Exam 4 - Diabetes Mellitus (DM)

Question 1

Causal factor for type 1 DM

Answer 1

• Exact cause unknown
• Genetic predisposition, environmental triggering event, T-lymphocyte-mediated hypersensitivity reaction against some beta cell antigen
• Immune system destroys islet cells in pancreas
• Over-production of glucagon –> gycogenolysis & gluconeogenesis
• Glucose levels rise –> “3 P’s” – polyuria, polydipsia, polyphagia

Question 2

Very-basically—What happens in diabetic ketoacidosis? Look at Laura’s slides.

Answer 2

• When body doesn’t have enough insulin, FFA’s (free fatty acids) are broken down as an alternate fuel
• Process produces an excess of ketones (toxic acids), leading to metabolic acidosis

Question 3

S/S of diabetic ketoacidosis

Answer 3

• “3 P’s” – polyuria, polydipsia, polyphagia (classic symptoms of hyperglycemia)
• Hyperglycemia
• Dehydration
• Ketosis
• Acidosis (metabolic)
• Ketone/sugar levels in urine
• Fruity (acetone) breath
• Kussmaul respirations
• (Can happen in T2 in extreme situations, but typically seen in T1 – especially with onset of diabetes or infection)

Question 4

Basic definition of type 2 DM? (for example: is there an absolute absence of insulin or a
resistance to insulin—simple information like this!)

Answer 4

• A combination of beta cell dysfunction and insulin resistance

Question 5

Important risk factors for type 2 DM. Which 2 are most important per Laura?

Answer 5

• *** Obesity
• *** Family history
• Aging
• Sedentary lifestyle

Question 6

How does obesity increase the risk for developing type 2 DM?

Answer 6

• Insulin resistance in fat cells leads to reduced glucose intake
• Overweight people also require more insulin

Question 7

Very basically—how do the oral medications for type 2 DM work? Are they oral insulin or do
they help the cells release insulin?

Answer 7

• Stimulate the cell release of insulin
• Inhibits the release of glucose
• Slows the breakdown of starches

Question 8

Be able to recognize the signs & symptoms of hypoglycemia. What are some general causes?

Answer 8

• Headache
• Irritable
• Hunger
• Weakness/fatigue
• Shaking
• Sweating
• Anxious
• Dizziness
• Tachycardia
• Impaired vision

Causes:

• Insufficient food intake
• Too much exercise
• Too much insulin

Question 9

Be able to distinguish between the signs & symptoms of diabetic ketoacidosis & hyperglycemic hyperosmolar nonketotic syndrome

Answer 9

DKA: T1 (or T2 in severe distress), glucose > 300, high ketones, pH acidotic, N/V ab pain diarrhea

HHNS: T2, glucose > 600, no ketones, normal pH, no GI symptoms

Question 10

Be able to recognize the 3 P’s of diabetes in a question/scenario

Answer 10

• Polydipsia
• Polyuria
• Polyphagia

Question 11

Be able to distinguish between hypoglycemia, the Somogyi effect & the dawn phenomenon

Answer 11

• Hypoglycemia: low blood sugar at any time
• Somogyi effect: insulin peaks in middle of night, hyperglycemia in morning. Treat with DECREASE of BEDTIME insulin dose (vs treating with more insulin in a.m.)
• Dawn phenomenon: high blood sugar in the morning related to GH release at night, encourage protein snack at bedtime (limit carbs)

Question 12

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently asleep. How would the nurse know whether the client was having a hypoglycemic reaction?

1. Feel the client and bed for dampness.
2. Observe the client for Kussmaul respirations.
3. Smell the client’s breath for acetone color.
4. Note if the client is incontinent of urine.

Answer 12

1. Feel the client and bed for dampness

Rationale: When clients are sleeping, the only observable sign of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated hyperglycemia.

Question 13

A client is found to be comatose and hypoglycemic with a blood glucose level of 50 mg/dL. What nursing action is implemented first?

1. Infuse 1000 mL of D5W over a 12-hour period.
2. Administer 50% glucose intravenously.
3. Check the client’s urine for the presence of sugar and acetone.
4. Encourage the client to drink orange juice with added sugar.

Answer 13

2. Administer 50% glucose intravenously

Rationale: The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). Administering 1000 mL of D5W over 12 hours does not provide enough glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available.

Question 14

What will the nurse teach the client with diabetes regarding exercise in the treatment program? Select all that apply.

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin.
2. With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required.
3. Exercise increases the HDL and decreases the chance of stroke and heart disease.
4. The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake.
5. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.

Answer 14

1, 3
(During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin; Exercise increases the HDL and decreases the chance of stroke and heart disease.)

As carbohydrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation. Increased HDLs have been associated with a decrease in Syndrome X (Metabolic Syndrome).

Question 15

What is characteristic of hypoglycemia that should alert the nurse to an early insulin reaction?

1. Diaphoresis
2. Drowsiness
3. Severe thirst
4. Coma

Answer 15

1. Diaphoresis

Diaphoresis and a shaky feeling (nervousness) are early signs of hypoglycemia. Severe thirst is a sign of hyperglycemia, whereas drowsiness and coma are late symptoms of hypoglycemia.

Question 16

A client is scheduled for a routine glycosylated hemoglobin (HbA1C) test. What is important for the nurse to tell the client before this test?

