 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

d 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 given to clients 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 newly admitted client with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the client 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."

d 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 client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan? a. Maintenance of blood glucose levels between 180 and 200 mg/dl b. Smoking reduction but not complete cessation c. An eye examination every 2 years until age 50 d. Weight reduction through diet and exercise

d Type 2 diabetes is commonly obesity-related; therefore, weight reduction may enhance the normalization of the blood glucose level. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained within normal limits to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes shouldn't smoke at all because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy.