Chapter 53: Diabetes Mellitus

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

“With type 2 diabetes, the body of the pancreas becomes inflamed.”

“With type 2 diabetes, the person is totally dependent on an outside source of insulin.”

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

“With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas.”

“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 person is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.

A patient with diabetes is scheduled for a fasting glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time?

6:00 PM on the evening before the test

Midnight before the test

4:00 AM on the day of the test

7:00 AM on the day of the test

Midnight before the test

Rationale:

Typically, a patient is ordered to be NPO for 8 hours before a fasting 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.

The nurse caring for a person hospitalized with diabetes would look for which laboratory test result to obtain information on their past glucose control?

Prealbumin level

Urine ketone level

Fasting glucose level

Glycosylated hemoglobin level

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 pre-albumin 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.

A person 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.)

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.

The patient may be excreting sodium and retaining potassium from malnutrition.

This level shows adequate treatment of the cellulitis and acceptable glucose control.

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 person’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 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.

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

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

Washes hands with soap and water to cleanse the site to be used.

Warms the finger before puncturing the finger to obtain a drop of blood.

Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

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

Rationale:

The person 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.

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

Excessive thirst

Gradual weight gain

Overwhelming fatigue

Recurrent blurred vision

Excessive thirst

Rationale:

The classic symptoms of diabetes are

Polydipsia (excessive thirst)

Polyuria (excessive urine output)

Polyphagia (increased hunger).

Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes but are not classic manifestations.

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

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

Ask the person to write down their current knowledge about diabetes.

Set goals for the person to actively participate in managing his diabetes.

Assume responsibility for all the person’s care to decrease stress level.

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

Rationale:

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

A person with type 1 diabetes reports a headache, changes in vision, and being anxious. A portable glucose monitor is not available. Which action would the nurse advise the patient to take?

Eat a piece of pizza.

Drink some diet pop.

Eat 15 g of simple carbohydrates.

Take an extra dose of rapid-acting insulin.

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 glucose as soon as possible.

The fat in the pizza and the diet pop would not allow the glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the glucose level.

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

A 21-yr-old with a hemoglobin A1C of 8.4%

A 35-yr-old with a fasting glucose of 111 mg/dL

A 68-yr-old with a random glucose of 190 mg/dL

A 78-yr-old with a 2-hour glucose tolerance glucose of 184 mg/dL

A 21-yr-old with a hemoglobin A1C of 8.4%

Rationale:

Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater

A fasting glucose level of 126 mg/dL or greater

A 2-hour glucose level of 200 mg/dL or greater during an oral glucose tolerance test

Classic symptoms of hyperglycemia or hyperglycemic crisis with a random glucose of 200 mg/dL or greater.

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

Increases insulin production from the pancreas.

Slows the absorption of carbohydrate in the small intestine.

Reduces glucose production by the liver and enhances insulin sensitivity.

Increases insulin release from the pancreas and inhibits glucagon secretion.

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.

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?

Central apnea

Hypoventilation

Kussmaul respirations

Cheyne-Stokes respirations

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.

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

Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease.

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

Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes.

Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.

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

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.

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

“Smokeless tobacco products decrease the risk of kidney damage.”

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

“I should have yearly dilated eye examinations by an ophthalmologist.”

“I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.”

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

Rationale:

The ADA recommends persons with type 2 diabetes should consume less than 2,300 mg of salt daily.

People 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.

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.

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?

Increased triglyceride levels

Increased high-density lipoproteins (HDL)

Decreased low-density lipoproteins (LDL)

Decreased very-low-density lipoproteins (VLDL)

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.

Which patient with type 1 diabetes has the highest risk for developing hypoglycemic unawareness?

A 58-yr-old patient with diabetic retinopathy

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

A 19-yr-old patient who is on the college track team

A 24-yr-old patient with a hemoglobin A1C of 8.9%

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.

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?

Avoid sick people and wash hands.

Obtain comprehensive dental care.

Maintain hemoglobin A1C below 7%.

Coughing and deep breathing with splinting.

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. Poor dental health increases the risk of septicemia and infective endocarditis.

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.

The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which patient statement requires an intervention by the nurse?

“I will discard any insulin bottle that is cloudy in appearance.”

“The best injection site for insulin administration is in my abdomen.”

“I can wash the site with soap and water before insulin administration.”

“I may keep my insulin at room temperature (75°F) for up to 1 month.”

“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 preparing the patient's skin for 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 are no longer recommended.

Patients should rotate the injection within one site, such as the abdomen.

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?

Cheese

Broccoli

Chicken

Oranges

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.

The nurse is teaching a patient with type 2 diabetes about exercise to help control glucose. The nurse determines the patient understands the teaching when the patient states:

“I will go running when my blood sugar is too high to lower it.”

“I will go fishing frequently and pack a healthy lunch with plenty of water.”

“I do not need to increase my exercise routine since I am on my feet all day at work.”

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

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 a moderate activity.

Fishing and walking at work are light activities,

Running is considered a vigorous activity.

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?

“I should only walk barefoot in nice dry weather.”

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

“I will need to cut back the number of times I shower per week.”

“My shoes should fit nice and tight because they will give me firm support.”

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

Rationale:

People 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.

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

Routine insulin therapy and exercise

Administer a different antibiotic for the UTI

Cardiac monitoring to detect potassium changes

Administer IV fluids rapidly to correct dehydration

Cardiac monitoring to detect potassium changes

Rationale:

This person 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.

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

“I plan to lose 25 pounds this year by following a high-protein diet.”

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

“I should include more fiber in my diet than a person who does not have diabetes.”

“If I use an insulin pump, I will not need to limit foods with saturated fat in my diet.”

“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 people with diabetes.

High-protein diets are not recommended for weight loss.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a 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?

8:40 PM to 9:00 PM

9:00 PM to 11:30 PM

10:30 PM to 1:30 AM

12:30 AM to 8:30 AM

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.