Diabetes Mellitus P2

A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis. During an acute exacerbation of the patient's arthritis, the physician prescribes prednisone (Deltasone) to control inflammation. What will the nurse anticipate? a. Administration of insulin while taking prednisone b. Development of acute hypoglycemia during the rheumatoid arthritis exacerbation c. Evidence of rashes caused by metformin-prednisone interactions d. Requirement of a diet higher in calories while receiving prednisone

ANS: A Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose.

Which of the following is a common side effect of metformin? a. Nausea and diarrhea b. Edema and weight gain c. Upper respiratory tract infections d. Hypoglycemia

ANS: A Nausea and diarrhea are common side effects of metformin; others include upset stomach, less weight gain than with sulphonylureas, no hypoglycemia, and potential lactic acidosis in renal or hepatic impairment.

A patient using a split mixed-dose insulin regimen tells the nurse that he is interested in using intensive insulin therapy because he has read that it promotes fewer and less severe complications of diabetes. In response to the patient's comment, what should the nurse explain? a. Intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. Intensive insulin therapy is indicated only for patients who have recently received a diagnosis of type 1 diabetes and who have never experienced ketoacidosis. c. Studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. The use of an insulin pump does not require as much attention as intensive insulin therapy and offers the same protection against long-term complications.

ANS: A Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly.

Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.

ANS: A Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat, such as cheese and crackers, will help prevent hypoglycemia.

The nurse has been teaching the patient to administer a dose of 10 units regular insulin and 28 units Lente insulin. Which of the following statements by the patient indicates a need for additional instruction? a. "I should rotate injection sites among my arms, legs, and abdomen each day." b. "I may reuse my insulin syringes for more injections if I recap them after use." c. "I should draw up the regular insulin first after injecting air into the Lente bottle." d. "I do not have to pull back on the plunger to check for blood before I inject the insulin."

ANS: A Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low.

Cardiac monitoring is initiated for a patient in diabetic ketoacidosis. The nurse recognizes that this measure is important to identify which of the following complications? a. Electrocardiogram (ECG) changes and dysrhythmias related to hypokalemia b. Fluid overload resulting from aggressive fluid replacement c. The presence of hypovolemic shock related to osmotic diuresis d. Cardiovascular collapse resulting from the effects of excess glucose on cardiac muscle

ANS: A The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring.

A patient with type 1 diabetes has been using self-capillary blood glucose monitoring (CBGM) as part of his diabetes management. During evaluation of his technique of CBGM, the nurse identifies a need for additional teaching when the patient does which of the following actions? a. Chooses a puncture site in the centre of the finger pad b. Washes his hands with soap and water to cleanse the puncture site c. Tells the nurse that the result of 130 mg indicates good control of his diabetes d. Hangs his arm down before a second puncture site attempt for an adequate drop of blood

ANS: A The patient is taught to choose a puncture site at the side of the finger pad.

While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, what should the nurse do? a. Obtain a glucose reading using a finger stick. b. Administer 1 mg glucagon subcutaneously. c. Have the patient eat a chocolate bar. d. Have the patient drink 113 g of orange juice.

ANS: A The patient's clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient's glucose with a finger stick or order an immediate blood glucose test.

A patient with type 1 diabetes is found unresponsive in the morning by his wife and is admitted to the emergency department. On admission, the patient is unresponsive to stimuli and has fruity, sweet breath with Kussmaul's respirations. Laboratory results include arterial blood gases of pH 7.32, PCO2 34 mm Hg, and HCO3 11 mmol/L, and a plasma glucose of 28.8 mmol/L (518 mg/dL). Which of the following interventions does the nurse anticipate will be prescribed initially for the patient? a. IV fluid and electrolyte replacement therapy b. Administration of an IV bolus of regular insulin c. Low-dose insulin infusion in a normal saline solution d. IV administration of sodium bicarbonate to replace bicarbonate and reverse the acidosis

ANS: A The priority action is to administer IV fluid and electrolyte replacement therapy.

Glyburide (Diabeta) is prescribed for a patient when her type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, what should the nurse explain? a. Glyburide is thought to stimulate insulin production and release from the pancreas. b. Glyburide is a substitute for insulin and acts by directly stimulating glucose uptake into the cell. c. Glyburide, like all oral antidiabetes agents, does not cause the hypoglycemic reactions that may occur with insulin use. d. Glyburide and other sulphonylureas lower blood sugar by decreasing the rate of hepatic glucose production, preventing gluconeogenesis.

ANS: A The sulphonylureas stimulate the production and release of insulin from the pancreas.

Amitriptyline (Elavil) is prescribed for a patient with diabetes with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.

ANS: A Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants are also moderately effective in treating the symptoms of diabetic neuropathy. They work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters that are believed to play a role in the transmission of pain through the spinal cord.

When assessing the patient experiencing the onset of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-coloured?"

ANS: A Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.

A patient newly diagnosed with type 1 diabetes likes to run 5 km several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."

ANS: B Blood sugar increases after meals, so this will be the best time to exercise.

A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse that she hates to exercise and asks whether just following her diet would control her diabetes. What primary reason should the nurse stress to the patient for planning a pleasant, regular exercise routine? a. It will give her increased energy and a sense of well-being. b. It will facilitate weight loss, which will decrease peripheral insulin resistance. c. It will improve cardiovascular and respiratory fitness, which is important for all individuals. d. It will set a pattern for the other routines of dietary changes and meal scheduling necessary for diabetes control.

ANS: B Exercise is essential to decrease insulin resistance and improve blood glucose control

A patient with newly diagnosed type 2 diabetes asks the nurse what "type 2" means in relation to diabetes. Which of the following statements best explains to the patient how type 2 diabetes primarily differs from type 1 diabetes? a. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." b. "With type 2 diabetes, decreased insulin secretion, cellular resistance to insulin, or both are produced." c. "With type 2 diabetes, islet cell antibodies and insulin autoantibodies destroy beta cells in the pancreas." d. "With type 2 diabetes, the C-peptide chain of proinsulin secreted by the pancreas cannot be removed by the liver, resulting in a lack of active insulin."

ANS: B In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately.

A patient recovering from diabetic ketoacidosis asks the nurse how acidosis occurs. What is the best response? a. Excess glucose in the blood is metabolized by the liver into acetone, which is acidic in nature. b. An insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones. c. Insufficient insulin leads to cellular starvation, and as cells rupture, they release organic acids into the blood. d. When an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products.

ANS: B Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism.

When intensive insulin therapy is used for control of diabetes, the nurse recognizes that which of the following types of insulin is preferred for mealtime coverage? a. NPH insulin b. Lispro insulin c. Lente insulin d. Insulin glargine

ANS: B Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy.

A patient receives a daily injection of 70/30 NPH/regular insulin premix at 0700 hours. The nurse expects that a hypoglycemic reaction is most likely to occur between which of the following times? a. 0800 and 1000 hours b. 1600 and 1800 hours c. 1900 and 2100 hours d. 2200 and 2400 hours

ANS: B The greatest insulin effect with this combination occurs in midafternoon

Which of these laboratory values noted by the nurse when reviewing the chart of a patient with diabetes indicates the need for further assessment of the patient? a. Fasting blood glucose of 6.5 mmol/L b. Noon blood glucose of 2.6 mmol/L c. HbA1C of 6.9% d. HbA1C of 5.8%

ANS: B The nurse should assess the patient with a blood glucose level of 2.6 mmol/L for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice.

A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. What will the nurse teach the patient? a. The feet should be soaked in warm water on a daily basis. b. Flat-soled leather shoes are the best choice to protect the feet from injury. c. Heating pads should always be set at a very low temperature. d. Over-the-counter callus remover may be used to remove calluses and prevent pressure.

ANS: B The patient is taught to avoid high heels and that leather shoes are preferred.

A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent HbA1C result was 6%. b. The patient takes metformin every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 7.1 mmol/L (128 mg/dL).

ANS: B To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast medium is administered.

