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Chapter 48: Diabetes Mellitus Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a

hyperglycemic coma. ANS: C

For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections. DIF: Cognitive Level: Understand (comprehension) REF: 1134 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7

mmol/L). The nurse will plan to teach the patient about self-monitoring of blood glucose. using low doses of regular insulin. lifestyle changes to lower blood glucose. effects of oral hypoglycemic medications.

a. b. c. d.

ANS: C

The patient’s impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. DIF: Cognitive Level: Apply (application) REF: 1133 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and

glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine. ANS: D

When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught to avoid exercise when ketosis is present. The other statements are correct.

DIF: Cognitive Level: Apply (application) REF: 1134 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1

diabetes. To which question would the nurse anticipate a positive response? c. “Have you lost weight lately?” d. “Do you crave sugary drinks?”

a. “Are you anorexic?” b. “Is your urine dark colored?” ANS: C

Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugarcontaining fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. DIF: Cognitive Level: Apply (application) REF: 1121 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months

from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Fasting blood glucose c. Glycosylated hemoglobin b. Oral glucose tolerance d. Urine dipstick for glucose ANS: C

The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not used for monitoring glucose control after diabetes has been diagnosed. DIF: Cognitive Level: Apply (application) REF: 1124 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass

index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet. ANS: A

The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of glucose to near-normal levels. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are appropriate but are not as high in priority. DIF: Cognitive Level: Analyze (analysis) REF: 1124 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic

nurse will plan to teach the patient to

a. b. c. d.

check glucose level before, during, and after swimming. delay eating the noon meal until after the swimming class. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. time the morning insulin injection so that the peak occurs while swimming.

ANS: A

The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. DIF: Cognitive Level: Apply (application) REF: 1132 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. The nurse determines a need for additional instruction when the patient with newly diagnosed

type 1 diabetes says which of the following? “I will need a bedtime snack because I take an evening dose of NPH insulin.” “I can choose any foods, as long as I use enough insulin to cover the calories.” “I can have an occasional beverage with alcohol if I include it in my meal plan.” “I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.”

a. b. c. d.

ANS: B

Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. DIF: Cognitive Level: Apply (application) REF: 1132 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. To assist an older patient with diabetes to engage in moderate daily exercise, which action is

most important for the nurse to take? Determine what types of activities the patient enjoys. Remind the patient that exercise improves self-esteem. Teach the patient about the effects of exercise on glucose level. Give the patient a list of activities that are moderate in intensity.

a. b. c. d.

ANS: A

Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions may be helpful but are not the most important in improving compliance. DIF: Cognitive Level: Analyze (analysis) REF: 1134 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which statement by the patient indicates a need for additional instruction in administering

insulin? a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”

b. “I can buy the 0.5-mL syringes because the line markings will be easier to see.” c. “I do not need to aspirate the plunger to check for blood before injecting insulin.” d. “I should draw up the regular insulin first, after injecting air into the NPH bottle.” ANS: A

Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed. DIF: Cognitive Level: Apply (application) REF: 1128 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11. Which patient action indicates good understanding of the nurse’s teaching about

administration of aspart (NovoLog) insulin? The patient avoids injecting the insulin into the upper abdominal area. The patient cleans the skin with soap and water before insulin administration. The patient stores the insulin in the freezer after administering the prescribed dose. The patient pushes the plunger down while removing the syringe from the injection site.

a. b. c. d.

ANS: B

Cleaning the skin with soap and water is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection. DIF: Cognitive Level: Apply (application) REF: 1128 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse

anticipate the highest risk for hypoglycemia? a. 10:00 AM b. 12:00 AM

c. 2:00 PM d. 4:0 PM

ANS: A

The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur. DIF: Cognitive Level: Understand (comprehension) REF: 1132 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 13. Which patient action indicates a good understanding of the nurse’s teaching about the use of

an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans a diet with more calories than usual when using the pump. ANS: A

In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours a day. DIF: Cognitive Level: Apply (application) REF: 1129 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 14. A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the

nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus)

c. Detemir (Levemir) d. NPH (Humulin N)

ANS: A

Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. DIF: Cognitive Level: Apply (application) REF: 1125 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. Which information will the nurse include when teaching a patient who has type 2 diabetes

about glyburide ? Glyburide decreases glucagon secretion from the pancreas. Glyburide stimulates insulin production and release from the pancreas. Glyburide should be taken even if the morning blood glucose level is low. Glyburide should not be used for 48 hours after receiving IV contrast media.

a. b. c. d.

ANS: B

The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide. DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose

levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. “If I overeat at a meal, I will still take the usual dose of medication.” b. “Other medications besides the Glucotrol may affect my blood sugar.” c. “When I am ill, I may have to take insulin to control my blood sugar.” d. “My diabetes won’t cause complications because I don’t need insulin.” ANS: D

The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

DIF: Cognitive Level: Apply (application) REF: 1130 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an

allergic rash from an unknown cause, the health care provider prescribes prednisone. The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions. ANS: C

Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone but will not need a diet that is higher in calories. DIF: Cognitive Level: Apply (application) REF: 1124 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the

patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patient’s later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat. ANS: D

Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. DIF: Cognitive Level: Analyze (analysis) REF: 1127 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse identifies a need for additional teaching when the patient who is self-monitoring

blood glucose washes the puncture site using warm water and soap. chooses a puncture site in the center of the finger pad. hangs the arm down for a minute before puncturing the site. says the result of 120 mg indicates good blood sugar control.

a. b. c. d.

ANS: B

The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

DIF: Cognitive Level: Apply (application) REF: 1136 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes

about home management of the disease. Which action should the nurse take first? Ask the patient’s family to participate in the diabetes education program. Assess the patient’s perception of what it means to have diabetes mellitus. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.

a. b. c. d.

ANS: B

Before planning teaching, the nurse should assess the patient’s interest in and ability to selfmanage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. DIF: Cognitive Level: Analyze (analysis) REF: 1139 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 21. An unresponsive patient with type 2 diabetes is brought to the emergency department and

diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give 50% dextrose. c. initiate O2 by nasal cannula. b. insert an IV catheter. d. administer glargine (Lantus) insulin. ANS: B

HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated. DIF: Cognitive Level: Apply (application) REF: 1145 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22. A 26-yr-old female with type 1 diabetes develops a sore throat and runny nose after caring for

her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. ANS: C

Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

DIF: Cognitive Level: Apply (application) REF: 1139 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM

blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? Avoid snacking at bedtime. Increase ...