Diabetes

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

Rationale:
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.

2. 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. 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 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.

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

Rationale.
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.

4. 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. Assess patient’s perception of what it means to have diabetes.

Rationale.
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 is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.

Rationale.
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.

6.
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. Excessive thirst

Rationale.
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.

7. 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. Midnight before the test

Rationale.
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.

8. 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. 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.

9. 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

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.

10. 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. 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.

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

Rationale.
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.

12. 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. The level may be increased as a result of dehydration that accompanies hyperglycemia.
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.Rationale.
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.

13. 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. 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 10-30 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.

14. 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. Eat 15 g of simple carbohydrates.

Rationale.
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.

15. 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. Cardiac monitoring to detect potassium changes

Rationale.
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.

16. 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. 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.

17. 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. “I will take a brisk 30-minute walk 5 days per week 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 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.

18. 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 A1 c below 7%.

D. Coughing and deep breathing with splinting

B. 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 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.

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

A. A 48-year-old woman with a hemoglobin A1C of 8.4%

B. A 58-year-old man with a fasting blood glucose of 111 mg/dL

C. A 68-year-old woman with a random plasma glucose of 190 mg/dL

D. A 78-year-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A. A 48-year-old woman with a hemoglobin A1C of 8.4%

Rationale.
Criteria for a diagnosis of diabetes mellitus include a hemoglobin A1C ≥ 6.5%, fasting plasma glucose level =126 mg/dL, 2-hour plasma glucose level =200 mg/dL during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose =200 mg/dL.

The nurse teaches a 38-year-old man who was recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse?

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

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

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

D. “I may keep my insulin at room temperature (75o F) for up to a month.”

A. “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 skin preparation for the patient during 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 (less than 32° F [0° C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

The nurse instructs a 22-year-old female patient with diabetes mellitus about a healthy eating plan. Which statement made by the patient indicates that teaching was successful?

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

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

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

D. “If I use an insulin pump, I will not need to limit the amount of saturated fat in my diet.”

B. “I may have a hypoglycemic reaction if I drink alcohol on an empty stomach.”
Rationale.
The risk for alcohol-induced hypoglycemia is reduced by eating carbohydrates when drinking alcohol. 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 patients with diabetes mellitus. High-protein diets are not recommended for weight loss.

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness?

A. A 58-year-old patient with diabetic retinopathy

B. A 73-year-old patient who takes propranolol (Inderal)

C. A 19-year-old patient who is on the school track team

D. A 24-year-old patient with a hemoglobin A1C of 8.9%

B. A 73-year-old patient who takes propranolol (Inderal)
Rationale.
Hypoglycemic unawareness is a condition in which a person does not experience 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 â-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

The nurse is teaching a 60-year-old woman with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful?

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

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

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

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

B. “I can help control my blood pressure by avoiding foods high in salt.”
Rationale.
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. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.

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. fluid shifts resulting from the osmotic effect of hyperglycemia

Rationale.
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. The patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome

Rationale.
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 finding for your patient with type 2 diabetes. Which result will need further assessment?

A. A1C 9%

B. BP 126/80 mmHg

C. FBG 130mg/dL (7.2 mmol/L)

D. LDL cholesterol 100 mg/dL (2.6mmol/dL)

A. A1C 9%

Rationale.
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. ” I am supposed to have a meal or snack if I drink alcohol”.

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

You are caring for a patient with newly diagnosed type I 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 portable blood glucose monitor

E. Hyperglycemia prevention, symptoms, and treatment

A. Insulin administration
D. Use of portable blood glucose monitor
E. Hyperglycemia prevention, symptoms, and treatmentRationale.
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. Check the patient’s blood glucose level

Rationale.
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 824mg/dL (45.7 mol/dL) 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 hydration

C. Rapid, deep respirations

D. Decreased serum potassium

C. Rapid, deep respirations

Rationale.
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. Use of statins to treat dyslipidemia
C. Use of ACE inhibitors to treat nephropathy
E. Use of laser photocoagulation to treat retinopathyRationale.
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.

This type of diabetes has Abnormal or No production of insulin and needs injections?
type 1 diabetes
This type of diabetes is a condition where the body can not fully utilize the insulin production and/or there is abnormal/little to no insulin produced in the body
type 2 diabetes
What are 3 other types of diabetes?
1. Gestational
2. Prediabetes
3. Secondary diabetes
Signs and symptoms are usually abrupt for this type of diabetes.
type 1 diabetes
Insulin is a hormone produced by______ cells in the islets of ___________of the __________
Produced by the B cells in the Islets of Langerhans of the pancreas
Approximate Normal range for glucose
70-120mg/dL

In the first hour or two after meals, insulin concentrations_____rapidly in blood

A. Rises
B. Decreases

A. Rises
4 examples of counterregulatory hormones
1. Glucagon
2. Epinephrine
3. Cortisol
4. Growth hormone
what do Glucagon, Epinephrine, Cortisol, and Growth Hormone do to blood sugar?
Increase it

Promotes glucose transport into the cell

Insulin or Glucagon?

Insulin

Decreases blood glucose levels

Insulin or Glucagon?

Insulin
Group of hormones that oppose effects of insulin
Counterregulatory hormones
Major complication of type 1 diabetes

DKA (Diabetic Ketoacidosis) –

Profound insulin deficiency characterized by hyperglycemia, ketosis, acidosis and dehydration

Major complication in type 2 diabetes

HHS Hyperosmolar Hyperglycemic Syndrome

life-threatening syndrome ; able to produce enough insulin to prevent DKA but not enough to prevent hyperglycemia, osmotic diuresis and extracellular depletion; less common than DKA

Requires exogenous insulin to sustain life
Type 1 or Type 2?
Type 1
Caused by genetic predisposition (HLAs) and exposure to a virus
Type 1 or Type 2?
Type 1
Gradual onset
Type 2

Pancreas continues to produce some endogenous insulin but insulin produced is insufficient or is poorly utilized by tissues

Type 1 or Type 2?

Type 2
Classic symptoms of diabetes type 1
Polyuria (excessive urination)
Polydipsia (Excessive thirst)
Polyphasia (Excessive hunger)
Recurrent infections
Type 2

Switches energy source to fat/protein which results in fatigue, weakness and weight loss

Type 1 or Type 2?

Type 1

Prolonged wound healing and recurrent infections

Type 1 or 2?

Type 2

Progressive destruction of beta cells by body’s own T cells,

Type 1 ot Type 2?

Type 1
Visual changes
Tupe 1 or Type 2?
Type 2

Nonspecific symptoms

Type 1 or Type 2?

Type 2
Recurrent vaginal yeast or candidate infections
Type 2
Rapid onset
Type 1 or type 2?
Type 1
Blood glucose high but not high enough to be diagnosed as having diabetes
Prediabetic
Impaired fasting glucose (IFG) range
100-125 mg/dL
Impaired glucose tolerance (IGT) range
140-199mg/dL
Hemoglobin A1C (Hb A1C) range
5.7-6.4%
Prediabetics may have long term damage already occurring in the body.
True or False
True
Diabetes that develops during the 2nd trimester of pregnancy
Gestational Diabetes
Glucose levels usually return to normal at 10 weeks post partum
True or False
False. Glucose levels usually return to normal at 6 weeks post partum
Criteria for high risk pregnancy are (select all that apply):
A. Obesity
B. Prior history of gestational diabetes
C. Presence of glucouria
D. Mood swings
E. Strong family history of type 2 diabetes
F. Diagnosis of polycystic ovary syndrome
A, B C, E, F
This type of diabetes results from another medical condition or medication to treat a condition
Secondary diabetes
This diagnostic test can be tested accurately every 3 months and it depends solely on the blood glucose level.
HG A1C
The 4 methods of diagnostic studies

1. A1C GREATER THAN OR EQUAL TO 6.5%

2. Fasting Plasma Glucose (FPG) greater than or equal to 126mg/dL (7.0mmol/L)

3. Two hour plasma glucose level greater than or equal to 200 mg/dl (11.0mmol/L) using glucose load of 75g during an OGTT

4. Random Plasma Glucose greater than or equal to 200mg/dL (11.0mmol/L) with symptoms of hyperglycemia

Long term complications of diabetes
1. End stage renal disease
2. Lower limb Amputation
3. Eye Complications
Rapid Acting (bolus):time before meal, onset, peak, duration
Time – Injected 0-15 minutes before meal
Onset- 15 minutes
Peak- 60-90 minutes
Duration- 3-4 hours
Examples of Rapid Acting Insulin Medication
Humalog (lispro)
NovoLog (aspart)
Examples of Short Acting Medication
Humulin R (Regular)
Novolin R (Regular)
Short Acting (bolus): time before meal, onset, peak, duration
Time: Injected 30-40 minutes before meal
Onset: 30 min- 1 hour
Peak: 2-3 hours
Duration: 3-6 hours
Examples of Intermediate acting
NPH ( Humulin N, Novolin N)
What is the onset, peak and duration of Intermediate-acting insulin?
Onset: 2-4 hours
Peak: 4-10 hours
Duration: 10-16 hours
Long-Acting (basal) time frame of injection, onset, peak, duration?
-Injected once QD HS or in the AM
Onset: 1-2 hours
No peak action
Duration: 24 hours
This insulin is the only type that can be mixed with other insulins
Regular (NPH)
Preferred site for injections
Abdomen
List the 4 injection sites
1. Abdomen
2. Arm
3. Thigh
4.Buttocks
In-use vials may be left at room temperature up to 4 weeks.
True or false?
True
Rotate injections within one particular site.
True or false?
True
what is the only type insulin that can be adminstered IV?
Regular
Characterized by hyperglycemia upon awakening. Suggested that the growth hormone and cortisol are excreted increased amounts in the early AM. It is treated by increasing the insulin dosage or an adjustment in administration time.
Dawn Phenomenon
A rebound effect. Hyperglycemia in the AM. A high dose of insulin produces a decline in the blood glucose levels in the night furthermore resulting in the release of counter regulatory hormones. These hormones stimulate lipolysis, gluconeogenesis, and glycogenolysis which produces rebound hyperglycemia. Treated by decreasing the bedtime insulin or a bedtime snack.
The Somogyi effect
Oral agents works on these three defects of type 2 diabetes
Insulin resistance
Decreased insulin production
Increased hepatic glucose production
Hypoglycemia symptoms
Weakness visual disturbances confusion, irritability, diaphoresis, tremors, hunger

Which statement is true regarding the difference between type 1 and type 2 diabetes mellitus?

