Chapter 46: Management of Patients with Diabetes

Question 1

1. A client with type 1 diabetes has told the nurse that the client’s most recent urine test
   for ketones was positive. What is the nurse’s most plausible conclusion based on this
   assessment finding?
   A. The client should withhold the next scheduled dose of insulin.
   B. The client should promptly eat some protein and carbohydrates.
   C. The client’s insulin levels are inadequate.
   D. The client would benefit from a dose of metformin.

Answer 1

ANS: C
Rationale: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client’s ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

Question 2

2. A client presents to the clinic reporting symptoms that suggest diabetes. What criteria
   would support checking blood levels for the diagnosis of diabetes?
   A. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L)
   B. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L)
   C. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate
   occasions
   D. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)

Answer 2

ANS: A
Rationale: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).

Question 3

3. A client newly diagnosed with type 2 diabetes is attending a nutrition class. What
   general guideline should the nurse teach the clients at this class?
   A. Low fat generally indicates low sugar.
   B. Protein should constitute 30% to 40% of caloric intake.
   C. Most calories should be derived from carbohydrates.
   D. Animal fats should be eliminated from the diet.

Answer 3

ANS: C
Rationale: For all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low
fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

Question 4

4. A nurse is providing health education to a teenage client newly diagnosed with type 1
   diabetes mellitus, as well as the client’s family. The nurse teaches the client and family
   nonpharmacologic measures that will decrease the body’s need for insulin. What
   measure provides the greatest impact on glucose reduction?
   A. Adequate sleep
   B. Low stimulation
   C. Exercise
   D. Low-fat diet

Answer 4

ANS: C
Rationale: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not
reduce a client’s need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is as pronounced as that of exercise.

Question 5

5. A nurse is caring for a client with type 1 diabetes. The client’s medication
   administration record includes the administration of regular insulin three times daily.
   Knowing that the client’s lunch tray will arrive at 11:45 AM, when should the nurse
   administer the client’s insulin?
   A. 10:45 AM
   B. 11:30 AM
   C. 11:45 AM
   D. 11:50 AM

Answer 5

ANS: B
Rationale: Short-acting insulin is called regular insulin. It is in a clear solution and is usually given 15 minutes before a meal or in combination with a longer-acting insulin.
Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

Question 6

6. A client has just been diagnosed with type 2 diabetes. The health care provider has
   prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver
   and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did
   the health care provider prescribe for this client?
   A. A sulfonylurea
   B. A biguanide
   C. A thiazolidinedione
   D. An alpha-glucosidase inhibitor

Answer 6

ANS: B
Rationale: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin, and therefore require a functioning pancreas to be effective.
Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor
site without increasing insulin secretion from the beta cells of the pancreas. Alpha-glucosidase inhibitors work by delaying the absorption of glucose in the intestinal
system, resulting in a lower postprandial blood glucose level.

Question 7

7. A diabetes nurse educator is teaching a group of clients with type 1 diabetes about
   “sick day rules.” What guideline applies to periods of illness in a diabetic client?
   A. Do not eliminate insulin when nauseated and vomiting.
   B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L).
   C. Eat three substantial meals a day, if possible.
   D. Reduce food intake and insulin doses in times of illness.

Answer 7

ANS: A
Rationale: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take
their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but
should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

Question 8

8. The nurse is discussing macrovascular complications of diabetes with a client. The
   nurse would address what topic during this dialogue?
   A. The need for frequent eye examinations for clients with diabetes
   B. The fact that clients with diabetes have an elevated risk of myocardial infarction
   C. The relationship between kidney function and blood glucose levels
   D. The need to monitor urine for the presence of albumin

Answer 8

ANS: B
Rationale: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular.

Question 9

9. A school nurse is teaching a group of high school students about risk factors for
   diabetes. What action has the greatest potential to reduce an individual’s risk for
   developing diabetes?
   A. Have blood glucose levels checked annually.
   B. Stop using tobacco in any form.
   C. Undergo eye examinations regularly.
   D. Lose weight, if obese.

Answer 9

ANS: D
Rationale: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been
diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent diabetes.

Question 10

10. A teenage client is brought to the emergency department with symptoms of
    hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the
    client would be diagnosed with what type of diabetes?
    A. Type 1 diabetes
    B. Type 2 diabetes
    C. Non–insulin-dependent diabetes
    D. Prediabetes

Answer 10

ANS: A
Rationale: Beta cell destruction is the hallmark of type 1 diabetes. Non–insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

Question 11

11. A client newly diagnosed with type 2 diabetes has been told by their family that they
    can no longer consume alcohol. The client asks the nurse if abstaining from all alcohol is
    necessary. What is the nurse’s best response?
    A. “You should stop all alcohol intake. Alcohol is absorbed by your body before
    other important nutrients and may lead to very high blood glucose levels.”
    B. “You do not need to give up alcohol entirely but there are potential side effects
    specific to clients with diabetes that you should consider.”
    C. “You should no longer consume alcohol since it causes immediate low blood
    glucose levels in diabetic clients.”
    D. “You can still consume alcohol, but limit your consumption to no more than 3
    glasses of wine or beer daily because of the high sugar content of alcohol.”

Answer 11

ANS: B
Rationale: Clients with diabetes do not need to give up alcoholic beverages entirely. Moderation is the key. Moderate intake is no more than 1 alcoholic beverage (light beer, wine) for women and 2 drinks for men daily. Recommendations include avoiding mixed drinks and liqueurs because of the possibility of excessive weight gain, elevated glucose levels, and hyperlipidemia. Clients should be aware of potential side effects of alcohol consumption. These include diabetic ketoacidosis and hypoglycemia To combat possible hypoglycemia, clients with diabetes should not consume alcohol on an empty stomach.

Question 12

12. An occupational health nurse is screening a group of workers for diabetes. What
    statement should the nurse interpret as being suggestive of diabetes?
    A. “I’ve always been a fan of sweet foods, but lately I’m turned off by them.”
    B. “Lately, I drink and drink and can’t seem to quench my thirst.”
    C. “No matter how much sleep I get, it seems to take me hours to wake up.”
    D. “When I went to the washroom the last few days, my urine smelled odd.”

Answer 12

ANS: B
Rationale: Classic clinical manifestations of diabetes include the “three Ps”: polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.

Question 13

13. A diabetes educator is teaching a client about type 2 diabetes. The educator
    recognizes that the client understands the primary treatment for type 2 diabetes when
    the client states:
    A. “I read that a pancreas transplant will provide a cure for my diabetes.”
    B. “I will take my oral antidiabetic agents when my morning blood sugar is high.”
    C. “I will make sure to follow the weight loss plan designed by the dietitian.”
    D. “I will make sure I call the diabetes educator when I have questions about my
    insulin.”

Answer 13

ANS: C
Rationale: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise
are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral
agents may be used. Some clients may require insulin on an ongoing basis, or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

Question 14

14. A diabetes nurse educator is presenting current recommendations for levels of caloric
    intake. What are the current recommendations that the nurse would describe?
    A. 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from
    protein
    B. 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the
    remaining 50% to 60% from protein
    C. 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the
    remaining 10% to 20% from protein
    D. 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the
    remaining 10% to 20% from protein

Answer 14

ANS: D
Rationale: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to
60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat
does not need to be eliminated from the diet.

Question 15

15. An older adult client with type 2 diabetes is brought to the emergency department by
    the client’s daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3
    mmol/L). The client’s daughter reports that the client recently had a gastrointestinal
    virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic
    hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
    A. Administration of antihypertensive medications
    B. Administering sodium bicarbonate intravenously
    C. Reversing acidosis by administering insulin
    D. Fluid and electrolyte replacement

Answer 15

ANS: D
Rationale: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not
indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually
normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

Question 16

16. A nurse is caring for a client with type 1 diabetes who is being discharged home
    tomorrow. What is the best way to assess the client’s ability to prepare and
    self-administer insulin?
    A. Ask the client to describe the process in detail.
    B. Observe the client drawing up and administering the insulin.
    C. Provide a health education session reviewing the main points of insulin delivery.
    D. Review the client’s first hemoglobin A1C result after discharge.

Answer 16

ANS: B
Rationale: Nurses should assess the client’s ability to perform diabetes-related self-care as soon as possible during the hospitalization or office visit to determine whether the client requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the client performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the client about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.

Question 17

17. The nurse reviews foot care with an older adult client. Why would the nurse feel that
    foot care is so important to this client?
    A. An older adult client with foot ulcers experiences severe foot pain due to the
    diabetic polyneuropathy.
    B. Avoiding foot ulcers may mean the difference between institutionalization and
    continued independent living.
    C. Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults
    with diabetes.
    D. Oral antihyperglycemics have the possible adverse effect of decreased
    circulation to the lower extremities.

Answer 17

ANS: B
Rationale: The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the older adult with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs given for diabetes.

Question 18

18. A diabetic educator is discussing “sick day rules” with a newly diagnosed type 1
    diabetic. The educator is aware that the client will require further teaching when the
    client states what?
    A. “I will not take my insulin on the days when I am sick, but I will certainly check
    my blood sugar every 2 hours.”
    B. “If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six
    to eight times a day.”
    C. “I will call the doctor if I am not able to keep liquids in my body due to vomiting
    or diarrhea.”
    D. “I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I
    have ketones in my urine.”

Answer 18

ANS: A
Rationale: The nurse must explain the “sick day rules” again to the client who plans to stop taking insulin when sick. The nurse should emphasize that the client should take
insulin agents as usual and test the blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring clients may need supplemental doses of regular insulin every 3 to
4 hours. The client should report elevated glucose levels (greater than 300 mg/dL or 16.6 mmol/L, or as otherwise instructed) or urine ketones to the health care provider. If the client is not able to eat normally, the client should be instructed to substitute with soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the client should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

Question 19

19. Which of the following clients with type 1 diabetes is most likely to experience
    adequate glucose control?
    A. A client who skips breakfast when the glucose reading is greater than 220 mg/dL
    (12.3 mmol/L)
    B. A client who never deviates from the prescribed dose of insulin
    C. A client who adheres closely to a meal plan and meal schedule
    D. A client who eliminates carbohydrates from the daily intake

Answer 19

ANS: C
Rationale: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require
insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the
approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

Question 20

20. A pregnant client has been diagnosed with gestational diabetes. The client is shocked
    by the diagnosis, stating that they are conscientious about their health, and asks the
    nurse what causes gestational diabetes. The nurse should explain that gestational
    diabetes is a result of what etiologic factor?
    A. Increased caloric intake during the first trimester
    B. Changes in osmolality and fluid balance
    C. The effects of hormonal changes during pregnancy
    D. Overconsumption of carbohydrates during the first two trimesters

Answer 20

ANS: C
Rationale: Hyperglycemia and eventual gestational diabetes develop during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The
disease is not the result of food intake or changes in osmolality.

Question 21

21. A medical nurse is aware of the need to screen specific clients for their risk of
    hyperglycemic hyperosmolar syndrome (HHS). In what client population does this
    syndrome most often occur?
    A. Clients who are obese and who have no known history of diabetes
    B. Clients with type 1 diabetes and poor dietary control
    C. Adolescents with type 2 diabetes and sporadic use of antihyperglycemics
    D. Middle-aged or older people with either type 2 diabetes or no known history of
    diabetes

Answer 21

ANS: D
Rationale: HHS occurs most often in older clients (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. HHS is a serious metabolic disorder resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. Obesity does play a role in HHS but clients usually have a history of type 2 diabetes. Clients with type 1 diabetes usually present with DKA (diabetic ketoacidosis). Adolescents with type 2 have a low incidence of this condition.

Question 22

22. A nurse is caring for a client newly diagnosed with type 1 diabetes. The nurse is
    educating the client about self-administration of insulin in the home setting. The nurse
    should teach the client to do what action?
    A. Avoid using the same injection site more than once in 2 to 3 weeks.
    B. Avoid mixing more than one type of insulin in a syringe.
    C. Cleanse the injection site thoroughly with alcohol prior to injecting.
    D. Inject at a 45-degree angle.

Answer 22

ANS: A
Rationale: To prevent lipodystrophy, the client should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable,
within specific guidelines, and the needle is usually inserted at a 90-degree angle. Cleansing the injection site with alcohol is optional.

Question 23

23. A client with type 2 diabetes normally achieves adequate glycemic control through
    diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however,
    the client has required insulin injections on two occasions. The nurse would identify what
    factor most likely caused this short-term change in treatment?
    A. Alterations in bile metabolism and release have likely caused hyperglycemia.
    B. Stress has likely caused an increase in the client’s blood sugar levels.
    C. The client’s efforts did not control the diabetes using nonpharmacologic
    measures.
    D. The client’s volatile fluid balance surrounding surgery has likely caused unstable
    blood sugars.

Answer 23

ANS: B
Rationale: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase because levels of stress hormones (epinephrine, norepinephrine,
glucagon, cortisol, and growth hormone) increase. The client’s need for insulin is unrelated to the action of bile. The client’s normal routine of nonpharmacological
strategies of diet and exercise have been changed due to the client’s admission to the hospital. Therefore, the client cannot overestimate what they cannot control. Electrolyte/
fluid balances may have some bearing on glucose levels, but stress is the most impactful cause of the change happening to this client.

Question 24

24. The health care provider has explained to a client that the client has developed
    diabetic neuropathy in the right foot. Later that day, the client asks the nurse what
    causes diabetic neuropathy. What would be the nurse’s best response?
    A. “Research has shown that diabetic neuropathy is caused by fluctuations in blood
    sugar that have gone on for years.”
    B. “The cause is not known for sure but it is thought to have something to do with
    ketoacidosis.”
    C. “The cause is not known for sure but it is thought to involve elevated blood
    glucose levels over a period of years.”
    D. “Research has shown that diabetic neuropathy is caused by a combination of
    elevated glucose and ketone levels.”

Answer 24

ANS: C
Rationale: The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugar (rather than fluctuations or variations in blood sugars)
is thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.

Question 25

25. A client with type 2 diabetes has been managing his blood glucose levels using diet
    and metformin. Following an ordered increase in the client’s daily dose of metformin, the
    nurse should prioritize which of the following assessments?
    A. Monitoring the client’s neutrophil levels
    B. Assessing the client for signs of impaired liver function
    C. Monitoring the client’s level of consciousness and behavior
    D. Reviewing the client’s creatinine and BUN levels

Answer 25

ANS: D
Rationale: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the client’s kidney function. This drug does not typically affect clients’ neutrophils, liver function, or cognition.

Question 26

26. A client with a long-standing diagnosis of type 1 diabetes has a history of poor
    glycemic control. The nurse recognizes the need to assess the client for signs and
    symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what
    nursing diagnosis?
    A. Infection
    B. Acute pain
    C. Acute confusion
    D. Impaired urinary elimination

Answer 26

ANS: A
Rationale: Decreased sensations of pain and temperature place clients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes
associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function.

Question 27

27. A client has been brought to the emergency department by paramedics after being
    found unconscious. The client’s MedicAlert bracelet indicates that the client has type 1
    diabetes and the client’s blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should
    anticipate what intervention?
    A. IV administration of 50% dextrose in water
    B. Subcutaneous administration of 10 units of Humalog
    C. Subcutaneous administration of 12 to 15 units of regular insulin
    D. IV bolus of 5% dextrose in 0.45% NaCl

Answer 27

ANS: A
Rationale: In hospitals and emergency departments, for clients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV
for the treatment of hypoglycemia. Five percent dextrose would be inadequate, and insulin would exacerbate the client’s condition.

Question 28

28. A nurse is working for the summer at a camp for adolescents with diabetes. When
    providing information on the prevention and management of hypoglycemia, what action
    should the nurse promote?
    A. Always carry a form of fast-acting sugar.
    B. Perform exercise prior to eating whenever possible.
    C. Eat a meal or snack every 8 hours.
    D. Check blood sugar at least every 24 hours.

Answer 28

ANS: A
Rationale: The following teaching points should be included in information provided to the client on how to prevent hypoglycemia: Always carry a form of fast-acting sugar,
increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.

Question 29

29. A nurse is teaching basic “survival skills” to a client newly diagnosed with type 1
    diabetes. What topic should the nurse address?
    A. Signs and symptoms of diabetic nephropathy
    B. Management of diabetic ketoacidosis
    C. Effects of surgery and pregnancy on blood sugar levels
    D. Recognition of hypoglycemia and hyperglycemia

Answer 29

ANS: D
Rationale: It is imperative that newly diagnosed clients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for
education, but are not components of the client’s immediate “survival skills” following a new diagnosis.

Question 30

30. A nurse is conducting a class on how to self-manage insulin regimens. A client asks
    how long a vial of insulin can be stored at room temperature before it “goes bad.” What
    would be the nurse’s best answer?
    A. “If you are going to use up the vial within 1 month, it can be kept at room
    temperature.”
    B. “If a vial of insulin will be used up within 21 days, it may be kept at room
    temperature.”
    C. “If a vial of insulin will be used up within 2 weeks, it may be kept at room
    temperature.”
    D. “If a vial of insulin will be used up within 1 week, it may be kept at room
    temperature.”

Answer 30

ANS: A
Rationale: If a vial of insulin will be used up within 1 month, it may be kept at room temperature.

Question 31

31. A client has received a diagnosis of type 2 diabetes. The diabetes nurse has made
    contact with the client and will implement a program of health education. What is the
    nurse’s priority action?
    A. Ensure that the client understands the basic pathophysiology of diabetes.
    B. Identify the client’s body mass index.
    C. Teach the client “survival skills” for diabetes.
    D. Assess the client’s readiness to learn.

