HESI Case Study: Diabetes Mellitus

Manifestations: Once the acute ketoacidosis is controlled, the client is told that they have Type 1 diabetes mellitus. The nurse obtains the client's history. The client states that prior to the flu, they had been healthy. However, the client had noticed that they had been eating more than normal, but had not been gaining any weight. The client also states that they had been drinking a lot of diet colas and that got up at night frequently to go to the bathroom. The nurse identifies that the client has experienced classic symptoms of diabetes, which are: A. Dysuria, dyspepsia, and dysphagia. B. Polyuria, polyphagia, and polydipsia. C. Abnormal diet, drink, and distention. D. Increased metabolism, increased fluid volume, and increased urgency.

B. Polyuria, polyphagia, and polydipsia. Rationale: Increased urinary output (polyuria), increased appetitie (polyphagia), and increased thirst (polydipsia) are the three classic manifestations of diabetes mellitus.

The client tells the nurse that they hope they never get HHNS. The client's grandmother's blood glucose level was almost 1,000 mg/dl (55.5 mmol/L). The client states that their blood glucose level was only 370 mg/dl (20.54 mmol/L) when they were really sick. What intervention should the nurse implement? A. Explain to the client that HHNS is not as serious as DKA, since ketosis does not occur. B. Tell the client that HHNS is less likely to occur in Type 1 diabetes than in Type 2 diabetes. C. Suggest that the client may be misinformed because it is unlikely the blood glucose level was that high. D. Advise the client to share their concerns about this syndrome with their grandmother.

B. Tell the client that HHNS is less likely to occur in Type 1 diabetes than in Type 2 diabetes. Rationale: HHNS primarily affects Type 2 diabetics who are significantly dehydrated. However, the client should be aware of the nature of symptoms and the treatment for HHNS.

Insulin: The goal of treatment with hypoglycemic agents is the maintenance of stable blood glucose levels to prevent the acute complications of hypoglycemia and hyperglycemia, and the long-term complications associated with hyperglycemia. The client will initially be taking 70% NPH/30% regular insulin subcutaneously every a.m., a sliding-scale dose of regular insulin subcutaneously before lunch and dinner, and NPH (N) insulin at bedtime. Which statement made by the client indicates that they correctly understands self-administration of insulin? A. My daily dose of 70% NPH/30% regular insulin is based on how much I ate the day before. B. The amount of short-acting insulin I take every day is based on my blood sugar readings. C. I should store my insulin in the refrigerator and remove it 30 minutes before I need it. D. I will alternate my injection sites from leg to abdomen each day to avoid overuse.

B. The amount of short-acting insulin I take every day is based on my blood sugar readings. Rationale: Sliding scale refers to the administration of a dose of regular (short-acting) insulin based on the client's current blood glucose level.

A student nurse is assigned to work with the charge nurse in caring for the client during their acute illness. The student tells the nurse that they plan to present information about the client to fellow students during a post-clinical conference, and asks the charge nurse for permission to copy the client's lab data to take to the conference. Which response is best for the charge nurse to provide? A. Information about the client cannot be removed from the nursing unit. B. The lab values can be copied as long as there is no identifying client data. C. Since this is for educational purposes, you can remove any information you need. D. Your instructor should tell you what information you are allowed to copy.

B. The lab values can be copied as long as there is no identifying client data. Rationale: Information used for educational purposes may be shared, as long as the data does not permit identification of the client.

Classifications of DiabetesThe client states that their grandmother became diabetic after she retired, but that their mother had gestational diabetes mellitus (GDM) when she was pregnant with them. The client asks the nurse if this is related to their condition now. How should the nurse respond? A. Your mother's diabetes during pregnancy increased your risk for diabetes. B. There is no direct correlation, but family history is important in diabetes. C. You most likely inherited your tendency for diabetes from your grandmother. D. Diabetes is an autoimmune disorder, with little likelihood of family inheritance.