A. Type 2 diabetes has decreased insulin secretion and increased insulin resistance.

B. Type 2 diabetes has a total dependency on an outside source of insulin.

C. Type 1 diabetes typically occurs in older, obese adults.

D. Type 1 diabetes can result in hyperosmolar hyperglycemic syndrome (HHS).

A. Type 2 diabetes has decreased insulin secretion and increased insulin resistance.

Rationale.
In type 2 diabetes mellitus, secretion of insulin by the pancreas is reduced, and the cells become resistant to insulin. Patients with type 2 diabetes retain the ability to make insulin, although in inadequate amounts. The patient with type 1 diabetes is typically a thin, younger person. An uncontrolled type 1 diabetic may progress to a state of diabetic ketoacidosis. Type 2 diabetes can advance to hyperosmolar hyperglycemic syndrome (HHS).

Which finding is the best indication that the patient needs instruction regarding consistent control of her diabetes?

A. Fasting serum glucose level is 150 mg/dL.

B. Postprandial glucose level is 140 mg/dL.

C. Urine ketone level is zero.

D. Glycosylated hemoglobin (A1C) level is 9%

D. Glycosylated hemoglobin (A1C) level is 9%

Rationale.
The glycosylated hemoglobin is the amount of glucose bound to hemoglobin, and it remains there for the life of the cell (120 days). This test indicates glycemic control over 2 to 3 months. The other glucose levels may be temporarily high based on recent intake or indicate prediabetes with impaired glucose tolerance that is not yet diabetes. No ketones indicate good control.

The patient has vision problems. What intervention can help the patient independently manage her insulin administration?

A. Use an insulin pen, listening to the clicks.

B. Have family members prefill syringes for a month ahead of time.

C. Ask the physician to change the prescription to oral insulin.

D. Mix the basal insulin with rapid-acting insulin in the same syringe.

A. Use an insulin pen, listening to the clicks.

Rationale.
Patients with poor vision cannot see markings on a syringe but can count the audible clicks of the pen. Prefilled syringes are stable only for a week when stored in the refrigerator. Although oral insulin is a term used by lay people, it is inaccurate. Insulin is inactivated by gastric juices; the oral antidiabetic medications stimulate the body’s production of and sensitivity to insulin and are not interchangeable with insulin. Basal insulin cannot be mixed with any other insulin or solution

The patient has a 3:00 AM blood glucose level of 50 mg/dL and a 7:00 AM glucose level of 150 mg/dL. What is the proper explanation of these findings and anticipated intervention?

A. Somogyi effect with need for less insulin at night

B. Somogyi effect with need for a snack at 3:00 AM

C. Dawn phenomenon with need for more insulin in the morning

D. Dawn phenomenon with need for less food in the morning

A. Somogyi effect with need for less insulin at night

Rationale.
Somogyi effect is rebound caused by too much insulin at bedtime. The hypoglycemia produces counterregulatory hormones, causing rebound hyperglycemia. It is treated with less insulin at night. The dawn phenomenon is hyperglycemia in the morning due to release of counterregulatory hormones (e.g., growth hormone, cortisol) in the predawn hours. It is treated by increasing the insulin dose and an appropriate bedtime snack.

What is the correct teaching regarding oral antidiabetic medications?

A. Double the glipizide (Glucotrol) dose if consuming alcohol.

B. Hold all antidiabetic medication if vomiting is related to the flu.

C. Hold metformin 48 hours before a procedure with contrast medium.

D. Acarbose (Precose) is taken 2 hours after meals.

C. Hold metformin 48 hours before a procedure with contrast medium.

Rationale.
Metformin (Glucophage) is held 24 to 48 hours before and after a procedure with contrast medium to minimize the risk of acute renal failure and lactic acidosis. Alcohol consumption must be carefully managed and depends on amount, timing, and type of medication. It is never the recommendation to double the medication. Medication should be continued during illness, with close glucose and ketone monitoring. The α-glucosidase inhibitors (“starch blockers” such as acarbose [Precose] and miglitol [Glyset]) work by slowing absorption of carbohydrates in the small intestine. They should be taken with the first bite of each main meal.

You are teaching a 54-year-old patient with diabetes about proper composition of the daily diet. You explain that the guideline for carbohydrate intake is

A. 80% of daily intake.

B. minimum of 80 g/day.

C. minimum of 130 g/day.

D. maximum of 130 g/day.

C. minimum of 130 g/day

Rationale.
The recommendation for carbohydrate intake is a minimum of 130 g/day. Low-carbohydrate diets are not recommended for diabetes management.

