Ch 51 Brunner
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?
"You'll need less insulin when you exercise or reduce your food intake." Explanation: 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 nurse knows to assess a patient with type 1 diabetes for postprandial hyperglycemia. The nurse knows that glycosuria is present when the serum glucose level exceeds:
180 mg/dL Explanation: Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).
Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?
3 months Explanation: Glycosylated hemoglobin is a blood test that reflects average blood glucose concentrations over a period of 3 months.
A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?
Albumin Explanation: 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.
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Below-normal serum potassium level Explanation: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
During a follow-up visit 3 months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure?
Glycosylated hemoglobin level Explanation: Glycosylated hemoglobin is a blood test that reflects the average blood glucose concentration over a period of approximately 2 to 3 months. When blood glucose is elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycosylated hemoglobin level becomes.
The nurse is educating the client with diabetes 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?
Increase frequency of glucose self-monitoring. Explanation: 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 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?
Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
Increased urine output Explanation: Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.
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?
Increases ability for glucose to get into the cell and lowers blood sugar Explanation: Exercise increases trans membrane 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.
A patient with a diagnosis of type 2 diabetes has been vigilant about glycemic control since being diagnosed and has committed to increasing her knowledge about the disease. To reduce her risk of developing diabetic nephropathy in the future, this patient should combine glycemic control with what other preventative measure?
Maintenance of healthy blood pressure and prompt treatment of hypertension Explanation: Hypertension significantly increases a diabetic patient's risk of nephropathy. A low-sodium, low-protein diet does not appreciably reduce this risk. Exercise is of benefit, but hypertension is a greater risk than inactivity. Heparin is not a relevant intervention.
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?
Metformin Explanation: 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 preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer?
NPH Explanation: 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 patient who is diagnosed with type 1 diabetes would be expected to:
Need exogenous insulin. Explanation: Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.
Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?
Presence of islet cell antibodies Explanation: Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
Rapid, thready pulse Explanation: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.
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?
Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns Explanation: 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.
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?
Sensory neuropathy Explanation: 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.
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?
Sweating, tremors, and tachycardia Explanation: 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.
Which factor is the focus of nutrition intervention for clients with type 2 diabetes?
Weight loss Explanation: Weight loss is the focus of nutrition intervention for clients with type 2 diabetes. A low-calorie diet may improve clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action. Consistency in the total amount of carbohydrates consumed is considered an important factor that influences blood glucose level. Protein metabolism is not the focus of nutrition intervention for clients with type 2 diabetes.
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?
Weight reduction through diet and exercise Explanation: 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
A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
suggest referral to a sex counselor or other appropriate professional. Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.
Which instruction about insulin administration should a nurse give to a client?
"Always follow the same order when drawing the different insulins into the syringe." Explanation: The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?
"Test your blood glucose every 4 hours." Explanation: The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.
A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?
7:45 AM Explanation: Insulin lispro has an onset of 5 to 15 minutes. Therefore, the nurse would need to ensure that the client has his breakfast by 7:45 AM at the latest. Otherwise, the client may experience hypoglycemia.
A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
9 units regular insulin and 21 units neutral protamine Hagedorn (NPH). Explanation: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 units of NPH and 9 units of regular insulin. The other choices are incorrect dosages for the ordered insulin.
A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.
Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment Explanation: All the options are correct except for weight loss and anorexia. Obesity is almost always associated with type 2 diabetes.
Which factors will cause hypoglycemia in a client with diabetes? Select all that apply.
Client has not consumed food and continues to take insulin or oral antidiabetic medications. Client has not consumed sufficient calories. Client has been exercising more than usual. Explanation: Hypoglycemia can occur when a client with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications, is not eating sufficient calories to compensate for glucose-lowering medications, or is exercising more than usual. Excessive sleep and aging are not factors in the onset of hypoglycemia.
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:
Deficient knowledge (treatment regimen). Explanation: The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.
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?
Dietitian Explanation: 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.
Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.
Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes Explanation: DKA is characterized by an elevated BUN and creatinine, rapid onset, and it is more common in type 1 diabetes. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by the absence of urine and serum ketones and a normal arterial pH level.
NPH is an example of which type of insulin?
Intermediate-acting Explanation: NPH is an intermediate-acting insulin.
Lispro (Humalog) is an example of which type of insulin?
Rapid-acting Explanation: 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 client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?
This insulin has no peak action and does not cause a hypoglycemic reaction. Explanation: "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 client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?
