Chapter 50: Diabetes Mellitus and the Metabolic Syndrome

A young child develops type 1A diabetes. The parents ask, "They tell us this is genetic. Does that mean our other children will get diabetes?" The best response by the health care provider would be:

"This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes." -Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes.

A client's primary care provider has ordered an oral glucose tolerance test (OGTT) as a screening measure for diabetes. Which of the following instructions should the client be given?

-"The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals." -The OGTT measures the plasma glucose response to 75 g of concentrated glucose solution at selected intervals, usually 1 and 2 hours. A fasting blood glucose test requires 8 hours without food, and A1C measures glucose binding to hemoglobin. A casual blood glucose test is administered without regard for time or last meal.

Diabetic ketoacidosis is a condition that mostly occurs in type 1 diabetics. What are the definitive diagnostic criteria for DKA?

-Blood glucose level greater than 250 mg/dL; bicarbonate less than 15 mEq/L and pH less than 7.3 -The definitive diagnosis of DKA consists of hyperglycemia (blood glucose levels >250 mg/dL), low bicarbonate (<15 mEq/L), and low pH (<7.3), with ketonemia (positive at 1:2 dilution) and moderate ketonuria.

When providing nutrition education to the client with diabetes, the nurse should include which of these statements regarding fat intake?

- "If you have diabetes, avoiding saturated fats is important." -Guidelines for caloric intake for those with diabetes may include 45% to 60% carbohydrate, 20% to 35% fat, and 10% to 20% protein. Because diabetes is a risk factor for cardiovascular disease, it is recommended that less than 7% of daily calories should be obtained from saturated fat and that dietary cholesterol be limited to 200 mg or less, and intake of trans fats minimized.

Which of the following findings in a patient would support a diagnosis of diabetic ketoacidosis (DKA)? Select all that apply

- Ketonuria Low-serum bicarbonate Blood glucose > 250 mg/dL -DKA is characterized by hyperglycemia, ketosis, osmotic diuresis, and metabolic acidosis. It is an acute, life-threatening complication of uncontrolled diabetes.

A client diagnosed with type 2 diabetes has been instructed about managing his condition with diet. The nurse determines further teaching is necessary when the client states:

-"I must avoid all candies and cookies, but can eat unlimited amounts of pasta and breads." -The client needs more education regarding carbohydrate sources. All the other statements are correctly stated and demonstrate good understanding of dietary needs for the type 2 diabetic.

The mother of a 2-year-old newly diagnosed with type 1 diabetes asks why insulin has to be given by injection. The best response by the nurse is:

-"Insulin is destroyed by the stomach contents and has to be administered by injection." -Insulin is destroyed by the gastrointestinal tract and needs to be administered via injection or inhalation. Type 1 diabetes is not treated with oral medications at this time. Insulin is administered subcutaneously rather than in the vein, and the final statement does not address the mother's concerns.

A diabetic client presents to a clinic for routine visit. Blood work reveals a HbA1C of 11.0% (high)? Which response by the patient may account for this abnormal lab result?

-"My meter broke so I have not been checking my blood glucose levels for a while." -Glycosylated hemoglobin is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cell is not insulin dependent, the rate at which glucose becomes attached to the hemoglobin molecule depends on blood glucose; the level is an index of blood glucose levels over the previous 6 to 12 weeks. If the diabetic client is not monitoring his or her blood glucose, he or she could be having more periods of hyperglycemia and just is not aware of the need for insulin coverage.

Which manifestation indicates a client is at risk for developing diabetes mellitus?

-2 hour oral GTT 175 mg/dl -Laboratory values that are considered normal are hemoglobin A1c less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dl or less than 140 mg/dl 2 hours after an oral glucose tolerance test (GTT). A hemoglobin A1c value that is greater than or equal to 6.5 percent, a fasting blood glucose greater than 126mg/dl, or a blood glucose level greater than 200 mg/dl 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus.

The nurse educates a patient newly diagnosed with diabetes regarding diet and energy requirements. The nurse knows that one gram of fat will provide _____ kcal of energy

-9 -Fat, with 9 kcal/g, has the greatest per gram amount of available energy. Carbohydrates and proteins provide 4 kcal/g.

The nurse is reviewing assessment data and determines which client is at highest risk for developing type 2 diabetes?

