chapter 40

  1. The nurse is caring for a patient admitted to the emergency department in acute distress. Data collection reveals rapid deep breathing, fruity odor, lethargy, and weight loss. Laboratory results include a blood glucose of 720 mg/dL. Which of the patient’s symptoms indicates type 1 diabetes mellitus?

    a.

    Lethargy

    b.

    Thirst

    c.

    Hunger

    d.

    Fruity odor
    ANS:    D

    All are symptoms of diabetes, but fruity odor occurs with ketoacidosis in type 1 diabetes, which is very rare in type 2.
  2. What is a major factor in the development of type 1 diabetes?

    a.

    A high-fat diet

    b.

    A diet high in concentrated carbohydrates

    c.

    An autoimmune response

    d.

    Obesity
    ANS:   C

    In type 1 diabetes, it is believed that the pancreas may attack itself following certain viral infections or administration of certain drugs; this is called an autoimmune response. Almost 90% of patients newly diagnosed with type 1 diabetes have islet cell antibodies in their blood. Diet can be a risk factor in many disorders but does not directly cause diabetes. Obesity is a risk factor for type 2 diabetes.
  3. The nurse is assisting with teaching a patient with newly diagnosed type 1 diabetes. The patient asks what caused the fruity odor that was present at diagnosis. How should the nurse respond?

    a.

    “The excess sugar in the blood is metabolized to fructose and excreted via the lungs.”

    b.

    “In the absence of available sugar, the body breaks down fat into ketones, which have a fruity odor.”

    c.

    “The proteins in the blood are metabolized to a substance that has a fruity odor.”

    d.

    “Excess sugar is excreted in the urine, which causes the fruity odor.”
    ANS:     B

    The body attempts to compensate for acidosis by deepening respirations, thereby blowing off excess carbon dioxide. The deep, sighing respiratory pattern is called Kussmaul’s respirations. The expired air has a fruity odor caused by the ketones and may be mistaken for alcohol. Some nurses have likened the odor to Juicy Fruit gum. A, C, and D are not accurate.
  4. A patient is newly diagnosed with type 1 diabetes mellitus. How should the nurse respond when the patient asks how long the insulin injections will be necessary?

    a.

    “Once your pancreas recovers, you may be able to discontinue the injections.”

    b.

    “You will need insulin injections for the rest of your life.”

    c.

    “If you follow your diet closely, your blood sugar may be controlled by just taking insulin pills.”

    d.

    “You may be able to stop the injections if you exercise regularly and adhere to the prescribed diet.”
    ANS:     B

    Unless the patient receives a pancreas or islet cell transplant, insulin will be required for life. The pancreas will not recover. Patients with type 1 diabetes must have insulin to survive. At the time of this writing, oral insulin is not available.
  5. The nurse is assisting with nutrition teaching for a patient who voices concern over coping with a diabetic diet. What response about medical nutrition therapy is correct?

    a.

    “You will have a well-balanced, individualized meal plan that will be healthy for your whole family.”

    b.

    “You will need to avoid sugars and fats, but the dietitian will assist you in finding acceptable alternatives.”

    c.

    “Medical nutrition therapy stresses high protein and low carbohydrate intake, but most people readily adapt to these restrictions.”

    d.

    “Your diabetes will require special foods, but many stores now stock a variety of choices for people with diabetes.”
    ANS:    A

    Because all diabetic nutrition recommendations emphasize low fat intake and balanced intake of other food groups, it is healthy for the whole family. Patients with diabetes do not have to avoid all sugars and fats. High protein is not recommended; low protein may be necessary if nephropathy occurs. Special foods are not necessary.
  6. The nurse is providing care for a marathon runner who is newly diagnosed with diabetes mellitus. What explanation about exercise is best for the nurse to provide?

    a.

    “You will need to avoid regular exercise since it will lower your blood sugar.”

    b.

    “You can still exercise, but running is too strenuous for someone with diabetes.”

    c.

    “You should always take some emergency glucose with you when you are running.”

    d.