They increase the need for insulin. Explanation: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.
A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:
polyphagia. Explanation: While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose
Which of the following insulins are used for basal dosage?
Glargine (Lantus) Explanation: Lantus is used for basal dosage. NPH is an intermediate acting insulin, usually taken after food. Humalog and Novolog are rapid-acting insulins.
The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?
10 to 15 minutes Explanation: 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 client with diabetes is receiving an oral anti diabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?
Metformin Explanation: 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.
A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?
Obtain a repeat fingerstick glucose level. Explanation: The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.
Which of the following would lead a nurse to suspect that a client is experiencing hypoglycemia?
Slow, bounding pulse Explanation: A client with hypoglycemia typically exhibits a normal or slow bounding pulse, pale moist skin, normal to rapid shallow respirations, and absent thirst.
Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?
High sugar pulls fluid into the bloodstream, which results in more urine production. Explanation: 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.
What is the duration of regular insulin?
4 to 6 hours Explanation: The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.
Insulin is secreted by which of the following types of cells?
Beta cells Explanation: Insulin is secreted by the beta cells, in the islets of Langerhans of the pancreas. In diabetes, cells may stop responding to insulin, or the pancreas may decrease insulin secretion or stop insulin production completely. Melanocytes are what give the skin its pigment. Neural cells transmit impulses in the brain and spinal cord. Basal cells are a type of skin cell.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
Fruity breath Explanation: 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 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.
When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?
Hypoglycemia Explanation: The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.
Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:
Synthesis of glucose from noncarbohydrate sources. Explanation: Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?
The client has eaten and has not taken or received insulin. Explanation: If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than usual.
A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?
Control blood glucose levels. Explanation: Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy. Drinking plenty of fluids does not prevent diabetic nephropathy. Taking antidiabetic drugs regularly may help to control blood glucose levels, but it is the control of these levels that is most important. A high-fiber diet is unrelated to the development of diabetic nephropathy.
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?
Hypokalemia and hypoglycemia Explanation: 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.
The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?
Reflects the amount of glucose stored in hemoglobin over past several months. Explanation: 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.
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?
Serum glucose level of 52 mg/dl Explanation: 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.
When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:
"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." Explanation: The nurse should make the client aware that diabetes affects sensation in the feet and that he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information.
A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:
"I'm going to give your son some insulin. Then I'll be happy to talk with you." Explanation: Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs. By informing the mother that she's going to administer the insulin and will then make time to talk with her, the nurse recognizes the mother's needs as legitimate. She provides a reasonable response while attending to the priority of administering insulin as soon as possible. Telling the mother that she can't talk with her or telling her to wait for the physician could increase the mother's fear and anxiety. The nurse shouldn't tell the mother that everything will be fine; the nurse doesn't know that everything will be fine.
A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?
"I'm thirsty all the time. I just can't get enough to drink." Explanation: Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite). Decreased appetite, lingering cough and cold, and pain on urination aren't related to diabetes. Decreased appetite reflects a GI disorder; cough and cold indicate an upper respiratory problem; and pain on urination suggests a urinary tract infection.
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?
"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Explanation: Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.
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?
"Ketones will tell us if your body is using other tissues for energy." Explanation: 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?
"Your body is using protein and fat for energy instead of glucose." Explanation: 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 physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?
"Your child will need less blood work as his glucose levels stabilize." Explanation: Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician if he can reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.
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:
10 to 15 g of a simple carbohydrate. Explanation: 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 nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
100 units of regular insulin in normal saline solution Explanation: Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:
15 g of carbohydrates. Explanation: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates
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:
8:30 AM. Explanation: Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.
When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?
Accuracy of the dosage Explanation: The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.
A client with diabetic ketoacidosis has been brought into the ED. Which intervention is not a goal in the initial medical treatment of diabetic ketoacidosis?
Administer glucose. Explanation: Insulin is given intravenously. Insulin reduces the production of ketones by making glucose available for oxidation by the tissues and by restoring the liver's supply of glycogen. As insulin begins to lower the blood glucose level, the IV solution is changed to include one with glucose. Periodic monitoring of serum electrolytes and blood glucose levels is necessary. Isotonic fluid is instilled at a high volume, for example, 250 to 500 mL/hour for several hours. The rate is adjusted once the client becomes rehydrated and diuresis is less acute. Potassium replacements are given despite elevated serum levels to raise intracellular stores.
Which information should be included in the teaching plan for a client receiving glargine, a "peakless" basal insulin?