-A 45-year-old obese female with a sedentary lifestyle -The person most at risk for developing type 2 diabetes is the 45-year-old obese female with a sedentary lifestyle. Other risk factors include family history, over age 40, and history of gestational diabetes. The 60-year-old would have developed it before age 60, if there were additional risk factors. Diabestes and metabolic syndrome is due to pancreatic problems, not liver problems.

A nurse is evaluating patients for the risk of developing type 2 diabetes. Which of the following patients has the highest risk?

-A 45-year-old obese woman with a sedentary lifestyle -The person most at risk for developing type 2 diabetes is the 45-year-old obese woman with a sedentary lifestyle. Other risk factors include family history, age older than 40, and history of gestational diabetes. The 10-year-old boy, despite family history, would be at low risk as long as obesity and sedentary lifestyle are avoided. The 60-year-old woman most likely would have developed type 2 diabetes within 20 years after the pregnancy.

Which of the following clients would be considered to be exhibiting manifestations of "prediabetes"?

-A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. -Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.

The critical care nurse has just admitted a client with diabetic ketoacidosis (DKA) whose blood glucose level is 877 mg/dL. The client's breath has a fruity odor and the client is confused. Which of these does the nurse set as the priority at this time?

-Administration of intravenous fluids -Goals of care for clients with DKA include administration of insulin and intravenous fluid and electrolyte replacement solutions. A common reason for development of DKA is an infection; monitoring for a fever should not take priority over administration of insulin and fluid replacement.

Hypoglycemia has a sudden onset with a progression of symptoms. What are the signs and symptoms of hypoglycemia?

-Altered cerebral function and headache. -The signs and symptoms of hypoglycemia can be divided into two categories: (1) those caused by altered cerebral function and (2) those related to activation of the autonomic nervous system. Because the brain relies on blood glucose as its main energy source, hypoglycemia produces behaviors related to altered cerebral function. Headache, difficulty in problem solving, disturbed or altered behavior, coma, and seizures may occur. Muscle spasms are not one of the signs or symptoms of hypoglycemia.

The nurse knows that type 1 diabetes mellitus results from destruction of the pancreatic beta cells by two mechanisms. The mechanism for type 1A diabetes is _______ destruction.

-Autoimmune -Type 1 diabetes is subdivided type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes involves autoimmune destruction of beta cells. The pathophysiology of type 2 diabetes has both genetic and acquired factors.

A client with a history of diabetes presents to the emergency department following several days of polyuria and polydipsia with nausea/vomiting. On admission, the client labs show a blood glucose level of 480 mg/dL and bicarbonate level of 7.8 mEq/dL. The nurse suspects the client has diabetic ketoacidosis (DKA). The priority intervention should include

-Begin a loading dose of IV regular insulin followed by a continuous insulin infusion. -The goals in treating DKA are to improve circulatory volume and tissue perfusion, decrease blood glucose, and correct the acidosis and electrolyte imbalances. These objectives usually are accomplished through the administration of insulin and intravenous fluid and electrolyte replacement solutions. An initial loading dose of short-acting (i.e., regular) or rapid-acting insulin often is given intravenously, followed by continuous low-dose short-acting insulin infusion. Frequent laboratory tests are used to monitor blood glucose. The fluids need to be replaced, not withheld. Too rapid a drop in blood glucose may cause hypoglycemia that can occur with a large dose of regular insulin. The client may require bicarbonate, but glucose levels are lowered with insulin in this emergency situation, not by oral medication.

The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which of the following pathophysiologic processes underlies the client's new diagnosis?

-Beta cell exhaustion due to long-standing insulin resistance -Exhaustion of the beta cells arising from insulin resistance is characteristic of type 2 diabetes. Beta cell destruction in the absence of an autoimmune reaction is associated with type 1b diabetes, while autoimmune processes contribute to type 1a diabetes.

The pancreas is an endocrine organ that is composed of the acini and the islets of Langerhans. The islets of Langerhans have alpha, beta, and delta cells as well as the PP cell. Which cells secrete insulin?

-Beta cells -Each islet is composed of beta cells that secrete insulin and amylin, alpha cells that secrete glucagon, and delta cells that secrete somatostatin. In addition, at least one other type of cell, the PP cell, is present in small numbers in the islets and secrets a hormone of uncertain function called pancreatic polypeptide.