The polydipsia and polyuria related to diabetes mellitus are primarily caused by the

A. 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 red blood cells resulting from attachment of excessive glucose to hemoglobin.

B. fluid shifts resulting from the osmotic effect of hyperglycemia.

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

The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute, and 28 deep, sighing respirations/minute. What is the priority need for the patient?

A. Oxygen

B. Intravenous (IV) fluids

C. Albuterol (Ventolin)

D. Metformin (Glucophage)

B Intravenous (IV) Fluids

Rationale.
A patient in diabetic ketoacidosis (DKA) needs IV fluids and insulin to stop the tissue breakdown resulting in ketone bodies and acidosis. The initial goal is fluid and electrolyte balance. Kussmaul respirations indicate the body is attempting to compensate by blowing off the carbon dioxide, but it is ineffective as long as the body continues to break down the ketone bodies and remains in metabolic acidosis. The issue is not respiratory insufficiency, and a bronchodilator is not indicated. Diabetic ketoacidosis occurs in type 1 diabetes and requires insulin; the pancreas no longer has the ability to respond to oral hypoglycemic medication.

The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor?

A. Magnesium (Mg)

B. Hemoglobin (Hb)

C. White blood cells (WBCs)

D. Potassium (K)

D. Potassium (K)

Rationale.
Even if the patient has normal potassium levels, there can be significant hypokalemia when insulin is administered as it pushes the serum potassium intracellularly. This can lead to life-threatening hypokalemia. The other options are not as significant.

The patient presents to the emergency department with a glucose level of 400 mg/dL, ketone result of 2+, and rapid respirations with a fruity odor. What finding do you anticipate?

A. pH below 7.30

B. Urine specific gravity below 1.005

C. High sodium bicarbonate levels

D. Low blood urea nitrogen (BUN) level

A. pH below 7.30

Rationale.
The patient is in metabolic acidosis, which is a pH below 7.35. Dehydration results in a high urine specific gravity (at the upper end of the normal range, or above 1.025 to 1.030). Sodium bicarbonate levels are low in metabolic acidosis. The dehydration that occurs with DKA elevates the BUN level.

Which assessment is the most sensitive indicator that the IV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease?

A. Pedal edema

B. Tachypnea

C. Urine output of 40 mL/hour

D. Change in the level of consciousness

D. Change in the level of consciousness

Rationale.
Too rapid fluid replacement can lead to hyponatremia and cerebral edema. Pedal edema is a later and relatively insignificant sign. In a bedridden patient, edema is more evident in the sacral area. The Kussmaul respirations are expected; crackles auscultated in the lungs are a more sensitive indicator. The desired urine output for adequate hydration is 30 to 60 mL/hr.

What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)?

A. Glucose level above 400 mg/dL

B. Hyperkalemia

C. Ketones in blood

D. Urine output of 30 mL/hr

C. Ketones in blood

Rationale.
The main difference between the two conditions is that ketone bodies are absent or minimal in HHS because the body has enough insulin to prevent ketoacidosis. Both have high glucose levels, although the level in HHS tends to be higher (above 600 mg/dL). Hypokalemia is possible in both, although it is more likely and serious in DKA. Urine output of 30 mL/hr is normal obligatory output; both conditions are likely to have dehydration and decreased output.

What is a typical finding of hyperosmolar hyperglycemic syndrome (HHS)?

A. Occurs in type 1 diabetes as the presenting symptom

B. Slow onset resulting in a blood glucose level greater than 600 mg/dL

C. Ketone bodies higher than 4+ in urine

D. Signs and symptoms of diabetes insipidus

B. Slow onset resulting in a blood glucose level greater than 600 mg/dL

Rationale.
HHS has a slower onset than diabetic ketoacidosis. HHS is often related to impaired thirst sensation, inadequate fluid intake, or functional inability to replace fluids. Because of the slower onset, the blood glucose levels can be quite high (more than 600 mg/dL) before diagnosis. HHS is seen in type 2 diabetics, and there is enough circulating insulin to prevent ketoacidosis. Diabetes insipidus is related to inadequate antidiuretic hormone secretion or kidney response with dilute, frequent urination. It is not related to HHS.

The elderly patient with type 2 diabetes mellitus presents to the clinic with a fever and productive cough. The diagnosis of pneumonia is made. You notice tenting skin, deep tongue furrows, and vital signs of 110/80 mm Hg, 120 beats/minute, and 24 breaths/minute. What assessment is important for you to obtain?

A. Blood glucose

B. Orthostatic blood pressures

C. Urine ketones

D. Temperature

A. Blood glucose

Rationale.
HHS is typically seen in patients with type 2 diabetes and infection, such as pneumonia. The main presenting sign is a glucose level above 600 mg/dL. Enough evidence of dehydration already exists that orthostatic vital sign assessments are not a priority, and they are often inaccurate in the elderly due to poor vascular tone. Patients with HHS do not have elevated ketone levels, which is a key distinction between HHS and DKA. Temperature will eventually be taken but is often blunted in the elderly and diabetics. An infectious diagnosis has already been made. The glucose level for appropriate fluid and insulin treatment is the priority.

