Metabolic Regulation
A client with type 1 diabetes mellitus has a finger stick glucose level of 258 mg/dL (14.3 mmol/L) at bedtime. A prescription for sliding-scale regular insulin exists. What should the nurse do?
1 Call the health care provider. 2 Encourage the intake of fluids. Correct 3 Administer the insulin as prescribed. 4 Give the client a half cup of orange juice. A value of 258 mg/dL (14.3 mmol/L) is above the expected range of 70 to 100 mg/dL (3.6 to 5.6 mmol/L); the nurse should administer the regular insulin as prescribed. Calling the health care provider is unnecessary; a prescription for insulin exists and should be implemented. Encouraging the intake of fluids is insufficient to lower a glucose level this high. Giving the client a half cup of orange juice is contraindicated because it will increase the glucose level further; orange juice, a complex carbohydrate, and a protein should be given if the glucose level is too low.
The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client?
1 Cystitis 2 Thin and dry skin 3 Decreased bone density Correct 4 Frequent yeast infections Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.
An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client?
1 "Adhere to the medical regimen." 2 "Remain normoglycemic for 3 weeks." Correct 3 "Demonstrate correct use of the insulin pump." 4 "List three self-care activities that help control the diabetes." Demonstrating correct use of the insulin pump is the short-term, client-oriented goal necessary for the client to manage the pump and avoid hypo- and hyperglycemia; this outcome can be measured by observing a return demonstration by the client. Adhering to the medical regimen is not a short-term goal. Remaining normoglycemic for 3 weeks is measurable but requires the client to manage the insulin pump. Although listing three self-care activities that help control the diabetes is a measurable short-term goal, it is not the priority when the client must master use of the insulin pump.
An adolescent who has just been found to have type 1 diabetes asks a nurse about exercise. What is the best response by the nurse?
1 "Exercise should be restricted." 2 "Exercise will increase blood glucose." Correct 3 "Extra snacks are needed before exercise." 4 "Extra insulin is required during exercise." Exercise lowers the blood glucose level; an extra snack can prevent hypoglycemia. Exercise is encouraged, not restricted. Exercise lowers, not increases, blood glucose. Extra insulin is contraindicated because exercise decreases the blood glucose level; extra insulin may precipitate hypoglycemia.
During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" What is the nurse's best response?
1 "Insulin cannot be manufactured in pill form." Correct 2 "Insulin is destroyed by gastric juices, rendering it ineffective." 3 "Your health care provider decides the route of administration." 4 "Your health care provider will prescribe pills when you are ready." Insulin in tablet form is inactivated by gastric juices; insulin given by injection avoids exposure to digestive enzymes. Insulin is not given orally at this time because it is inactivated by digestive enzymes. The response "Your health care provider will prescribe pills when you are ready" is incorrect information and provides false reassurance; the client currently is insulin dependent. The response "Your health care provider decides the route of administration" does not answer the client's question; insulin is administered intravenously or subcutaneously, and the route depends on the client's needs.
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor?
1 Abnormal P waves and depressed T waves Correct 2 Peaked T waves and widened QRS complexes 3 Abnormal Q waves and prolonged ST segments 4 Peaked P waves and an increased number of T waves Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change.
An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?
1 Clamping the cord a second time Correct 2 Obtaining heel blood to test the glucose level 3 Starting an intravenous (IV) infusion of glucose in water 4 Instilling an ophthalmic antibiotic to prevent an eye infection Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; it should not be damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined.
A client with type 1 diabetes receives 30 units of NPH insulin at 7 am. At 3:30 pm the client becomes diaphoretic, weak, and pale. What does the nurse determine that these physiologic responses are associated with?
1 Diabetic coma 2 Somogyi effect 3 Diabetic ketoacidosis Correct 4 Hypoglycemic reaction These are sympathetic nervous system responses to hypoglycemia; the peak action of NPH insulin is 8 to 12 hours after administration, and 8.5 hours have elapsed since it was given. The signs and symptoms of diabetic coma are dry mucous membranes; hot, flushed skin; deep, rapid respirations (Kussmaul breathing); acetone odor to the breath; nausea and vomiting; and, as with hypoglycemia, weakness. The Somogyi effect includes wide swings in blood glucose levels between hyperglycemia and a profound hypoglycemia caused by insulin rebound. Ketoacidosis results from excess use of fats for energy when carbohydrates cannot be used. Lipids are metabolized incompletely, and dehydration, acidosis (both ketotic and lactic), and electrolyte imbalance result. It is not the result of insulin administration.
What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy?
1 Exercise regularly. Correct 2 Rotate injection sites. 3 Use the Z-track technique. 4 Avoid massaging the injection site. Fibrous scar tissue can result from the trauma of repeated injections at the same site. Exercise is unrelated to lipodystrophy, but it reduces blood glucose, which decreases insulin requirements. Insulin is given subcutaneously; the Z-track technique is used with some intramuscular injections. Gentle pressure over the injection site after insulin administration promotes absorption.
While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes?
1 Having diabetes insipidus 2 Eating low-cholesterol foods Correct 3 Being 20 pounds (9 kilograms) overweight 4 Drinking a daily alcoholic beverage Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.
A nurse is caring for a client newly diagnosed with type 1 diabetes. When the primary healthcare provider tries to regulate this client's insulin regimen, the client experiences episodes of hypoglycemia and hyperglycemia, and 15 g of a simple sugar is prescribed. What is the reason this is administered when a client experiences hypoglycemia?
1 Inhibits glycogenesis 2 Stimulates release of insulin Correct 3 Increases blood glucose levels 4 Provides more storage of glucose A simple sugar provides glucose to the blood for rapid action. It does not inhibit glycogenesis. It does not stimulate the release of insulin. It does not stimulate the storage of glucose.
When assessing the laboratory values of a client with type 2 diabetes, what would the nurse expect the results to reveal?
1 Ketones in the blood but not in the urine 2 Glucose in the urine but not in the blood 3 Urine and blood positive for glucose and ketones Correct 4 Urine negative for ketones and positive glucose in the blood The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.
While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli?
1 Peas 2 Corn Correct 3 Green beans 4 Mashed potato According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas are a starch and are not an equivalent vegetable substitute for broccoli. Corn is a starch and is not an equivalent vegetable substitute for broccoli. Mashed potato is a starch and is not an equivalent vegetable substitute for broccoli.
At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?
1 Polydipsia 2 Ketoacidosis 3 Glycogenesis Correct 4 Hypoglycemia The time of the client's response corresponds to the expected peak action (4 to 12 hours after administration) of the intermediate-acting insulin that was administered in the morning; this can result in hypoglycemia. Hypoglycemia triggers the sympathetic nervous system; epinephrine causes diaphoresis and nervousness. Osmotic diuresis causes thirst; this is related to hyperglycemia, not to hypoglycemia. Warm, dry, flushed skin and lethargy are associated with ketoacidosis. Glycogenesis, the formation of glycogen in the liver, is unrelated to nervousness and cool, moist skin.
An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). What finding does the nurse expect during the initial assessment?
1 Pyrexia Correct 2 Hyperpnea 3 Bradycardia 4 Hypertension Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.
A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do?
1 Reduce the intake of protein-rich foods 2 Drink 8 ounces (240 mL) of water with meals Correct 3 Divide the daily caloric intake into six smaller meals 4 Remain in an upright position for one hour after eating The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.
A nurse working in the diabetes clinic is evaluating a client's success with managing the medical regimen. What is the best indication that a client with type 1 diabetes is successfully managing the disease?
1 Reduction in excess body weight Correct 2 Stabilization of the serum glucose 3 Demonstrated knowledge of the disease 4 Adherence to the prescription for insulin A combination of diet, exercise, and medication is necessary to control the disease; the interaction of these therapies is reflected by the serum glucose level. Weight loss may occur with inadequate insulin. Acquisition of knowledge does not guarantee its application. Insulin alone is not enough to control the disease.
A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?
1 Sodium bicarbonate, causing alkalosis 2 Ketones as a result of rapid fat breakdown, causing acidosis 3 Nitrogen from protein catabolism, causing ammonia intoxication 4 Glucose from rapid carbohydrate metabolism, causing drowsiness1 Sodium bicarbonate, causing alkalosis Correct 2 Ketones as a result of rapid fat breakdown, causing acidosis 3 Nitrogen from protein catabolism, causing ammonia intoxication 4 Glucose from rapid carbohydrate metabolism, causing drowsiness Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate. Diabetes does not interfere with removal of nitrogenous wastes. Carbohydrate metabolism is impaired in the client with diabetes.
A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child?
