TYPE 1 DIABETES

Manifestation & Insulin

100

Once the acute ketoacidosis is controlled, Lara is told that she has Type 1 diabetes mellitus. The nurse obtains Lara's history. Lara states that prior to the flu, she had been healthy. However, she had noticed that she had been eating more than normal, but had not been gaining any weight. Lara also states that she had been drinking a lot of diet colas and that she got up at night frequently to go to the bathroom. 7.The nurse identifies that Lara has experienced classic symptoms of diabetes, which are: A) Dysuria, dyspepsia, and dysphagia. B) Polyuria, polyphagia, and polydipsia. C) Abnormal diet, drink, and distention. D) Increased metabolism, increased fluid volume, and increased urgency.

What is B) Polyuria, polyphagia, and polydipsia. CORRECT Increased urinary output (polyuria), increased appetitie (polyphagia), and increased thirst (polydipsia) are the three classic manifestations of diabetes mellitus.

200

Lara starts to cry and says, "You have no idea how awful this is. I want to be by myself now. Please leave me alone." 10.What is the best response by the nurse? A) "I'll leave you alone for now, but I will stop back by in 30 minutes." B) "I'll notify the diabetes counselor that you need a visit right away." C) "You shouldn't be by yourself right now. I'll stay here with you." D) "You need to express your feelings. Tell me more about what you are feeling."

What is A) "I'll leave you alone for now, but I will stop back by in 30 minutes." CORRECT This response respects Lara's request to be left alone, but the nurse is offering support and physical presence.

300

The goal of treatment with hypoglycemic agents is the maintenance of stable blood glucose levels to prevent the acute complications of hypoglycemia and hyperglycemia, and the long-term complications associated with hyperglycemia. Lara will initially be taking Humulin N/Humulin R 70/30 insulin subcutaneously every a.m., a sliding-scale dose of regular insulin subcutaneously before lunch and dinner, and Humulin N insulin at bedtime. 11.Which statement made by Lara indicates that she correctly understands self-administration of insulin? A) "My daily dose of 70/30 insulin is based on how much I ate the day before." B) "The amount of short-acting insulin I take every day is based on my blood sugar readings." C) "I should store my insulin in the refrigerator and remove it 30 minutes before I need it." D) "I will alternate my injection sites from leg to abdomen each day to avoid overuse."

What is B) "The amount of short-acting insulin I take every day is based on my blood sugar readings." CORRECT Sliding scale refers to the administration of a dose of regular (short-acting) insulin based on Lara’s current blood glucose level.

400

An hour before the next dose of sliding-scale insulin is scheduled, Lara tells the nurse, "I guess I'm really nervous about giving myself insulin injections. Look how shaky and sweaty I am." 13.What is the priority nursing action? A) Obtain Lara's vital signs. B) Check Lara's blood glucose. C) Assure Lara that she will be able to give herself the injections. D) Offer to bring Lara an orange so she can practice giving injections.

What is B) Check Lara's blood glucose. CORRECT Feeling shaky and sweaty are symptoms of hypoglycemia. Therefore, it is most important to check Lara's blood glucose. If Lara's blood glucose is low, the nurse should provide a snack of milk and graham crackers.

500

The nurse teaches a client with diabetes mellitus about the differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develops? Select all that apply. A.Polyuria B.Shakiness c.Palpitations D.Blurred vision E.Lightheadedness f.Fruity breath odor

What is B,C,E Shakiness, Palpitations & Lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria,blurred vision, and fruity breath odor are signs of hyperglycemia.

ASSESSMENT

100

The nurse notes that Lara's breath has a fruity odor, and she is exhibiting Kussmaul respirations. 1.What is the mechanism that results in Kussmaul respirations? A) To compensate for metabolic acidosis, the respirations are deep and rapid. B) To overcome respiratory acidosis, the respirations are fast and shallow. C) Injury to the brain's respiratory center results in periods of apnea. D) Hypoxemia causes labored, gasping, and irregular respirations.