    “Exercise is best done when insulin is peaking, so it is important to know the onset and peak of your type of insulin.”
    ANS:     C

    Persons with diabetes should always carry a quick source of sugar when exercising in case the blood glucose drops too low. Individuals on intermediate-acting insulin are taught to avoid exercising at the time of day when their blood glucose is at its lowest point (i.e., when insulin or medication is peaking) and to have a carbohydrate snack before exercising if blood glucose is less than 100 mg/dL. Exercising at similar times each day also helps prevent blood glucose fluctuations. Running is not too strenuous for someone who is used to doing it, but patients with neuropathy or foot problems should consult with a physician first.
  7. The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin should the nurse teach the patient to be alert for symptoms of hypoglycemia?

    a.

    1/2 hour

    b.

    3 hours

    c.

    8 hours

    d.

    12 hours
    ANS:     B

    Regular insulin peaks in 2 to 5 hours, so blood sugar will be lowest at this time. Onset is hour, and duration is 5 to 8 hours.
  8. The nurse teaches a patient to self-administer insulin. How can the nurse best evaluate whether the patient understands the instructions?

    a.

    Have the patient list the steps of the procedure for insulin administration.

    b.

    Ask the patient an open-ended question about feelings related to the procedure.

    c.

    Ask the patient to repeat the information in the insulin pamphlet that was provided.

    d.

    Observe as the patient prepares and injects a dose of insulin.
    ANS:    D

    Observing the patient as he or she demonstrates injection is the most objective measure. A, B, and C are good additional steps, but they are not the best way to evaluate effectiveness.
  9. The nurse is caring for a patient with diabetes. Which of the following symptoms would be most concerning?

    a.

    Fatigue

    b.

    Diaphoresis

    c.

    Heartburn

    d.

    Muscle cramps
    ANS:     B

    Tremor and sweating are sympathetic symptoms of hypoglycemia. Thirst, fatigue, and glycosuria are symptoms of hyperglycemia. Treatment of hypoglycemia is more urgent than treatment of hyperglycemia. Heartburn is more commonly related to gastric acid secretion. Muscle cramps are more commonly related to electrolyte imbalances.
  10. The nurse is assisting with a group class on complications of diabetes. Which information should the nurse include as factors that can precipitate hyperglycemia?

    a.

    Stress or illness

    b.

    Skipping meals

    c.

    Drinking too much water

    d.

    Frequent urination
    ANS:    A

    Stress or illness causes release of stress hormones, which are associated with hyperglycemia. Skipping meals causes hypoglycemia. Thirst and urination are symptoms of hyperglycemia, not causes.
  11. An LPN answers the call light of a patient with diabetes. The patient has a mild tremor and slight diaphoresis and is fully oriented. What should the nurse do?

    a.

    Administer 4 oz of orange juice with one packet of sugar.

    b.

    Check the patient’s blood glucose level.

    c.

    Call the laboratory for a STAT glucose level.

    d.

    Call the RN to administer dextrose 50% intravenously.
    ANS:     BSince the patient is oriented, there is time to check the blood glucose. Calling the laboratory takes too long and is unnecessary. Giving orange juice or another CHO (carbohydrate) source will be the next step, but adding sugar increases the risk of hyperglycemia. 50% dextrose is used if the patient is unable to take oral CHO.
  12. What is the most important action for a patient to take to prevent or delay long-term complications of diabetes?

    a.

    Carefully control blood glucose.

    b.

    Regularly inspect feet.

    c.

    Limit fluids to prevent stress to kidneys.

    d.

    Keep orange juice with sugar available at all times.
    ANS:    A

    Over time, chronic hyperglycemia causes a variety of serious complications in persons with diabetes. The Diabetes Control and Complications Trial showed that individuals with type 1 diabetes who maintain tight control of blood glucose experience fewer long-term complications than individuals who take traditional care of their diabetes. Feet should be inspected daily, but this is not the most important strategy to prevent complications. Fluids are only limited in patients who already have end-stage nephropathy. Orange juice (without sugar) is good to have on hand but will not prevent long-term complications.
  13. A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient is 40% overweight and has a blood glucose value of 987 mg/dL. What is the priority nursing diagnosis for this patient?

    a.

    Noncompliance related to diabetes self-care regimen

    b.

    Deficient Fluid Volume related to osmotic diuresis

    c.

    Ineffective Self Health Management

    d.