B. There is no direct correlation, but family history is important in diabetes. Rationale: The highest risk for the onset of Type 1 diabetes is linked to the presence of certain antigens, so there seems to be a genetic predisposition combined with an environmental trigger. There is a strong genetic predisposition for Type 2 diabetes. Although there is no direct correlation between the GDM that te client's mother experienced and the Type 2 diabetes the grandmother probably has, family history is important.

Management: Priorities Once the client is feeling better, the client practice injection skills and later states that they feel more comfortable about giving themself the injections. The next morning, the client is preparing to administer their insulin with the nurse's supervision. However, the nurse is called back to the desk by the unit clerk where they learn that several clients are having problems that require attention. Which action should the nurse take first? A. Return to the client's room to supervise the scheduled insulin injection. B. Administer a dose of IV antibiotics to a diabetic with an infected foot ulcer. C. Administer IV dextrose to a diabetic client with a blood glucose level of 25 mg/dl (1.39 mmol/L). D. Hang a new bag of normal saline on a diabetic with a blood glucose level of 275 mg/dl (14.26 mmol/L).

C. Administer IV dextrose to a diabetic client with a blood glucose level of 25 mg/dl (1.39 mmol/L). Rationale: This is the most critical client care need. The client's blood glucose is dangerously low, and lack of action by the nurse could endanger the client's life. The charge nurse uses a form of triage based on the client with the most critical need.

A Complication Occurs: The client is discharged with controlled blood glucose levels and sufficient knowledge of diet and insulin therapy. The client will continue to attend the series of classes on diabetes management offered at the hospital by the diabetes educator. Two months later, the client's college roommate calls the nurse late at night in a panic and reports that the client described feeling like their heart is beating out of their chest. The client was weak and shaky, so the roommate brought some juice but the client became confused and lethargic before they could drink it, and now the client will not wake up. What is the best nursing action? A. Advise the roommate to stay with the client, remain calm, and check the client's pulse, respirations, and skin color. B. Tell the roommate to immediately find the dorm supervisor while she calls an ambulance. C. Ask the roommate if the client has emergency supplies such as Glucagon or cake icing available. D. Instruct the roommate to hold the client's head up and put small sips of juice in the side of their mouth.

C. Ask the roommate if the client has emergency supplies such as Glucagon or cake icing available. Rationale: The client is experiencing symptoms of hypoglycemia, which include disorientation, tremors, palpitations, lightheadedness, confusion, cool, clammy skin, slurred speech, and lethargy. Since she is not arousable, the roommate should first be instructed to use any emergency supplies readily available. These might include Glucagon, which is administered subcutaneously or IM, or a concentrated glucose paste which can be squeezed in the mouth and absorbed through the mucosa.

Sick Day Management: The client talks to the nurse about what to do if they gets sick. The client states that it just doesn't make sense to take insulin when not feeling sick, knowing they won't want to eat anything. How should the nurse respond? A. You are right. You should not take your insulin if you are feeling sick. B. Take only sliding-scale insulin, not your regular dose, if you are feeling sick. C. Being sick increases your blood sugar. Taking your usual insulin dose is important. D. When you are sick, you should test your urine and only take insulin if ketones are present.

C. Being sick increases your blood sugar. Taking your usual insulin dose is important. Rationale: Illness increases the risk for dehydration and hyperglycemia. Continued administration of the regular dose of insulin and adequate fluid and carbohydrate intake are critical to prevent ketoacidosis. The client should monitor their blood glucose at least every 4 hours when ill, and report persistent hyperglycemia, ketosis, nausea and vomiting, or other significant symptoms to the health care provider.

Acute Problems of DiabetesThe client tells the nurse that her grandmother was very sick after her gallbladder was removed last year, in a coma and was diagnosed with hyperglycemic-hyperosmolar nonketotic syndrome (HHNS). The client asks the nurse to describe differences in HHNS and DKA. How should the nurse respond? A. HHNS is the result of excess insulin, rather than hyperglycemia and ketosis. B. HHNS is primarily caused by excess ketone bodies, although hyperglycemia occurs. C. HHNS is caused by persistent hyperglycemia, but ketosis does not occur. D. HHNS is the result of fluid and electrolyte imbalance, not blood glucose.

C. HHNS is caused by persistent hyperglycemia, but ketosis does not occur. Rationale: HHNS is caused by persistent hyperglycemia resulting in osmotic diuresis, which results in fluid and electrolyte losses. There is enough insulin present to prevent breakdown of fats which leads to ketosis. Therefore, ketones are not found in the urine.

The client asks the nurse why their mother does not have diabetes, since it developed while she was pregnant. What is the best response? A. Women with gestational diabetes only experience diabetes during the time they are pregnant. B. She probably had pregnancy-induced glucose intolerance, rather than true gestational diabetes. C. Women with gestational diabetes are at high risk for developing diabetes after pregnancy, but not all will get the disease. D. She will eventually develop diabetes. All women who experience gestational diabetes eventually get the disease.

C. Women with gestational diabetes are at high risk for developing diabetes after pregnancy, but not all will get the disease. Rationale: Women who develop GDM often, but not always, develop Type 2 diabetes at some point following their pregnancy. Those who have gestational diabetes have up to a 63% chance of developing type 2 diabetes.

What is the mechanism that results in Kussmaul respirations? A. To compensate for metabolic acidosis, the respirations are deep and rapid. B. To overcome respiratory acidosis, the respirations are fast and shallow. C. Injury to the brain's respiratory center results in periods of apnea. D. Hypoxemia causes labored, gasping, and irregular respirations.

A. To compensate for metabolic acidosis, the respirations are deep and rapid. Rationale: To compensate for the ketoacidosis (metabolic acidosis), the lungs attempt to remove CO2 through a pattern of deep, rapid respirations referred to as Kussmaul respirations.

Therapeutic Communication: The client states that they wish they hadn't gotten the flu so that the diabetes wouldn't have been discovered, and they could keep having a normal life. What is the best initial response by the nurse? A. What do you mean when you say a normal life? B. It's better to find out now before complications develop. C. Perhaps you would like to speak to someone who has diabetes. D. It must be quite a shock to learn that you have diabetes.

D. It must be quite a shock to learn that you have diabetes. Rationale: This statement acknowledges the client's feelings, and is open-ended, allowing the client to continue to verbalize their feelings if they wish.

To restore the client's blood glucose to a normal level, what should the nurse prepare to administer? A. An IV infusion containing regular insulin. B. Humulin-N insulin SC before meals. C. 50% dextrose IV push. D. Glucagon subcutaneously PRN per sliding scale.

A. An IV infusion containing regular insulin. Rationale: Continuous IV infusions containing regular insulin are used to reduce the client's blood glucose level. The client's IV solution will be changed to one that contains glucose when her blood glucose level reaches 250 mg/dl.

When returning to the client's room, the nurse learns that breakfast trays have not yet arrived on the unit and all the other clients with diabetes have already received insulin. What action should the nurse take first? A. Ask the unit clerk to find out when the trays will be available. B. Distribute orange juice to all clients who have received insulin. C. Notify the dietary supervisor that client safety is being compromised. D. Observe the client to ensure that they give themself the insulin injection correctly.

A. Ask the unit clerk to find out when the trays will be available. Rationale: How quickly the trays will be available will determine what further action needs to be taken.

Which findings indicate that the client is experiencing complication of diabetes? (Select all that apply. One, some, or all options may be correct.) A. Burning sensation in the toes. B. Visual acuity of 60/20. C. Protein in their urine. D. Blood pressure of 110/60. E. A sore on their foot that is having trouble healing.

A. Burning sensation in the toes. B. Visual acuity of 60/20. C. Protein in their urine. E. A sore on their foot that is having trouble healing. Rationale: Paresthesia, such as a burning sensation, is an indication of neuropathy-progressive deterioration of the nerves resulting in loss of nerve function. Neuropathy can cause multiple problems in the diabetic, including loss of sensation, muscle weakness, and altered autonomic function. Peripheral neuropathy is especially significant as a major contributing factor to the onset of diabetic foot ulcers, which may ultimately lead to amputation. VA 60/20 finding indicates that the client is far-sighted. Diabetic retinopathy is a major problem, but it is indicated by a reduction in visual acuity, such as 20/60. A measurement of 20/200 is considered legal blindness. Once protein is found in the urine, the diabetic will progress to end-stage renal disease and renal failure. Poor wound healing is a result of long-term hyperglycemia. High levels of blood glucose damage the intima of capillaries, decreasing perfusion to the periphery, which can result in delayed wound healing.

The client learns about good foot care and the importance of regular monitoring of vision, kidney function, cardiovascular, and cerebrovascular systems. The client is aware of problems associated with neuropathies that can occur, both peripheral and autonomic. The client recognizes that they will be part of a collaborative healthcare team to manage their diabetes. The client states that single most important thing they can do is make sure blood glucose level are well controlled. What response should the nurse make? A. You're absolutely right, and your health care team will be there to help you. B. It is most important to keep your spirits up to avoid long-term complications. C. Diet and exercise are the most important parts of maintaining daily control. D. Taking your insulin every day is the most important thing you can do.

A. You're absolutely right, and your health care team will be there to help you. Rationale: Good glycemic control promotes health and well-being, and reduces the risk for complications, both acute and long-term. This is a multi-faceted challenge, which can be met by an effective collaborative health care team effort, with the client at the center.

Lifestyle Modifications: The client attends a series of classes on management of diabetes and learns that the goals of diet therapy for clients with Type 1 diabetes are to consume all essential nutrients, achieve and maintain ideal body weight, and maintain blood glucose levels as near normal as possible. The client tells the nurse that they understand the importance of a well-balanced diet, and states that they are in college an will want to go out for a beer every now and again. The client states that they understand that a can of beer has a lot of calories and they will watch what they eat if they plan to have a drink.What is the best response by the nurse? A. Drinking alcohol is prohibited on a diabetic diet, because you cannot predict how your blood glucose will react. B. Alcohol does contain a lot of empty calories, but it is also likely to cause your blood glucose to decrease. C. Plan to take extra insulin when you drink beer, because drinking will increase your blood glucose. D. A can of beer equals one carbohydrate exchange, so adjust your calories and food intake accordingly.

B. Alcohol does contain a lot of empty calories, but it is also likely to cause your blood glucose to decrease. Rationale: Twelve ounces of beer is the equivalent of two fat exchanges, which may elevate triglyceride levels, as well as adding empty calories. It is important that the diabetic understand that alcohol may induce hypoglycemia. Therefore, the client should drink alcohol only in moderation, and with, or shortly after meals.

Long-Term Complications: The client learns that there are a number of things they can do to reduce the risk for the numerous long-term complications associated with diabetes. The client understands that cardiovascular complications are a major cause of death in diabetics. Which lab value indicates that the client is working to reduce her risk for cardiovascular disease? A. Fasting blood glucose of 120 mg/dl (6.66 mmol/L). B. Glycosylated hemoglobin at 9% (75 mmol/mol). C. Low-density lipoprotein (LDL) cholesterol of 80 mg/dl (2.07 mmol/L). D. High-density lipoprotein (HDL) cholesterol of 30 mg/dl (0.78 mmol/L).

C. Low-density lipoprotein (LDL) cholesterol of 80 mg/dl (2.07 mmol/L). Rationale: Desired level is <100 mg/dl (2.59 mmol/L). Increases risk of heart disease are these serum lipid levels: Total cholesterol >200 mg/dL (5.18 mmol/L), Triglycerides ≥150 mg/dL (1.69 mmol/L), LDL cholesterol >130 mg/dL (3.37 mmol/L), HDL cholesterol <40 mg/dL (1.04 mmol/L) in men or <50 mg/dL (1.29 mmol/L) in women.

Diagnostic Tests: After discharge, the client is scheduled for a follow-up evaluation at the outpatient clinic. A glycosylated Hgb level is drawn, and the results were 11%. Which statement by the client reflects understanding of glycosylated Hgb? A. The results of the test are probably high, because I was not fasting before my blood was drawn this morning. B. The results of my test are probably high, because I went to a party last night and did not follow my diet. C. I know that I need to check my glycosolated Hgb before each meal and at bedtime, but I don't always have time. D. At least I won't have this done again for 3 months. I will really work at following my diet between now and then.

D. At least I won't have this done again for 3 months. I will really work at following my diet between now and then. Rationale: This test reflects average blood glucose levels over a period of approximately 120 days, the life of the average RBC. Glucose molecules attach to hemoglobin in the red blood cell. The longer the glucose in the blood is above normal, the higher the percentage of glycosylated hemoglobin. Normal levels range from 4-6% (20 - 42 mmol/mol), with levels over 8% (42 mmol/mol) indicating poor glycemic control. Note: Normal values may differ, depending on the lab.

The client's blood glucose level is stabilized, and they are transported to the acute care facility where blood glucose is monitored carefully. The admitting physician suspects that the client is experiencing Somogyi's effect. What technique should the nurse use to assess for this occurrence? A. Obtain preprandial and postprandial blood glucose measurements. B. Compare a baseline glycosylated Hgb to a current measurement. C. Compare venous blood glucose levels to capillary blood glucose levels. D. Monitor blood glucose levels during the night and before breakfast.

D. Monitor blood glucose levels during the night and before breakfast. Rationale: Somogyi's effect is the term for rebound morning hyperglycemia after night-time hypoglycemia. It is often caused by too much insulin or the lack of an adequate bedtime snack.

The client starts to cry and says that the nurse has no idea how awful this is and asks to be left alone. What is the best response by the nurse? A. I'll leave you alone for now, but I will stop back by in 30 minutes. B. I'll notify the diabetes counselor that you need a visit right away. C. You shouldn't be by yourself right now. I'll stay here with you. D. You need to express your feelings. Tell me more about what you are feeling.

A. I'll leave you alone for now, but I will stop back by in 30 minutes. Rationale: This response respects the client's request to be left alone, but the nurse is offering support and physical presence.

Once the client is more alert, what instructions should the nurse provide the roommate? A. Give the client some crackers and milk while waiting for the emergency transport. B. Help the client to bed and allow them to sleep as long as necessary. C. Encourage the client to drink a regular cola and eat a candy bar to keep blood glucose level up. D. Drive the client to the hospital, keeping the client NPO so they do not vomit.

A. Give the client some crackers and milk while waiting for the emergency transport. Rationale: The effect of the glucagon is only temporary. Therefore, the client should also eat a small snack containing carbohydrates and proteins to prevent hypoglycemia from recurring.

The client tells the nurse that her 15-year-old sister had a fasting blood glucose test last week, because she felt that she had some of the same symptoms that they had before being diagnosed with diabetes. The client states her sister's results were 135 mg/dl (7.49 mmol/L. How should the nurse respond? A. She needs a second test performed before a diagnosis is made. B. Since her value is high, it sounds like both of you have diabetes. C. Her value is low and indicates that she does not have diabetes. D. She is too young to develop Type 1 diabetes. She may have Type 2.

A. She needs a second test performed before a diagnosis is made. Rationale: The diagnosis of diabetes is based on two fasting blood glucose levels greater than 126 mg/dl (6.99 mmol/L).

In addition to monitoring the client's blood glucose level, what additional lab values should the nurse monitor carefully? (Select all that apply. One, some, or all options may be correct.) A. Uric acid. B. Hemoglobin. C. Calcium. D. Potassium. E. Blood Urea Nitrogen (BUN).

B, C, D, E. Rationale: Though blood glucose and potassium are the most critical lab values to assess, hemoglobin levels may be altered related to the state of hydration and should be monitored. Treatment with an IV insulin infusion will cause the potassium to return to the cells and may result in hypokalemia. Lara should be closely monitored for symptoms of hypokalemia. Supplemental potassium may be added to the IV infusion to prevent or correct this. Dehydration that occurs with DKA can lead to an increased BUN and should be monitored for signs of renal insufficiency.

To achieve the goal of restoring the client's fluid volume, the nurse would expect to implement which intervention? A. Insert a saline lock for PRN diuretic administration. B. Administer an albumin/furosemide continuous infusion. C. Maintain an infusion of normal saline solution. D. Obtain a type and crossmatch for 2 units of packed RBCs.

