Med Surg Diabetes Study Guide for final Exams

Med Surg Diabetes Med Surg Diabetes Study Guide for final Exams Med Surg Diabetes Type I Diabetes -Age at Onset: More common in young people but can occur at any age. - Type of Onset: Signs and symptoms usually abrupt, but disease process may be present for several years. - Prevalence: Accounts for 5-10% of all cases -Primary Defect: Absent or minimal insulin production. -Islet cell antibodies: Often present at onset -Endogenous insulin: Absent -Nutritional status: thin, normal, or obese -Symptoms: Polydipsia, polyuria, polyphagia, fatigue, weight loss without trying. -Insulin: required for all Type II Diabetes -Age at Onset: More common in adults but can occur at any age. -Type of onset: Insidious, may go undiagnosed for years. -Primary Defect: Insulin resistance, decreased insulin production over time, and alteration in production of adipokines. -Islet cell antibodies: Absent Prevalence: Accounts for 90-95% of cases. -Endogenous insulin: initially increased in response to insulin resistance. secretion diminishes over time. -Nutritional status: Frequently overweight or obese. May be normal. -Symptoms: Frequently none. Fatigue, recurrent infections. May also experience polyuria, polyphagia, and polydipsia. -Insulin: Required for some. Disease is progressive and insulin treatment may need to be added to treatment regimen. A1C 6.5% or higher Fasting plasma glucose (FPG) Greater than or equal to 126mg/dL Two-hour plasma glucose Greater than or equal to 200 mg/dL, when using a glucose load of 75g. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose Greater than or equal to 200 mg/dL A1C measures what? Measures the amount of glycosylated hemoglobin as a percent of total hemoglobin. Risk Factors for Type 1 Diabetes -Predisposition to this is related to human leukocyte antigens (HLAs) Risk Factors for Type II Diabetes: Overweight or obese, being older, and having a family history of type 2 diabetes. -This is more prevalent in some ethnic populations. African Americans, Asian Americans, Hispanics, Native Hawaiians or other Pacific Islanders, and Native Americans have a higher rate of this than whites. Prediabetes -A diagnosis of IGT with the 2-hour oral glucose tolerance test values of 140-199 mg/dL. -A diagnosis of IFG when blood glucose levels are 100-125 mg/dL Rapid Acting Insuling Lispro (Humalog) Aspart (NovoLog) Glulisine (Apidra) -Onset: 10-30 minutes -Peak: 30 min-3hr -Duration: 3-5hr -Often preferred by those taking insulin with their meals. Short Acting Insulin Regular (Humulin R, Novolin R) -Onset: 30min-1hr -Peak: 2.5hr -Duration: 5-8hr -More likely to cause hypoglycemia because of a longer duration of action. -Should be injected 30-45 minutes before a meal to ensure that the onset of action coincides with meal absorption. Intermediate Acting Insulin NPH (Humulin N, Novolin N) -Onset: 1.5-4hr -Peak: 4-12hr -Duration: 12-18hr -Disadvantage is that it has a peak ranging from 4-12hrs, which can result in hypoglycemia. -Can be mixed with short and rapid-acting insulins. -should never be given IV Long Acting Insulin Glargine (Lantus) Detemir (Levemir) Degludec (Tresiba) -Onset: 0.8-4hr -Peak: Less defined or no pronounced peak. -Duration: 16-24hrs -Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced. Inhaled Insulin Afrezza -Onset: 12-15min -Peak: 60min -Duration: 2.5-3hr What are some problems with insulin Therapy? -Allergic Reactions -Lipdystrophy -Somogyi Effect -Dawn Phenomenon Lipdystrophy -Atrophy or hypertrophy of SubQ tissue. -May occur if the same injection sites are used frequently. Somogyi Effect -A high dose of insulin produces a decline in blood glucose levels during the night. As a result, counterregulatory hormones (Glucagon, Epi, GH, and cortisol) are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produces rebound hyperglycemia. -Danger is that patient may increase insulin dose due to hyperglycemic symptoms which can be too much insulin. -A bedtime snack, a reduction in the dose of insulin, or both can prevent this. -Checking BG between 2-4 AM for hyperglycemia can help determine this diagnosis. Dawn Phenomenon -Characterized by hyperglycemia that is present on awakening. -Two counterregulatory hormones (GH and Cortisol), which are excreted in increased amounts in the early morning may be cause of this. -Increased BG is caused by the body producing more glucose due to levels being low and since insulin dose may not be large enough the body can produce glucose to try and compensate for the lack of glucose which can result in Hyperglycemia. -Treatment is increase insulin. - Biguanides (Metformin) -MOA: Decreases rate of hepatic glucose production. Augments glucose uptake by tissues, especially muscles. -Side Effects: Diarrhea, lactic acidosis. Must be held 1-2 days before IV contrast media given and for 48 hrs after. -DRUG ALERT: -Do not use in patients