Answer 31

ANS: D
Rationale: Before initiating diabetes education, the nurse assesses the client’s (and family’s) readiness to learn. This must precede other physiologic assessments (such as
BMI) and providing health education.

Question 32

32. A student with diabetes reports feeling nervous and hungry. The school nurse
    assesses the student and finds the child has tachycardia and is diaphoretic with a blood
    glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?
    A. A combination of protein and carbohydrates, such as a small cup of yogurt
    B. Two teaspoons of sugar dissolved in a cup of apple juice
    C. Half of a cup of juice, followed by cheese and crackers
    D. Half a sandwich with a protein-based filling

Answer 32

ANS: C
Rationale: Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. Initial treatment should be followed with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and the additional sugar may result in a sharp rise in blood sugar that will last for several hours.

Question 33

33. A client with a history of type 1 diabetes has just been admitted to the critical care
    unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment
    during the client’s initial phase of treatment?
    A. Monitoring the client for dysrhythmias
    B. Maintaining and monitoring the client’s fluid balance
    C. Assessing the client’s level of consciousness
    D. Assessing the client for signs and symptoms of venous thromboembolism

Answer 33

ANS: B
Rationale: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the
hyperglycemia with insulin. The nurse should monitor the client for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the
highest priority.

Question 34

34. A client has been living with type 2 diabetes for several years, and the nurse realizes
    that the client is likely to have minimal contact with the health care system. In order to
    ensure that the client maintains adequate blood sugar control over the long term, what
    should the nurse recommend?
    A. Participation in a support group for persons with diabetes
    B. Regular consultation of websites that address diabetes management
    C. Weekly telephone “check-ins” with an endocrinologist
    D. Participation in clinical trials relating to antihyperglycemics

Answer 34

ANS: A
Rationale: Participation in support groups is encouraged for clients who have had diabetes for many years as well as for those who are newly diagnosed. This is more
interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may
or may not be beneficial and appropriate, depending on clients’ circumstances.

Question 35

35. A client with type 1 diabetes mellitus is seeing the nurse to review foot care. What
    would be a priority instruction for the nurse to give the client?
    A. Examine feet weekly for redness, blisters, and abrasions.
    B. Avoid the use of moisturizing lotions.
    C. Avoid hot-water bottles and heating pads.
    D. Dry feet vigorously after each bath.

Answer 35

ANS: C
Rationale: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.
Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but
never between the toes. After a bath, the client should gently, not vigorously, pat feet dry to avoid injury.

Question 36

36. The most recent blood work of a client with a long-standing diagnosis of type 1
    diabetes has shown the presence of microalbuminuria. What is the nurse’s most
    appropriate action?
    A. Teach the client about actions to slow the progression of nephropathy.
    B. Ensure that the client receives a comprehensive assessment of liver function.
    C. Determine whether the client has been using expired insulin.
    D. Administer a fluid challenge and have the test repeated.

Answer 36

ANS: A
Rationale: Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular
complication are warranted. Expired insulin does not cause nephropathy, and the client’s liver function is not likely affected. There is no indication for the use of a fluid challenge.

Question 37

37. A nurse is assessing a client who has diabetes for the presence of peripheral
    neuropathy. The nurse should question the client about what sign or symptom that would
    suggest the possible development of peripheral neuropathy?
    A. Persistently cold feet
    B. Pain that does not respond to analgesia
    C. Acute pain, unrelieved by rest
    D. The presence of a tingling sensation

Answer 37

ANS: D
Rationale: Although approximately half of clients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication.

Question 38

38. A client with diabetes is asking the nurse what causes diabetic ketoacidosis (DKA).
    Which of the following is a correct statement by the nurse?
    A. “DKA can be caused by taking too much insulin.”
    B. “DKA can be caused by taking too little insulin.”
    C. “DKA can happen without a cause.”
    D. “DKA will not happen with type 1 diabetes.”

Answer 38

ANS: B
Rationale: Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and undiagnosed and untreated diabetes. DKA may be the initial manifestation of type 1 diabetes. For prevention of DKA related to illness, the client should attempt to consume frequent small portions of carbohydrates. Drinking fluid every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4
hours, and the client should take the usual dose of insulin.

Question 39

39. A client is brought to the emergency department. The client is a type 2 diabetic and
    is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify
    what components of HHS? Select all that apply.
    A. Leukocytosis
    B. Glycosuria
    C. Dehydration
    D. Hypernatremia
    E. Hyperglycemia

Answer 39

ANS: B, C, E
Rationale: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the
intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hyponatremia and increased osmolarity occur. Leukocytosis does not take place.