Chapter 51 Caring for Clients with Diabetes Mellitus

12. A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response by the nurse is most appropriate? A) "Diet, exercise, and weight loss can eliminate the need for medication." B) "You will be placed on a strict low-sugar diet for better control." C) "Some doctors do not treat blood sugar elevation until symptoms appear." D) "You misunderstood the doctor. Let's ask for clarification."

Ans: A Feedback: Dieting, exercise, and weight loss can control and/or delay the need for medication to treat type 2 diabetes mellitus in some clients. Because the client is controlling blood sugars, changing the diet is not indicated. Controlling blood glucose levels will prevent multisystem complications and should be the mainstay of treatment for diabetes mellitus. Although clarification is appropriate, stating the client misunderstood can close the line of communication between client and nurse.

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action? A) It carries glucose into body cells. B) It aids in the process of gluconeogenesis. C) It stimulates the pancreatic beta cells. D) It decreases the intestinal absorption of glucose.

Ans: A Feedback: Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose. Insulin does not have an effect on the intestinal absorption of glucose.

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled? A) 6.5% B) 7.5% C) 8.0% D) 8.5%

Ans: A Feedback: Normally, the level of glycosylated hemoglobin is less than 7%. Thus, a level of 6.5% would indicate that the client's blood glucose level is well controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dL. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.

A diabetic client maintains glucose control with the use of long-acting and short-acting insulin. Which nursing instruction would be considered a priority teaching issue for this client? A) Mix short-acting and long-acting insulin. B) Monitor blood glucose levels immediately following injection. C) Use stomach for nighttime injections. D) If using Lantus or Levemir, give in separate syringe.

Ans: D Feedback: Long-acting insulin (Lantus and Levemir) cannot be mixed with other insulin in the same syringe. Blood glucose levels should be monitored prior to giving insulin and any time symptoms present. The thighs are the preferred site for slower absorption of nighttime insulin dose.

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? A) Respirations of 12 breaths/minute B) Cloudy urine C) Blood sugar 170 mg/dL D) Fruity breath

Ans: D Feedback: The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul's respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.

An active type 2 diabetic reports recurrent symptoms of weakness and nervousness. Which is the best response from the nurse? A) "These symptoms are related to added stress." B) "Maybe you should eat simple carbohydrates." C) "Sounds like high blood sugar symptoms." D) "Exercise and activity can lower glucose levels."

Ans: D Feedback: Weakness and nervousness are typical symptoms of hypoglycemia. Exercise and increased activity can lower available blood glucose. Eating more complex carbohydrates will sustain and prolong adequate blood levels of glucose.

The nurse is teaching an older client how to self-administer insulin. Which of the following would be most helpful to the client who is having difficulty drawing up the correct dosage of insulin in the syringe? A) Syringe magnifier B) Insulin pen C) Jet injector D) Insulin pump

Ans: A Feedback: A magnifier that fits over the syringe may be used for clients who experience difficulty in preparing insulin for injection, especially older clients. The device is easy to use and relatively inexpensive. An insulin pen, although preloaded, requires the client to select the number of units for injection by dialing in the dose, which may be difficult for the older client to manipulate or see. A jet injector may be helpful, but this device is often expensive; the older client may not be able to afford it. An insulin pump, although advantageous, requires frequent monitoring of blood glucose levels, which may or may be appropriate for the older client.

A client asks why pancreas transplantation is not an option offered to all insulin-dependent diabetics. Which is the best response by the nurse? A) Type 1 diabetes can be managed in most clients with insulin. B) Pancreas transplant is becoming more common. C) There is a long waiting list to receive a new pancreas. D) For every transplant, two deceased donors are needed.

Ans: A Feedback: As with any transplant, lifelong immunosuppressive drug therapy is required. Because type 1 diabetes can be managed with insulin, many experts believe that the risks involved with the transplant outweigh the benefit. Pancreas transplant is more commonly done when the client also needs a kidney transplant. Living donors can be used when islet cell transplantation is done. The list and time restraints for transplantation are not appropriate.