The nurse is caring for a client with diabetes who has developed gastroparesis. Which of these symptoms does the nurse expect the client to report?

-Vomiting after eating -Gastroparesis (delayed emptying of stomach) is characterized by complaints of epigastric discomfort, nausea, postprandial vomiting, bloating, and early satiety.

The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. Which of these effects on blood glucose levels does the nurse teach the student epinephrine will cause?

-Blood glucose will elevate. -Epinephrine, a catecholamine, helps to maintain blood glucose levels during periods of stress. Epinephrine causes glycogenolysis in the liver, thus causing large quantities of glucose to be released into the blood.

When caring for the client with diabetic ketoacidosis, the nurse recognizes that fatty acids and ketones may be used for energy by most organs. Which of these organs does the nurse recognize is reliant on glucose as the major energy source?

-Brain -Although many tissues and organ systems are able to use other forms of fuel, such as fatty acids and ketones, the brain and nervous system rely almost exclusively on glucose as a fuel source. Because the brain can neither synthesize nor store more than a few minutes' supply of glucose, normal cerebral function requires a continuous supply from the circulation.

A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increase risks associated with exercise, the health care provider should encourage the client to

-Carry a snack with carbs to prevent profound hypoglycemia -People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia

The nurse caring for a client with HHS (hyperosmolar hyperglycemic state) should perform which priority assessment on this client?

-Cerebral edema -The treatment of HHS requires judicious medical observation and care as water moves back into brain cells, posing a threat of cerebral edema. The other signs and symptoms are manifestations of HHS.

A client with diabetes mellitus has sudden onset of slurred speech, incoordination, and cool, clammy skin. What will the nurse do first?

-Check blood glucose -Hypoglycemia is a medical emergency. Because other conditions can also cause these symptoms, the blood glucose level should be checked first. Then glucose should be given. The client should follow this with a protein and complex carbohydrate to avoid a recurrence of hypoglycemia. Blood glucose should be tested about 15 minutes after the glucose is given to monitor progress.

A client with diabetes mellitus reports morning hyperglycemia for several days. What action may be taken to assist with diagnosis of the problem?

-Check blood glucose at 2 AM -The Somogyi effect is a rebound hyperglycemia that occurs after hypoglycemia. The client may experience hypoglycemia while sleeping. If nocturnal hypoglycemia is occurring, the balance of diet and insulin will be recalibrated to prevent it.

Which of the following criteria about insulin would prompt a diagnosis of type 1 diabetes?

-Complete failure of insulin secretion -In type 1 diabetes there is an absolute lack of insulin due to complete failure of the pancreas. In type 2 diabetes some insulin is produced but may not be properly used.

A client tells his health care provider that his body is changing. It used to be normal for his blood glucose to be higher during the latter part of the morning. However, now his fasting blood glucose level is elevated in the early AM (07:00). The health care provider recognizes the client may be experiencing:

-Dawn phenomenon -A change in the normal circadian rhythm for glucose tolerance, which usually is higher during the later part of the morning, is altered in people with diabetes, with abnormal nighttime growth hormone secretion as a possible factor. The dawn phenomenon is characterized by increased levels of fasting blood glucose or insulin requirements, or both, between 5 AM and 9 AM without preceding hypoglycemia. The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. The cycle begins when the increase in blood glucose and insulin resistance is treated with larger insulin doses. The insulin-induced hypoglycemia produces a compensatory increase in blood levels of catecholamines, glucagon, cortisol, and growth hormone, leading to increased blood glucose with some insulin resistance.

A patient with type 2 diabetes experiences unexplained elevations of fasting blood glucose in the early morning hours. Which of the following conditions can account for this effect?

-Dawn phenomenon -The dawn phenomenon involves increased levels of fasting blood glucose or insulin requirement between the hours of 5 and 9 in the morning. It is not preceded by hypoglycemia. Circadian release of growth hormone and cortisol may be contributing factors. The other answer selections are not characterized by increased early morning levels of blood glucose.

The nurse knows that patients with which of the following diabetic complications have the greatest risk for the development of foot ulcers?

-Distal symmetric neuropathy -Distal symmetric neuropathy is a major risk factor for foot ulcers due to the fact that people with sensory neuropathies have impaired pain sensation and can be unaware of foot injuries and infections. Autonomic neuropathy, microangiopahty, or diabetic ketoacidosis, while not affecting risk for foot injuries, suggest that the patient's diabetes is inadequately controlled.