    Imbalanced Nutrition: More Than Body Requirements
    ANS:     B

    Hyperosmolar hyperglycemia causes diuresis and dehydration. This is more immediately life threatening than noncompliance, ineffective health management, or imbalanced nutrition.
  14. The nurse is caring for a patient with diabetes who has peripheral neuropathy. What is the best way to prevent related complications?

    a.

    Soak feet in soap and water for 20 minutes daily.

    b.

    Avoid wearing shoes as much as possible.

    c.

    Wash, dry, and inspect feet daily.

    d.

    Use a lubricating lotion on feet daily.
    ANS:     C

    The feet must be washed, dried, and inspected daily to recognize pressure points or red areas before they turn into problems. Soaking feet can macerate skin. Well-fitting shoes protect the feet. Lubricating lotion is a good idea but is only one way to protect the feet and is not as essential as daily washing and inspection for the patient with neuropathy.
  15. A patient develops a small sore on the sole of the left foot. The nurse notifies the physician and implements a standard care plan for impaired skin integrity. What action by the nurse would help evaluate the effectiveness of the plan?

    a.

    Assess and document the wound condition daily.

    b.

    Monitor and record blood glucose levels daily.

    c.

    Assess the patient’s understanding of preventive foot care.

    d.

    Observe the patient’s ability to change the dressing.
    ANS:    A

    Evaluation must address skin integrity—assessing and documenting wound condition is the only response that does this. Monitoring glucose levels evaluates diabetes control, not skin integrity. Assessing the patient’s understanding or observing a dressing change evaluates the patient’s knowledge, not skin integrity.
  16. A patient on an American Diabetes Association (ADA) exchange list diet receives a dinner meal tray and does not wish to eat the rice. Which of the following foods can the nurse substitute for the rice?

    a.

    A slice of bread

    b.

    A half cup of cottage cheese

    c.

    A half cup of custard

    d.

    A 4-oz glass of juice
    ANS:    A

    Rice and bread are both starches. Cottage cheese and custard are in the milk group, and juice is a fruit.
  17. A nurse notes a glycohemoglobin of 14% in a patient attending a follow-up visit at a diabetes outpatient clinic. On what conclusion does the nurse base further assessment?

    a.

    The patient has not been following the treatment regimen at home.

    b.

    The patient generally adheres to the treatment regimen but has had increased carbohydrate intake in the last 3 months.

    c.

    The patient’s blood glucose levels have been elevated for the last 2 to 3 months.

    d.

    The patient may have had numerous hypoglycemic episodes during the last month.
    ANS:     C

    Normal glycohemoglobin is 4% to 6%, so the patient’s glucose levels have been elevated. The result simply shows that glucose has been high, not the reason behind it.
  18. The nurse is caring for a nondiabetic individual. Which of the following glucose results would the nurse expect on routine laboratory work?

    a.

    45 mg/dL

    b.

    88 mg/dL

    c.

    115 mg/dL

    d.

    270 mg/dL
    ANS:     B

    Normal is 70 to 100 mg/dL. Target level for patients with diabetes is 90 to 130 mg/dL.
  19. What precaution should a nurse teach a female patient who is taking glyburide (DiaBeta) once daily for control of blood glucose?

    a.

    “Do not take it if you skip a meal.”

    b.

    “Be sure it is discontinued before any tests involving contrast dye.”

    c.

    “Avoid drinking alcohol.”

    d.

    “You will need to use two forms of birth control.”
    ANS:     C

    Sulfonylureas interact with alcohol and can make the patient very ill. A refers to meglitinides and alpha-glucosidase inhibitors. B refers to metformin. Glitazones may interfere with birth control.
  20. Many long-term complications of diabetes are related to underlying damage to which structure(s)?

    a.

    Heart

    b.

    Liver

    c.

    Brain

    d.

    Blood vessels
    ANS:    D

    Most of the complications of diabetes involve either the large blood vessels in the body (macrovascular complications) or the tiny blood vessels, such as those in the eyes or kidneys (microvascular complications). This in turn can affect the brain or heart. Liver complications are not common in diabetes.
  21. A patient at home with type 1 diabetes has a glucose level of 324 mg/dL. It is usually less than 150 mg/dL. What should the patient do first?

    a.

    Have a glass of orange juice.

    b.

    Call the physician.

    c.

    Check the urine for ketones and drink water.

    d.

