Diabetes Mellitus (Ch. 48-Section 10)
A nurse is providing discharge teaching to a patient with a new diagnosis of type I diabetes mellitus who will need to give self-injections of insulin at home. What statement by the patient indicates to the nurse that the discharge teaching was effective? "I can use my lower forearm for insulin injections." "If my intermediate-acting insulin looks cloudy, I should discard the bottle." "I need to rotate sites of injection to allow for better absorption of the insulin." "I should push the plunger all the way down and then remove the needle as soon as possible."
"I need to rotate sites of injection to allow for better absorption of the insulin." Teaching the patient to rotate the injection within and between sites is important to allow for better insulin absorption. The lower forearm is not an injection site for subcutaneous insulin administration. The abdomen, arm, thigh, and buttock are the preferred sites. Intermediate-acting insulin is normally cloudy, and the patient should gently roll the bottle between the palms of hands to mix the insulin. The patient should push the plunger all the way down and leave the needle in place for 5 seconds to ensure that all of the insulin has been injected before removing the needle. p. 1128
The nurse is caring for a patient in an outpatient diabetes clinic. Which statement by the patient indicates an understanding of the teaching? "I will be sure to measure my finger stick blood glucose level four times a day, and more frequently when I am ill." "When I am ill, I will eliminate my Lantus insulin and only cover my finger stick blood glucose if it is over 250." "When I am ill, I will continue to take my Lantus insulin only." "When I am ill I will only take my rapid-acting insulin."
"I will be sure to measure my finger stick blood glucose level four times a day, and more frequently when I am ill." When a patient with diabetes is ill, it is recommended he or she continues checking blood sugar every four hours and more frequently to prevent hyperglycemia and hypoglycemia during illness. The diabetic patient should adhere to the sick day rules, which indicate to continue with your basal dosing of insulin and continue to correct a finger stick blood sugar greater than 200. The patient also should be checking urine ketones for two blood sugars over 250 in a row. p. 1139
Which statement of the diabetic patient suggests the need for additional learning about foot care? "I will wear only padded socks." "I will wash my feet daily with gentle soap." "I will check my feet for swelling and cuts every day." "I will give a hot water bottle treatment to my feet daily."
"I will give a hot water bottle treatment to my feet daily." A patient suffering from severe diabetes may have sensory neuropathy. Hot water is not recommended, because the patient will not be able to sense the degree of warmth of the water and may get burns. Using padded socks will protect the patient from cuts. Washing the feet daily with gentle soap will reduce the risk of infection. By checking for swelling and cuts every day, the patient can get timely treatment if needed. p. 1151
Which statement by the patient shows effective learning about insulin therapy? "I will not use an alcohol swab before injection." "I will not push the needle straight into the pinched-up area." "I will not use the insulin if any particles appear in the solution." "I will not rotate the injection within one anatomical site for at least one week
"I will not use the insulin if any particles appear in the solution." Insulin should be discarded if any particles appear in the solution. The skin should be cleaned with an alcohol swab before injection and the needle should be pushed straight into the pinched-up area. The injection site should be rotated in a single anatomical spot, for example the abdomen, for at least one week before using a different site in order to allow better insulin absorption. p.1127
The nurse is teaching a patient with type 2 diabetes about exercise as a method to control blood glucose levels. 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 five days per week and do resistance training three times a week."
"I will take a brisk 30-minute walk five days per week and do resistance training three times a week."
Which statement by a patient indicates an insufficient understanding of the prescribed medication metformin? "I should take this medication in the morning with breakfast." "I will need to have my hemoglobin A1c level checked in three months." "I may have diarrhea with this medication but I should not stop taking it." "I will take this medication when my blood sugar is greater than 200 mg/dL."
"I will take this medication when my blood sugar is greater than 200 mg/dL." Metformin should be taken daily for diabetes control; it is not indicated for as-needed use. It should be taken with breakfast and may initially cause diarrhea, which will resolve. p. 1130
fter discussing prevention of type 1 diabetes complications with the nurse, the patient is correct when making which statement? "I must limit fats in my diet to help prevent neuropathy." "I should use a hot water bottle on my feet when they feel cold." "I should have an eye examination at least once every two years for glaucoma screening." "It is important that I take my blood pressure medication to help prevent kidney damage."