What is A) To compensate for metabolic acidosis, the respirations are deep and rapid. CORRECT To compensate for the ketoacidosis (metabolic acidosis), the lungs attempt to remove CO2 through a pattern of deep, rapid respirations referred to as Kussmaul respirations.

200

Lab work reveals that Lara's blood glucose level is 370 mg/dl, plasma bicarbonate is 8 mEq/L, potassium is 5.2 mEq/L, and she has elevated ketones in her urine. Goals of treatment in DKA include correcting fluid imbalance and restoring normal pH, electrolytes, and glucose. 3.To restore Lara's blood glucose to a normal level, what should the nurse prepare to administer? A) An IV infusion containing regular insulin. B) Administer an Albumin/Lasix continuous infusion. C) Maintain an infusion of normal saline solution. D) Obtain a type and crossmatch for 2 units of packed RBCs.

What is A) An IV infusion containing regular insulin. CORRECT Continuous IV infusions containing regular insulin are used to reduce the client's blood glucose level. Lara's IV solution will be changed to one that contains glucose when her blood glucose level reaches 250 mg/dl.

300

4.In addition to monitoring Lara's blood glucose level, what additional lab values should the nurse monitor carefully? (Select all that apply.) A) Uric acid.B) Hemoglobin.C) Calcium.D) Potassium. E) Blood Urea Nitrogen (BUN).

What is B) Hemoglobin. CORRECT Though blood glucose and potassium are the most critical lab values to assess, hemoglobin levels may be altered related to the state of hydration and should be monitored. C) Calcium. CORRECT Calcium levels should also be monitored for clients that have DKA. D) Potassium. CORRECT Treatment with an IV insulin infusion will cause the potassium to return to the cells and may result in hypokalemia. Lara should be closely monitored for symptoms of hypokalemia. Supplemental potassium may be added to the IV infusion to prevent or correct this. E) Blood Urea Nitrogen (BUN). CORRECT Dehydration that occurs with DKA can lead to an increased BUN and should be monitored for signs of renal insufficiency.

400

Lara's blood glucose level stabilizes, and she begins taking oral fluids. Her IV solutions are switched to D5.45 at a keep-open rate, and the insulin infusion is discontinued. While hospitalized, family members and many of Lara's college friends call the nursing unit to check on her condition. 5.The nurse's decision about what to tell these callers should be based on what primary consideration? A) The instructions of the nursing unit supervisor. B) The nature of the caller's relationship to Lara. C) The seriousness of Lara's condition at the time of the call. D) Lara's right to privacy regarding her health information.

What is D) Lara's right to privacy regarding her health information. CORRECT The Health Information Privacy Protection Act stipulates that a client has the right to privacy regarding health information and must give permission for the release of that information.

500

A student nurse is assigned to work with the charge nurse in caring for Lara during her acute illness. The student tells the nurse that she plans to present information about Lara to her fellow students during a post-clinical conference, and asks the charge nurse for permission to copy Lara's lab data to take to the conference. 6.Which response is best for the charge nurse to provide? A) "Information about the client cannot be removed from the nursing unit." B) "The lab values can be copied as long as there is no identifying client data." C) "Since this is for educational purposes, you can remove any information you need." D) "Your instructor should tell you what information you are allowed to copy."

What is B) "The lab values can be copied as long as there is no identifying client data." CORRECT Information used for educational purposes may be shared, as long as the data does not permit identification of the client.

Management

100

Once she is feeling better, Lara does practice injection skills and later states that she feels more comfortable about giving herself the injections. The next morning, Lara is preparing to administer her insulin with the nurse's supervision. However, the nurse is called back to the desk by the unit clerk where she learns that several clients are having problems that require attention. 14. Which action should the nurse take first? A) Return to Lara's room to supervise the scheduled insulin injection. B) Administer a dose of IV antibiotics to a diabetic with an infected foot ulcer. C) Administer IV dextrose to a diabetic client with a blood glucose level of 25 mg/dl. D) Hang a new bag of normal saline on a diabetic with a blood glucose level of 275 mg/dl.

