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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.
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.
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.
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.
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
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.
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
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.
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.”
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.
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)
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).
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.
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.
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.
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).
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.
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.
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."
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.
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.
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.
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."
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.
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
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.
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.
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.-
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."
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.
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
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.
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
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.
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.
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.
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."
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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).