Diabetes (chapter 48)
The nurse is teaching a patient with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? "Smokeless tobacco products decrease the risk of kidney damage." "I can help control my blood pressure by avoiding foods high in salt." "I should have yearly dilated eye examinations by an ophthalmologist." "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."
"I can help control my blood pressure by avoiding foods high in salt." Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.
The nurse instructs a patient with diabetes mellitus about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? "I plan to lose 25 lb this year by following a high-protein diet." "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." "I should include more fiber in my diet than a person who does not have diabetes." "If I use an insulin pump, I will not need to limit the amount of saturated fat in my diet."
"I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes mellitus. High-protein diets are not recommended for weight loss.
The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? "I should only walk barefoot in nice dry weather." "I should look at the condition of my feet every day." "I am lucky my shoes fit so nice and tight because they give me firm support." "When I am allowed up out of bed, I should check the shower water with my toes."
"I should look at the condition of my feet every day." Patients with diabetes mellitus need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Water temperature should be tested with the hands first.
The nurse teaches a patient recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse? "I will discard any insulin bottle that is cloudy in appearance." "The best injection site for insulin administration is in my abdomen." "I can wash the site with soap and water before insulin administration." "I may keep my insulin at room temperature (75oF) for up to 1 month."
"I will discard any insulin bottle that is cloudy in appearance." Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86°F (30°C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.
The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." "I will go running each day when my blood sugar is too high to bring it back to normal." "I will plan to keep my job as a teacher because I get a lot of exercise every school day." "I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week."
"I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week." The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days per week and resistance training three times a week. Brisk walking is moderate activity. Fishing and teaching are light activity, and running is considered vigorous activity.
A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? "With type 2 diabetes, the body of the pancreas becomes inflamed." "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."
"With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? 8:40 PM to 9:00 PM 9:00 PM to 11:30 PM 10:30 PM to 1:30 AM 12:30 AM to 8:30 AM
10:30 PM to 1:30 AM Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.
Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness? A 58-yr-old patient with diabetic retinopathy A 73-yr-old patient who takes propranolol (Inderal) A 19-yr-old patient who is on the school track team A 24-yr-old patient with a hemoglobin A1C of 8.9%
73-yr-old patient who takes propranolol (Inderal) Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.
The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus? A 48-yr-old woman with a hemoglobin A1C of 8.4% A 58-yr-old man with a fasting blood glucose of 111 mg/dL A 68-yr-old woman with a random plasma glucose of 190 mg/dL A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL
A 48-yr-old woman with a hemoglobin A1C of 8.4% Criteria for a diagnosis of diabetes mellitus include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.
The nurse is assigned to the care of a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? Assess patient's perception of what it means to have diabetes. Ask the patient to write down current knowledge about diabetes. Set goals for the patient to actively participate in managing his diabetes. Assume responsibility for all of the patient's care to decrease stress level.
Assess patient's perception of what it means to have diabetes. For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.
The patient with type 1 diabetes mellitus eats a large meal but does not take his insulin as prescribed. In what order do the following physiologic events occur in the development of a hyperglycemic emergency? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Fat metabolism leads to ketonemia. b. Insufficient insulin in the blood stream c. Fat is mobilized for energy from the adipose tissue. d. Potassium and water are excreted with H+ and ketones in the urine. e. Organic acid accumulation in the blood causes metabolic acidosis.
B, C, A, E, D A patient with type 1 diabetes who develops blood glucose greater than 250 mg/dL is at risk to develop diabetic ketoacidosis (DKA). In DKA, the patient's cells lack fuel (glucose), despite excess serum glucose because there is insufficient insulin available to metabolize the glucose and drive it into the cells. So the body turns to fat for fuel and produces ketones as a byproduct of fat metabolism. Ketonemia decreases the serum pH as H+ ions accumulate, and hyperglycemia causes osmotic diuresis, leading to the excretion of electrolytes, especially potassium and chloride (as a carrier of H+).
A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration.
Cardiac monitoring to detect potassium changes This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? Cheese Broccoli Chicken Oranges
Cheese Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.
The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Chooses a puncture site in the center of the finger pad Washes hands with soap and water to cleanse the site to be used Warms the finger before puncturing the finger to obtain a drop of blood Tells the nurse that the result of 110 mg/dL indicates good control of diabetes
Chooses a puncture site in the center of the finger pad The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.
A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise her to take? Eat a piece of pizza. Drink some diet pop. Eat 15 g of simple carbohydrates. Take an extra dose of rapid-acting insulin.
Eat 15 g of simple carbohydrates. When the patient with type 1 diabetes is unsure about the meaning of the symptoms she is experiencing, she should treat herself for hypoglycemia to prevent seizures and coma from occurring. She should also be advised to check her blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease her blood glucose.
The nurse is evaluating a patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient correlates with the diagnosis? Excessive thirst Gradual weight gain Overwhelming fatigue Recurrent blurred vision
Excessive thirst The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.
The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? Prealbumin level Urine ketone level Fasting glucose level Glycosylated hemoglobin level
Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.
The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased triglyceride levels Increased high-density lipoproteins (HDL) Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL)
Increased triglyceride levels Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.
A patient, admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? Central apnea Hypoventilation Kussmaul respirations Cheyne-Stokes respirations
Kussmaul respirations In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.
The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.
Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.
A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? 6:00 PM on the evening before the test Midnight before the test 4:00 AM on the day of the test 7:00 AM on the day of the test
Midnight before the test Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Avoid sick people and wash hands. Obtain comprehensive dental care. Maintain hemoglobin A1C below 7%. Coughing and deep breathing with splinting
Obtain comprehensive dental care. A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.
The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to best explain how this medication works? Increases insulin production from the pancreas Slows the absorption of carbohydrate in the small intestine Reduces glucose production by the liver and enhances insulin sensitivity Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying
Reduces glucose production by the liver and enhances insulin sensitivity Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.
A patient is admitted with diabetes mellitus, malnutrition cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? Select all that apply. The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy. The patient may be excreting extra sodium and retaining potassium because of malnutrition. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control..
The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy.