diabetes

Question 1

1. Polydipsia and polyuria related to diabetes are primarily due to

Answer 1

b. fluid shifts resulting from the osmotic effect of hyperglycemia

Rationale: The osmotic effect of glucose cause the manifestations of polydipsia and polyuria.

Question 2

2. Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia?

Answer 2

d. The patient may have enough endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemia syndrome.

Rationale: Hyperosmolar hyperglycemia syndrome (HHS) is a life-threatening syndrome that
can occur in a patient with diabetes who is able to make enough insulin to prevent diabetesrelated ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis,
and extracellular fluid depletion.

Question 3

3. Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?

Answer 3

a. A1C 9%

Rationale: Lowering hemoglobin A1C (to less than 7%) reduces microvascular and neuropathic
complications. Keeping blood glucose levels in a tighter range (normal hemoglobin A1C level,
less than 6%) may further reduce complications but increases hypoglycemia risk.

Question 4

4. Which statement by the patient with type 2 diabetes is accurate?

Answer 4

a. “I will limit my alcohol intake to 1 drink each day.”

Rationale: The guideline for alcohol consumption in men with diabetes is 0-2 drinks per day.
For women with diabetes it is 0-1 drink per day.

Question 5

5. You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply)

Answer 5

a. Insulin administration
d. Use of a portable blood glucose monitor
e. Hypoglycemia prevention, symptoms, and treatment

Rationale: The nurse ensures that the patient understands the proper use of insulin. The nurse
teaches the patient how to use the portable blood glucose monitor and how to recognize and treat
signs and symptoms of hypoglycemia and hyperglycemia. These are referred to as “survival
skills.”

Question 6

6. What is the priority action for the nurse to take if the patient with type 2 diabetes reports blurred vision and irritability?

Answer 6

d. Check the patient’s blood glucose level.

Rationale: Check blood glucose whenever hypoglycemia is suspected so that immediate action
can be taken if necessary.

Question 7

7. A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetes-related ketoacidosis rather than hyperosmolar hyperglycemia syndrome based on the finding of

Answer 7

c. rapid, deep respirations.

Rationale: Signs and symptoms of DKA include manifestations of dehydration, such as poor
skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms
may include lethargy and weakness. As the patient becomes severely dehydrated, the skin
becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations (i.e., rapid, deep breathing associated with dyspnea) are the body’s attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.

Question 8

8. Which are appropriate therapies for patients with diabetes? (select all that apply)

Answer 8

a. Use of statins to reduce CVD risk
c. Use of ACE inhibitors to treat nephropathy
e. Use of laser photocoagulation to treat retinopathy

Rationale: In patients with diabetes who have albuminuria, angiotensin-converting enzyme
(ACE) inhibitors (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (ARBs)
(e.g., losartan [Cozaar]) are used. Both classes of drugs are used to treat hypertension and delay
the progression of nephropathy in patients with diabetes. The statin drugs are the most widely
used lipid-lowering agents. Laser photocoagulation therapy is indicated to reduce the risk of
vision loss in patients with proliferative retinopathy, in those with macular edema, and in some
cases of Nonproliferative retinopathy

Question 9

diabetes mellitus

Answer 9

Diabetes mellitus (DM), most often referred to as diabetes, is a chronic multisystem disease characterized by hyperglycemia from abnormal insulin production, impaired insulin use, or both.

Question 10

where’s insulin made

Answer 10

Insulin is a hormone made by the β cells in the islets of Langerhans of the pancreas

Question 11

normal glucose level

Answer 11

normal glucose range of about 74 to 106 mg/dL (4.1 to 5.9 mmol/L).

Question 12

insulin

Answer 12

Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell (Fig. 48.2). Cells break down glucose to make energy. Liver and muscle cells store excess glucose as glycogen. The rise in plasma insulin after a meal inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis. For this reason, insulin is an anabolic, or storage, hormone. The fall in insulin level during normal overnight fasting promotes the release of stored glucose from the liver, protein from muscle, and fat from adipose tissue.

Question 13

type 1

Answer 13

Type 1 diabetes, formerly known as juvenile-onset diabetes or insulin-dependent diabetes mellitus (IDDM), accounts for about 5% to 10% of all people with diabetes. Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age.3

Etiology and Pathophysiology
Type 1 diabetes is an autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic β cells that make insulin. This eventually results in not enough insulin for a person to survive. A genetic predisposition and exposure to a virus are factors that may contribute to the development of immune-related type 1 diabetes.

Question 14

onset type 1

Answer 14

In type 1 diabetes, the islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onset of symptoms. Manifestations develop when the person’s pancreas can no longer make enough insulin to maintain normal glucose. Once this occurs, the onset of symptoms is usually rapid. Patients often are initially seen with impending or actual ketoacidosis. The patient usually has a history of recent and sudden weight loss and the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger).
The person with type 1 diabetes requires insulin from an outside source (exogenous insulin) to sustain life. Without insulin, the patient will develop diabetes-related ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis. Newly diagnosed patients may have a remission, or “honeymoon period,” for 3 to 12 months after starting treatment. During this time, the patient needs little injected insulin because β-cell insulin production is still sufficient for healthy blood glucose levels. Eventually, as more β cells are destroyed and blood glucose levels increase, the honeymoon period ends and the patient will require insulin on a permanent basis.

Question 15

type 2

Type 2 diabetes is more prevalent in some ethnic populations. Blacks, Asian Americans, Hispanics, Native Hawaiians or other Pacific Islanders, and Native Americans have a higher rate of type 2 diabetes than whites.2

Answer 15

combination of inadequate insulin secretion and insulin resistance. The pancreas usually makes some endogenous (self-made) insulin. However, the body either does not make enough insulin or does not use it effectively, or both. The presence of endogenous insulin is a major distinction between type 1 and type 2 diabetes. In type 1 diabetes, there is an absence of endogenous insulin.

Question 16

insulin resistence, type 2

Answer 16

first factor is insulin resistance, a condition in which body tissues do not respond to the action of insulin because insulin receptors are unresponsive, are insufficient in number, or both.
A second factor in the development of type 2 diabetes is a marked decrease in the ability of the pancreas to make insulin, as the β cells become fatigued from the compensatory overproduction of insulin or when β-cell mass is lost.
This leads to a third factor, which is inappropriate glucose production by the liver. Instead of properly regulating the release of glucose in response to blood levels, the liver does so in a haphazard way that does not correspond to the body’s needs at the time.

Question 17

clinical manifestation type 1

Answer 17

type 1 diabetes is rapid, the first manifestations are usually acute. The classic symptoms are polyuria, polydipsia, and polyphagia. The osmotic effect of excess glucose in the bloodstream causes polydipsia and polyuria. Polyphagia is a result of cellular malnourishment when insulin deficiency prevents cells from using glucose for energy. Weight loss may occur because the body cannot get glucose and instead breaks down fat and protein to try to make energy. Weakness and fatigue may result because body cells lack needed energy from glucose. Ketoacidosis, a complication most common in those with untreated type 1 diabetes, is associated with additional manifestations. It is discussed later in this chapter.

Question 18

clincal manifestation type 2

Answer 18

The manifestations of type 2 diabetes are often nonspecific. It is possible a person with type 2 diabetes will have classic symptoms associated with type 1 diabetes, including polyuria, polydipsia, and polyphagia. Some of the more common manifestations associated with type 2 diabetes are fatigue, recurrent infections, recurrent vaginal yeast or candida infections, prolonged wound healing, and vision problems.

Question 19

diagnose diabetes

Answer 19

1. A1C of 6.5% or higher
2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or greater. Fasting is defined as no caloric intake for at least 8 hours
3. A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or greater during an OGTT, using a glucose load of 75 g
4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or greater

Question 20

diabetes drug therapy

Answer 20

• Insulin (Fig. 48.3 and Tables 48.3 and 48.4)
• OAs and noninsulin injectable agents (Table 48.7)
• Enteric-coated aspirin (81–162 mg/day)
• ACE inhibitors (see Table 32.6)
• Angiotensin II receptor blockers (ARBs) (see Table 32.6)
• Antihyperlipidemic drugs (see Table 33.6)

Question 21

type 1 long/intermediate acting insulin

Answer 21

Without 24-hour background insulin, people with type 1 diabetes are more prone to developing DKA. Many people with type 2 diabetes who use OAs will need basal insulin to adequately manage blood glucose levels.