A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings? A) Finger B) Upper arm C) Thigh D) Forearm

Ans: A Feedback: Even though the fingertips have a higher number of nerve endings, this site provides the most accurate blood sugar reading. Alternate sites, such as upper arm, forearm, and thighs are regarded as lagging test sites and are not an option for people who require tight glucose control.

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine? A) Increases ability for glucose to get into the cell and lowers blood sugar B) Creates an overall feeling of well-being and lowers risk of depression C) Decreases need for pancreas to produce more cells D) Decreases risk of developing insulin resistance and hyperglycemia

Ans: A Feedback: Exercise increases transmembrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fuel. Exercise can provide an overall feeling of well-being but is not the primary purpose of including in the daily routine of diabetic clients. Exercise does not stimulate the pancreas to produce more cells. Exercise can promote weight loss and decrease risk of insulin resistance but not the primary reason for adding to daily routine.

Which of the following assessment findings is most important in determining nursing care for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)? A) Hypotension B) Blood pH 7.38 C) Mental changes D) Fever

Ans: A Feedback: Hypotension signifies a loss of fluids from the extracellular compartment. In HHNKS, fluid movement from intracellular to extracellular compartments can be significant and must be corrected to decrease incidence of coma and/or death. The blood pH of 7.38 is within normal range and is not significant with HHNKS. Mental changes and fever are symptoms associated with NNHKS but are not as primary concern as fluid electrolyte imbalances.

Which factor presents the most likely cause for weight gain in a diabetic client who is controlled with insulin? A) Insulin is an anabolic hormone. B) Insulin provides more efficient use of glucose. C) Faulty fat metabolism is shut off. D) Weight gain is attributed to fluid retention.

Ans: A Feedback: Insulin is an anabolic hormone that is known to cause weight gain. Insulin does lower blood glucose levels by allowing for active transport of glucose into the cells. Faulty fat and protein metabolism will cease once glucose provides the needed the fuel for energy. The restoration of normal metabolism is not the primary cause for weight gain in a client prescribed insulin. Fluid retention is not indicated in this client.

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer? A) Metformin B) Glyburide C) Repaglinide D) Glipizide

Ans: A Feedback: Metformin is a biguanide and, along with the thiazolidinediones (rosiglitazone and pioglitazone), are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide, which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

The nurse is educating the diabetic client on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include? A) Increase frequency of glucose self-monitoring. B) Decrease food intake until nausea passes. C) Do not take insulin if not eating. D) Take half the usual dose of insulin until symptoms resolve.

Ans: A Feedback: Minor illnesses such as influenza can present a special challenge to a diabetic client. The body's need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis.

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client? A) The client's consumption of carbohydrates B) History of radiographic contrast studies that used iodine C) The client's mental and emotional status D) The client's exercise routine

Ans: A Feedback: While assessing a client, it is important to note the client's consumption of carbohydrates because he has high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client's to be noted in a client with high blood sugar.

The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications? A) High blood pressure B) Urinary tract infections C) Lifelong obesity D) Elevated triglycerides

Ans: B Feedback: Elevated levels of blood glucose and glycosuria supports bacterial growth and places the diabetic at greater risk for urinary tract, skin, and vaginal infections. Obesity, elevated triglycerides, and high blood pressure are considered symptoms of metabolic syndrome, which can result in type 2 diabetes mellitus.

A type 2 diabetic is ordered metformin (Glucophage) as part of the management regime. Which is the best nursing explanation for the action of this drug in controlling glucose levels? A) Delays digestion of carbohydrates B) Helps tissues use insulin more efficiently C) Stimulates insulin release D) Reduces the production of glucose by the liver

Ans: B Feedback: Glucophage improves the use of insulin in type 2 diabetes. Alpha-glucosidase inhibitors work by delaying digestion of carbohydrates. Meglitinides stimulates insulin release and/or reduce the production of glucose by the liver.