    Exercise and recheck glucose level in 2 hours.
    ANS:     C

    Patients with type 1 diabetes are at risk of ketoacidosis when blood glucose is out of control. Orange juice will further increase blood glucose. The physician should be contacted if it remains high or if ketones are present. Exercise is not recommended when glucose is high.
  22. A patient whose blood glucose level usually is 150 to 200 mg/dL has an episode of hypoglycemia. Which of the following activities the patient engaged in before the episode was most likely the cause of the hypoglycemia?

    a.

    Went to a birthday party

    b.

    Took a bicycle ride

    c.

    Received news of a pay raise

    d.

    Took a nap
    ANS:     B

    Exercise can lower blood glucose. Eating at a party or stress (such as a pay raise) can raise glucose. Taking a nap should not affect it.
  23. A patient being treated with rosiglitazone (Avandia) for type 2 diabetes mellitus is receiving a routine follow-up assessment. In addition to hemoglobin A1c and a fasting plasma glucose test, which other laboratory test is important in the patient receiving rosiglitazone?

    a.

    Liver function tests

    b.

    Complete blood count (CBC)

    c.

    Blood lipids

    d.

    Urine for microalbumin
    ANS:    A

    Liver function must be monitored in patients taking glitazones. Lipids and microalbumin are important to monitor in any diabetic patient but are not unique to glitazones. CBC is nonspecific.
  24. A student nurse is preparing to administer insulin. Which of the following injection sites is acceptable? (Select all that apply.)

    a.

    Posterior aspect of the arm

    b.

    Forearm

    c.

    Ventrogluteus

    d.

    Abdomen

    e.

    Buttocks

    f.

    Anterior thigh
    ANS: A, D, E, F

    The abdomen, back of the arm, buttocks, and thigh have adequate subcutaneous tissue for injection. The ventrogluteus is a muscle. The forearm does not have adequate subcutaneous tissue.
  25. The nurse is providing teaching to a patient with reactive hypoglycemia. Which of the following instructions related to glucose monitoring should be provided? (Select all that apply.)

    a.

    “You should check your blood sugar when you get up in the morning.”

    b.

    “It is important to check blood sugar 1 hour before meals.”

    c.

    “Two hours before each meal is the best time to check your blood sugar.”

    d.

    “It is important to check your blood sugar at bedtime.”

    e.

    “You will need to check your blood sugar 2 hours after meals.”

    f.

    “Checking your blood sugar once a day, at the same time each day, is sufficient.”
    ANS: A, D, E

    Low blood glucose may occur as an overreaction of the pancreas to eating. The pancreas senses a rising blood glucose and produces more insulin than is necessary for the use of that glucose. As a result, the blood glucose drops to below normal. Readings should be taken in the morning on arising, 2 hours after each meal, at bedtime, and during symptoms of hypoglycemia. These results may then be taken to the physician for interpretation.
  26. Which of the following are signs or symptoms of diabetic ketoacidosis (DKA)? (Select all that apply.)

    a.

    Kussmaul’s respirations

    b.

    Hypertension

    c.

    Flulike symptoms

    d.

    Edema associated with fluid overload

    e.

    Dehydration

    f.

    Cheyne-Stokes respirations
    ANS: A, C, E

    The body attempts to compensate for acidosis by deepening respirations, thereby blowing off excess carbon dioxide. The deep, sighing respiratory pattern is called Kussmaul’s respirations. With such high blood glucose and the accompanying polyuria, the body becomes dehydrated very quickly. Tachycardia, hypotension, and shock can result. Acidosis also causes potassium to leave the cells and accumulate in the blood (hyperkalemia). Potassium is then lost in large amounts in the urine. The combination of dehydration, potassium imbalance, and acidosis causes the patient to develop flulike symptoms, including abdominal pain and vomiting. The patient loses consciousness and death occurs if DKA is not treated. Cheyne-Stokes respirations are not associated with diabetes.
  27. Goals and recommendations of the American Diabetes Association (ADA) include which of the following? (Select all that apply.)

    a.

    Statin therapy for patients over 40 years old

    b.

    Aspirin therapy

    c.

    Peak postprandial capillary glucose less than 180 mg/dL

    d.

    Hemoglobin A1c less than 7%

    e.