1 Sweating Correct 2 Hyperpnea 3 Bradycardia 4 Hypertension Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.
A 9-year-old child with type 1 diabetes is hospitalized for insulin dosage regulation. A nurse observes the child sneaking food and trying to talk family members into bringing candy. What action should the nurse take when the child complains of feeling hypoglycemic?
1 Test the urine for ketones. Correct 2 Obtain a blood glucose level. 3 Offer orange juice with sugar. 4 Determine when the child ate last. A check of the blood glucose level will confirm whether the child is hypoglycemic. Ketones are not in the urine during a hypoglycemic episode. Although offering orange juice with sugar might be appropriate to counter hypoglycemia, it does not reveal whether the child is hypoglycemic or is being manipulative. Although the nurse may eventually ask when the child ate last, this is not the priority.
A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise?
1 To decrease insulin sensitivity 2 To stimulate glucagon production Correct 3 To improve the cellular uptake of glucose 4 To reduce metabolic requirements for glucose Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client?
1 Weight loss 2 Hypoglycemia 3 Decreased blood pressure Correct 4 Inadequate wound healing Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on?
1. Correct: Maintaining normoglycemia 2 Complying with the diabetic diet 3 Adhering to an exercise program 4 Developing a nonstressful lifestyle Maintaining normoglycemia is a realistic goal because it decreases the risk of complications such as neuropathy, retinopathy, and atherosclerosis. A regimen of insulin, exercise, and diet will help the adolescent achieve this goal. Compliance with a diabetic diet is an objective because it will help the adolescent achieve the long-term goal; diet alone is insufficient to achieve normoglycemia. Adherence to an exercise program is an objective because it will help the adolescent achieve the long-term goal; exercise alone is insufficient to achieve normoglycemia. Development of a nonstressful lifestyle is a worthwhile goal, but it is not realistic.
How does the nurse arrange the events that take place during the promotion of glucose transportation into the cells through cell membranes?
2. Secretion of proinsulin by beta cells 3. Storage of proinsulin in the pancreas 4. Transformation of proinsulin into active insulin 1. Attachment of insulin to receptors Proinsulin is a prohormone that is secreted by beta cells and is stored in the beta cells of islets of Langerhans of the pancreas. Active insulin is a protein made up of 51 amino acids; it is produced when C-peptide is removed from the proinsulin. Insulin attaches to receptors present on the target tissues, such as adipose tissue or muscle, where the promotion of glucose transport into the cells through cell membranes occurs.
The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis?
A low pH and bicarbonate reflect metabolic acidosis; a low PCO2 indicates compensatory hyperventilation. A low pH and elevated PCO2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO2 indicates compensatory hypoventilation. An elevated pH and low PCO2 reflect hyperventilation and respiratory alkalosis.
A nurse is planning to teach facts about hyperglycemia to a client with diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?
Correct 1 Breakdown of fat stores for energy 2 Ingestion of too many highly acidic foods 3 Excessive secretion of endogenous insulin 4 Increased amounts of cholesterol in the extracellular compartment In the absence of insulin, which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.
A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include to decrease the risk of complications? Select all that apply.
Correct 1 Examine the feet daily Correct 2 Wear well-fitting shoes Correct 3 Perform regular exercise 4 Powder the feet after showering 5 Visit the primary healthcare provider weekly 6 Test bathwater with the toes before bathing Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary healthcare provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.
A client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide?
Correct 1 Stimulates the pancreas to produce insulin 2 Accelerates the liver's release of stored glycogen 3 Increases glucose transport across the cell membrane 4 Lowers blood glucose in the absence of pancreatic function Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.
A school-aged child is receiving 45 units of intermediate-acting insulin at 7:00 AM and 7:00 PM. What will the nurse tell the parents regarding a bedtime snack?
Offer a snack at bedtime if there are signs of hyperglycemia. Correct 2 Provide a bedtime snack to prevent hypoglycemia during the night. 3 Withhold the snack after dinner to prevent hyperglycemia during sleep. 4 Leave a snack at the bedside in case the child becomes hungry during the night Intermediate-acting insulin peaks in 4 to 12 hours; a bedtime snack will prevent hypoglycemia during the night. Offering a snack at bedtime if there are signs of hyperglycemia is unsafe because it will intensify the hyperglycemia; if hyperglycemia is present, the child needs insulin. Bedtime snacks are recommended for people taking intermediate-acting insulin. When hypoglycemia develops, the child will be asleep; the snack should be eaten before bed