A client reports taking oral medication for control of sugar problems. Which is the best nursing interpretation of this verbal accounting? A) Lack of knowledge of disease process B) Client has type 2 diabetes mellitus. C) Client has prediabetes mellitus. D) Lack of knowledge on medication regime

Ans: B Feedback: Oral antidiabetic drugs are prescribed for the treatment of diabetes type 2. Not enough information in the report to determine if the client has a lack of knowledge of disease process and/or medication regime. Prediabetes is not treated with medication.

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? A) Glargine B) Regular C) NPH D) Lente

Ans: B Feedback: Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

Which is the primary reason for encouraging injection site rotation in an insulin dependent diabetic? A) Avoid infection. B) Promote absorption. C) Minimize discomfort. D) Prevent muscle destruction.

Ans: B Feedback: Subcutaneous injection sites require rotation to avoid breakdown and/or buildup of subcutaneous fat, either of which can interfere with insulin absorption in the tissue. Infection and discomfort are risks involved with injection site but not the primary reason for rotation of sites. Insulin is not injected into the muscle.

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes? A) Onset most common during adolescence B) Insufficient insulin production C) Less common than type 1 diabetes D) Little relation to prediabetes

Ans: B Feedback: Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence; although, it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Prediabetes can lead to type 2 diabetes.

On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. Which is the immediate action taken by the nurse? A) Call the physician. B) Obtain a glucometer reading. C) Administer fruit juice. D) Start an IV of dextrose.

Ans: B Feedback: When a client with diabetes is found unconscious, DKA and hypoglycemia need to be ruled out. Completing a glucometer reading will provide the necessary information for treating the client. A client in a stuporous state would be at risk for aspiration on juice. IV dextrose would require an order from a physician. Calling the physician prior to obtaining blood sugar would not be the first action taken.

A client is admitted with the diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) following steroids therapy. Which of the following symptoms are associated with HHNKS? Select all that apply. A) High blood pressure B) Extreme thirst28. Which of the following assessment findings is most important in determining nursing care for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)? A) Hypotension B) Blood pH 7.38 C) Mental changes D) Fever E) Acidosis F) Hypoglycemia

Ans: B, D Feedback: Assessment findings for HHNKS include mental changes, low blood pressure, extreme thirst, dehydration with poor skin turgor, tachycardia, fever, hypokalemia, and hyponatremia.

Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy? A) Skeletal deformities B) Paresthesias C) Erectile dysfunction D) Soft tissue ulceration

Ans: C Feedback: Autonomic neuropathy affects organ functioning. According the American Diabetes Association, up to 50% of men with diabetes develop erectile dysfunction when nerves that promote erection become impaired. Skeletal deformities and soft tissue ulcers may occur with motor neuropathy. Paresthesias are associated with sensory neuropathy.

Which is the primary dietary consideration for a client receiving insulin isophane suspension (NPH) at breakfast? A) Make sure breakfast is not delayed. B) Provide fewest amount of carbohydrates at lunch meal. C) Encourage midday snack. D) Delay dinner meal.

Ans: C Feedback: Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 12 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia. NPH insulin has no immediate effects. Carbohydrates are distributed throughout the meal plan of diabetics to avoid highs and lows. Delaying dinner meal is not indicated with NPH insulin use.

The client asks the nurse if dipstick of urine can be used for monitoring glucose levels. Which is the best response by the nurse? A) "Yes, it is a cheaper method of monitoring glucose and ketones in the urine." B) "This test can detect ketones but not glucose levels." C) "The most accurate way to monitor glucose levels is by blood testing." D) "Dipstick of urine will only indicate lower levels of glucose and ketones."

Ans: C Feedback: Because glycosuria and ketonuria may not become evident until glucose levels exceed the renal threshold, blood testing is the most helpful way to determine the effects of treatment and management of the diabetes mellitus. Dipstick of urine is a cheaper diagnostic test and can be useful in screening clients for diabetes.