What is C) Administer IV dextrose to a diabetic client with a blood glucose level of 25 mg/dl. CORRECT This is the most critical client care need. The client's blood glucose is dangerously low, and lack of action by the nurse could endanger the client's life.

200

When returning to Lara's room, the nurse learns that breakfast trays have not yet arrived on the unit and all the other clients with diabetes have already received insulin. 15.What action should the nurse take first? A) Ask the unit clerk to find out when the trays will be available. B) Distribute orange juice to all clients who have received insulin. C) Notify the dietary supervisor that client safety is being compromised. D) Observe Lara to ensure that she gives herself the insulin injection correctly.

What is A) Ask the unit clerk to find out when the trays will be available. CORRECT How quickly the trays will be available will determine what further action needs to be taken.

300

Lara attends a series of classes on management of her diabetes. She learns that the goals of diet therapy for clients with Type 1 diabetes are to consume all essential nutrients, achieve and maintain ideal body weight, and maintain blood glucose levels as near normal as possible. Lara tells the nurse that she understands the importance of a well-balanced diet, and states, "You know I am in college, and I know I'll want to go out for a beer every now and again. I understand that a can of beer has a lot of calories, so I'll watch what I eat if I am going to have a drink." 16. What is the best response by the nurse? A) "Drinking alcohol is prohibited on a diabetic diet, because you cannot predict how your blood glucose will react." B) "Alcohol does contain a lot of empty calories, but it is also likely to cause your blood glucose to decrease." C) "Plan to take extra insulin when you drink beer, because drinking will increase your blood glucose." D) "A can of beer equals one carbohydrate exchange, so adjust your calories and food intake accordingly."

What is B) "Alcohol does contain a lot of empty calories, but it is also likely to cause your blood glucose to decrease." CORRECT Twelve ounces of beer is the equivalent of two fat exchanges, which may elevate triglyceride levels, as well as adding empty calories. It is important that the diabetic understand that alcohol may induce hypoglycemia. Therefore, Lara should drink alcohol only in moderation, and with, or shortly after meals.

400

Lara tells the nurse that she will make sure she drinks plenty of water and will take a little extra regular insulin before beginning strenuous exercise. 17.What is the best response by the nurse? A) Remind Lara that she should also carry a simple carbohydrate snack with her. B) Acknowledge Lara's understanding of correct pre-exercise measures. C) Advise Lara that extra insulin should not generally be taken before exercise. D) Teach Lara that the extra insulin will give her more energy.

What is C) Advise Lara that extra insulin should not generally be taken before exercise. CORRECT Exercise may cause hypoglycemia during or after the activity. Therefore, additional carbohydrates may be needed before, during, or after exercise. Clients should perform self-monitoring of blood glucose levels to determine the effects of exercise on blood glucose levels. In addition, it is important to remember that exercise in the client with uncontrolled diabetes results in hyperglycemia and may lead to ketosis. Diabetics with ketonuria and a blood glucose of 250 or above should avoid exercise.

Complications

100

Lara is discharged with controlled blood glucose levels and sufficient knowledge of diet and insulin therapy. She will continue to attend the series of classes on diabetes management offered at the hospital by the diabetes educator. Two months later, Lara's college roommate calls the nurse late at night in a panic and reports that Lara described feeling like "my heart is beating out of my chest." Lara was weak and shaky, so the roommate brought her some juice. Lara became confused and lethargic before she could drink it, and now she will not wake up. 18. What is the best nursing action? A) Advise the roommate to stay with Lara, remain calm, and check Lara's pulse, respirations, and skin color. B) Tell the roommate to immediately find the dorm supervisor while she calls an ambulance. C) Ask the roommate if Lara has emergency supplies such as Glucagon or cake icing available. D) Instruct the roommate to hold Lara's head up and put small sips of juice in the side of her mouth

What is C) Ask the roommate if Lara has emergency supplies such as Glucagon or cake icing available. CORRECT Lara is experiencing symptoms of hypoglycemia, which include disorientation, tremors, palpitations, lightheadedness, confusion, cool, clammy skin, slurred speech, and lethargy. Since she is not arousable, the roommate should first be instructed to use any emergency supplies readily available. These might include Glucagon, which is administered subcutaneously or IM, or a concentrated glucose paste which can be squeezed in the mouth and absorbed through the mucosa.