A 23-year-old man is admitted to the hospital. He is experiencing polyphagia, polyuria, and polydipsia. He states that the condition has come on very suddenly. This client is likely to require what treatment?

-Exogenous insulin injections -Type 1 diabetes is the best diagnosis as the client has no other symptoms and the disease presented so rapidly. Insulin will likely be necessary and oral antihyperglycemics will not be sufficient.

A 15-year-old girl who has just been diagnosed with type 1 diabetes says she read on the Internet that diabetes is the leading cause of acquired blindness among Canadians. She asks nurse if she will lose her sight. In addition to explaining that new treatment technologies are being worked on every day, which response would be the most appropriate?

-Explain that most people with type 1 diabetes do experience some loss of sight by about 20 years from the onset of their disease. -Twenty years after the onset of diabetes, nearly all people with type 1 diabetes and more than 60% of people with type 2 diabetes have some degree of retinopathy. Pregnancy, puberty, and cataract surgery can accelerate these changes.

Type 1A diabetes is now considered an autoimmune disorder. What factors are considered necessary for type 1A diabetes to occur?

-Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen -Type 1A diabetes is thought to be an autoimmune disorder resulting from a genetic predisposition (i.e., diabetogenic genes); an environmental triggering event, such as an infection; and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen.

The nurse is caring for a client who received regular insulin at 7 am. Four hours later the nurse finds the client diaphoretic, cool, and clammy. Which of these interventions is the priority?

-Give the client a concentrated carbohydrate. -The client is displaying symptoms of hypoglycemia, which include headache, difficulty in problem solving, altered behavior, coma, and seizures. Hunger may occur. Activation of the sympathetic nervous system may cause anxiety, tachycardia, sweating, and cool and clammy skin

The family of a client in the hospital with diabetes mellitus out of control asks the nurse to explain the client's recent weight loss while eating more than usual. How will the nurse respond?

-Glucose is unused without insulin, so body fats are used for energy. -Most of these options are true statements, but they do not answer the question asked by the family. Normally, nutrients are metabolized in a number of ways. Glucose is transported into cells by insulin and then is broken down to carbon dioxide and water. When there is surplus glucose present, it is metabolized and stored as glycogen in the liver and skeletal muscles. Further surplus is converted by the liver to fatty acids and stored as triglycerides. When triglycerides are metabolized the glycerol molecule enters the glycolytic pathway to release energy. Excess proteins are also converted to fatty acids for storage. Insulin is needed to transport glucose into cells, prevent fat breakdown, and inhibit gluconeogenesis. When diabetes is out of control there is lack of insulin. Weight loss occurs as the cells break down fats to use fatty acids for energy.

A diabetic client's long-term control of blood glucose levels is to be evaluated by which test that measures of fluctuation of blood glucose over the previous 120-day span?

-Glycosylated hemoglobin -Glycosylated hemoglobin (A1C) is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cells is not insulin dependent, the rate of hemoglobin glycation depends on blood glucose levels. Red blood cells have a 120-day life span, and A1C estimates blood glucose levels over the previous 6 to 12 weeks. The oral glucose tolerance test measures the body's ability to remove glucose from the circulatory system. Capillary blood glucose measures the current level of circulating glucose. Fasting blood glucose levels, measured after food has been withheld for at least 8 hours, will determine whether glucose is being efficiently removed from the blood.-

A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes. The best diagnostic indicator that would support the client's response would be:

-Glycosylated hemoglobin, hemoglobin A1C (HbA1C) -Glycosylated hemoglobin, hemoglobin A1C (HbA1C), and A1C are terms used to describe hemoglobin into which glucose has been incorporated. Glycosylation is essentially irreversible, and the level of A1C present in the blood provides an index of blood glucose levels over the previous 6 to 12 weeks. In uncontrolled diabetes or diabetes with hyperglycemia, there is an increase in the level of A1C. The other options would not reflect the 2-month period.

During periods of fasting and starvation, the glucocorticoid and other corticosteroid hormones are critical for survival because of their stimulation of gluconeogenesis by the liver. When the glucocorticoid hormones remain elevated for extended periods of time, what can occur?

