Diabetes [DKA/HHS Final Exam Questions]

34. The most common maintenance dose of intravenous insulin for a patient with hyperglycemic hyperosmolar syndrome (HHS) would be A. 0.1 U/kg/hr. B. 1.0 U/kg/hr. C. 2.0 U/kg/hr. D. 5.0 U/kg/hr.

ANS A 0.1 U/kg/hr. Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 units/hr for a person weighing 70 kg) should lower the plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If the measured glucose does not decrease by this amount, the insulin infusion rate may be doubled until the blood glucose is declining at a rate of 50 to 70 mg/dL per hour.

23. As a patient with diabetic ketoacidosis receives insulin and fluids, the nurse knows careful assessment must be given to which of the following electrolytes? A. Potassium B. Sodium C. Phosphorus D. Calcium

ANS A Potassium Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.

10. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). The treatment of DKA involves A. extensive hydration. B. oral hypoglycemic agents. C. large doses of IV insulin. D. limiting food and fluids.

ANS A extensive hydration. Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

42. After a patient has been diagnosed with SIADH, the nurse would expect the first line of treatment to include A. fluid restriction. B. hypotonic intravenous fluid. C. D5W. D. fluid bolus.

ANS A fluid restriction. Reduction in fluid intake is one component of the treatment plan for SIADH.

36. A patient presenting with diabetes insipidus (DI) exhibits A. hyperosmolality and hypernatremia. B. hyperosmolality and hyponatremia. C. hypo-osmolality and hypernatremia. D. hypo-osmolality and hyponatremia.

ANS A hyperosmolality and hypernatremia. In central DI, there is an inability to secrete an adequate amount of antidiuretic hormone (arginine vasopressin) in response to an osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine. Hypernatremia is usually associated with serum hyperosmolality.

15. The nurse knows that the dehydration associated with diabetic ketoacidosis results from A. increased serum osmolality and urea. B. decreased serum osmolality and hyperglycemia. C. ketones and potassium shifts. D. acute renal failure.

ANS A increased serum osmolality and urea. Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal. 16. The nurse knows that the dehydration in diabetic ketoacidosis stimulates catecholamine release, which results in A. decreased glucose release. B. increased insulin release. C. decreased cardiac contractility. D. increased gluconeogenesis. =ANS D Dehydration stimulates catecholamine production in an effort to provide emergency support. Catecholamine output stimulates further glycogenolysis, lipolysis, and gluconeogenesis, pouring glucose into the bloodstream.

28. To assist the nurse in evaluating the patient's hydration status, assessment would include A. orthostatic hypotension and neck vein filling. B. pupil checks and Kernig sign. C. Chvostek and Trousseau signs. D. S4 gallop and edema.

ANS A orthostatic hypotension and neck vein filling. Assessment for orthostatic hypotension and neck vein filling is an important way to evaluate hydration status.

3. The primary intervention for hyperglycemic hyperosmolar syndrome (HHS) is A. rapid rehydration. B. monitoring vital signs. C. high-dose intravenous (IV) insulin. D. hourly urine sugar and acetone testing.

ANS A rapid rehydration. The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.

22. A nondiabetic patient presents ketoacidosis. Reasons may include A. starvation and alcoholism. B. drug overdose. C. severe vomiting. D. hyperaldosteronism.

ANS A starvation and alcoholism. Other nondiabetic causes of ketoacidosis are starvation ketosis and alcoholic ketoacidosis.

5. Patients with central DI are treated with A. vasopressin. B. insulin. C. glucagon. D. propylthiouracil.

ANS A vasopressin. Patients with central DI who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH analog. The most commonly prescribed drug is the synthetic analog of ADH,desmopressin (DDAVP). DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or subcutaneously every 12 hours.

48. The neuroendocrine stress response produces which of the following? (Select all that apply.) A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia D. Heightened pain awareness E. Increased glucose

ANS A, B, C, E A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia E. Increased glucose The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.

49. A patient was admitted to the critical care unit with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) A. NS 1.5 L IV fluid bolus B. Insulin infusion at 5 units/hr C. Sodium bicarbonate 50 mmol IV push D. Vasopressin 10 units IM every 3 hr E. Potassium 20 mEq/L of IV fluid

ANS A, B, E A. NS 1.5 L IV fluid bolus B. Insulin infusion at 5 units/hr E. Potassium 20 mEq/L of IV fluid Dehydration is a common presenting issue in DKA, so the administration of fluids and insulin will help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is necessary.

43. During the first 24 hours when the nurse administers hypertonic saline in a patient with SIADH, the serum sodium should be raised no more than A. 5 mEq/day. B. 12 mEq/day. C. 20 mEq/day. D. 25 mEq/day.

ANS B 12 mEq/day. One recommended regimen is an IV rate that provides sufficient sodium to raise serum sodium levels by up to 12 mEq/day for the first 24 hours (no more than 0.5 mEq each hour), with a total increase of 18 mEq/L in the initial 48 hours.

8. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which of the following symptoms is most suggestive of DKA? A. Irritability B. Excessive thirst C. Rapid weight gain D. Peripheral edema

ANS B Excessive thirst DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

41. In evaluating the patient's hyponatremia, the nurse understands the problem is A. increased cortisol release. B. decreased aldosterone release. C. increased glucocorticoid release. D. decreased glucagon release.

ANS B decreased aldosterone release. In SIADH, the increased levels of circulating ADH are unrelated to the serum sodium concentration. Aldosterone production from the adrenal glands is also suppressed.

47. Decreased urine osmolality is a sign of A. hyperglycemia. B. diabetes insipidus. C. thyroid crisis. D. SIADH.

ANS B diabetes insipidus. Decreased urine osmolality is a sign of DI.

6. In the syndrome of inappropriate antidiuretic hormone (SIADH), the physiologic effect is A. massive diuresis, leading to hemoconcentration. B. dilutional hyponatremia, reducing sodium concentration to critically low levels. C. hypokalemia from massive diuresis. D. serum osmolality greater than 350 mOsm/kg.

ANS B dilutional hyponatremia, reducing sodium concentration to critically low levels. Patients with SIADH have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

24. The top priority in the initial treatment of diabetic ketoacidosis (DKA) is A. lowering the blood sugar. B. giving fluids. C. giving sodium bicarbonate to reverse the acidosis. D. determining the reason for the DKA.

ANS B giving fluids. A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

11. The most common problem in the patient with type 2 diabetes is a(n) A. lack of insulin production. B. imbalance between insulin production and use. C. overproduction of glucose. D. increased uptake of glucose in the cells.

ANS B imbalance between insulin production and use. Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.

29. A patient with diabetic ketoacidosis has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include A. Kussmaul respirations and flushed skin. B. irritability and paresthesia. C. abdominal cramps and nausea. D. hypotension and itching.

ANS B irritability and paresthesia. Irritability and paresthesia are seen in hypoglycemia.

17. The major electrolyte disturbances that result from diuresis are A. low calcium and high phosphorus levels. B. low potassium and low sodium levels. C. high sodium and low phosphorus levels. D. low calcium and low potassium levels.

ANS B low potassium and low sodium levels. Serum sodium may be low as a result of the movement of water from the intracellular space into the extracellular (vascular) space. The serum potassium level is often normal; a low serum potassium level in diabetic ketoacidosis suggests that a significant potassium deficiency may be present.

27. When a patient in diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of A. sodium and potassium. B. potassium and phosphate. C. bicarbonate and calcium. D. sodium and phosphate.

ANS B potassium and phosphate. Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is recommended.

32. An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to A. clotting factors. B. rehydration. C. administration of insulin. D. sodium replacement.

ANS B rehydration The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.

2. The hallmark of hyperglycemic hyperosmolar syndrome (HHS) is A. hyperglycemia with low serum osmolality. B. severe hyperglycemia with minimal or absent ketosis. C. little or no ketosis in serum with rapidly escalating ketonuria. D. hyperglycemia and ketosis.

ANS B severe hyperglycemia with minimal or absent ketosis. The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.

33. A patient with hyperglycemic hyperosmolar syndrome (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. The intravenous fluid of choice would be A. D5W. B. 0.45% NS. C. 0.9% NS. D. D5/NS.

ANS C 0.9% NS. The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/hr, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient's hydration state and sodium level.

45. Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing A. type 1 diabetes. B. type 2 diabetes. C. DI. D. myxedema coma.

ANS C DI. Any patient who has head trauma or resection of a pituitary tumor has an increased risk of developing DI.

7. Which of the following nursing interventions should be initiated on all patients with SIADH? A. Placing the patient on an air mattress B. Forcing fluids C. Initiating seizure precautions D. Applying soft restraints

ANS C Initiating seizure precautions The patient with SIADH has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an inability to concentrate, mental confusion, apprehension, seizures, a decreased level of consciousness, coma, and death.

39. A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine specific gravity of 1.035. The nurse would suspect A. diuresis. B. DI. C. SIADH. D. hyperaldosteronism.

ANS C SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) A decreased urine output, hyponatremia, hypoosmolality, and high urine specific gravity are classic signs of SIADH. Oat cell carcinoma is a precipitating factor for SIADH.

19. A patient in diabetic ketoacidosis has the following arterial blood gasses: pH 7.25; pCO2 30 mm Hg; HCO3- 16. The patient has rapid, regular respirations. The nurse's best response would be to A. ask the patient to breathe into a paper bag to retain CO2. B. administer sodium bicarbonate. C. administer insulin and fluids intravenously. D. prepare for intubation.

ANS C administer insulin and fluids intravenously. Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.

18. The patient admitted in diabetic ketoacidosis has dry, cracked lips and is begging for something to drink. The nurse's best response would be to A. keep the patient NPO. B. allow the patient a cup of coffee. C. allow the patient water. D. allow the patient to drink anything he chooses.

ANS C allow the patient water. The thirst sensation is the body's attempt to correct the fluid deficit. Water is the best replacement.

25. The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis, the IV line should be changed to a solution containing glucose when the A. patient becomes more alert. B. IV insulin has been infusing for 4 hours. C. blood glucose drops to 200 mg/dL. D. blood glucose drops to 100 mg/dL.

ANS C blood glucose drops to 200 mg/dL. When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.

21. A patient in diabetic ketoacidosis is comatose with a temperature of 102.2° F. The nurse would suspect A. head injury. B. infarct of the hypothalamus. C. infection. D. heat stroke.

ANS C infection A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.

4. Characteristics of diabetes insipidus (DI) are A. hyperglycemia and hyperosmolarity. B. hyperglycemia and peripheral edema. C. intense thirst and passage of excessively large quantities of dilute urine. D. peripheral edema and pulmonary crackles.

ANS C intense thirst and passage of excessively large quantities of dilute urine. The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.

1. A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis (DKA) secondary to A. excess insulin administration. B. inadequate food intake. C. physiologic and psychologic stress. D. increased release of antidiuretic hormone (ADH).

ANS C physiologic and psychologic stress. Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.

35. A patient is admitted with a long history of mental illness. Her husband states she has been drinking up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse suspects A. central diabetes insipidus (DI). B. nephrogenic DI. C. psychogenic (dipsogenic) DI. D. iatrogenic DI.

ANS C psychogenic (dipsogenic) DI. Psychogenic diabetes insipidus (DI) is a rare form of the disease that occurs with compulsive drinking of more than 5 L of water a day. Long-standing psychogenic DI closely mimics nephrogenic DI because the kidney tubules become less responsive to antidiuretic hormone as a result of prolonged conditioning to hypotonic urine.

37. The onset of seizures in the patient with DI indicates A. increased potassium levels. B. hyperosmolality. C. severe dehydration. D. toxic ammonia levels.

ANS C severe dehydration. This excessive intake of water reduces the serum osmolality to a more normal level and prevents dehydration. In the person with decreased level of consciousness, the polyuria leads to severe hypernatremia, dehydration, decreased cerebral perfusion, seizures, loss of consciousness, and death.

26. The nurse knows that the patient with DKA will need A. subcutaneous insulin. B. IV insulin. C. subcutaneous and IV insulin. D. combination 70%/30% insulin.

ANS C subcutaneous and IV insulin. The patient needs IV insulin for rapid onset but will also need subcutaneous insulin about 1 hour before the IV insulin is discontinued.

12. A patient weighs 140 kg and is 60 in. tall. The patient's blood sugar is being controlled by glipizide. As the nurse discusses discharge instructions, the primary treatment goal with this type 2 diabetes patient would be A. signs of hypoglycemia. B. proper injection technique. C. weight loss. D. increased caloric intake.

ANS C weight loss. This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients with type 2 diabetes.

14. A patient who has type 2 diabetes is on the unit after aneurysm repair. His serum glucose levels have been elevated for the past 2 days. He is concerned that he is becoming dependent on insulin. The best response for the nurse would be A. "This surgery may have damaged your pancreas. We will have to do more evaluation." B. "Perhaps your diabetes was more serious from the beginning." C. "You will need to discuss this with your physician." D. "The stress on your body has temporarily increased your blood sugar levels."

ANS D "The stress on your body has temporarily increased your blood sugar levels." Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

13. A patient is admitted to the unit with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes but has been on an insulin pump for 6 months. He states, "I know it could not be my diabetes because my pump gives me 24-hour control." The nurse's best response would be A. "You know a lot about your pump, and you are correct." B. "You're right. This is probably a virus." C. "We'll get an abdominal CT and see if your pancreas is inflamed." D. "We'll check your serum blood glucose and ketones."

ANS D "We'll check your serum blood glucose and ketones." Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.

46. The diagnosis of SIADH is made when which of the following conditions is present? A. Decreased ADH level and hyperkalemia B. Decreased ADH level and hypernatremia C. Increased ADH level and serum ketones D. Increased ADH level and low serum osmolality

ANS D Increased ADH level and low serum osmolality SIADH occurs when there are increased levels of ADH in the blood compared with a low serum osmolality.

9. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis.Which of the following statements best describes the rationale for administrating potassium supplements with the patient's insulin therapy? A. Potassium replaces losses incurred with diuresis. B. The patient has been in a long-term malnourished state. C. IV potassium renders the infused solution isotonic. D. Insulin drives the potassium back into the cells.

ANS D Insulin drives the potassium back into the cells. Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with DKA who are receiving fluid resuscitation and insulin therapy.

40. The patient at risk for developing SIADH may be taking A. adenosine (Adenocard). B. diltiazem (Cardizem). C. heparin sodium. D. acetaminophen.

ANS D acetaminophen Tylenol increases the release of ADH.

20. A patient in diabetic ketoacidosis is very lethargic and has a "funny" odor to his breath. The nurse would suspect this to be a result of A. alcohol intoxication. B. hyperglycemia. C. hyperphosphatemia. D. acetone.

ANS D acetone Acid ketones dissociate and yield hydrogen ions (H) that accumulate and precipitate a fall in serum pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.

38. A priority for patient education when discharged with long-term antidiuretic hormone deficiency is A. daily intake and output. B. attention to thirst. C. a low-sodium diet. D. daily weights.

ANS D daily weights. Daily weights on the same scale are an excellent assessment of fluid status. A weight gain or loss of 1 kg (2.2 lb) is equal to 1 L of fluid.

30. A patient was admitted with diabetic ketoacidosis 1 hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The expected intervention would be to A. administer a lidocaine bolus. B. administer a lidocaine drip. C. synchronize cardioversion. D. evaluate electrolytes.

ANS D evaluate electrolytes. Hyperkalemia occurs with acidosis or with overaggressive administration of potassium replacement in patients with renal insufficiency. Severe hyperkalemia is demonstrated on the cardiac monitor by a large, peaked T wave; flattened P wave; and widened QRS complex.

44. While a patient with SIADH is receiving hypertonic saline, the nurse assesses for signs that the saline must be stopped. These signs would include A. decreased CVP and decreased PAP. B. bradycardia and thirst. C. hypotension and wheezing. D. hypertension and lung crackles.

ANS D hypertension and lung crackles. Hypertension and lung crackles are signs of fluid overload. The hypertonic solution may pull fluid out of cells and tissues. Whereas weight gain signifies continual fluid retention, weight loss indicates loss of body fluid.

31. A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made based on laboratory values of A. decreased serum glucose and increased serum ketones. B. increased urine ketones and decreased serum osmolality. C. increased serum osmolality and increased serum potassium. D. increased serum osmolality and increased serum glucose.

ANS D increased serum osmolality and increased serum glucose. Laboratory findings are used to establish the definitive diagnosis of HHS. Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.