Question 22

intermediate acting

Answer 22

typically cloudy. must roll in hands to disolve

Question 23

insulin injection site

Answer 23

abdomen, back arms, thighs, buttock

Question 24

somogi effect

Answer 24

hyperglycemia in the morning.. high dose of insulin given at night decreases glucose at night, stimulates release counterregulatory hormones (glucagon, epi, GH, cortisol) which stimulates lipolysis, gluconeogenesis, and glycogenolysis, which causes rebound hyperglycemia

tx:
snack at night and insulin reduction

Question 25

dawn phenomenon

Answer 25

hyperglycemia upon waking. GH and cortisol may be the cause.

Question 26

oral insulin

Answer 26

see

Question 27

metformin

Answer 27

Drug Alert
Metformin

• Do not use in patients with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication of metformin accumulation.
• IV contrast media that contain iodine pose a risk for CIN, which could worsen metformin-induced lactic acidosis.
• To reduce risk for CIN, discontinue metformin 2 days before the procedure.
• May be resumed 48 hours after the procedure, assuming kidney function is normal.
• Do not use in people who drink excess amounts of alcohol.
• Take with food to minimize GI side effects.

Question 28

nutrition diabetes 1

Answer 28

People with type 1 diabetes base their meal planning on usual food intake and preferences balanced with insulin and exercise patterns. The patient coordinates insulin dosing with eating habits and activity pattern in mind. Day-to-day consistency in timing and amount of food eaten makes it much easier to manage blood glucose levels, especially for those using conventional, fixed insulin regimens. Patients using rapid-acting insulin can adjust the dose before each meal based on the current blood glucose level and the carbohydrate content of the meal. Intensified insulin therapy, such as multiple daily injections or the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for changes from usual eating and exercise habits. This does not diminish or replace the need for healthy food choices and a well-balanced diet.

Question 29

nutrition diabetes 2

Answer 29

emphasizes achieving glucose, lipid, and BP goals. Modest weight loss has been associated with improved insulin sensitivity. Therefore weight loss is recommended for all persons with diabetes who are overweight or obese.13
There is no one proven strategy or method. A nutritionally adequate meal plan with appropriate serving sizes, a reduction of saturated and trans fats, and low carbohydrates can decrease calorie consumption. Spacing meals is another strategy that spreads nutrient intake throughout the day. A weight loss of 5% to 7% of body weight often improves blood glucose levels, even if desirable body weight is not achieved. Weight loss is best achieved by a moderate decrease in calories and an increase in caloric expenditure. Regularly exercising and adopting new behaviors and attitudes can promote long-term lifestyle changes. Monitoring blood glucose levels, A1C, lipids, and BP gives feedback on how well the goals of nutrition therapy are being met.

Question 30

exercise

Answer 30

The ADA recommends that people with diabetes engage in at least 150 min/wk (30 minutes, 5 days/week) of a moderate-intensity aerobic physical activity (Table 48.9). The ADA encourages people with type 2 diabetes to perform resistance training 3 times a week unless contraindicate

Question 31

glucose monitoring

Answer 31

self-monitoring blood glucose - finger sticks
continuous monitoring - insulin pump and sub q monitor injection

**use rapid acting (lispro) insulin

**programmed to deliver continuous infusion rapid acting for 24hrs a day, known as basal rate

teaching is essential for monitoring

Question 32

diabetes S/S and findings

Answer 32

eyes- sunken eyeballs, cataracks
skin - ulcers, lesions, feet
respiratory- kussmal (rapid and deep)
heart- hypotension, weak and rapid pulse
GI- dry mouth, vomiting, fruity breath
neurological - restlessness
muscles- wasting
possible findings- Serum electrolyte abnormalities. Fasting blood glucose level ≥126 mg/dL. OGTT >200 mg/dL, random glucose ≥200 mg/dL. Leukocytosis. ↑ BUN, creatinine, triglycerides, cholesterol, LDL, VLDL. ↓ HDL. A1C >6.0% (A1C >7.0% in those with diagnosed diabetes), glycosuria, ketonuria, albuminuria. Acidosis

Question 33

caring pt diabetes

Answer 33

Caring for the Patient With Diabetes
You will need to collaborate with many health care team members to deliver, delegate, and coordinate care based on the patient’s status.