"It is important that I take my blood pressure medication to help prevent kidney damage." Patients with diabetes who have albumin in their urine should receive angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists to treat hypertension, which would also delay the progression of nephropathy. Dietary fat intake will not affect kidney function. Hot water bottle use increases the risk of tissue damage because of the diabetic's neuropathy and delayed healing. Diabetics should have an eye examination once a year to screen for retinopathy. pp. 1148, 1149
A patient with type 2 diabetes who takes metformin daily to manage blood sugar is scheduled for an intravenous pyelogram (IVP). Which question by the nurse is most important to ask the patient when preparing for the procedure? "Have you ever skipped a dose of metformin?" "When was the last time you took your metformin?" "How many times a day do you take your metformin?" "How long have you been taking metformin for diabetes?
"When was the last time you took your metformin?" During an IVP, contrast dye is injected so that the urinary system can be visualized. To reduce risk of kidney injury, metformin should be discontinued a day or two before the procedure and for 48 hours following the procedure. Medication administration adherence, dosage, and history are important to assess, but will not affect the interaction. p. 1130
The nurse is providing education to a patient that is diagnosed with diabetes mellitus (DM). What instructions are appropriate for the nurse to include in the teaching? "You should decrease your dietary sugar intake." "I will teach you how to self-administer your insulin." "It is important to consume a diet that is high in fats." "It is important for you to reduce your physical activity." "You should monitor your blood sugar as prescribed."
"You should decrease your dietary sugar intake." "I will teach you how to self-administer your insulin." "You should monitor your blood sugar as prescribed." The nurse should teach the patient to decrease dietary sugar intake, self-administer insulin, and regularly monitor blood glucose levels as prescribed. A high-fat diet increases the patient's cholesterol levels and may increase the blood sugar levels. Reduction of physical exercise can also lead to increase in blood glucose level. p. 1142
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 two to five 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 to 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. p. 1127
The patient received regular insulin eight units subcutaneously (SQ) at 0900. The nurse plans to monitor this patient for signs of hypoglycemia during which time? 1000 and 1100 1100 and 1400 1200 and 1300 1300 and 1500
1100 and 1400 Regular insulin exerts peak action in two to five hours, placing the patient at greatest risk for hypoglycemia between 1100 and 1400. At this time, the nurse should offer the patient a snack. 1000 and 1100, 1200 and 1300, and 1300 and 1500 are not consistent with peak action of insulin administered at 0900. p. 1127
A patient is prescribed lispro therapy. Related to meal times, the nurse should instruct the patient to administer the insulin when? On an empty stomach, between meals Simultaneously with a meal 15 minutes after a meal 30 to 45 minutes before a meal
15 minutes after a meal Lispro is a rapid-acting synthetic insulin that has an onset of action of approximately 15 minutes. Lispro should be administered 15 minutes after mealtime because its rapid action closely mimics natural insulin secretion in response to a meal. Lispro is not administered on an empty stomach or simultaneously with a meal. Short-acting regular insulin, not rapid-acting synthetic insulin, is administered 30 to 45 minutes before a meal to ensure the onset of action coincides with meal absorption. pp. 1125-1126
When preparing a continuous intravenous (IV) administration of insulin for the patient in diabetic ketoacidosis (DKA), which concentration is correct? 1:1 concentration of regular insulin in units and normal saline in mLs 2:1 concentration of regular insulin in units and normal saline in mLs 1:1 concentration of NovoLog insulin in units and normal saline in mLs 1:1 concentration of Lantus insulin in units and normal saline in mLs
1:1 concentration of regular insulin in units and normal saline in mLs Regular insulin is the only insulin approved for intravenous administration by the Food and Drug Administration. It is always mixed in a 1:1 concentration with normal saline. Normal saline is the fluid it is to be mixed in. A 2:1 concentration is not accurate dosing. NovoLog and Lantus insulin are not approved for intravenous administration. pp. 1144-1145
The patient with diabetes should consume fiber as part of a healthy diet. The current recommendation for persons with diabetes is 25 to 30 g/day 20 to 25 g/day 40 to 50 g/day 10 to 20 g/day
25 to 30 g/day The American Diabetes Association (ADA) recommends that diabetics consume 25 to 30 grams of fiber daily. This is the same level recommended for the nondiabetics, because there is no evidence that a higher intake of fiber is essential. Forty to 45 grams is too much fiber for the patient to consume, and 10 to 25 grams is not enough fiber. p. 1133
A patient with type 2 diabetes complains of severe dehydration, dry mouth, fever associated with chills, and fruity odor of the breath. What is the line of treatment? Monitor serum calcium levels. Administer 5 percent to 10 percent dextrose when the glucose levels are below 250 mg/dL.
Administer potassium to correct hypokalemia. Administer sodium bicarbonate if severe acidosis is present. Administer 0.9 percent sodium chloride (NaCl) to correct fluid imbalance. Severe dehydration, dry mouth, fever associated with chills, fruity odor of breath, and a burning sensation while urinating are the clinical manifestations of diabetic ketoacidosis. It is a complication of untreated type I diabetes mellitus. The line of treatment is to administer potassium, sodium bicarbonate, and 0.9 percent NaCl to correct the acid-base balance in the body. Monitoring serum calcium levels is not related to diabetes. A solution of 5 percent to 10 percent dextrose is given when the glucose levels approach 250 mg/dL. pp. 1142-1144
A patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? Routine insulin therapy and exercise Administer a different antibiotic for the UTI Cardiac monitoring to detect potassium changes Administer intravenous (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. pp. 1145-1146
A patient diagnosed with type 1 diabetes has had elevated blood sugar readings each morning for the past four days. Which intervention by the nurse should be performed initially? Check the patient's blood sugar at 3 AM. Provide the patient with an evening snack. Rotate insulin injection sites between the abdomen, thigh, and arm. Contact the health care provider to increase the evening insulin dose.
Check the patient's blood sugar at 3 AM. Hyperglycemia in the morning may be caused by the Somogyi effect. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. Diabetics should be given evening snacks to prevent hypoglycemia during the night, but glucose assessment is a priority to rule out the Somogyi effect. Injection sites are rotated to prevent lipodystrophy. An increased dose of evening insulin may cause further decrease in early morning glucose and increased rebound hyperglycemia. p. 1129
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 it 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. pp. 1135-1136
Which medications does the nurse expect to be beneficial in a patient with diabetes mellitus who complains of numbness and a tingling sensation in the lower extremities? Losartan Duloxetine Gabapentin Bethanechol Amitriptyline
Duloxetine Gabapentin Amitriptyline Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor that is used for treatment of sensory neuropathy in patients with diabetes. Gabapentin is an antiseizure medication that decreases the release of neurotransmitters that transmit pain in patients with neuropathy. Amitriptyline is a tricyclic antidepressant used in the treatment of sensory neuropathy. Losartan is an angiotensin receptor blocker used to delay the progression of kidney damage in patients with diabetes. Bethanechol is used for the treatment of neurogenic bladder, which is caused by autonomous neuropathy. pp. 1149-1150
A college student is newly diagnosed with type 1 diabetes. The patient now has a headache, changes in vision, and is anxious, but does not have the portable blood glucose monitor with him or her. Which action should the campus nurse advise the patient to take? Eat a piece of pizza Drink some diet soft drink 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 he or she is experiencing, the patient should treat him- or herself for hypoglycemia to prevent seizures and coma from occurring. The patient also should be advised to check the blood glucose as soon as possible. The fat in the pizza and the diet soft drink would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose. p. 1133
A patient presents with diabetic ketoacidosis (DKA). The nurse initiates the collaborative plan of care with the understanding that the initial goal of the treatment plan is:
Fluid imbalance is potentially life threatening for patients with DKA. The initial goal of therapy is to establish intravenous (IV) access and begin fluid replacement. Once urine output is established, electrolyte replacement will be addressed. Potassium levels will need to be monitored, because insulin therapy, which is needed to correct the hyperglycemia, may further reduce the potassium level. Insulin therapy will be used to lower the blood glucose gradually, to prevent rapid drops in serum glucose, which could lead to fluid shifts and the potential for cerebral edema. Ketosis results from the use of fat stores for energy, because excess glucose is not being transported to the cells and used as a source of energy. Patients with DKA often present with nausea and vomiting; oral nourishment may be limited until symptoms lessen. pp. 1142-1144
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 unlabored. 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. pp. 1142-1144
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 prescribed to be nothing by mouth (NPO) for eight hours before a fasting blood glucose level. For this reason, the patient who has a laboratory draw at 8:00 AM should not have any food or beverages containing any calories after midnight. p. 1124
What is a risk factor associated with macrovascular complications of diabetes mellitus? Obesity Seizures Hypovolemia Adrenal insufficiency
Obesity Obesity increases the risk for blood vessel and cardiovascular disease. Hypoglycemia, if untreated, results in seizures and coma. Hypovolemia, due to excessive dehydration, may lead to shock. Patients with adrenal insufficiency may have minimal glycogen stores and may not respond to glucagon therapy. pp. 1147-1148
One of the unlicensed assistive personnel (UAP) reports to the nurse that a patient with diabetes is slow to respond, pale, and diaphoretic. What is the nurse's priority intervention? Obtain a bedside glucose reading. Ask patient to drink 4 ounces of orange juice. Ask the unlicensed assistive personnel (UAP) to obtain a set of vital signs. Administer 50 mL of 50% dextrose intravenously.