C. Maintain an infusion of normal saline solution. Rationale: The treatment of hyperglycemia includes fluid replacement to correct dehydration caused by the increased concentration of glucose in the blood. Isotonic fluids, such as normal saline, are used initially to treat the dehydration.

The nurse observes the client administer their morning dose of insulin. The client pinches the skin on the front of their thigh and inserts the needle at a 90-degree angle. What action should the nurse implement? A. Advise the client to remove the needle and reinsert it at a 45-degree angle. B. Instruct the client to pull the plunger back slightly before injecting the insulin. C. Tell the client to remove the needle, and draw up a new dose of insulin. D. Encourage the client to inject the insulin with the needle in place, as inserted.

D. Encourage the client to inject the insulin with the needle in place, as inserted. Rationale: The client has performed the steps for subcutaneous injection correctly. Since aspiration is not necessary, the client is ready to inject the insulin.

Ethical-Legal Issues: Client Information The client's blood glucose level stabilizes, and they begin taking oral fluids. IV solutions are switched to dextrose 5% in sodium chloride 0.45% at a keep-open rate, and the insulin infusion is discontinued.While hospitalized, family members and many of the client's college friends call the nursing unit to check on the client's condition. The nurse's decision about what to tell these callers should be based on what primary consideration? A. The instructions of the nursing unit supervisor. B. The nature of the caller's relationship to the client. C. The seriousness of the client's condition at the time of the call. D. The client's right to privacy regarding her health information.

D. The client's right to privacy regarding her health information. Rationale: The Health Information Privacy Protection Act (HIPAA) stipulates that a client has the right to privacy regarding health information and must give permission for the release of that information.

The client tells the nurse that they know that diabetes is a chronic condition and realizes that they probably had it for a while. The client asks why didn't they experience any symptoms before now. How should the nurse respond? A. The symptoms were so minor that you just didn't notice them until you got the flu. B. The type of diabetes you have is the acute form of diabetes, rather than the chronic form. C. The onset of symptoms is so gradual that your body adjusts to the changes. D. The symptoms have an abrupt onset that is often brought on by a viral illness, like the flu.

D. The symptoms have an abrupt onset that is often brought on by a viral illness, like the flu. Rationale: Since Type 1 diabetes seems to involve an interaction of genetic predisposition with an environmental trigger, the onset of symptoms is often abrupt, following an illness such as the flu.

An hour before the next dose of sliding-scale insulin is scheduled, the client tells the nurse that they guess they are really nervous about giving self-administering the insulin and shows the nurse how shaky and sweaty hands. What is the priority nursing action? A. Obtain the client's vital signs. B. Check the client's blood glucose. C. Assure the client that they will be able to give themself the injections. D. Offer to bring the client an orange so they can practice giving injections.

B. Check the client's blood glucose. Rationale: Feeling shaky and sweaty are symptoms of hypoglycemia. Therefore, it is most important to check the client's blood glucose. If the client's blood glucose is low, the nurse should provide a snack of milk and graham crackers.

The client tells the nurse that they will make sure they drink plenty of water and will take a little extra regular insulin before beginning strenuous exercise. What is the best response by the nurse? A. Remind the client that they should also carry a simple carbohydrate snack with them. B. Acknowledge the client's understanding of correct pre-exercise measures. C. Advise the client that extra insulin should not generally be taken before exercise. D. Teach the client that the extra insulin will give her more energy.

C. Advise the client that extra insulin should not generally be taken before exercise. Rationale: Exercise may cause hypoglycemia during or after the activity. Therefore, additional carbohydrates may be needed before, during, or after exercise. Clients should perform self-monitoring of blood glucose levels to determine the effects of exercise on blood glucose levels. In addition, it is important to remember that exercise in the client with uncontrolled diabetes results in hyperglycemia and may lead to ketosis. Diabetics with ketonuria and a blood glucose of 250 mg/dL (11.10 mmol/L) or above should avoid exercise.