Do not mix with other insulins. Explanation: 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 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 action should the nurse take first in the management of DKA?
Begin fluid replacements. Explanation: Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?
Blood glucose level 1,100 mg/dl Explanation: 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.
Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?
Blurred vision Explanation: Blurred vision occurs when blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?
Coma, anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mf/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.
Which of the following is an age-related change that may affect diabetes? Select all that apply.
Decreased renal function Taste changes Decreased vision Explanation: Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.
An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?
Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Explanation: 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.
Which of the following would be considered a "free" item from the exchange list?
Diet soda Explanation: Free items include unsweetened iced tea, diet soda, and ice water with lemon. A green salad is exchanged for 1 vegetable. A medium apple is 1 fruit; 1 tsp of olive oil is 1 fat.
A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
Glucagon Explanation: During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn't effective in reversing hypoglycemia.
A nurse is preparing to discharge a client with coronary artery disease and hypertension who is at risk for type 2 diabetes. Which information is important to include in the discharge teaching?
How to control blood glucose through lifestyle modification with diet and exercise Explanation: Persons at high risk for type 2 diabetes receive standard lifestyle recommendations plus metformin, standard lifestyle recommendations plus placebo, or an intensive program of lifestyle modifications. The 16-lesson curriculum of the intensive program of lifestyle modifications focuses on reducing weight by more than 7% of initial body weight and moderate-intensity physical activity. It also includes behavior modification strategies designed to help clients achieve the goals of weight reduction and participation in exercise. These findings demonstrate that type 2 diabetes can be prevented or delayed in persons at high risk for the disease.
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?
Hyperglycemic hyperosmolar syndrome Explanation: 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).
A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which condition when caring for this client?
Hypoglycemia Explanation: The nurse should observe the client receiving an oral antidiabetic agent for 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. Polyuria, polydipsia, and blurred vision are symptoms of diabetes mellitus.
For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Increased urine osmolarity Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.
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?
It enhances the transport of glucose across the cell membrane. Explanation: 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.
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.
Ketosis-prone Little or no endogenous insulin Younger than 30 years of age Explanation: 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.
Which type of insulin acts most quickly?
Lispro Explanation: 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 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?
Presence of autoantibodies against islet cells Explanation: 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 client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?
Regular Explanation: 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.
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?
Serum osmolarity Explanation: 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.
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias?
Serum potassium level Explanation: The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.
Which category of oral antidiabetic agents exerts the primary action by directly stimulating the pancreas to secrete insulin?
Sulfonylureas Explanation: A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate the action of insulin on peripheral receptor sites. Alpha-glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.
After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. What should the nurse expect the physician to do?
Switch the client to a different oral antidiabetic agent. Explanation: The nurse should anticipate that the physician will order a different oral antidiabetic agent. Many clients (25% to 60%) who take glipizide respond to a different oral antidiabetic agent. Therefore, it wouldn't be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin may be used in addition to the antidiabetic agent. Restricting carbohydrate intake isn't necessary.
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?
The client's consumption of carbohydrates Explanation: 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 pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar:
The pancreatic hormone glucagon will stimulate the liver to release stored glucose. Explanation: When sugar levels are low, glucagon promotes hyperglycemia by stimulating the release of stored glucose. Glycogenolysis and gluconeogenesis will both be increased. Insulin secretion would promote hypoglycemia.
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?
The participants are unlikely to develop a new onset of type 1 diabetes. Explanation: 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?
The short-acting insulin is withdrawn before the intermediate-acting insulin. Explanation: 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."
The greatest percentage of people have which type of diabetes?
Type 2 Explanation: Type 2 diabetes accounts for 90% to 95% of all diabetes. Type 1 accounts for 5% to 10% of all diabetes. Gestational diabetes has an onset during pregnancy. Impaired glucose tolerance is defined as an oral glucose tolerance test value between 140 mg/dL and 200 mg/dL.
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?
Underlying problem of insulin resistance Explanation: 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.
The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan?
When mixing insulin, the regular insulin is drawn up into the syringe first. Explanation: When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before being drawn into the syringe. The American Diabetic Association recommends that the regular insulin be drawn up first. The most important issues are that patients (1) are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) do not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:
at least three times per week. Explanation: Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.
A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of:
hypoglycemia Explanation: 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 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?
ketoacidosis Explanation: 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 nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:
providing client education at every opportunity. Explanation: 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.