with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication. -IV contrast media that contain iodine pose a risk of acute kidney injury which could exacerbate lactic acidosis. -Do no use in people who drink excessive amounts of alcohol -Take with food to minimize Gi side effects. Sulfonylureas: Glipizide Glyburide Glimepiride -MOA: Stimulates release of insulin from pancreatic islets. Decrease glycogenolysis and gluconeogenesis. Enhance Cellular sensitivity to insulin. Side Effects: Weight gain and hypoglycemia. Meglitinides: Nateglinide Repaglinide -MOA: Stimulates a rapid and short-lived release of insulin from the pancreas. -Side Effects: Weight gain and hypoglycemia a-Glucosidase inhibitors: acarbose miglitol -MOA: Delay absorption of complex carbohydrates from Gi tract. -Side Effects: Gas, abdominal pain, diarrhea Thiazolidinediones: pioglitazone rosiglitazone -MOA: Increase glucose uptake in muscle. Decrease endogenous glucose production. -Side Effects: Weight Gain, edema -Pioglitazone: may increase risk for bladder cancer and exacerbate heart failure -Rosiglitazone: May increase risk for cardiovascular events (MI, Stroke) Dipeptidy Peptidase-4 Inhibitors -linagliptin saxagliptin sitagliptin alogliptin -MOA: Enhance activity of incretins. Stimulate release of insulin form pancreatic B-cells. Decrease hepatic glucose production. -Side Effects: Pancreatitis, allergic reactions Dopamine Receptor Agonists -Bromocriptine -MOA: Activates dopamine receptors in CNS. Unknown how it improves glycemic levels. -SIde Effects: Orthostatic Hypotension Sodium-Glucose Co-transporter 2 inhibitors -MOA: Decreases renal glucose reabsorption and increases urinary glucose excretion. -Side Effects: Increased risk of genital and UTIs. Hypoglycemia. Glucagon-like peptide-1 Receptor Agonists -MOA: Stimulate release of insulin, decrease glucagon secretion, and slow gastric emptying. Increase satiety. -Side Effects: Nausea, vomiting, hypoglycemia, diarrhea, headache Amylin Analogs -MOA: slow gastric emptying, decrease glucagon secretion and endogenous glucose output from liver. -Side Effect: Hypoglycemia, nausea, vomiting, decreased appetite, headache. Nutritional Therapy for Type I -Base their meal planning on usual food intake and preferences balanced with insulin and exercise patterns. The patient coordinates insulin dosing with eating habits and activity pattern in mind. Day to day consistency in timing and amount of food eaten makes it much easier to manage BG levels. Especially for those individuals using conventional, fixed insulin regimens. Nutritional Therapy for Type II -Emphasizes achieving glucose, lipid, and BP goals. Modest weight loss has been associated with improved insulin resistance. Therefor weight loss is recommended for all individuals with diabetes who are overweight or obese. Importance of Exercise Regular, consistent exercise is an essential part of diabetes and prediabetes management. The ADA recommends that people with diabetes engage in at least 150 min/wk of a moderate intensity aerobic physical activity. -The ADA also encourages people with type 2 diabetes to perform resistance training three times a week in the absence of contraindications. -Exercise decreases insulin resistance and can have a direct effect on lowering BG levels. It also contributes to weight loss, which further decreases insulin resistance. -The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications to reach target BG goals in people with type 2 diabetes. Regular exercise may also help reduce triglyceride and low density lipoprotein (LDL) cholesterol levels, increase HDLs, reduce BP, and improve circulation. Outline how you would teach a newly diagnosed patient with diabetes to use a self monitoring machine 1. Wash hands in warm water. Finger should be dry before puncturing. Alcohol swab should not be used. 2. If it is difficult to obtain an adequate drop of blood for testing. Warm hands in warm water or let harms hang for a few minutes. 3. A lancing device is usually used. Place Lancet in the device and use side of finger pad to puncture instead of center of the finger. 4. Set lancing device to make a puncture just deep enough to obtain a sufficiently large drop of blood. 5. Follow instructions on monitor for checking the blood. 6. Record results. Compare with personal target BG goals. Why is it important for patients with diabetes to do SMBG -It provides a current BG reading. SMBG enables the patient to make decisions regarding food intake, activity patterns, and medication dosages. It also produces accurate records of daily glucose fluctuations and trends, and it alerts the patient to acute episodes of hyperglycemia and hypoglycemia. -it provides patients with a tool for achieving and maintaining specific glycemic goals. Criteria Patients must meet for a Pancreas Transplant 1. history of frequent, acute , and severe metabolic complications (hypoglycemia, hyperglycemia, ketoacidosis) requiring medical attention. 2. Clinical and emotional problems with the use of exogenous insulin therapy that are so severe as to be incapacitating. 3. Consistent failure of insulin-based management to prevent acute complications. Why is a pancreas transplant a good alternative for many diabetics. Improve quality of life for people with diabetes, eliminating the need for exogenous insulin, frequent blood glucose measurements, and the risk involved with hyper- and hypoglycemia, eliminate acute complications with type 1s. What are some nursing interventions you might do R/T Insulin Therapy -proper administration, assessment of the pt response to insulin therapy, and teaching the pt about administration, storage, and side effects of insulin.; - new user to understand the interaction of insulim, food, and activity, and to recognize and treat the symptoms of hypoglycemia; explore the patients underlying fears before beginning the teaching. -Asses the pts beliefs and concerns starting insulin. Follow up assessment that includes injection site for signs of lipodystrophy and other reactions What are some nursing interventions for oral and noninsulin injectable agents factor the patients mental status, eating habits, home environment, attitude toward diabetes, and medication history all play a significant role in determining the most appropriate drug; teach pts that OAs and noninsulin injectable agents are used in addition to food choices and activity as therapy for diabetes and the important of following their meal and activity plans; do not take extra pills if they overeat What are some nursing interventions for personal hygiene encourage daily brushing and flossing in addition to regular visits to the dentist; regular bathing, with particular emphasis on foot are, inspect feet daily, avoid going barefoot, wear shoes that are comfortable and supportive; treat cuts, burns, scrapes—if not heling in 24 hr call HCP what are some nursing interventions for medication identification and travel Carry medical identification at all times indicating that he or she has diabetes; wear a medic alert bracelet or necklace TRAVEL: requires planning; sitting long periods cause rise in glucose levels, get up and walk around every 2 hours to lower risk for DVT; have diabetic supplies when traveling n a plane, train, or bus. Have equitant like syringe, lancing devices, insulin vials or pens, and insulin pumps handy and have professional labels printed to delay checks at security points. Pts on OAs, keep snack items and quick acting carbohydrates source for treating hypoglycemia handy; if out of the country have letter from doctor for airport; plan an appropriate insulin schedule. Key to travel when taking insulin is to know the type of insulin being taken, its onset, anticipated peak, and mealtimes Hyperglycemia: Manifestations: • High blood glucose • Increased urine • Increased appetite followed by lack of it • Weakness, fatigue • Blurred vision • Headache • Glycosuria • Abdominal cramping • Progression to DKA or HHS Causes: • Illness, infection • Corticorsteroids • Too much food • Too little or no diabetes medication • Inactvitiy • Emotional, physical stress • Poor absorption of insulin Treatments: • Get medical care • Continue diabetes medication as prescribed • Check blood glucose frequently and check urine for ketones; record results • Drink fluids at least on hour basis • Contact HCP Preventive measures: • Take prescribed dose of mediation at proper time • Accurately administer insulin, noninsulin, injectable, OA • Make healthy food choices • Follow sick day rules when ill • Check blood glucose routinely • Wear identification band Hypoglycemia: Manifestations: • Blood glucose less than 70 • Cold clammy skin • Numbness of fingers, toes, mouth • rapid heartrate • emotional changes • headache • nervousness, tremors • faintness, dizziness • unsteady gait, slurred speech • hunger • changes in vision • seizures, coma Causes: • Alcohol intake without food • Too littelfood-delayed, omitted, inadequate intake • Too much diabetes medication • Too much exercise without adequate food intake • Wrong time of meds • Loss of weight without change in medication • Use of b blockers interfering with recognition of symptoms Treatments: Follow rule of 15 Preventive Measures: • Take prescribed dose of mediation at proper time • Accurately administer insulin, noninsulin, and OAs • Coordinate eating with medications • Eat adequate food intake needed for calories for exercise • Know symptoms to treat immediately • Carry simple carbs • Teach fam and caregiver about symptoms • Wear diabetes identification Rule of 15 A BG less than 70 mg/dL is treated by ingesting 15 g of a simple fast acting carbohydrate such as 4-6 ounces of fruit juice or a regular soft drink. -Commercial products such as gels or tablets containing specific amount of glucose are convenient for carrying in a purse or pocket to be used in such situations. -Recheck BG 15 min later. If the value is still less than 70 mg/dL ingest 15 g more of carbohydrate and recheck the BG in 15 minutes. -If no improvement after 2-3 administrations contact HCP. Complications of Diabetes Stroke, hypertension, dermopathy, atherosclerosis, nephropathy, peripheral neuropathy, neurogenic bladder, erectile dysfunction, retinopathy, cataracts, glaucoma, blindness, coronary artery disease, gastroparesis, islet cell loss, infections, gangrene Gerontological considerations for diabetes • Higher rates of premature death, functional disability, and coexisting illness such as hypertension and stroke than those without diabetes • Progress of aging associated with a reduction in B cell function, decreased insulin sensitivity, and altered carbohydrate metabolism increased the prevalence of diabetes • Undiagnosed or untreated diabetes is more common because of the normal physiologic changes of aging resemble those of diabetes, such as low energy levels, falls, dizziness, and confusion, and chronic urinary tract infections • Hypoglycemia unawareness is more common in older patients • Diabetes increased the rate of decline of cognitive function • Educated about meal planning and exercise • Assess renal function and creatine clearance in patients over 80 yrs old taking metformin • Insulin pens safer for older pts because decreased vision to accurately administer • Issues with teaching an older adult: altered vision, mobility, cognitive status, and functional ability, try and used slower pace and simple printed or audio materials in patients with limitations Mr. Steve has been admitted to the hospital with complications from liver failure. After reviewing Mr. Steves chart, the nurse notices he has lost 3 pounds in two days, and is showing signs of ketoacidosis. The nurse knows from this information that---> A- Mr. Steve treats his diabetes regularly and keeps it under control B- She should give Mr. Steve Metformin for his diabetes C- Mr. Steve has poorly treated type 1 diabetes Mellitus D- She should monitor for recurrent infections, monitor wound healing, and watch for visual changes Correct Answer- C Ketoacidosis and weight loss are signs of poorly or untreated type 1 diabetes mellitus A- (page 1124) showing synptoms of ketoacidosis losing weight shows that his diabetes is poorly treated B- (page 1130 DRUG ALLERT) the drug metformin should not be used with patients that have kidney disease, liver disease, or heart failure C- see above* (page 1124) D- (page 1124) infections, prolonged wound healing, and visual changes are all signs of type 2 diabetes mellitus A prediabetic patient's Glycosylated Hemoglobin (A1C) test results in a reading of 6.5% during their regular checkup. What would be the best next step in the care of this patient? a. Begin teaching the patient about a treatment plan for Type II Diabetes Mellitus b. Initiate testing to obtain a Fasting Plasma Glucose level c. Repeat the Glycosylated Hemoglobin (A1C) test d. Obtain the patient's current Plasma Glucose level e. Document the reading of 6.5% as an expected lab value for this patient C **Confirmation of the A1C level is obtained by a repeat test to rule out laboratory errors. It is preferable for the repeat test to be the same test used initially. (p.1124) The nurse is teaching a pre-diabetic patient how to look for signs of Type 2 diabetes. Which of the following symptoms should the nurse tell the patient to look for? (Select all that apply) A. slow healing wounds B. fatigue C. weight loss D. polyuria E. frequent infections The symptoms for Type 2 diabetes would be A, B, D and E. Slow healing wounds and frequent infections would occur because of the lack of inflammation to wounds. Fatigue is another symptom because of the increased amount of glucose in the blood that cannot get into the cells to create energy due to the resistance of insulin. Polyuria occurs because the kidneys are trying to compensate for the hyperglycemia by eliminating as much glucose as they can through the urine. C would not be an answer because type 2 diabetics tend to gain weight, not lose weight. Pg. Which of the following statements shows that a patient newly diagnosed with Diabetes Mellitus has had sufficient teaching about insulin administration? A.) "I can administer my insulin in the same location because it makes the dose more effective." B.) "I can administer my insulin even if I am about to exercise that area because there is no effect." C.) "I should always check the label to make sure I have the proper type, concentration, and expiration date of the insulin, even if I have been taking insulin for a long time." D.) "The insulin will be absorbed at the same rate regardless of which site I administer it in." Answer/Rationale: (C)- The patient should always be reminded of the insulin administration process, regardless of how long they've been on insulin therapy. There is potential that they misunderstood previous guidelines, or have had a decrease in eyesight and may not double check their insulin viles for accurate dosing. The patient should be educated to rotate injection sites to avoid lipodystrophy. Absorption is quickest in the order of abdomen, arm, thigh, then buttock. Insulin should not be administered in a site that is about to be exercised (ex administered in the thigh prior to jogging) because the increase in body heat can cause a faster absorption of the insulin with the potential risk for hypoglycemia. (Pages ). Your patient, who has been newly diagnosed with diabetes, demonstrates that they have proper knowledge of the precautions and self-care that comes with diabetes when they say (select all that apply): A. I do not need to worry about my foot care. B. Exercise can help me control my glucose levels. C. I need to wear properly fitting shoes and avoid going barefoot. D. I don't need to monitor my insulin as long as I eat less sugar. E. I cannot eat the same amount of sugar even if I use a sugar substitute. Answers: B, C, E A nurse knows a patient understands his/her drug therapy of taking Meglitinides when the patient states the following: A) "My blood sugar may rise above normal after taking this drug due to its side effects." B) "I should take this drug 30 minutes prior to eating." C) "I can take this when I am experiencing hypoglycemia." D) "I should notify my HCP if I have sudden weight gain." Answer: C. Meglitinides mimic normal responses to eating by increasing pancreatic insulin production. p. 1130. A patient comes in with concerns of having diabetes, select all of the responses that a patient who may have Diabetes will present. 1. Hypotension 2. Potruding Eyeballs 3. Second Cousin who has been diagnosed as diabetic 4. Breath that smells Fruity 5.Dry Mouth 6. Nocturia Answers: 1, 4, 5, 6 Rationale: Table 48-12 on page 1138, and also table 48-13. What should be included in your teaching for a Type 1 Diabetic? (Select all that apply) 1. Examine feet daily for skin integrity 2. DKA signs and symptoms 3. Make sure to take oral insulin sensitizers daily 4. Prick the middle of the finger to check BG levels 5. Monitor your BG before, during, and after exercise 6. Alcohol should not effect your BG levels 7. Rotate injection sites for insulin injection 8. It is best to eat before exercise Answer: (1, 2, 5, 7, 8) A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the healthcare provider is the priority? A. Administer oxygen per nasal cannula B. Administer the prescribed insulin C. Administer 50% dextrose IV per protocol D. Send blood to the laboratory for analysis Answer: Administer 50% dextrose IV per protocol Rationale on pg. Which noninsulin injectable agent slows down absorption of carbohydrate in the small intestine and are taken with each meal? A. Biguanides B. Dipeptidyl Peptidase-4 Inhibitors C. Alpha-Glucosidase Inhibitors D. Sulfonylureas The answer is C. because the drugs block absorption of carbohydrates which in turn lowers overall blood glucose. A 63 year old male who was diagnosed with type II diabetic mellitus 12 years ago is admitted into the ER with metabolic syndrome. Patient is showing signs of diaphoreses, fatigue, confusion, and hyperglycemia. What else might the nurse expect to see prior to therapy? Select all that apply Increased LDL's HgbA1C of 3% Hypotension Increased Triglycerides Order to Administer Insulin Rationale: Diabetic patients have a decrease in HDL's. (pg. 1123) HDL's break down LDL's, so decreased HDL leads to increased LDL. Patients with hyperglycemia have an increased percentage of glucose to bind to hemoglobin (pg. 1124), so HgbA1C would be elevated and not declined. Patients with metabolic syndrome have HTN and triglycerides (pg. 1123) Type II Diabetes is insulin resistant, so initially, insulin is not needed to fix this problem, but table 48-1 states that the primary defects of diabetes mellitus type 2 are "decrease production of insulin" (pg. 1121) What are some clinical manifestations of DKA? Select all that apply. A.Hypertension B. Orthostatic Hypotension C. dry mucous membranes D. Pallor E. tachycardia Answers: B, C, E Rationale on pages 1176 and 1177 What is the priority action for the nurse to take if the patient is admitted to the hospital with HHS? A. Monitor electrolytes B. Assess vital signs C. Fluid replacement D. Give a rapid acting insulin Answer: C pg. 1145 A 17 year old patient is experiencing nausea, vomiting, and excessive urination with complaints of severe fatigue and and excessive thirst over the course of several days. What might the nurse suspect of this patient? A) hyperosmolar hyperglycemia B) metabolic syndrome C) diabetic ketoacidosis D) gestational diabetes C Rationale: DKA typically develops over several days with symptoms such as polyuria, polydipsia, nausea, vomting, and severe fatigue, progressing to stupor and eventaul coma. Pg 1114. A patient has just been diagnosed with Type I diabetes mellitus. What response by the patient shows that they need further education about their disease? A. "I need to take my prescribed insulin on the prescribed schedule." B. "As long as I take my insulin regularly, I don't need to adjust my diet at all." C. "Low blood sugar is a possible side effect of my medication." D. "Exercise is an important aspect in my diabetes treatment." ... A 48 year old male has been diagnosed with Diabetes Mellitus. Which of the following suggest that he understood his patient teaching? A. "If I become emotionally or physically stressed, this can result in a higher blood glucose." B. "I should self-inject myself with insulin at the end of the day with the combined doses for the whole day." C. "I should let me dentist know I am diabetic next time I go in for an appointment." D. "It's important for me to inspect my feet daily, avoid going barefoot, and for me to wear supportive and comfortable shoes." E. "In times of illness I should check my blood glucose at a minimum of once every 4 hours." Answers: A,C,D,E (Page) A patient recently diagnosed with Type I Diabetes Mellitus is receiving education about self-monitoring of her glucose. Which of the following statements indicates that she has sufficient understanding of her condition? A. "When I am sick, my glucose level will be lower than normal, so I should plan to eat more often to counteract this." B. "When I am sick with a major illness, I need to monitor my glucose level more frequently because the stress on my body could increase my need for insulin." C. "My blood glucose is higher when I am sick with even a minor cold, so I need to check my glucose level more often and call my doctor if it is consistently high." D. "I am only at risk for diabetic ketoacidosis when I am sick, so monitoring my glucose level at home is only important if I feel ill." Correct Answer: C Rationale: P. 1139; blood glucose levels increase in response to stress including physical stress from illness. The patient should alert the provider to consistently high levels when sick, because additional insulin may be needed to counter risk for DKA. Increase in glucose levels occurs even with only minor illness such as a cold, not only in major illnesses. Mr. Jones, a newly diagnosed Type 1 diabetic, is being released from the hospital. What would indicate he needs more teaching about monitoring his glucose levels? A. I should check my glucose levels when I'm sick. B. I should check my glucose levels before or after exercise. C. I only have to check my glucose levels whenever I suspect hyperglycemia. D. I should check my glucose levels before I eat. Rationale: pg. 1136 ... A patient with long-term diabetes mellitus comes to the clinic with which complications? select all that apply hypotension peripheral neuropathy erectile dysfunction gain in islet cells stroke correct answers: peripheral neuropathy, erectile dysfunction, stroke A 55 year-old female with hypertension and prediabetes is scheduled for a CT scan of her lower GI tract in the morning, and will be given an iodine containing contrast medium. She has been instructed to discontinue use of her prescribed metformin. Which of the following statements indicate the patient requires further teaching. Select all that apply. A. I will resume taking my metformin 48 hours after the procedure is done after the doctor has checked that my serum albumin levels are normal. B. I should discontinue my metformin while receiving IV contrast media that contain iodine because it poses a risk to the insulin producing cells of my pancreas. C. I can take metformin until 12 hours before my procedure. D. I shouldn't resume taking my metformin if I have decreased kidney function. E. I should stop taking my metformin because it poses a risk for kidney injury, and can increase my risk for diabetic ketoacidosis. A,B,C,E When educating a patient with type 1 diabetes, what should you teach the patient about the signs and symptoms of diabetic ketoacidosis? A) dry mouth and excessive thirst B) Rapid weak pulse C) fast bounding pulse D) abdominal pain E) flushed dry skin answer: ABDE A nurse is providing education to a group of young adults regarding the development of type 2 diabetes. Which information should be included? Select all that apply. a. "Follow a vegetarian diet." b. "Do not eat sugar-containing foods." c. "Include physical activity in your daily routine." d. "Try to maintain a healthy diet." e. "You are not at risk for this disease yet because it is not diagnosed until after age 30." correct answers: C, D Rationale: Obesity is a major risk factor for developing type 2 diabetes therefore you should maintain a healthy diet and include physical activity in your daily routine to lower the risk of developing type 2 diabetes. page number: Your patient, Mr. Snickers, is a newly diagnosed Type 1 diabetic who will be going home on insulin therapy. Which statements by Mr. Snickers would mean he needed further teaching on insulin therapy? Select all that apply A. I should use the same injection site each time to limit damage to tissue. B. I should wash my hands, and make sure site is clean and dry prior to injection. C. I can reuse my single-use syringe as long as I boil it in water first. D. My Insulin is still good for up to 4 weeks after the expiration date on bottle. E. For my intermediate acting (cloudy) insulins I should roll the bottle between my hands to agitate solution instead of shaking. Answers: A, C, D Which of the following tasks would the RN caring for a diabetic patient be unable to delegate to an unlicensed person? A) Check blood glucose levels B) Monitor vital signs, urine output, or changes in behavior and level of consciousness C) Administer insulin to patient in a home care setting D) Assess for chronic complications of diabetes Correct answer: D) Assess for chronic complications of diabetes. Rational: pg 1152 It is the job of the RN to assess for chronic complications such as cardiovascular disease, retinopathy, nephropathy, neuropathy, and foot complications. UAP may check glucose levels, administer insulin in a home or community setting, and monitor vitals, urine output, and changes in behavior and levels of consciousness. Ricky Bobby is a 40 year old diabetic who is currently on insulin therapy. He reports having headaches in the morning when he wakes up, morning hyperglycemia, and night sweats. What actions would you recommend to help relieve these symptoms? A) an increase in insulin dosage in the evenings B) adjust insulin administration times C) limit snacking before bed D) all of the above E) none of the above Answer: E. Page 1129. He is experiencing the Somogyi effect. A bedtime snack, reduction in insulin, or both can help prevent this Somogyi effect. A patient diagnosed with Type 1 diabetes has assured you that they have been administering their insulin (NPH) per the instructions diligently. However, the lab report shows that their A1C level is 6.8%. Which of the following statements by the patient leads you to believe that they may require more teaching? A. "I rub the injection site for 15 seconds and let it dry completely before I inject the insulin" B. "after I pull the insulin out of the fridge I immediately begin to draw out the dose" C. "I inject the insulin at a 90 degree angle" d. "I take my insulin before breakfast and again 12 hours later" Correct: B. Rationale: NPH is a cloudy insulin " because it contains protamine. This substance decreases solubility, and as a result these insulins must be gently agitated before administration" A patient believes they have developed type 2 diabetes. With what symptoms would they present? A. insomnia, irritability, nervousness B. Increased thirst, increased hunger, increased urination C. Increased hunger, decreased thirst, increased neuromuscular activity D. Decreased hunger, decreased urination, decreased thirst ... A patient with type 2 diabetes is about to undergo a radiologic procedure that involves using a contrast medium. The doctor orders for the patient to continue to take Metformin. What nursing action should you take? A. Give Metformin at a scheduled time B. Question the order because you should temporarily discontinue metformin before the procedure and wait until 48 hours afterward to continue the medicine when serum creatinine is normal C. Stop taking the medicine before the procedure and then continue medicine normally directly after procedure D. Instruct the patient to take this medicine with food before the procedure Answer: B rationale page 1130 "Patients who are undergoing surgery or any radiologic procedures that involve the use of contrast medium are instructed to temporarily discontinue metformin before the surgery or the procedure. They should not resume the metformin until 48 hours afterward, once their serum creatinine has been checked and is normal." A nurse is preparing discharge materials for a patient newly diagnosised with Type I Diabetes Mellitus, which of the following statements indicates that the patient is in need of further education? a. There are many ways to receive insulin therapy and I should discuss the most appropriate method for my lifestyle and specific conditions with my doctor. b. So after the first couple of weeks of insulin therapy when my blood glucose levels have reached the normal range I can stop taking my medication. c. Since I will be taking insulin, I will need to know the signs of hypoglycemia and what to do if they occur. d. I should purchase and wear a medical alert bracelet indicating I have diabetes so that I can be properly cared for in a emergency. Correct answer: B, because type 1 diabetics must continue insulin replacement therapy for the remainder of life and the patient must be aware of this. (pg. 1125) A() Of the many