NCLEX: Diabetes

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A 54-year-old patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse?
a. "With type 2 diabetes, the body of the pancreas becomes inflamed."
b. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased."
c. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin."
d. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

B - In type 2 diabetes mellitus, 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 patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control?
a. prealbumin level
b. urine ketone level
c. fasting glucose level
d. glycosylated hemoglobin level

D - 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 prealbumin 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.

The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what?
a. chooses a puncture site in the center of the finger pad.
b. washes hands with soap and water to cleanse the site to be used.
c. warms the finger before puncturing the finger to obtain a drop of blood.
d. tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

A - The patient should select a site on the sides of the fingertips, not on the center of the finger pad as 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 assigned to the care of a 64-year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention?
a. assess patient's perception of what it means to have diabetes.
b. ask the patient to write down current knowledge about diabetes.
c. set goals for the patient to actively participate in managing his diabetes.
d. assume responsibility for all of the patient's care to decrease stress level.

A - In order for teaching to be effective, the first step is to assess the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include?
a. macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease.
b. microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.
c. renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.
d. macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.

B - Microangiopathy occurs in diabetes mellitus. 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 evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes?
a. excessive thirst
b. gradual weight gain
c. overwhelming fatigue
d. recurrent blurred vision

A - The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

A 51-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time?
a. 6:00 PM on the evening before the test
b. midnight before the test
c. 4:00 AM on the day of the test
d. 7:00 AM on the day of the test

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

A patient, who is admitted with diabetes mellitus, has a glucose level of 380 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?
a. central apnea
b. hypoventilation
c. kussmaul respirations
d. Cheyne-Stokes respirations

C - 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 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?
a. cheese
b. broccoli
c. chicken
d. oranges

A - 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.

Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes?
a. increased triglyceride levels
b. increased high-density lipoproteins (HDL)
c. decreased low-density lipoproteins (LDL)
d. decreased very-low-density lipoproteins (VLDL)

A - 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.

The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement?
a. "I should only walk barefoot in nice dry weather."
b. "I should look at the condition of my feet every day."
c. "I am lucky my shoes fit so nice and tight because they give me firm support."
d. "When I am allowed up out of bed, I should check the shower water with my toes."

B - Patients with diabetes mellitus 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. Water temperature should be tested with the hands first.

A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply)?
a. the level may be increased as a result of dehydration that accompanies hyperglycemia.
b. the patient may be excreting extra sodium and retaining potassium because of malnutrition.
c. the level is consistent with renal insufficiency that can develop with renal nephropathy.
d. the level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.
e. this level demonstrates adequate treatment of the cellulitis and effective serum glucose control.

A, C, D - The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. Kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis since potassium will leave the cell when hydrogen enters in an attempt 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 elevated potassium level does not demonstrate adequate treatment of cellulitis or effective serum glucose control.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood 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?
a. 8:40 PM to 9:00 PM
b. 9:00 PM to 11:30 PM
c. 10:30 PM to 1:30 AM
d. 12:30 AM to 8:30 AM

C - 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 10-30 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.

A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take?
a. eat a piece of pizza.
b. drink some diet pop.
c. eat 15 g of simple carbohydrates.
d. take an extra dose of rapid-acting insulin.

C - When the patient with type 1 diabetes is unsure about the meaning of the symptoms she is experiencing, she should treat herself for hypoglycemia to prevent seizures and coma from occurring. She should also be advised to check her blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease her blood glucose.

A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient?
a. routine insulin therapy and exercise
b. administer a different antibiotic for the UTI.
c. cardiac monitoring to detect potassium changes
d. administer IV fluids rapidly to correct dehydration.

C - This patient 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 newly diagnosed patient with type 2 diabetes has been prescribed metformin (Glucophage). What should the nurse tell the patient to best explain how this medication works?
a. increases insulin production from the pancreas.
b. slows the absorption of carbohydrate in the small intestine.
c. reduces glucose production by the liver and enhances insulin sensitivity.
d. increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying.

C - 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.

The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control his blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan?
a. "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen."
b. "I will go running each day when my blood sugar is too high to bring it back to normal."
c. "I will plan to keep my job as a teacher because I get a lot of exercise every school day."
d. "I will take a brisk 30-minute walk 5 days per week and do resistance training 3 times a week."

D - The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days per week and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and teaching are light activity, and running is considered vigorous activity.

A patient with diabetes mellitus 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?
a. avoid sick people and wash hands.
b. obtain comprehensive dental care.
c. maintain hemoglobin A1c below 7%.
d. coughing and deep breathing with splinting

B - 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 because the risk of septicemia and infective endocarditis increases with poor dental health. 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 not the priority with mitral valve replacement for this patient.

Polydipsia and polyuria related to diabetes mellitus are primarily due to:
a. the release of ketones from cells during fat metabolism
b. fluid shifts resulting from the osmotic effect of hyperglycemia
c. damage to the kidneys from exposure to high levels of glucose
d. changes in RBCs resulting from attachment of excessive glucose to hemoglobin

B - The osmotic effect of glucose produces the manifestations of polydipsia and polyuria.

Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia?
a. the patient must receive insulin therapy to prevent ketoacidosis
b. the patient has islet cell antibodies that have destroyed the pancreas's ability to produce insulin
c. the patient has minimal or absent endogenous insulin secretion and requires daily insulin injections
d. the patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome

D - Hyperosmolar hyperglycemic syndrome (HHS) is a life-threatening syndrome that can occur in a patient with diabetes who is able to produce enough insulin to prevent diabetic ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.

Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment?
a. A1C 9%
b. BP 126/80 mm Hg
c. FBG 130 mg/dL (7.2 mmol/L)
d. LDL cholesterol 100 mg/dL (2.6 mmol/L)

A - Lowering hemoglobin A1C (to less than 7%) reduces microvascular and neuropathic complications. Tighter glycemic control (normal hemoglobin A1C level, less than 6%) may further reduce complications but increases hypoglycemia risk.

Which statement by the patient with type 2 diabetes is accurate?
a. "I am supposed to have a meal or snack if I drink alcohol."
b. "I am not allowed to eat any sweets because of my diabetes."
c. "I do not need to watch what I eat because my diabetes is not the bad kind."
d. "The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar."

A - Alcohol should be consumed with food to reduce the risk of hypoglycemia.

You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply)
a. insulin administration
b. elimination of sugar from diet
c. need to reduce physical activity
d. use of a portable blood glucose monitor

A, D, E - The nurse ensures that the patient understands the proper use of insulin. The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia.

What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability?
a. call the physician
b. administer insulin as ordered
c. check the patient's blood glucose level
d. assess for other neurologic symptoms

C - Blood glucose testing should be performed whenever hypoglycemia is suspected so that immediate action can be taken if necessary.

A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of:
a. polyuria
b. severe dehydration
c. rapid, deep respirations
d. decreased serum potassium

C - Signs and symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations (i.e., rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.

Which are appropriate therapies for patients with diabetes mellitus (select all that apply)?
a. use of statins to treat dyslipidemia
b. use of diuretics to treat nephropathy
c. use of ACE inhibitors to treat nephropathy
d. use of serotonin agonists to decrease appetite
e. use of laser photocoagulation to treat retinopathy

A, C, E - In patients with diabetes who have microalbuminuria or macroalbuminuria, angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (ARBs) (e.g., losartan [Cozaar]) should be used. Both classes of drugs are used to treat hypertension and have been found to delay the progression of nephropathy in patients with diabetes. The statin drugs are the most widely used lipid-lowering agents. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, in those with macular edema, and in some cases of nonproliferative retinopathy.

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