200

Lara is discharged with controlled blood glucose levels and sufficient knowledge of diet and insulin therapy. She will continue to attend the series of classes on diabetes management offered at the hospital by the diabetes educator. Two months later, Lara's college roommate calls the nurse late at night in a panic and reports that Lara described feeling like "my heart is beating out of my chest." Lara was weak and shaky, so the roommate brought her some juice. Lara became confused and lethargic before she could drink it, and now she will not wake up. 19. Once Lara is more alert, what instructions should the nurse provide the roommate? A) Give Lara some crackers and milk while waiting for the emergency transport. B) Help Lara to her bed and allow her to sleep as long as necessary. C) Encourage Lara to drink a regular cola and eat a candy bar to keep her blood glucose level up. D) Drive Lara to the hospital, keeping her NPO so she does not vomit.

What is A) Give Lara some crackers and milk while waiting for the emergency transport. CORRECT The effect of the Glucagon is only temporary. Therefore, Lara should also eat a small snack containing carbohydrates and proteins to prevent hypoglycemia from recurring.

300

Lara's blood glucose level is stabilized, and she is transported to the acute care facility where her blood glucose is monitored carefully. The admitting physician suspects that Lara is experiencing Somogyi's phenomenon. 20.What technique should the nurse use to assess for this occurrence? A) Obtain preprandial and postprandial blood glucose measurements. B) Compare a baseline glycosylated Hgb to a current measurement. C) Compare venous blood glucose levels to capillary blood glucose levels. D) Monitor blood glucose levels during the night and before breakfast.

What is D) Monitor blood glucose levels during the night and before breakfast. CORRECT "Somogyi's phenomenon" is the term for rebound morning hyperglycemia after night-time hypoglycemia. It is often caused by too much insulin or the lack of an adequate bedtime

400

Lara learns that there are a number of things she can do to reduce her risk for the numerous long-term complications associated with diabetes. She understands that cardiovascular complications are a major cause of death in diabetics. 28. Which lab value indicates that Lara is working to reduce her risk for cardiovascular disease? A) Fasting blood glucose of 120 mg/dl. B) Glycosylated hemoglobin at 9%. C) Low-density lipoprotein (LDL) cholesterol of 80 mg/dl. D) High-density lipoprotein (HDL) cholesterol of 30 mg/dl.

What is C) Low-density lipoprotein (LDL) cholesterol of 80 mg/dl. CORRECT Desired level is <100 mg/dl.

500

Lara talks to the nurse about what to do if she gets sick. She states, "It just doesn't make sense to take my insulin when I feel sick, knowing I won't want to eat anything." 23. How should the nurse respond? A) "You are right. You should not take your insulin if you are feeling sick." B) "Take only sliding-scale insulin, not your regular dose, if you are feeling sick." C) "Being sick increases your blood sugar. Taking your usual insulin dose is important." D) "When you are sick, you should test your urine and only take insulin if ketones are present."

what is C) "Being sick increases your blood sugar. Taking your usual insulin dose is important." CORRECT Illness increases the risk for dehydration and hyperglycemia. Continued administration of the regular dose of insulin and adequate fluid and carbohydrate intake are critical to prevent ketoacidosis. Lara should monitor her blood glucose at least every 4 hours when ill, and report persistent hyperglycemia, ketosis, nausea and vomiting, or other significant symptoms to the health care provider.

Diagnostic Test & Classifications of Diabetes

100

Lara states that her grandmother became diabetic after she retired, but that her mother had gestational diabetes mellitus (GDM) when she was pregnant with Lara. Lara asks the nurse why her mother does not have diabetes, since it developed while she was pregnant. 25. What is the best response? A) "Women with gestational diabetes only experience diabetes during the time they are pregnant." B) "She probably had pregnancy-induced glucose intolerance, rather than true gestational diabetes." C) "Women with gestational diabetes are at high risk for developing diabetes after pregnancy, but not all will get the disease." D) "She will eventually develop diabetes. All women who experience gestational diabetes eventually get the disease."

