Chapter 51: Assessment and Management of Patients With Diabetes NCLEX

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patient's fluid balance C) Assessing the patient's level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

B (In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.)

The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue? A) The need for frequent eye examinations for patients with diabetes B) The fact that patients with diabetes have an elevated risk of myocardial infarction C) The relationship between kidney function and blood glucose levels D) The need to monitor urine for the presence of albumin

B (Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and renal function are considered to be microvascular.)

The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse's most appropriate action? A) Teach the patient about actions to slow the progression of nephropathy. B) Ensure that the patient receives a comprehensive assessment of liver function. C) Determine whether the patient has been using expired insulin. D) Administer a fluid challenge and have the test repeated.

A (Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the patient's liver function is not likely affected. There is no indication for the use of a fluid challenge.)

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A) Fasting plasma glucose greater than or equal to 126 mg/dL B) Random plasma glucose greater than 150 mg/dL C) Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions D) Random plasma glucose greater than 126 mg/dL

A (Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.)

A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A) Infection B) Acute pain C) Acute confusion D) Impaired urinary elimination

A (Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function.)

A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer? A) "If you are going to use up the vial within 1 month it can be kept at room temperature." B) "If a vial of insulin will be used up within 21 days, it may be kept at room temperature." C) "If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature." D) "If a vial of insulin will be used up within 1 week, it may be kept at room temperature."

A (If a vial of insulin will be used up within 1 month, it may be kept at room temperature.)

A patient has been brought to the emergency department by paramedics after being found unconscious. The patient's Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaCl

A (In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patient's condition.)

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time? a) 7:45 AM b) 8:30 AM c) 8:00 AM d) 8:15 AM

A (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 diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer? a) Metformin b) Glyburide c) Glipizide d) Repaglinide

A (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 patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following? A) Participation in a support group for persons with diabetes B) Regular consultation of websites that address diabetes management C) Weekly telephone "check-ins" with an endocrinologist D) Participation in clinical trials relating to antihyperglycemics

A (Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on patients' circumstances.)

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

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

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A) Always carry a form of fast-acting sugar. B) Perform exercise prior to eating whenever possible. C) Eat a meal or snack every 8 hours. D) Check blood sugar at least every 24 hours.

A (The following teaching points should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.)

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

A (The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.)

A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patient's ability to prepare and self-administer insulin? A) Ask the patient to describe the process in detail. B) Observe the patient drawing up and administering the insulin. C) Provide a health education session reviewing the main points of insulin delivery. D) Review the patient's first hemoglobin A1C result after discharge.

B (Nurses should assess the patient's ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the patient performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the patient about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.)

The nurse expects that a type 1 diabetic patient may receive what percentage of his or her usual morning dose of insulin preoperatively? a) 10% to 20% b) 50% to 60% c) 25% to 40% d) 85% to 90%

B (One half to two thirds of the patient's usual morning dose of insulin (either intermediate-acting insulin alone or both short- and intermediate-acting insulins) is administered subcutaneously in the morning before surgery. The remainder is then administered after surgery.)

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

B (Regular insulin is usually administered 20-30 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.)

A diabetes nurse is assessing a patient's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient's knowledge of nutritional therapy in diabetes? A) Ask the patient to describe an optimally healthy meal. B) Ask the patient to keep a food diary and review it with the nurse. C) Ask the patient's family what he typically eats. D) Ask the patient to describe a typical day's food intake.

B (Reviewing the patient's actual food intake is the most accurate method of gauging the patient's diet.)

A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient? A) A sulfonylurea B) A biguanide C) A thiazolidinedione D) An alpha glucosidase inhibitor

B (Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.)

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? a) "Your child is young and will soon forget this experience." b) "Your child will need less blood work as his glucose levels stabilize." c) "I'll see if the physician can reduce the number of blood draws." d) "Our laboratory technicians use tiny needles and they're really good with children."

B (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.)

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what? A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." B) "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." C) "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea." D) "I will call the doctor if my blood sugar is over 300 mg/dL or if I have ketones in my urine."

A (The nurse must explanation the "sick day rules" again to the patient who plans to stop taking insulin when sick. The nurse should emphasize that the patient should take insulin agents as usual and test one's blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the patient should have an intake of liquids every 30 to 60 minutes to prevent dehydration.)

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question? a) Change the second I.V. solution to dextrose 5% in water. b) Infuse 500 ml of normal saline solution over 1 hour. c) Add 40 mEq potassium chloride to an infusion of half normal saline solution and infuse at a rate of 10 mEq/hour. d) Hold insulin infusion for 30 minutes.

A (The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.)

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? a) Rapid, thready pulse b) Cool, moist skin c) Arm and leg trembling d) Slow, shallow respirations

A (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 nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following? A) Avoid using the same injection site more than once in 2 to 3 weeks. B) Avoid mixing more than one type of insulin in a syringe. C) Cleanse the injection site thoroughly with alcohol prior to injecting. D) Inject at a 45º angle.

A (To prevent lipodystrophy, the patient should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable, within specific guidelines, and the needle is usually inserted at a 90º angle. Cleansing the injection site with alcohol is optional.)

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find? a) Blood pH of 6.9 b) Blood glucose level of 250 mg/dL c) Serum bicarbonate of 19 mEq/L d) PaCO2 of 40 mm Hg

A (With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.)

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: a) at least three times per week. b) at least once per week. c) at least five times per week. d) every day.

A (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 patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? (Select all that apply.) a) Ketosis-prone b) Obesity at diagnoses c) Younger than 30 years of age d) Older than 65 years of age e) Little endogenous insulin

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

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes? A) "I've always been a fan of sweet foods, but lately I'm turned off by them." B) "Lately, I drink and drink and can't seem to quench my thirst." C) "No matter how much sleep I get, it seems to take me hours to wake up." D) "When I went to the washroom the last few days, my urine smelled odd."

B (Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.)

A patient with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment? A) Alterations in bile metabolism and release have likely caused hyperglycemia. B) Stress has likely caused an increase in the patient's blood sugar levels. C) The patient has likely overestimated her ability to control her diabetes using nonpharmacologic measures. D) The patient's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

B (During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The patient's need for insulin is unrelated to the action of bile, the patient's overestimation of previous blood sugar control, or fluid imbalance.)

A diabetic patient calls the clinic complaining of having a "flu bug." The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) "Make sure to stick to your normal diet." B) "Try to eat small amounts of carbs, if possible." C) "Ensure that you check your blood glucose every hour." D) "For now, check your urine for ketones every 8 hours."

B (For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.)

An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient? A) An elderly patient with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy. B) Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. C) Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. D) Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities.

B (The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs administered for diabetes.)

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor? a) Hyponatremia b) Hypoglycemia c) Polyphagia d) Ketonuria

B (The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.)

A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to: a) Stimulate the beta cells of the pancreas to secrete insulin. b) Inhibit the production of glucose by the liver. c) Increase the absorption of carbohydrates in the intestines. d) Decrease the body's sensitivity to insulin.

B (The action of the biguanides can be found in Table 30-6 in the text.)

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

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

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What is the best response by the nurse? a) "The fruit has less sugar than the juice." b) "Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." c) "Eating the fruit is more satisfying than drinking the juice. You will get full faster." d) "Eating the fruit will give you more vitamins and minerals than the juice will."

B (Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption.)

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: a) 140 mg/dL b) 180 mg/dL c) 120 mg/dL d) 160 mg/dL

B (Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).)

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

B, C, D, E (In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.)

A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class? A) Low fat generally indicates low sugar. B) Protein should constitute 30% to 40% of caloric intake. C) Most calories should be derived from carbohydrates. D) Animal fats should be eliminated from the diet.

C (Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.)

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body's need for insulin? A) Adequate sleep B) Low stimulation C) Exercise D) Low-fat diet

C (Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low fat intake and low levels of stimulation do not reduce a patient's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.)

A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient? A) Examine feet weekly for redness, blisters, and abrasions. B) Avoid the use of moisturizing lotions. C) Avoid hot-water bottles and heating pads. D) Dry feet vigorously after each bath.

C (High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury.)

A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor? A) Increased caloric intake during the first trimester B) Changes in osmolality and fluid balance C) The effects of hormonal changes during pregnancy D) Overconsumption of carbohydrates during the first two trimesters

C (Hyperglycemia and eventual gestational diabetes develops during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality.)