• Assess for risk factors for prediabetes and type 1 and type 2 diabetes.
• Teach the patient and caregiver about diabetes management, including SMBG, insulin, noninsulin injectables, OAs, nutrition, physical activity, and managing hypoglycemia.
• Develop a plan to avoid hypoglycemia or hyperglycemia in a patient with DM who is acutely ill or having surgery.
• Assess for acute complications and implement appropriate actions for hypoglycemia, DKA, and HHS.
• In patients having acute complications, perform or directly supervise actions, including IV fluid and insulin administration.
• Assess for chronic complications, including CVD, retinopathy, nephropathy, neuropathy, and foot complications.
• Teach the patient and caregiver about prevention and management of chronic complications related to diabetes.
• Oversee LPN/VNs, and in some states and settings UAP, administer insulin, noninsulin injectable agents, and OAs to stable patients.

Collaborate With Other Team Members
Dietitian
• Obtain a diet history from the patient.
• Work with patient and caregiver to create an individualized meal plan.
• Provide instructions for meal plan as needed.

Physical Therapist
• Assess patient’s current level of fitness.
• Develop an exercise plan with the patient.

Occupational Therapist
• Teach with patient with vision impairment how to use devices to draw up and measure insulin.
• Provide teaching on how to use a talking blood glucose monitor or use any blood glucose monitor one handed.
• Develop protective techniques for activities that involve exposure to heat, cold, and sharp objects.

Social Worker
• Aid the patient in finding resources to meet medical and financial needs.
• Help with coping with diabetes, including managing problems within the family or workplace.

Question 34

teaching management diabetes

Answer 34

see

Question 35

teaching instructions diabetes

Answer 35

TABLE 48.15 Patient & Caregiver TeachingInstructions for Patients With Diabetes
Include the following essential instructions for diabetes management for the patient and caregiver:

Blood Glucose

• Monitor your blood glucose at home and record results in a log.
• Take your insulin, OA, and/or noninsulin injectable agent as prescribed.
• Take insulin consistently, especially when you are sick.
• Keep an adequate supply of insulin on hand at all times.
• Obtain A1C blood test every 3–6 mo as an indicator of your long-term blood glucose levels.
• Be aware of symptoms of hypoglycemia and hyperglycemia.
• Always carry a form of rapid-acting glucose so that you can treat hypoglycemia quickly.
• Teach family members how and when to use glucagon if patient becomes unresponsive because of hypoglycemia.

Exercise

• Learn how exercise and food affect your blood glucose levels.
• Remember that exercise will usually lower your blood glucose level.
• Begin an exercise program after approval from HCP.

Food

• Work with a dietitian to create a patient specific meal plan.
• Make healthy food choices and eat regular meals at regular times.
• Choose foods low in saturated and trans fat. Know your cholesterol level.
• Limit the amount of alcohol you drink.
• Be aware that excess amounts of alcohol may lead to unpredictable low blood glucose events.
• Avoid fad diets.
• Limit regular soda and fruit juice.

Other Guidelines

• Obtain an annual eye examination by an ophthalmologist.
• Obtain annual urine monitoring for protein.
• Examine your feet at home.
• Wear comfortable, well-fitting shoes to help prevent foot injury. Break in new shoes gradually.
• Always carry identification that says you have diabetes.
• Have other medical problems treated, especially high BP and high cholesterol.
• Have a yearly influenza vaccination.
• Quit or never start smoking cigarettes or using nicotine products.
• Avoid applying heat or cold directly to your feet.
• Avoid going barefoot.
• Keep skin moisturized by applying cream to surfaces of feet, but not between toes.

Question 36

ch 48 med surg questions

Answer 36

next

Question 37

1. rn teaches pt recently diagnosed w/ type 1 diabetes about insulin admin. which statement by pt requires intervention by rn

Answer 37

i will discard any insulin bottle that is cloudy in appearance

Rationale:
Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

Question 38

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet?