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason? A) Increased risk for urologic complications B) Need for exocrine enzymatic drainage C) Underlying problem of insulin resistance D) Need for lifelong immunosuppressive therapy

Ans: C Feedback: Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.

When the nurse inspects the feet of a diabetic, a tack is found sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding? A) In diabetes, the autonomic nerves are affected. B) Motor neuropathy causes muscles to weaken and atrophy. C) High blood sugar decreases blood circulation to nerves. D) Nephropathy is a common complication of diabetes mellitus.

Ans: C Feedback: Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness. Autonomic neuropathy is a complication of diabetes mellitus but not significant with peripheral injuries. Motor neuropathy does occur with poor glucose control but not specific to this injury. Nephropathy is a common complication that directly affects the kidneys.

A recently widowed diabetic comments that blood sugar levels are running higher than usual. Which is the best response from the nurse? A) "People who eat alone tend to eat more." B) "Cooking lower carbohydrate meals for one person is a challenge." C) "This must be a stressful time for you." D) "Quit checking your blood sugars for now."

Ans: C Feedback: High stress levels can result in fluctuating blood sugar levels and may require treatment modifications. Cooking meals for one person can be challenging but not as significant as the added stress associated with grieving. People who are distracted while eating do tend to eat more but not as significant for this client. Blood sugars should be monitored to determine if modifications in treatment are needed.

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet? A) Autonomic neuropathy B) Retinopathy C) Sensory neuropathy D) Nephropathy

Ans: C Feedback: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus? A) With diabetes, drinking more results in more urine production. B) Increased ketones in the urine promote the manufacturing of more urine. C) High sugar pulls fluid into the bloodstream, which results in more urine production. D) The body's requirement for fuel drives the production of urine.

Ans: C Feedback: The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which nursing action is most important in the management of DKA? A) Give prescribed antiemetics. B) Begin fluid replacements. C) Administer prescribed dose of insulin. D) Administer bicarbonate to correct acidosis.

Ans: C Feedback: The main goals of treatment for DKA are to reduce the blood glucose level and then to correct the fluid electrolyte imbalance and to clear the urine and blood of ketones. Insulin is given immediately to lower the blood glucose levels and reduce the production of ketones in an effort to improve blood pH. Antiemetics are not required if the blood sugar level is corrected and is not the most important action. Fluid replacement is part of the treatment but is not the first priority. Bicarbonate is usually not required.

The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include? A) "Wash your feet in hot water every day." B) "Use a razor to remove corns or calluses." C) "Be sure to apply a moisturizer to feet daily." D) "Wear well-fitting comfortable rubber shoes."

Ans: C Feedback: The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water, not hot water, to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic, or vinyl, which would cause the feet to perspire.

A diabetic client is having difficulty with blood glucose control even though the client claims to be following a strict diet, exercise, and medication regime. Which of the following conditions would the nurse suspect to be the most likely cause of poor control? A) Hypertension B) Retinopathy C) Peripheral vascular disease D) Emphysema

Ans: D Feedback: Emphysema and COPD may be treated with the use of theophylline or corticosteroids both of which interfere with carbohydrate metabolism and can result in hyperglycemia. Hypertension, retinopathy, and peripheral vascular disease are complications often associated with diabetes and poor glucose control.

The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order? A) Provides best information on the body's ability to maintain normal blood functioning B) Best indicator for the nutritional state of the client C) Is less costly than performing daily blood sugar test D) Reflects the amount of glucose stored in hemoglobin over past several months

Ans: D Feedback: Hemoglobin A1c tests reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. This test provides a more accurate picture of overall glucose control in a client. Glycosylated hemoglobin test does not indicate normal blood functioning or nutritional state of the client. Self-monitoring with a glucometer is still encouraged in clients who are taking insulin or have unstable blood glucose levels.