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A) A combination of protein and carbohydrates, such as a small cup of yogurt B) Two teaspoons of sugar dissolved in a cup of apple juice C) Half of a cup of juice, followed by cheese and crackers D) Half a sandwich with a protein-based filling

C (Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.)

A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what? A) "I read that a pancreas transplant will provide a cure for my diabetes." B) "I will take my oral antidiabetic agents when my morning blood sugar is high." C) "I will make sure to follow the weight loss plan designed by the dietitian." D) "I will make sure I call the diabetes educator when I have questions about my insulin."

C (Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.)

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? A) The patient should withhold his next scheduled dose of insulin. B) The patient should promptly eat some protein and carbohydrates. C) The patient's insulin levels are inadequate. D) The patient would benefit from a dose of metformin (Glucophage).

C (Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patient's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.)

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

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

A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse's best response? A) "Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years." B) "The cause is not known for sure but it is thought to have something to do with ketoacidosis." C) "The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years." D) "Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels."

C (The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugars (rather than fluctuations or variations in blood sugars) are thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.)

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation? a) Ask the physician for a referral for a diabetes nurse-educator to see the client before discharge. b) Suggest the client find a supportive friend or family member to assist in his care. c) Ask the physician to delay the discharge because the client requires further teaching. d) Tell the charge nurse she doesn't believe this client will be safe and refuse to rush.

C (The nurse's primary concern should be the safety of the client after discharge. She should provide succinct information to the physician concerning the client's needs, express her concern about ensuring the client's safety, and ask the physician to delay the client's discharge. The nurse shouldn't suggest that the client rely on a friend or family member because she doesn't know if a friend or family member will be available to help. Refusing to rush and telling the charge nurse she isn't sure the client will be safe demonstrate appropriate intentions, but these actions don't alleviate the pressure to discharge the client. Asking a physician to refer the client to a diabetic nurse-educator addresses the client's needs, but isn't the best response because there's no guarantee a diabetic nurse-educator will be available on such short notice.)

Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control? A) A patient who skips breakfast when his glucose reading is greater than 220 mg/dL B) A patient who never deviates from her prescribed dose of insulin C) A patient who adheres closely to a meal plan and meal schedule D) A patient who eliminates carbohydrates from his daily intake

C (The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.)

A 36-year-old mother of six has been recently diagnosed with type 2 diabetes. She reports increased hunger and food consumption while continuing to lose weight. What is the term used to describe this condition? a) Polyuria b) Anorexia c) Polyphagia d) Polydipsia

C (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. Polyphagia describes a medical symptom that means excessive hunger or appetite.)

A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy? A) Persistently cold feet B) Pain that does not respond to analgesia C) Acute pain, unrelieved by rest D) The presence of a tingling sensation

D (Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication.)

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

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

A female diabetic patient who weighs 130 lb has an ideal body weight of 116 lb. For weight reduction of 2 lb/week, approximately what should her daily caloric intake be? a) 1500 calories b) 1200 calories c) 1,800 calories d) 1000 calories

D (Calorie-controlled diets are planned by first calculating a person's energy needs and caloric requirements based on age, gender, height, and weight. An activity element is then factored in to provide the actual number of calories required for weight maintenance. To promote a 1- to 2-pound weight loss per week, 500 to 1,000 calories are subtracted from the daily total.)

A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA's recommendations include? A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

D (Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.)

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? A) Patients who are obese and who have no known history of diabetes B) Patients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

D (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.)

A nurse is teaching basic "survival skills" to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address? A) Signs and symptoms of diabetic nephropathy B) Management of diabetic ketoacidosis C) Effects of surgery and pregnancy on blood sugar levels D) Recognition of hypoglycemia and hyperglycemia

D (It is imperative that newly diagnosed patients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for education, but are not components of the patient's immediate "survival skills" following a new diagnosis.)

A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin (Glucophage). Following an ordered increase in the patient's daily dose of metformin, the nurse should prioritize which of the following assessments? A) Monitoring the patient's neutrophil levels B) Assessing the patient for signs of impaired liver function C) Monitoring the patient's level of consciousness and behavior D) Reviewing the patient's creatinine and BUN levels

D (Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient's renal function. This drug does not typically affect patients' neutrophils, liver function, or cognition.)

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual's risk for developing diabetes? A) Have blood glucose levels checked annually. B) Stop using tobacco in any form. C) Undergo eye examinations regularly. D) Lose weight, if obese.