Answer 38

cheese

Rationale:
Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

Question 39

The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes?

Answer 39

Increased triglyceride levels

Rationale:
Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

Question 40

The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful?

Answer 40

“I can help control my blood pressure by avoiding foods high in salt.”

Rationale:
Patients with type 2 diabetes to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment of retinopathy.

Question 41

The nurse caring for a patient hospitalized with diabetes would look for which laboratory test result to obtain information on the patient’s past glucose control?

Answer 41

(HbA1C) Glycosylated hemoglobin level

Rationale:
A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

Question 42

a pt newly diagnosed type 1 reports headache, changes vision, anxious but does not have portable blood glucose monitor. what should rn advise pt tp take?

Answer 42

Eat 15 g of simple carbohydrates.

Rationale:
When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.

Question 43

The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis?

Answer 43

Excessive thirst

Rationale:
The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

Question 44

The nurse is assigned to care for a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in managing diabetes, what should be the nurse’s initial intervention?

Answer 44

Assess patient’s perception of what it means to have diabetes.

Rationale:
For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient’s care will not facilitate the patient’s health.

Question 45

The nurse is teaching a patient with type 2 diabetes about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan?

Answer 45

“I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week.”

Rationale:
The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.

Question 46

Which patient with type 1 diabetes would be at the highest risk for developing hypoglycemic unawareness?

Answer 46

A 73-yr-old patient who takes propranolol (Inderal)

Rationale:
Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

Question 47

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes?

Answer 47

A 48-yr-old woman with a hemoglobin A1C of 8.4%

Rationale:
Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.

Question 48

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin’s peak action?

Answer 48

10:30 PM to 1:30 AM

Rationale:
Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin’s onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

Question 49

The nurse teaches a patient with diabetes about a healthy eating plan. Which statement made by the patient indicates that teaching was successful?

Answer 49

“I may have a hypoglycemic reaction if I drink alcohol on an empty stomach.”

Rationale:
Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes. High-protein diets are not recommended for weight loss.

Question 50

A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively?

Answer 50

Obtain comprehensive dental care.

Rationale:
A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.

Question 51

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to explain how this medication works?

Answer 51

Reduces glucose production by the liver and enhances insulin sensitivity.

Rationale:
Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue’s insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

Question 52

A patient admitted with type 2 diabetes asks the nurse what “type 2” means. What is the most appropriate response by the nurse?

Answer 52

“With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased.”

Rationale:
In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.

Question 53

A patient is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.)

Answer 53

The level is consistent with renal insufficiency from renal nephropathy.

The level may be high because of dehydration that accompanies hyperglycemia.

The level may be raised due to metabolic ketoacidosis caused by hyperglycemia.

Rationale:
The additional stress of cellulitis may lead to an increase in the patient’s serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient’s potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.

Question 54

pt w diabetes schedule for fasting blood glucose level at 0800. rn teaches pt to only drink water after what time?

Answer 54

Midnight before the test
Rationale:
Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

Question 55

A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?

Answer 55

Kussmaul respirations

Rationale:
In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

Question 56

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time?

Answer 56

Cardiac monitoring to detect potassium changes

Rationale:
This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

Question 57

The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include?

Answer 57

Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin.

Rationale:
Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

Question 58

The nurse has been teaching a patient with diabetes how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient’s technique, the nurse identifies a need for additional teaching when the patient does what?

Answer 58

Chooses a puncture site in the center of the finger pad.

Rationale:
The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

Question 59

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement?

Answer 59

“I should look at the condition of my feet every day.”

Rationale:
Patients with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.