The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority?

A. Obtain a serum glucose level.

B. Give hard candy under the tongue.

C. Administer glucagon per standing order.

D. Notify the health care provider.

C. Administer glucagon per standing order.

Rationale.
The patient has signs and symptoms of hypoglycemia for which treatment should be the priority. Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Waiting for a serum result (up to an hour) is improper because brain cells continue to die from a lack of glucose. Nothing solid should be placed in the mouth when the patient has an altered level of consciousness and can aspirate. With obvious symptoms, emergent treatment takes priority over notifying the health care provider.

The patient had a hypoglycemic episode and is treated with a concentrated glucose oral tablet. Fifteen minutes later the capillary glucose level (Accu-Check) is 150 mg/dL. What action should you take?

A. Administer a second bolus of glucose solution.

B. Administer regular insulin per sliding scale.

C. Have the patient eat peanut butter and toast.

D. Obtain a serum glucose level.

C. Have the patient eat peanut butter and toast

Rationale.
The patient has had an appropriate response to the glucose. Now a complex carbohydrate is needed to prevent hypoglycemia from reoccurring. There is no need for a second bolus of glucose because the result is within normal range. Insulin is not given, even though the glucose level is slightly elevated. The short-acting glucose is metabolized and insulin administration can increase the risk of a second hypoglycemic reaction. A serum confirmation of the level can be obtained but is not the priority.

The patient with type 1 diabetes mellitus is diaphoretic and shaky, and he reports feeling very lightheaded. There is no readily accessible blood glucose monitoring equipment. What action should you take?

A. Give 8 oz of milk.

B. Give 6 oz of juice with four packets of sugar in the juice.

C. Wait to act until there is confirmation of the blood glucose level.

D. Administer the patient’s insulin.

A. Give 8 oz of milk.

Rationale.
Hypoglycemia is treated with 15 to 20 grams of simple (fast-acting) carbohydrate, such as 8 ounces of low-fat milk. Avoid overtreatment with large quantities of quick-acting carbohydrates that can cause a rapid fluctuation to hyperglycemia. If the patient has manifestations of hypoglycemia and monitoring equipment is not available, hypoglycemia should be assumed and treatment should be initiated. The patient has signs of hypoglycemia and insulin is not indicated.

The patient is managed with NPH and regular insulin injections before breakfast and before dinner. When is the patient most likely to have a hypoglycemic reaction?

A. After breakfast

B. Before lunch

C. During lunch

D. After lunch

B. Before lunch

Rationale.
The regular insulin peak occurs about 2 to 3 hours with a duration of 5 to 6 hours. If too much insulin or not enough food is given, the most likely time of hypoglycemia is before lunch, when the regular insulin is still present, the NPH has its onset, and the breakfast food has been metabolized.

The patient received 10 units of regular insulin subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. You plan to monitor this patient for signs of hypoglycemia at which peak action times?

A. 9:00 PM to 10:30 PM

B. 10:30 PM to 11:30 PM

C. 12:30 AM to 1:30 AM

D. 2:30 AM to 4:30 AM

B. 10:30 PM to 11:30 PM

Rationale.
Regular insulin exerts peak action in 2 to 3 hours making the patient most at risk for hypoglycemia between 10:30 PM and 11:30 PM.

What priority action should you 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 his blood glucose level.

D. Assess for other neurologic symptoms.

C. Check his blood glucose level.

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

Which symptoms reported by a patient with diabetes mellitus are most important to follow-up?

A. “My vision has been getting fuzzier over the past year.”

B. “I cannot read the small print anymore.”

C. “There is something like a veil of blackness coming across my vision.”

D. “I have yellow discharge from one eye.”

C. “There is something like a veil of blackness coming across my vision.”

Rationale.
Diabetic retinopathy, particularly proliferative retinopathy, can cause retinal detachment, which has the classic new symptom of a veil coming across the field of vision. This requires emergency treatment. Chronic blurry vision can be cataracts and is not emergent. Change in the ability to read things near to the eye (presbyopia or farsightedness) is an age-related change and not emergent. Conjunctivitis needs treatment but is not as emergent as retinal detachment.

What is the best teaching for a patient who is newly diagnosed with diabetes mellitus type 2?

A. Read a Snellen chart yearly.

B. Be checked out for presbycusis.

C. Notify the doctor if your vision has color distortion.

D. See an ophthalmologist for a dilated eye examination yearly.

D. See an ophthalmologist for a dilated eye examination yearly.

Rationale.
The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Because of this, the patient with type 2 diabetes should have a dilated eye examination by an ophthalmologist at the time of diagnosis and annually thereafter for early detection and treatment. The Snellen test is used to determine vision acuity and the need for glasses, and it is not specific to diabetes. Presbycusis is age-related hearing impairment and is not specific to diabetes. Cataracts related to age typically cause some vision distortion.

The patient with diabetes mellitus confides to you that he is afraid he will lose his vision like his friend did. What is the best response?