D (Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent the diabetes.)

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: a) provide support for the spouse or significant other. b) provide time for privacy. c) encourage the client to ask questions about personal sexuality. d) suggest referral to a sex counselor or other appropriate professional.

D (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.)

A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site? a) Wear sterile gloves when inserting the needle. b) Use clean technique when changing the needle. c) Take the ordered antibiotics before initiating treatment. d) Change the needle every 3 days.

D (The nurse should teach the client to change the needle every 3 days to prevent infection. The client doesn't need to wear gloves when inserting the needle. Antibiotic therapy isn't necessary before initiating treatment. Sterile technique, not clean technique, is needed when changing the needle.)

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

D (The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).)

A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe? A) "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase." B) "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it." C) "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." D) "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."

D (Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose.)

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? a) Administer insulin. b) Correct diabetic ketoacidosis. c) Determine the cause of diabetic ketoacidosis. d) Initiate fluid replacement therapy.

D (The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.)

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: a) Glycogenesis will be decreased by the liver. b) Insulin will be released to facilitate the transport of sugar. c) The process of gluconeogenesis will be inhibited. d) The pancreatic hormone glucagon will stimulate the liver to release stored glucose.

D (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 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the child's pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes? A) Type 1 diabetes B) Type 2 diabetes C) Non-insulin-dependent diabetes D) Prediabetes

A (Beta cell destruction is the hallmark of type 1 diabetes. Non-insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.)

The nurse is preparing to administer IV fluids for a patient with ketoacidosis who has a history of hypertension and congestive heart failure. What order for fluids would the nurse anticipate infusing for this patient? a) 0.9% normal saline b) 0.45 normal saline c) D5 normal saline d) D5W

B (Half-strength NS (0.45%) solution (also known as hypotonic saline solution) may be used for rehydration of patients with hypertension or hypernatremia and those at risk for heart failure.)

A patient with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestations associated with this classic symptom? a) Altered mental state b) Muscle wasting and tissue loss c) Weight gain d) Dehydration

B (Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although people with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.)

Which statement best indicates that a client understands how to administer his own insulin injections? a) "If I'm not feeling well, I can get a friend or neighbor to help me." b) "I wrote down the steps in case I forget what to do." c) "I need to wash my hands before I give myself my injection." d) "I need to be sure no air bubbles remain."

B (The fact that the client has written down each step of insulin administration provides the best assurance that he'll follow through with all the proper steps. Awareness of air bubbles and hand washing indicate that the client understands certain aspects of giving an injection, but doesn't confirm he understands all of the steps. Saying that he can ask a friend or neighbor for help indicates a need for further instruction.)

The nurse practitioner worked with a registered dietician 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? a) Carbohydrates 45%, fat 20%, and protein 15% b) Carbohydrates 35%, fat 10%, and protein 5% c) Carbohydrates 50%, fat 25%, and protein 20% d) Carbohydrates 40%, fat 15%, and protein 10%

C (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.)

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: a) 25 g of carbohydrates. b) 10 g of carbohydrates. c) 15 g of carbohydrates. d) 20 g of carbohydrates.

C (The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.)

Which of the following categories of oral antidiabetic agents exert their primary action by directly stimulating the pancreas to secrete insulin? a) Thiazolidinediones b) Alpha glucosidase inhibitors c) Biguanides d) Sulfonylureas

D (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 insulin's action on peripheral receptor sites. Alpha glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.)

Which of the following factors is the focus of nutrition intervention for patients with type 2 diabetes? a) Blood glucose level b) Carbohydrate intake c) Protein metabolism d) Weight loss

D (Weight loss is the focus of nutrition intervention for patients 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 carbohydrate consumed is considered an important factor influencing blood glucose level. Protein metabolism is not the focus of nutrition intervention for patients with type 2 diabetes.)

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: a) increasing intake of vitamins B and D and taking iron supplements. b) eating a candy bar if light-headedness occurs. c) increasing saturated fat intake and fasting in the afternoon. d) consuming a low-carbohydrate, high-protein diet and avoiding fasting.

D (To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.)

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? a) They have no effect. b) They decrease the need for insulin. c) They cause wide fluctuations in the need for insulin. d) They increase the need for insulin.

D (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.)