Chapter 51: Assessment and Management of Patients With Diabetes

A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of: 90 mg/dL before meals. 120 mg/dL, 1 hour postprandial. 80 mg/dL, 1 hour postprandial. 138 mg/dL, 2 hours postprandial.

138 mg/dL, 2 hours postprandial. Explanation: The goals for a 2-hour, postprandial blood glucose level are less than 120 mg/dL in a patient who might develop gestational diabetes.

NPH is an example of which type of insulin? Rapid-acting Short-acting Intermediate-acting Long-acting

Intermediate-acting Explanation: NPH is an intermediate-acting insulin.

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." "Shake the vials before withdrawing the insulin." "Store unopened vials of insulin in the freezer at temperatures well below freezing." "Discard the intermediate-acting insulin if it appears cloudy."

"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.

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating: "The test must be repeated following a 12-hour fast." "It looks like you aren't following the ordered diabetic diet." "It tells us about your sugar control for the last 3 months." "Your insulin regimen must be altered significantly."

"It tells us about your sugar control for the last 3 months." Explanation: The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

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? 6.5% 7.5 % 8.0% 8.5%

6.5% Explanation: 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.

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? Duration of the insulin Accuracy of the dosage Area for insulin injection Technique for injecting

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.

The nurse practitioner worked with a registered dietitian to customize a 1,800-calorie diabetic diet for a 53-year-old man with special dietary needs. Which of the following percent distribution of calories should be provided? Carbohydrates 35%, fat 10%, and protein 5% Carbohydrates 40%, fat 15%, and protein 10% Carbohydrates 45%, fat 20%, and protein 15% Carbohydrates 50%, fat 25%, and protein 20%

Carbohydrates 50%, fat 25%, and protein 20% Explanation: The American Dietetic Association currently recommends the following distribution of caloric intake: 50% to 60% carbohydrates, 20% to 30% fat, and 10% to 20% protein.

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

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 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 Obesity Rare ketosis Altered glucose metabolism

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 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 History of radiographic contrast studies that used iodine The client's mental and emotional status The client's exercise routine

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.

Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice? "Your insulin will begin to act in 15 minutes." "You should expect your insulin to reach its peak effectiveness by 12 noon if you take it at 8:00 AM." "You should take your insulin after you eat breakfast and dinner." "Your insulin will last 8 hours, and you will need to take it three times a day."

"You should take your insulin after you eat breakfast and dinner." Explanation: NPH (Humulin N) insulin is an intermediate-acting insulin that has an onset of 2 to 4 hours, a peak effectiveness of 6 to 8 hours, and a duration of 12 to 16 hours. See Table 30-3 in the text.

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer: I.M. or subcutaneous glucagon. I.V. bolus of dextrose 50%. 15 to 20 g of a fast-acting carbohydrate such as orange juice. 10 units of fast-acting insulin.

15 to 20 g of a fast-acting carbohydrate such as orange juice. Explanation: This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

Which statement is true regarding gestational diabetes? It occurs in most pregnancies. Onset usually occurs in the first trimester. A glucose challenge test should be performed between 24 and 28 weeks. There is a low risk for perinatal complications.

A glucose challenge test should be performed between 24 and 28 weeks. Explanation: A glucose challenge test should be performed between 24 and 48 weeks in women at average risk. It occurs in 2% to 5% of all pregnancies. Onset usually occurs in the second or third trimester. There is an above-normal risk for perinatal complications.

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first? Infuse 1000 mL D5W over a 12-hour period. Administer 50% glucose intravenously. Check the client's urine for the presence of sugar and acetone. Encourage the client to drink orange juice with added sugar.

Administer 50% glucose intravenously. Explanation: The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client's urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth.

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

Albumin Explanation: Albumin is one of the most important blood proteins that leak into the urine. Although small amounts may leak undetected for years, its leakage into the urine 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 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? Elevated serum acetone level Serum ketone bodies Serum alkalosis Below-normal serum potassium level

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.

Insulin is secreted by which of the following types of cells? Beta cells Melanocytes Neural cells Basal 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.

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. Decrease food intake until nausea passes. Do not take insulin if not eating. Take half the usual dose of insulin until symptoms resolve.

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

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

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? If two different types of insulin are ordered, they need to be given in separate injections. When mixing insulin, the NPH insulin is drawn up into the syringe first. When mixing insulin, the regular insulin is drawn up into the syringe first. There is no need to inject air into the bottle of insulin before withdrawing the insulin.

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.