A. Encourage the patient to look at the blessings he has instead of worrying.

B. Verify there is nothing that can influence that outcome but new measures to cope are being developed.

C. Stress that tight glycemic control can minimize microvascular complications such as retinopathy.

D. Remind the patient that every person is different.

C. Stress that tight glycemic control can minimize microvascular complications such as retinopathy.

Rationale.
Microvascular complications result from thickening of the vessel membrane in the capillaries and arterioles and is in response to chronic hyperglycemia. They are specific to diabetes, and good control can help prevent complications, including retinopathy, which causes blindness. The first option minimizes the patient’s concern and gives advice. The second option is inaccurate. The last option is true but minimizes the concern and omits actions the patient can take, such as controlling glucose and seeing an ophthalmologist for early detection of problems.

You are beginning to teach a diabetic patient about the vascular complications of diabetes. Which information is appropriate for you to include?

A. Macroangiopathy does not occur in type 1 diabetes but does affect 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 most patients with diabetes.

B. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.

Rationale.
Microangiopathy occurs in type 1 and type 2 diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Sexual impotency and slowed gastric emptying result from microangiopathy.

What therapies are appropriate 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 angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy

D. Use of laser photocoagulation to treat retinopathy

E. Use of protein restriction in patients with early signs of nephropathy

A. Use of statins to treat dyslipidemia
C. Use of angiotensin-converting enzyme (ACE) inhibitors to treat nephropathy
D. Use of laser photocoagulation to treat retinopathyRationale.
In patients with diabetes who have microalbuminuria or macroalbuminuria, ACE inhibitors (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (ARBs) (e.g., losartan [Cozaar]) should be used. Both of these drug classes 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 drugs. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, macular edema, and in some cases of nonproliferative retinopathy.

The patient has diabetes mellitus and macroalbuminuria. The patient asks you why the physician is prescribing the angiotensin-converting enzyme (ACE) inhibitor lisinopril (Zestril) for him even though his blood pressure is well-controlled. What is your response?

A. It helps prevent hypertension as diabetics are prone to it.

B. ACE inhibitors delay the progression of nephropathy in patients with diabetes.

C. ACE inhibitors prevent macrovascular complications.

D. ACE inhibitors help prevent atherosclerosis.

B. ACE inhibitors delay the progression of nephropathy in patients with diabetes.

Rationale.
ACE inhibitors and angiotensin II receptor antagonists (ARBs) are used to treat hypertension and delay the progression of nephropathy in patients with diabetes. ACE inhibitors are not used prophylactically. ACE inhibitors do not affect macrovascular complications. Nephropathy is a microvascular complication.

What is most helpful in the prevention of nephropathy in a patient with diabetes mellitus?

A. Acid-ash diet

B. Ensuring adequate fluid intake for renal perfusion

C. Preventing obstruction from benign prostatic hyperplasia (BPH)

D. Stopping smoking

D. Stopping smoking

Rationale.
Risk factors for diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Diabetic nephropathy is an intrarenal microvascular complication in which the glomeruli of the kidney are damaged. The acid-ash diet is used to prevent kidney stones, a potential postrenal cause. The kidney receives about 25% of the cardiac output, and inadequate fluids or shock resulting in adequate perfusion is a prerenal cause. BPH is a postrenal cause of kidney pathology.

Which elevated laboratory finding is the best indication of potential diabetic nephropathy?

A. Blood urea nitrogen (BUN) level

B. Urine albumin-to-creatinine ratio

C. Urine specific gravity

D. Chloride (Cl-) level

B. Urine albumin-to-creatinine ratio

Rationale.
Screening for nephropathy depends on the urinary albumin-to-creatinine ratio and a serum creatinine level. (Creatinine indicates how well the kidney is filtering). BUN alone, without correction to creatinine, can indicate many other issues, including dehydration and liver function. Unless there is renal failure, urine specific gravity is more indicative of dehydration. Chloride is not a direct indicator of kidney function.

The patient with diabetes and shortness of breath is brought from the nursing home to the hospital emergency department. The electrocardiogram (ECG) shows evidence of a myocardial infarction (MI), but the patient denied ever having chest pain. Which is the best explanation of what happened?

A. The patient had a “silent” MI related to autonomic neuropathy.

B. The patient had chest pain but forgot because of dementia.

C. The patient minimized the chest pain because he was worried about costs.

D. The patient has the psychologic defense mechanism of denial.

A. The patient had a “silent” MI related to autonomic neuropathy.

Rationale.
Cardiovascular abnormalities associated with autonomic neuropathy include painless myocardial infarction. Shortness of breath related to decreased cardiac functioning can be the first overt sign or symptom. Patients with dementia accurately report chest pain at the time it is occurring when asked, although they may later fail to recall it. Defense mechanisms should not be assumed without further evidence.

The patient with diabetes reports tingling and burning in the lower extremities at night. The patient asks you why the primary health care provider prescribed the selective serotonin reuptake inhibitor (SSRI) duloxetine (Cymbalta). What is the best response?

A. The doctor thought the discomfort was causing the patient to be depressed.

B. The drug is known to improve patients’ moods and enhance coping.

C. It regulates pain by affecting neurotransmitters that transmit pain through the spine.

D. It deadens the sensitivity to peripheral nerve endings.

C. It regulates pain by affecting neurotransmitters that transmit pain through the spine.

Rationale.
SSRI drugs work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters that are believed to play a role in the transmission of pain through the spinal cord. Duloxetine is thought to relieve pain by increasing the levels of serotonin and norepinephrine, which improves the body’s ability to regulate pain. The drugs are not given specifically for depression, although it may have a mood-enhancing effect. Duloxetine does not deaden the sensitivity of peripheral nerve endings.

The male patient with diabetes and heart disease confides to you that he can no longer have an erection. What is the reason for these changes?

A. It is a normal part of aging and is relieved with sildenafil (Viagra).

B. It usually is related to emotions and is a temporary problem.

C. It is often the first sign of diabetic autonomic neuropathy.

D. It indicates that the patient has developed a neurogenic bladder.

C. It is often the first sign of diabetic autonomic neuropathy.

Rationale.
Erectile dysfunction (ED) is common and often is the first manifestation of autonomic failure. ED is not a normal part of aging, and sildenafil cannot be effective if the problem is related to nerve transmission. Sildenafil should not be taken if the patient is on nitrates. ED is a common long-term complication of diabetes. Neurogenic bladder is related to urinary retention.

What is the proper teaching regarding diabetic foot care?

A. Cut toenails so corners are cut down.

B. Check your feet daily with a mirror.

C. Walk barefoot only in dry summer weather.

D. Check the temperature of bath water with your toes.

B. Check your feet daily with a mirror.

Rationale.
Feet should be inspected daily for broken areas that are at risk for delayed wound healing. Using a mirror allows visualization of areas not readily seen. Toenails should be cut straight across and the corners should not be cut down. Properly fitting shoes should be worn at all times to protect the feet. Improper footwear and stepping on foreign objects when barefoot are common causes of undetected foot injury. Water temperature should be tested with the hands first.

Which lower extremity or foot finding is a sign of sensory neuropathy in a patient with diabetes mellitus?

A. Dusky when legs are dependent

B. Pitting pedal edema

C. Intermittent claudication

D. Strong pedal pulse

C. Intermittent claudication

Rationale.
Peripheral arterial disease (PAD) is caused by a reduction of blood flow to the lower extremities. Classic signs include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor. Dusky legs when they are dependent, pitting pedal edema, and a strong pedal pulse are signs of peripheral venous disease.

What is routinely used to diagnose PAD?

A. Venous Doppler

B. V/Q scan

C. D-dimer

D. Ankle-brachial index (ABI)

D. Ankle-brachial index (ABI)

Rationale.
The disease is diagnosed by the medical history, ankle-brachial index (ABI), and angiography. The ABI is calculated by dividing the ankle systolic blood pressure by the highest brachial systolic blood pressure. Venous Doppler is performed for deep vein thrombosis. A V/Q scan is used for pulmonary embolism. D-dimer is used for abnormal clotting effects.

You taught a patient admitted with diabetes, cellulitis, and osteomyelitis the principles of foot care. You confirm that the patient understands the principles of foot care if he makes which statement?

A. “I should walk barefoot only 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. “I should look at the condition of my feet every day.”

Rationale.
Patients with diabetes mellitus need to inspect the feet daily for broken areas that are at risk for delayed wound healing. Water temperature should be tested with the hands first. Properly fitted (not tight) shoes should be worn at all times.

Which is a description of acanthosis nigricans, an integumentary complication of diabetes mellitus?

A. Dark, coarse, thickened skin predominantly on the neck

B. Widespread redness in the lower extremities

C. Unilateral, clustered skin vesicles along a peripheral sensory nerve

D. Threadlike, brownish, linear burrows between the fingers and inner wrists

A. Dark, coarse, thickened skin predominantly on the neck

Rationale.
Acanthosis nigricans is characterized by dark, coarse, thickened skin predominantly in the flexures and on the neck. Widespread redness is a sign of cellulitis. Unilateral, clustered skin vesicles along a peripheral sensory nerve describe herpes zoster (shingles). Threadlike, brownish, linear burrows between fingers and inner wrists describe scabies.

Which skin condition should you routinely assess in a patient with diabetes mellitus?

A. Contact dermatitis

B. Psoriasis

C. Malignant melanoma

D. Tinea pedis

D. Tinea pedis

Rationale.
A patient with diabetes is more susceptible to infections than other patients. The dark, moist environment of the feet make the diabetic patient more prone to athlete’s foot, a fungal infection. Contact dermatitis is an inflammatory response after contact with a specific antigen and is not related to diabetes. Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis and is not related to diabetes. Malignant melanoma is a skin cancer that can metastasize. Although important to notice, infectious skin conditions are more commonly related to diabetes mellitus.

Which symptom would make a clinic nurse suspect undiagnosed diabetes mellitus in a patient?