-Hyperglycemia -In predisposed persons, the prolonged elevation of glucocorticoid hormones can lead to hyperglycemia and the development of diabetes mellitus and starvation. They stimulate gluconeogenesis by the liver, sometimes producing a 6- to 10-fold increase in hepatic glucose production. A prolonged increase in glucocorticoid hormones does not cause hepatomegaly, portal hypertension, or adrenal hyperplasia.

A man is brought into the emergency department by paramedics who state that the client passed out on the street. The man smells of alcohol, and when roused says he has not eaten since yesterday. He is wearing a medic alert bracelet that says he is a diabetic. What would the nurse suspect as a diagnosis?

-Hypoglycemia -Alcohol decreases liver gluconeogenesis, and people with diabetes need to be cautioned about its potential for causing hypoglycemia, especially if alcohol is consumed in large amounts or on an empty stomach.

An extremely lethargic patient arrives by ambulance at the emergency department. His blood glucose level is 32 mg/dL. The nurse will anticipate that this patient will be diagnosed with which of the following?

-Hypoglycemia -Hypoglycemia is a blood glucose level of less than 60 mg/dL. Blood glucose levels would be elevated in diabetic ketoacidosis and in the dawn phenomenon. Autonomic neuropathy causes disorders of autonomic (for example, cardiovascular) function.

While working on the med-surg floor, the nurse has a client who is experiencing an insulin reaction. The client is conscious and can follow directions. The most appropriate intervention would be:

-Immediately administer 15 g of glucose (preferably via oral route if the client is alert enough to swallow) and wait for 15 minutes. Then repeat this if necessary. -The most effective treatment of an insulin reaction is the immediate administration of 15 g of glucose in a concentrated carbohydrate source. According to the so-called rule of 15, this 15 g of glucose can be repeated every 15 minutes for up to three doses. Alternative methods for increasing blood glucose may be required when the person having the reaction is unconscious or unable to swallow. Glucagon may be given intramuscularly or subcutaneously. Glucagon acts by hepatic glycogenolysis to raise blood glucose. In situations of severe or life-threatening hypoglycemia, administer glucose (20 to 50 mL of a 50% solution) intravenously.

While trying to explain the physiology behind type 2 diabetes to a group of nursing students, the instructor will mention which of the following accurate information?

-In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Following meals (postprandial), glucose levels are higher due to diminished efficiency of glucose clearance. -The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Although muscle glucose uptake is slightly increased after a meal, the efficiency with which it is taken up is decreased, resulting in an increase in blood glucose levels following a meal.

Which metabolic abnormality can lead to the development of type 2 diabetes?

-Insulin resistance -The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. Obese people have increased resistance to the action of insulin and impaired suppression of glucose production by the liver, resulting in both hyperglycemia and hyperinsulinemia. Lifestyle and overeating seem to be the triggering events (rather than metabolic abnormalities). Acute pancreatitis is a reversible impairment of alpha and beta cell function, with hypoinsulinemia as a complication.

Which of the following pregnant women likely faces the greatest risk of developing gestational diabetes? A client who:

-Is morbidly obese (defined as greater than 100 pounds over ideal weight) -Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.

A client with diabetic retinopathy develops a retinal bleed and asks the nurse, "How can I prevent this from happening again?" What response provides the most effective information?

-Maintain healthy blood pressure and blood sugar levels. -Diabetic retinopathy occurs when blood vessels have increased permeability, develop microaneurysms, vascular proliferation, scarring, and retinal detachment. These conditions are worsened when the client has poor glycemic control, poorly controlled hypertension, and hyperlipidemia. Laser photocoagulation can be used to stop vessel proliferation and bleeding. An annual examination will evaluate the disease, but does not prevent recurrence. Eye use patterns do not change retinopathy.

A client with severe hypoglycemia is unconscious. Which method of providing glucose should be avoided?

-Orange juice orally -When clients are unconscious it is not safe to attempt to have them swallow liquids. Alternate routes that reduce the risk of choking such as buccal absorption, intramuscular or intravenous injections are preferred.

A hospital client with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin?

-Promotion of glucose uptake by target cells -The actions of insulin are threefold: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

A woman in her 28th week of pregnancy tests positive for gestational diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome?

-Random blood glucose 85 mg/dl -The goals of the nutritional plan for gestational diabetes mellitus (GDM) include normal glucose levels, no ketosis, proper weight gain for the pregnancy, and adequate nutrition for fetal health

A client with diabetes carries insulin with him at all times. At 11:35, he obtains a blood glucose reading of 12.1 mmol/l and self-administers a dose of insulin in anticipation of eating lunch at noon. What type of insulin did he most likely inject?

-Short-acting -Short-acting (regular) insulin is used to facilitate the metabolism of the food that is being eaten. Premixed insulin is possible, but is not used as commonly. Intermediate- and long-acting insulin would have too distant an onset.

A client with diabetes mellitus is reporting burning pain of their feet and some numbness. These symptoms are likely due to which cause?

-Somatic neuropathy -Somatic neuropathy is usually bilateral and symmetric and associated with paresthesia, buring sensations, and numbness along with decreased senses of vibration, pain, temperature, and proprioception, particularly in the lower extremities. The autonomic neuropathies result in disorders of vasomotor function, decreased cardiac responses, inability to empty the bladder, gastrointestinal motility problems, and sexual dysfunction. Peripheral vascular disease is a general complication of diabetes, and intermittent claudication is pain associated with arterial insufficiency in the legs.

Research has identified a cycle of insulin-induced post-hypoglycemic episodes. What is this phenomenon called?

-Somogyi effect -The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. In 1924, Joslin and associates noticed that hypoglycemia was associated with alternate episodes of hyperglycemia

A client is managing their diabetes with exercise and diet. The health care provider reviews the client's most recent lab results: fasting blood sugar level at 80 mg/dL and a hemoglobin A1C of 5%. Select the response that best identifies the client.

-The client is achieving normal glycemic control. -The reading for the fasting blood sugar is appropriate, and the hemoglobin A1C level estimates good control of glucose levels over a 6- to 12-week period. This client should continue his exercise and diet routine as planned.

Select the most common symptoms of diabetes. Select all that apply.

-The most commonly identified signs and symptoms of diabetes are often referred to as the three polys: (1) polyuria (i.e., excessive urination), (2) polydipsia (i.e., excessive thirst), and (3) polyphagia (i.e., excessive hunger). Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. Polycythemia is a condition of increased red blood cells.

A client with long-standing type 2 diabetes is surprised at his high blood sugar readings while recovering from an emergency surgery. Which of the following factors may have contributed to the client's inordinately elevated blood glucose levels?

-The stress of the event caused the release of cortisol. -Elevation of glucocorticoid levels, such as during stressful events, can lead to hyperglycemia.

Which metabolic abnormalities can cause Type 2 diabetes? (Select all that apply.)

Deranged secretion of insulin Insulin resistance Increased glucose production by the liver -The metabolic abnormalities that lead to type 2 diabetes include (1) insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. The other answers are incorrect.

A client hospitalized with type 1 diabetes has been administered a scheduled dose of regular insulin. Which are the primary actions of insulin? Select all that apply.

Fat storage Glucose uptake by muscle and adipose tissue Protein synthesis -There are three actions of insulin: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

The nurse and nursing student are performing medication reconciliation. Which of these medications taken by the client with diabetes does the nurse teach the student are implicated in causing hyperglycemia? Select all that apply.

Loop diuretics Glucocorticoids Oral contraceptives -Diuretics, specifically thiazide and loop diuretics, can elevate blood glucose. These diuretics increase potassium loss, which is thought to impair beta cell release of insulin. Other drugs and therapies known to cause hyperglycemia include diazoxide, glucocorticoids, oral contraceptives, antipsychotic agents, and total parenteral nutrition.

A client with type 1 diabetes has been deemed to be a candidate for the use of a continuous subcutaneous infusion of insulin (insulin pump). Which educational points should the nurse address in anticipation of this treatment regimen? Select all that apply.

Teaching the client how to load and maintain the insulin pump. Educating the client about the necessity of frequent blood glucose checks. Educating the client about the potential complications of pump use. -Candidates for the use of an insulin pump must be motivated and informed of the need for frequent blood glucose monitoring, pump use, and potential complications. Pumps administer a form of short-acting insulin; separate injections are not administered because the pump can administer a bolus if needed. Oral antihyperglycemics are not normally used in the treatment of type 1 diabetes.