A patient with diabetes was admitted to the emergency department when he was found unresponsive at his desk at work. A capillary blood glucose level was 2.2 mmol/L (38 mg/dL), and he was treated for hypoglycemia. When he recovers, he tells the nurse that he had no warning of the hypoglycemia. Which of the following questions will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium channel-blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

ANS: C Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying, making the patient feel bloated after eating.

A patient with type 1 diabetes has received diet instruction as part of his treatment plan. The nurse determines a need for additional instruction when the patient makes which one of the following comments? a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I may eat whatever I want as long as I cover the calories with sufficient insulin." d. "I should eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia."

ANS: C Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol.

Which of the following is true of type 2 diabetes? a. Diet modifications and insulin are required for glucose control. b. Uniform timing of meals is crucial. c. Reduction in caloric intake is desirable to control weight. d. Intermeal and bedtime snacks are frequently necessary.

ANS: C Reduction in caloric intake is desirable for the patient with type 2 diabetes to control weight, whereas in type 1 diabetes, total calories may be increased to achieve a desirable body weight and restore body tissues.

Which of the following is an example of a short-acting insulin? a. Lispro (Humalog) b. Glulisine (Apidra) c. Regular (Novolin) d. Detemir (Levemir)

ANS: C Regular insulin is a short-acting insulin.

During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports that she has been following her reduced-calorie diet, but she has not lost any weight, and she has neglected to bring her record of glucose monitoring results. What does the nurse recognize as the best indicator of the patient's control of her diabetes since her initial diagnosis and instruction? a. A fasting glucose level b. Analysis for microalbuminuria c. A glycosylated hemoglobin (HbA1C) level d. The patient's verbal report of her symptoms

ANS: C The HbA1C test shows the overall control of glucose over 90 to 120 days.

A patient with diabetes is admitted with ketoacidosis, and the physician writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 units/hour. b. Give sodium bicarbonate 50 mmol/L IV push. c. Infuse 1 L of normal saline per hour. d. Administer regular IV insulin 30 units

ANS: C The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis, and the priority is to infuse IV fluids.

When teaching a patient with type 2 diabetes about taking an oral antihyperglycemic medication, the nurse determines that additional teaching about the medication is needed when the patient gives which of the following responses? a. "If I overeat at a meal, I should not take an extra dose of my medication." b. "If I become ill or especially stressed, I may have to take insulin to control my blood sugar." c. "Given that I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."

ANS: C The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents, as when using insulin.

What should the nurse emphasize when teaching a patient with type 1 diabetes about the Somogyi effect and dawn phenomenon? a. The Somogyi effect occurs early at night, and the dawn phenomenon occurs on arising. b. The Somogyi effect is characterized by hyperglycemia and the dawn phenomenon by hypoglycemia. c. The Somogyi effect occurs when the patient is asleep, and the dawn phenomenon occurs after the patient awakens. d. In the Somogyi effect, hyperglycemia results from too much insulin, and the dawn phenomenon results from too little insulin.

ANS: D In the Somogyi effect, hyperglycemia results from too much insulin, and the dawn phenomenon results from too little insulin.

A patient with type 1 diabetes develops a sore throat, cough, and fever. He calls the clinic when he finds his blood glucose level to be 11.67 mmol/L (210 mg/dL) with his monitor. What should the nurse advise the patient to do? a. Hold all food and insulin until his fever is relieved. b. Measure his urinary output, and test his urine for ketones. c. Reduce his carbohydrate intake until his glucose level is about 8.33 mmol/L (150 mg/dL). d. Monitor his blood glucose every 4 hours, and notify the clinic if it continues to rise.

ANS: D Infection and other stressors increase blood glucose levels, and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the physician if glucose levels continue to be elevated.

Which of the following is a characteristic of type 1 diabetes? a. Incidence in young people is increasing b. Insidious onset c. Absent islet-cell antibodies d. Patient prone to ketosis at onset

ANS: D Patients are prone to ketosis at onset in type 1 diabetes but in type 2 diabetes are resistant except during infections or stress.