1. Drink only water after midnight and come to the clinic early in the morning.
2. Eat a normal breakfast and be at the clinic 2 hours later.
3. Expect to be at the clinic for several hours because of the multiple blood draws.
4. Come to the clinic at the earliest convenience to have blood drawn.

Answer 16

4. Come to the clinic at the earliest convenience to have blood drawn.

Glucose attaches to the hemoglobin molecule of the red blood cell. A glycosylated hemoglobin test gives an average of blood glucose over the past 3 to 4 months, and a blood sample can be obtained at any time during the day. It does not need to be used in the diagnosis of diabetes and does not need to be a fasting specimen.

Question 17

A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritis pain. An expected change that requires close monitoring by the nurse is:

1. Increased blood glucose level
2. Increased platelet aggression
3. Increased creatinine clearance
4. Decreased white blood cell count

Answer 17

1. Increased blood glucose level

An adverse reaction to corticosteroids is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Creatinine clearance measures renal function. Plately aggregation is associated with hematologic disorders. Clients taking corticosteroids are at increased risk for infection due to suppressed immune response and not a decrease in WBCs.

Question 18

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at:

1. 12 PM to 1 PM (1200 to 1300 hours)
2. 9 AM and 5 PM (0900 and 1700 hours)
3. 10 AM and 10 PM (1000 and 2200 hours)
4. 8 AM and 11 AM (0800 and 1100 hours)

Answer 18

2. 9 AM and 5 PM (0900 and 1700 hours)

Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would likely occur between 9 AM and 5 PM (0900 to 1700 hours).

Question 19

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency department. Which finding would a nurse expect to note as confirming this diagnosis?

1. Comatose state
2. Decreased urine output
3. Increased respirations and an increase in pH
4. Elevated blood glucose level and a low plasma bicarbonate level

Answer 19

4. Elevated blood glucose level and a low plasma bicarbonate level

573

Question 20

A nurse teaches a client with diabetes mellitus about 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 of the following symptoms develops?

1. Polyuria
2. Shakiness
3. Blurred vision
4. Fruity breath odor

Answer 20

2. Shakiness

574

Question 21

A nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client states:

1. “I will stop taking my insulin if I’m too sick to eat.”
2. “I will decrease my insulin dose during times of illness.”
3. “I will adjust my insulin dose according to the level of glucose in my urine.”
4. “I will notify my physician if my blood glucose level is higher than 250 mg/dL.”

Answer 21

4. “I will notify my physician if my blood glucose level is higher than 250 mg/dL.”

576

Question 22

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of regular insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which of the following?

1. Ampule of 50% dextrose
2. NPH insulin subcutaneously
3. Intravenous fluids containing 5% dextrose
4. Phenytoin (Dilantin) for the prevention of seizures

Answer 22

3. Intravenous fluids containing 5% dextrose.

577

Question 23

A nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited in the client, would indicate hyperglycemia and warrant physician notification?

1. Polyuria
2. Diaphoresis
3. Hypertension
4. Increased pulse rate

Answer 23

1. Polyuria

578

Question 24

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing diagnosis would be:

1. Deficient knowledge
2. Deficient fluid volume
3. Compromised family coping
4. Imbalanced nutrition, less than body requirements

Answer 24

2. Deficient fluid volume

579

Question 25

A home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. 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 a need for further teaching?

1. “I need to stop my insulin.”
2. “I need to increase my fluid intake.”
3. “I need to monitor my blood glucose every 3 to 4 hours.”
4. “I need to call the physician because of these symptoms.”

Answer 25

1. “I need to stop my insulin.”

580

Question 26

A nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to:

1. Correct the acidosis.
2. Administer 5% dextrose intravenously.
3. Administer regular insulin intravenously.
4. Apply a monitor for an electrocardiogram.

Answer 26

3. Administer regular insulin intravenously

584

Question 27

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise?

1. “The best time for me to exercise is after I eat.”
2. “The best time for me to exercise is after breakfast.”
3. “The best time for me to exercise is mid- to late afternoon.”
4. “The best time for me to exercise is after my morning snack.”

Answer 27

3. “The best time for me to exercise is mid- to late afternoon.”

585

Question 28

A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/dL, temperature of 101F, pulse of 88 beats/min, respirations of 22 breaths/min, and blood pressure of 100/72 mm Hg. Which finding would be of most concern to the nurse?

1. Pulse
2. Respiration
3. Temperature
4. Blood pressure

Answer 28

3. Temperature

592

Question 29

A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder?

1. “I take oral insulin instead of shots.”
2. “By taking these medications, I am able to eat more.”
3. “When I become ill, I need to increase the number of pills I take.”
4. “The medications I’m taking help release the insulin I already make.”

Answer 29

4. “The medications I’m taking help release the insulin I already take.”

593

Question 30

The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client’s room, the nurse finds the client to be confused and diaphoretic. Which action is appropriate at this time?

1. Call a code to obtain needed assistance immediately.
2. Obtain a capillary blood glucose level and perform a focused assessment.
3. Stay with the client and ask the nursing assistant to call the physician for a prescription for intravenous 50% dextrose.
4. Ask the nursing assistant to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat.

Answer 30

2. Obtain a capillary blood glucose level and perform a focused assessment.

595

Question 31

A nurse is monitoring a client with was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

1. Tremors
2. Anorexia
3. Irritability
4. Nervousness
5. Hot, dry skin
6. Muscle cramps

Answer 31

1, 3, 4 (tremors, irritability, nervousness)

Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the signs of hypoglycemia.