A. Balanitis

B. Blepharoptosis

C. “Mole” with waxy border and recent central crater

D. Nits on the hair shaft with pruritus

A. Balanitis

Rationale.
Inflammation of the skin covering the glans penis is seen in uncircumcised males with undiagnosed diabetes mellitus as a result of glucosuria. Blepharoptosis is drooping of the upper eyelid and is not directly related to diabetes mellitus. A “mole” with waxy border and recent central crater is a description of basal cell carcinoma, which is not directly related to diabetes mellitus. Nits on the hair shaft with pruritus is a description of pediculosis capitis (lice).

Which presentation would make the clinic nurse suspicious that the patient has undiagnosed diabetes mellitus?

A. Has a throat infection that is resistant to the prescribed antibiotic

B. History of dry socket syndrome after a tooth extraction

C. Relates a history of recurring vaginal yeast infections

D. History of sensitivity to alcohol ingestion

C. Relates a history of recurring vaginal yeast infections

Rationale.
A patient with diabetes mellitus is more susceptible to infections than other patients. The mechanisms for this phenomenon include a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes. Recurring or persistent infections such as Candida albicans, as well as boils and furuncles, in the undiagnosed patient often lead the health care provider to suspect diabetes. The other options do not signal diabetes mellitus.

Which is the best patient to share a hospital room with a patient who has diabetes mellitus and is scheduled for surgery?

A. Admitted with community-acquired pneumonia

B. History of asthma on nebulized breathing treatments

C. Cultured vancomycin-resistant enterococcus (VRE) in the stool

D. History of tuberculosis and on medications for 1 week

B. History of asthma on nebulized breathing treatments

Rationale.
The patient with asthma is on nebulized breathing treatments. This patient is not infectious. A patient with diabetes mellitus is more susceptible to infections and should not cohabit with an infectious patient, which all the other patients are.

A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient’s potassium level is 5.6 mEq/L. Which factors could contribute to 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 because of metabolic ketoacidosis caused by hyperglycemia.

E. The level may be raised because excess insulin is being given and causing potassium shifts.

A. The level may be increased as a result of dehydration that accompanies hyperglycemia.
C. The level is consistent with renal insufficiency that can develop with renal nephropathy.
D. The level may be raised because of metabolic ketoacidosis caused by hyperglycemia.Rationale.
Malnutrition does not cause sodium excretion accompanied by potassium retention; it is not a contributing factor to this patient’s potassium level. 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. You must consider the potential for metabolic ketoacidosis because potassium leaves the cell when hydrogen enters in an attempt to compensate for a low pH.

Which statement correctly describes a patient with type 2 diabetes who is admitted to the hospital with pneumonia?

A. Must receive insulin therapy to prevent the development of ketoacidosis

B. Has islet cell antibodies that have destroyed the ability of the pancreas to produce insulin

C. Has minimal or absent endogenous insulin secretion and requires daily insulin injections

D. May have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome (HHS).

D. May have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome (HHS).

Rationale.
HHS is a life-threatening syndrome that can occur in the 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.

The patient has a history of poor control of her diabetes mellitus. When you ask the patient how the diet, insulin administration, and glucose testing are going, she responds with a flat affect and says, “I don’t know.” Which factor is most important for you to assess?

A. Dementia

B. Lack of resources

C. Depression

D. Lack of knowledge

C. Depression

Rationale.
Consistent “I don’t know” signals “I don’t care” and depression. Patients with diabetes have high rates of psychiatric disorders, particularly depression, which contributes to poor adherence, feelings of helplessness, and poor outcomes. Patients need to be assessed for the signs and symptoms of depression at each visit with a health care professional. Patients with dementia forget but care enough to answer. Depression should be ruled out before dealing with a lack of resources or lack of knowledge to use them.

You should suspect an eating disorder in a woman with type 1 diabetes when learning what information?

A. Eats 1 cup of ice cream every night before going to bed

B. Skips insulin doses to cause rapid weight loss

C. Gained a pound per month despite indicating she follows her diet

D. Admits to routinely skipping breakfast

B. Skips insulin doses to cause rapid weight loss

Rationale.
Women with diabetes and an eating disorder intentionally decrease their dose of insulin or omit the dose to result in a rapid weight loss through calorie purging. The hyperglycemia leads to glycosuria, which promotes weight loss of calories as glucose in the urine. The other options are less than optional behaviors but do not signal an eating disorder.

Types of sulfonylureas
glipizide (Glucotrol)
glimepiride (Amaryl)
Types of Meglitinides
Rapaglinide (Prandin)
Nateglinide (Starlix)
Biguanide
Metformin (Glucophage)
Purpose for sulfonylureas
increase insulin production from the pancreas
Purpose for Meglitinides
Increase insulin production from the pancreas
Purpose for Biguanide (4)
Reduce glucose production by liver
Increase glucose sensitivity at tissues
Increase glucose transport to cells
Lowers lipid levels
Contraindications for Metformin
ESRD, alcohol and CT contrast
Glycemic Index (GI)
Term used to describe rise in blood glucose levels 2 hours after carbohydrate-containing food is consumed
Self monitoring blood glucose readings (SMBG) vs Lab work readings
SMBG takes blood from the capillaries (whole blood)
Lab work from hospitals will use venous bloodVenous blood will show higher results than capillary blood. Normally 10-12% higher than cap blood. This is normal.

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