What is C) "Women with gestational diabetes are at high risk for developing diabetes after pregnancy, but not all will get the disease." CORRECT Women who develop GDM often, but not always, develop Type 2 diabetes at some point following their pregnancy.

200

Lara tells the nurse, "I hope I never get HHNS. My grandmother's blood glucose level was almost 1,000 mg/dl. My blood glucose level was only 370 mg/dl, and I was really sick. It's pretty amazing my grandmother didn't die!" 27. What intervention should the nurse implement? A) Explain to Lara that HHNS is not as serious as DKA, since ketosis does not occur. B) Tell Lara that HHNS is less likely to occur in Type 1 diabetes than in Type 2 diabetes. C) Suggest that Lara may be misinformed because it is unlikely the blood glucose level was that high. D) Advise Lara to share her concerns about this syndrome with her grandmother.

What is B) Tell Lara that HHNS is less likely to occur in Type 1 diabetes than in Type 2 diabetes. CORRECT HHNS primarily affects Type 2 diabetics who are significantly dehydrated. However, Lara should be aware of the nature of symptoms and the treatment for HHNS.

300

After discharge, Lara is scheduled for a follow-up evaluation at the outpatient clinic. A glycosylated Hgb level is drawn, and the results were 11%. 21.Which statement by Lara reflects understanding of glycosylated Hgb? A) "The results of the test are probably high, because I was not fasting before my blood was drawn this morning." B) "The results of my test are probably high, because I went to a party last night and did not follow my diet." C) "I know that I need to check my glycosolated Hgb before each meal and at bedtime, but I don’t always have time." D) "At least I won't have this done again for 3 months. I will really work at following my diet between now and then."

What is D) "At least I won't have this done again for 3 months. I will really work at following my diet between now and then." CORRECT This test reflects average blood glucose levels over a period of approximately 120 days, the life of the average RBC. Glucose molecules attach to hemoglobin in the red blood cell. The longer the glucose in the blood is above normal, the higher the percentage of glycosylated hemoglobin. Normal levels range from 4-6%, with levels over 8% indicating poor glycemic control. Note: Normal values may differ, depending on the lab.

400

Lara tells the nurse that her 15-year-old sister had a fasting blood glucose test last week, because she felt that she had some of the same symptoms that Lara had before being diagnosed with diabetes. Lara states her sister's results were 135 mg/dl. 22. How should the nurse respond? A) "She needs a second test performed before a diagnosis is made." B) "Since her value is high, it sounds like both of you have diabetes." C) "Her value is low and indicates that she does not have diabetes." D) "She is too young to develop Type 1 diabetes. She may have Type 2."

What is A) "She needs a second test performed before a diagnosis is made." CORRECT The diagnosis of diabetes is based on two fasting blood glucose levels greater than 126 mg/dl.

500

Lara learns about good foot care and the importance of regular monitoring of her vision, kidney function, cardiovascular, and cerebrovascular systems. She is aware of problems associated with neuropathies that can occur, both peripheral and autonomic. Lara recognizes that she will be part of a collaborative healthcare team to manage her diabetes. She states, "The single most important thing I can do is make sure my blood glucose level is well controlled." 30. What response should the nurse make? A) "You're absolutely right, and your health care team will be there to help you." B) "It is most important to keep your spirits up to avoid long-term complications." C) "Diet and exercise are the most important parts of maintaining daily control." D) "Taking your insulin every day is the most important thing you can do."

What is A) "You're absolutely right, and your health care team will be there to help you." CORRECT Good glycemic control promotes health and well-being, and reduces the risk for complications, both acute and long-term. This is a multi-faceted challenge, which can be met by an effective collaborative health care team effort, with the client at the center.