Question 60

glycogen

Answer 60

stored in liver as stored form glucose

Question 61

glucagon

Answer 61

created in the alpha cells of pancreas, released from pancreas to raises BS, tells liver to release glycogen to turn into glucose

Question 62

normal feedback loop

Answer 62

incr BS

• pancreas releases insulin and glucose enter cells
• left over glucose stored liver as glycogen

dec BS
- pancreas release glucagon, liver release glycogen turns into glucose

Question 63

DM pt

Answer 63

no insulin present (type 1) or body resistant insulin (type 2) = hyperglycemia

body starts metabolizes fats to produce ketones (type 1) OR has insulin but cant use (type 2)

Question 64

how DM type 1 present

Answer 64

thin, young, all of the sudden, ketones in urine, 3 P’s (poly)

Question 65

type 2 present

Answer 65

overweight, over time, rare for ketones in urine

Question 66

complications DM

Answer 66

hypoglycemia
- <60
- too much insulin or carb
- sweaty, cold, confused, clammy, blurriness,
treat
- simple carb (15 g) 4oz juice +++no candy)
- if unconscious - D50

DKA

• type 1 typical
• burning ketones, acidosis, fruity breath, thirsy, kussmaul (deep long rapid breaths)

HHSS (type 2) -
- no ketone breakdown, dehydration, altered loc, incr BS

S/S

• 3 P’s - polydipsia (drink), polyuria (pee), polyphagia (eat)
• glucosuria - glucose in urine

S - slow wound healing
U - bUrry vision
G - Glycosuria
A - Acetone breath (Type 1)
R - rashes skin and yeast women

Question 67

rn management

Answer 67

role: education, admin meds, assess, monitor

triangle management: monitor
diet, meds, exercise

Question 68

hypoglycemia

Answer 68

BG less than 70 or above 50 with S/S hypoglycemia

Question 69

insulin times

Answer 69

rapdid acting (linspro)
onset- 15 mins
peak - 1 hr
duration - 2-4 hrs

short acting (regular)
onset- 30-60 mins
peak- 2-6 hrs
duration- 3-8 hrs

intermediate (NPH)
onset- 2-4 hrs
peak- 4-10 hrs
duration10-20 hrs

long acting (glargine)
onset- 70 mins
peak- none
duration- 24 hrs

Question 70

insulin basal rates

Answer 70

continuous pump infusion of rapid acting insulin. can be increased or decreased based on need, carb intake, activity changes, and diff times of day

Question 71

dm diet

Answer 71

carbs - 45%
- grains, starchy vegs, dairy

fats- 20%

• limit sat and trans fats - whole milk, fatty red meats
• mono and poly sat fatas!!!

proteins- 15-20%
- lean, beans, egg white, low fat cheese

Question 72

hyperglycemia

Answer 72

3 P’s

I’m hot and dry, I must be on a sugar high

Question 73

oral medications- typical type 2

• cant control w diet and exercise

Answer 73

sulfonylureas - zides, mides, rides

• stim beta cells to make insulin
• • cause hypoglycemia and no alcohol experience extreme hypoglycemia

meglitinides - glinide

• stim beta cells make insulin
• taken w first bite food

biguanides - 
metformin
- decrease liver stores glucose
- help 48 hrs prior surgery and heart cath
--watch renal and diarrhea

alpha-glucoside inhibitors - starch blockers

• breaks starch foods in gut
• eatc with food

TZD

• decrease glucose prod in liver
• watch liver and heart function - increase risk MI

Question 74

drugs cause hypoglycemia

Answer 74

beta blockers
ETOH
ASA
MOA inhibitors
Bactrin
Sulfonylureas

Question 75

drugs cause hyperglycemia

Answer 75

thiazides
glucosteriods
estrogen therapy

Question 76

insulin

• *regular is only can be given IV**
• never massage- can increase hypoglycemia

Answer 76

ready, set, inject, love

rapid - 15 minutes feels like 1 hr during 2-4 rapid responses

short- short staffed nurses went from 30-60 patients 2 (to) 8 patients

intermediate - nurses play hero 2 (to) btw 4-10 10-20 year olds

long- the 20 minute long nursing shifts never peaked but lasted 24 hrs

Question 77

insulin categories

Answer 77

basal- background coverage, taken at night

• lowers average
• NPH, long acting glardine

insulin given at meals
prandial (fixed dosing) and correctional (based on glucose level/sliding scale)
**add these together to get pt dosing
- regular, lispro
-

Question 78

correctional insulin categories

Answer 78

responses to insulin

sensitive- high response to 1 unit insulin, requires less insulin
usual - normal response
resistant - low response, requires more insulin