    Yearly flu vaccine

    f.

    Blood pressure less than 140/90 mm Hg
    ANS: A, B, C, D, E

    The ADA recommends all of the goals except blood pressure should be less than 130/80 mm Hg.
  28. What are characteristics of insulin glargine (Lantus)? (Select all that apply.)

    a.

    It has no peak action time.

    b.

    It has a duration of 24 hours.

    c.

    It cannot be mixed with other insulins.

    d.

    It is not injectable.

    e.

    It can be inhaled.
    ANS: A, B, C

    A, B, and C are true. Lantus is injected subcutaneously. It cannot be inhaled.
  29. Which of the following is important for the nurse to assess and monitor in a patient prescribed metformin (Glucophage)? (Select all that apply.)

    a.

    Weight gain

    b.

    Presence of congestive heart failure (CHF)

    c.

    Need for diagnostic tests involving use of contrast dyes

    d.

    Fluid retention

    e.

    Presence of renal or hepatic disease

    f.

    Family history of glaucoma
    ANS: B, C, E

    Glucophage may enhance weight loss, not gain. Withhold if the patient is having tests involving contrast dye. It is contraindicated in renal and hepatic disease and CHF. Notify physician of early symptoms of lactic acidosis: hyperventilation, myalgia, and malaise.
  30. The nurse is teaching a patient at an outpatient clinic whose laboratory tests include an HbA1c. Which of the following client statements indicates teaching has been effective? (Select all that apply.)

    a.

    “This test can be used to help diagnose diabetes.”

    b.

    “If I eat anything with sugar in it the day before the test, it will show up on the test.”

    c.

    “The test shows long-term blood sugar control.”

    d.

    “The test looks back at blood sugar averages over the past 6 months.”

    e.

    “This test can help determine if my treatment plan is managing my diabetes effectively.”

    f.

    “The test can be done in the physician’s office while I’m waiting.”
    ANS: A, C, E, F

    The glycohemoglobin test (HbA1c) is used to gather baseline data and to monitor progress of diabetes control. In 2009, the American Diabetes Association (ADA) also changed its guidelines to include the HbA1c as a diagnostic test for diabetes. It also assists in determining the degree of effectiveness of a patient’s treatment plan. Newer methods allow this test to be done in a physician’s office while the patient waits.
  31. While providing care for a patient with type 2 diabetes, the nurse recognizes which of the following symptoms may indicate the patient could be experiencing a Somogyi effect? (Select all that apply.)

    a.

    Fasting morning glucose is 80 mg/dL.

    b.

    Fasting morning glucose is 264 mg/dL.

    c.

    Patient reports night sweats.

    d.

    Bedtime glucose is 110 mg/dL.

    e.

    Patient complains of headaches in the morning.

    f.

    Blood glucose is rising despite increased doses of insulin.
    ANS: B, C, E, F

    The Somogyi effect may be at fault when the patient’s blood glucose seems to be rising in spite of increasing insulin doses. If insulin levels are too high, the blood glucose may drop too low, stimulating release of counterregulatory hormones (epinephrine, glucagon, corticosteroids, growth hormone) that then elevate the blood glucose. The low glucose levels often occur during the night, and the patient may report night sweats or morning headaches. The high morning glucose is then interpreted as hyperglycemia, and the insulin dose may be further increased, compounding the problem.
  32. Hypoglycemia is usually defined as a blood glucose level less than ____________________ mg/dL.
    ANS:      

    50

    Hypoglycemia is usually defined as a blood glucose level below 50 mg/dL, although patients may feel symptoms at higher or lower levels.
  33. The American Diabetes Association recommends a preprandial blood glucose goal of 70 to ____________________ mg/dL for most patients.
    ANS:      

    130

    Preprandial glucose should be 70 to 130 mg/dL to maintain control and reduce risk of complications.
  34. Critically ill hospitalized patients should have blood glucose levels maintained between 140 and ____________________ mg/dL at all times to prevent complications and optimize outcomes.
    ANS:      

    180

    In 2009, the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists determined that glucose levels in critically ill hospitalized patients should be maintained between 140 and 180 mg/dL, preferably with the use of IV insulin.
Author
mayjher
ID
344390
Card Set
chapter 40
Description
pt with disorder of endocrine
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