Obtain a bedside glucose reading. The patient with diabetes is exhibiting signs and symptoms of hypoglycemia. The priority intervention at this time is to validate assessment findings with a bedside glucose reading. Although vital signs may add to assessment data findings, they are not as much a priority as validating hypoglycemia and initiating treatment. Because the patient is experiencing a change in level of consciousness, management of the hypoglycemia via oral nourishment is contraindicated. If the patient has an existing intravenous (IV) line, then treatment of documented hypoglycemia with intravenous dextrose may be indicated. p. 1152
A nurse teaches a student nurse about pancreas transplantation. While caring for a patient whose pancreas has been transplanted, which instruction given by the student nurse strongly suggests ineffective learning? "Exogenous insulin is not required." "Dietary restrictions are not required." "Immunosuppression is required for life." "Regular monitoring of glucose level is required."
Regular monitoring of glucose level is required." After pancreatic transplantation, homeostasis of glucose level is achieved. There is no need for regular monitoring of the glucose level. Pancreatic transplantation helps in maintaining a normal glucose level, so exogenous insulin is not required. Many dietary restrictions can be lifted. Lifetime immunosuppression is very important to avoid organ rejection, which may happen after pancreatic transplantation. p. 1137
The nurse is educating a diabetic patient about the use of premixed insulin neutral protamine hagedorn /regular 70/30. What should the nurse inform the patient about using this insulin? Shake the bottle thoroughly to mix the insulin. Rotate the injection within one anatomic site for a week. Inject insulin at a 15- to 30-degree angle. Inform that the fastest subcutaneous absorption is from the thigh.
Rotate the injection within one anatomic site for a week. The nurse should teach the patient to rotate the injection within one anatomic site, such as the abdomen, for at least one week before using a different site to allow for better absorption of insulin. It is important to gently roll the insulin bottle between the palms 10 to 20 times to warm the insulin and resuspend the particles. Injections must be administered at a 45- to 90-degree angle, depending on the thickness of the patient's fat pad. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock. pp. 1127-1128
After administering glucagon to an unconscious patient, the nurse should place the patient in which position? Supine Side-lying High-Fowler's Semi-Fowler's
Side-lying Nausea is a common reaction after glucagon injection. The patient should be placed in the side-lying position to prevent aspiration should the patient vomit. The supine, high-Fowler's, and semi-Fowler's positions are not advisable because of the risk of aspiration of vomitus. p. 1147
An unlicensed assistive personnel (UAP) reports to the nurse that a patient's blood glucose level at 0800 before breakfast was 324 mg/dL. The nurse is reviewing the electronic medical record and notices that the patient received a high dose of insulin the previous night before bedtime. The nurse recognizes that the patient's hyperglycemia is most likely due to which problem with insulin therapy? Lipodystrophy Somogyi effect Allergic reaction Dawn phenomenon
Somogyi effect The Somogyi effect occurs when a patient receives a high dose of insulin that produces a decline in blood glucose levels during the night. As a result, counterregulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. Lipodystrophy is atrophy or hypertrophy of the subcutaneous tissue. Allergic reactions related to insulin occur as local inflammatory reactions and do not produce hyperglycemia. The dawn phenomenon is characterized by hyperglycemia that is present on awakening; however, it is caused by growth hormone and cortisol excretion during the early morning hours, regardless of the amount of insulin given at nighttime. p. 1129
The nurse is caring for a diabetic patient with neurogenic bladder. What should the nurse tell the patient about emptying the bladder? Empty the bladder every five hours. Relax abdominal muscles during voiding. Massage the lower abdomen horizontally. Use the Credé maneuver to completely empty the bladder.
Use the Credé maneuver to completely empty the bladder. The nurse should instruct the patient with neurogenic bladder to use the Credé maneuver to completely empty the bladder; the Credé maneuver involves mild downward massage over the lower abdomen and bladder. The nurse should also instruct the patient to empty the bladder every three hours in a sitting position to prevent stasis and subsequent infection. The patient should tighten the abdominal muscles and massage the lower abdomen downward to empty the bladder completely. p. 1150