A patient screened for diabetes at a clinic has a fasting plasma glucose of 6.7 mmol/L (120 mg/dL). What will the nurse plan to teach the patient about? a. Use of low doses of regular insulin b. Self-monitoring of blood glucose c. Oral hypoglycemic medications d. Maintenance of a healthy weight

ANS: D The patient's impaired fasting glucose indicates prediabetes, and the patient should be counselled about lifestyle changes, for example, a healthy weight, to prevent the development of type 2 diabetes.

The nurse is preparing a mixed insulin dose for administration. After injecting air into both vials, what would be the immediate next step? a. Gently rotate the NPH insulin bottle. b. Invert and draw up regular insulin. c. Swab the tops of both vials with alcohol sponge or swab. d. Invert and draw up NPH insulin.

ANS:B After the nurse has injected air into both vials, the next action is to invert the regular insulin vial and withdraw the ordered amount.

During a diabetes screening program, a young woman tells the nurse that her mother died of complications of diabetes and asks whether she will inherit the disease. After determining that the woman's mother most likely had type 2 diabetes, what should the nurse explain? a. Her 60% chance of developing type 2 diabetes can be prevented by maintaining a normal weight and a low-carbohydrate diet. b. The patient has a higher familial risk for developing type 2 diabetes than for type 1 diabetes, and she should have her glucose level tested periodically. c. She would have a higher risk for developing diabetes if her father, rather than her mother, had diabetes, but she should still be tested periodically. d. Although there is a familial tendency for children or siblings of individuals with type 2 diabetes to develop diabetes, the inherited risk is not as high as it is for type 1 diabetes.

ANS:B The offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes.

A patient is diagnosed with type 2 diabetes at the clinic. A nursing assessment of the patient reveals vital signs of blood pressure 158/96 mm Hg, heart rate 88 beats/min, respiration 18 breaths/min, temperature 37.1°C, height 160 cm, and weight 82 kg. The physician prescribes a 1200-calorie diet with a daily exercise program as initial therapy for the patient. The nurse refers the patient to the dietitian for initial diet planning and teaching with the knowledge that which of the following is the primary goal of nutritional therapy for the patient? a. Control of dietary intake to achieve ideal body weight b. Elimination of simple sugars in exchange for complex carbohydrate in the diet c. Reduction in dietary calories and fat to normalize glucose, lipid, and blood pressure levels d. Maintenance of equal distribution of carbohydrate throughout the day with strict adherence to consistency in daily intake

ANS:C A nutritionally adequate meal plan with a reduction in total fat (especially saturated fats), an increase in fibre, and a decrease in simple sugars can bring about decreased calorie and carbohydrate consumption.

A hospitalized patient with diabetes receives 12 units of regular insulin mixed with 34 units of NPH insulin at 0700 hours. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. What is the most appropriate nursing action? a. Save the lunch tray to be provided on the patient's return to the unit. b. Call the diagnostic testing area, and ask the physician to start an intravenous (IV) line of 5% dextrose solution. c. Ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. Request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.

ANS:D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time.

A 20-year-old university student who has type 1 diabetes normally walks each evening as part of her exercise regimen. She now plans to enroll in a swimming class to meet her physical education requirement. What should the nurse teach the patient that adjustments to her treatment plan should include? a. Delaying the normal meal before the swimming class until the session is over b. Adding 10 units of regular insulin to her usual morning dose on the days she plans to swim c. Timing her morning insulin injection so that the peak action will occur during her swimming class d. Monitoring her glucose level before, during, and after swimming to determine the need for alterations in food or insulin

ANS:D The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration

A program of weight loss and exercise is recommended for a patient with insulin resistance syndrome. When the patient asks why these measures are necessary when she really does not have diabetes, what should the nurse explain? a. The high insulin levels associated with this syndrome damage the lining of blood vessels and cause osmotic diuresis. b. Although her fasting plasma glucose levels do not indicate diabetes, she has impaired glucose tolerance, which is characteristic of the syndrome. c. The liver is inappropriately producing glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. She has a variety of abnormalities associated with diabetes, which indicate a very high risk for cardiovascular disease, and the onset of diabetes can be delayed or prevented by weight loss and exercise.

ANS:D The patient with impaired fasting glucose is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes.