General DM
Which physiologic actions result from normal insulin secretion? (Select all that apply.)
a. Increased liver storage of glucose of glycogen
b. Increased gluconeogenesis
c. Increased cellular uptake of blood glucose
d. Increased breakdown of lipids (fats) for fuel
e. Increased production and release of epinephrine
f. Decreased storage of free fatty acids in fat cells
g. Decreased blood glucose levels
h. Decreased blood cholesterol levels
ANS: A, C, G, H
The main metabolic effects of insulin are to stimulate glucose uptake in skeletal muscle and heart muscle and to suppress liver production of glucose and very-low-density lipoprotein (VLDL). In the liver, insulin promotes the production and storage of glycogen (glycogenesis) at the same time that it inhibits glycogen breakdown into glucose (glycogenolysis). It increases protein and lipid (fat) synthesis and inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). In muscle, insulin promotes protein and glycogen synthesis. In fat cells, it promotes triglyceride storage. Overall, insulin keeps blood glucose levels from becoming too high and helps keep blood lipid levels in the normal range.
A nurse is providing discharge teaching to a client who has diabetic ketoacidosis. Which of the following information should the nurse include in the teaching? (Select all that apply)
Drink 2 L fluids daily
Monitor blood glucose every 4 hour when ill
Administer insulin as prescribed when ill
Notify provider when blood glucose is 200 mg/dl
Report ketones in the urine after 24 hour of illness
Answer: 1,2,3,5
Rationale: Option 1 is correct. Drinking 2 L of fluids can prevent dehydration if the client develops DKA. Option 4 is incorrect. Nurse should notify provider if BS is greater than 250 mg/dl.
The nurse performs a physical assessment on a client with type 2 DM. Findings include (6.8 mmol/L) temperature of 101F (38.3C) pulse of 102 bpm, RR 12 bpm, BP 142/72 mmHg. Which finding would be the priority concern to the nurse?
Pulse
Respiration
Temperature
Blood pressure
ANSWER: 3
Rationale: In client with Type 2 DM elevated temperature may indicate infection. Infection is leading cause of hyperosmolar hyperglycemic syndrome in client with Type 2 DM. The other findings are within normal limits.
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL (mmol/L) and a hemoglobin A1c (A1C) of 5.9%. What is the nurse’s interpretation of these findings?
a. The client’s glucose control for the past 24 hours has been good but the overall control is poor.
b. The client’s glucose control for the past 24 hours has been poor but the overall control is good.
c. The values indicate that the client has poorly managed his or her disease.
d. The values indicate that the client has managed his or her disease well.
ANS: D
Fasting blood glucose levels provide an indication of the client’s adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client’s FBG is well within the normal range.
A1C provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client’s A1C level is within the desirable range, indicating good long-term
The nurse is monitoring a client newly diagnosed with DM for signs of complications. Which sign and symptom, if exhibited in the client indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?
Polyuria
Diaphoresis
Pedal edema
Decreased respiratory rate
ANSWER: 1
Rationale: Chronic hyperglycemia resulting from poor glycemic control contributes to microvascular and macrovascular complications of DM. Classic symptoms include polydipsia, polyuria, polyphagia. Option 2 Diaphoresis occurs in hypoglycemia. Option 3 & 4 are not associated with DM.
The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client indicates the need for further teaching?
Withdraws NPH insulin first
Withdraws regular insulin first
Injects air into NPH insulin vial first
Injects an amount of air equal to the desired dose of insulin into each vial
ANSWER: 1
Rationale: When preparing a mixture of short acting insulin such as regular insulin with another insulin preparation, the short acting is drawn into syringe first. The sequence will avoid contaminating the vial of short acting insulin with another type. Options 2,3,4 identify correct actions for preparing NPH and short acting insulin.
Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites?
a. 75-year-old client whose blood glucose levels show little variation
b. 55-year-old client who has hypoglycemic unawareness
c. 80-year-old client with type 2 diabetes mellitus
d. 45-year-old client with type 1 diabetes mellitus
ANS: B
Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Teach patients that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness should never use alternate sites for SMBG.
3. The home health nurse visits a client with diagnosis of Type 1 DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates need for further teaching?
“I need to stop my insulin”
“I need to increase my fluid intake”
I need to monitor my blood glucose every 3-4 hours”
“I need to call the health care provider (HCP) because of these symptoms”
ANSWER: 1
Rationale: When a client with DM is unable to eat normally because of illness the client still should take the prescribed insulin or oral medication. The client should consumed additional fluid and should notify health care provider. The client should monitor blood glucose every 3 to 4 hours. The client should also monitor the urine for ketones during illness
The home care nurse visits a client recently diagnosed with DM who is taking Humulin NPH daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?
Freeze the insulin
Refrigerate the insulin
Store the insulin in a dark, dry place
Keep the insulin at room temperature
ANSWER: 2
Rationale: Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Option 1,3,4 are incorrect
The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse placed PRIORITY on which client problem?
Lack of knowledge
Inadequate fluid volume
Compromised family coping
Inadequate consumption of nutrients
ANSWER: 2
Rationale: Increased blood glucose level will cause kidneys to excrete glucose in the urine. The glucose is accompanied by fluids and electrolytes causing osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Option 1,3,4 are not related to the information question.
A client with Type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin exercise?
“I should not exercise since I am taking insulin”
“The best time for me to exercise is after breakfast”
“The best time for me to exercise is mid- to late afternoon”
NPH is a basal insulin so I should exercise in the evening”
ANSWER: 2
Rationale: Exercise is an important part of diabetes management. It promotes weight loss, decrease insulin resistance and helps control blood glucose levels. A hypoglycemia reaction may occur in response to increased exercise so clients should exercise either an hour after mealtime or after consuming 10- to 15- gram carbohydrate snack and they should check blood glucose level before exercising. Option 1 is incorrect because clients with diabetes should exercise though they should check with health care provider before starting a new exercise program. Option 3 is incorrect client should avoid exercise during peak time of insulin. NPH peaks at 4-12 hours therefore afternoon exercise takes place during the peak of medication. Option 4 is incorrect; NPH is intermediate acting insulin not a basal insulin.
The nurse is providing discharge teaching for a client newly diagnosed with type 2 DM who has been prescribed metformin. Which client statement indicates the need for further teaching?
“It is okay if I skip meals now and then”
“I need to constantly watch for signs of low blood sugar”
“I need to let my health care provider know if I get unusually tired”
"I will be sure to not drink alcohol excessively while on this medication"
ANSWER: 2
Rationale: Metformin is classified as a biguanide and is the most commonly used medication for type 2 DM initially. It is often used as a preventive medication for those at high risks for developing DM. When used alone, metformin lowers the blood sugar after meal intake as fasting blood glucose levels. Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia. For this reason, Metformin is well suited for clients who skip meals. Unusual somnolence as well as hyperventilation, myalgia and malaise are early signs of lactic acidosis, a toxic effect associated with Metformin. If any of these s/sx occur, the client should notify MD immediately. While it is best to avoid consumption of alcohol it is not always realistic to quit drinking altogether for this reason, clients should be informed excessive alcohol intake can cause an adverse reaction with metformin.
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes?
a. “Avoid drinking ice-cold beverages.”
b. “Be sure to check your blood pressure twice daily.”
c. “Change positions slowly when moving from sitting to standing.”
d. “Check your hands and feet weekly for areas of numbness or sensation change.”
ANS: C
Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults.
Although checking blood pressure twice daily is helpful, it does not prevent orthostatic hypotension, nor is there any guarantee that such hypotension will occur during blood pressure measurement.
Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy.
Avoiding cold beverages is no longer a recommended action.
A nurse is assessing client with DKA and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply)
Weight gain
Fruity odor of breath
Abdominal pain
Kussmaul respiration
Metabolic acidosis
ANSWER: 2,3,4,5
Rationale: Option 1 is incorrect, Weight loss occurs when the cells are unable to use glucose because of insulin deficiency and places body in catabolic state. Option 2 is a manifestation of elevated ketone levels that lead to metabolic acidosis
A nurse is reviewing the health record of a client who has HHS (hyperglycemic-hyperosmolar state) The nurse should identify which of the following data confirm this diagnosis? (Select all that apply)
Evidence of recent myocardial infarction
BUN 35mg/dl
Take Calcium channel blocker
Age 77
No insulin production
ANSWER: 1,2,3,4
Rationale: The client who has type 2 DM and had MI is at risk for developing HHS due to increased hormone production during illness or stress which can stimulate the liver to produce glucose and decrease effects of insulin. Optiom 4 is incorrect because client with Type 2 DM can produce enough insulin to prevent ketoacidosis but not enough to control blood glucose resulting in HHS