types of insulin administration, insulin pumps can provide freedom and ease of managment., C(1146) Hypoglycemia can occur as a adverse effect of diabetes management and can have life threating results, such as coma., D(1140) A medical alert bracelet can direct the care of an individual in the the event of loss of consciousness. A 55 year old male patient has been placed on Metaformin due to a new diagnosis of type II diabetes. Upon reviewing the patients chart, you notice that the patient is scheduled for an MRI of the pancreas that day. Knowing that this scan involves the use of Gadolinium, the nurse would do what next? A. Ask the patient about his current diet B. Explain to the patient that a mild sedative may be used for claustrophobia C. Notify the physician about the patients use of Metaformin D. Question the order for the MRI Correct answer: C Rationale: Diabetic patients using Metaformin cannot be administered any IV contrast mediums unless the Metaformin has been held for 1-2 days before and after the MRI. Page A patient comes in and is in diabetic ketoacidosis what clinic manifestations would you expect to find? Select all that apply. A. Bradycardia B. Tachycardia C. Poor skin turgor D. Dehydration E. Hypertension Answers: B, C, and D A patient diagnosed with type 1 diabetes is about to eat dinner in 15 minutes. Which insulin would be the best for the patient use to process the sugar that comes from the carbs in the meal? A. Insulin glargine (Lantus) B. Insulin lispro (Humalog) C. Insulin NPH (Humulin N, Novolin N) D. Insulin detemir (Levemir) Answer: B. Rationale: pg.1125 A patient has been admitted to the hospital due to complications with their diabetes. What are signs and symptoms that the nurse expects to see from this patient? Select all that apply ria 2. Headache 3. Excessive thirst 4.Nocturia 5. Polyphagia Answer: 1,3,4,5 A 50 year old patient with Type II diabetes has been managing his blood glucose levels with combination therapy of a biguanide and sulfonylurea. His health care provider tells the nurse that the patient is scheduled for surgery the following week where an iodine contrast agent will be used. The most appropriate action to be taken by the nurse is: A. To withhold both medications 24-48 hours prior to the surgery and resume treatment 48 hours after the surgery B. To withhold the Biguanide 24-48 hours prior to the surgery and resume treatment 48 hours after the surgery C. To withhold the Biguanide 24-48 hours prior to the surgery and obtain a serum creatinine measurement 48 hours after the surgery D. To administer both medications throughout the procedure to maintain glucose levels Answer: C Metformin (the only biguanide) should be discontinued before a surgery or procedure containing an iodine contrast media. It is safe to resume treatment 48 hours after the surgery or procedure, but only after kidney function has been evaluated using a creatinine test. Rationale: page 1130 Mr. Dinosaur is admitted to the ER because of Type I diabetes, what are some complications that the Nurses might expect to see with this? Select all that Apply: A. Accelerated atherosclerotic plaque build up. B. Diabetic Ketoacidosis C. Urine retention D. Hypersensitivity in the extremities E. Polyphagia Answer: A, B, E A 42-year-old construction worker presents with excessive perspiration, shakiness, anxiety,, and palpitations. He tells the nurse he has type 1 diabetes mellitus. Which of the following actions should the nurse do first? A. Give the client four to six glucose tablets B. Inject 1 mg of glucagon C. Administer 50 mL of 50% glucose IV D. Give 4 to 6 oz of orange juice ... When teaching a patient about insulin care, which of the following applies: --> Clear insulin should not be agitated --> Dispose of single use-syringes safely --> Ensure that the site is clean and dry --> Push the plunger all the way down and immediately remove immeditely once the syringe is emptied fully --> NPH, lispro, aspart should not be mixed Rationale: Page 1128 Table 48-5 --> You would want to leave the syringe in after the insulin had been fully administered for at least 5 seconds. --> NPH, lispro, aspart should be mixed by gently rolling the insulin bottle between the palms of hands. Poorly treated diabetes mellitus may result in chronic complications including: (Select All That Apply) A) End-stage renal disease B) Stroke C) Peripheral neuropathy D) Asthma E) Blindness Answers: A, B, C, E Rationale: Pages A 38 year old female comes into the emergency department and presents signs of hypoglycemia, what symptoms would she be exhibiting? (select all that apply) a) cold, clammy skin b) blood glucose level of 73 c) glycosuria d) emotional changes e) changes in vision Answers: A, D, E Rationale: Pg. 1143 An 8 year old male presents to the clinic complaining of worsening increased thirst, urination, and hunger. His parents state he started out feeling ill, having a 100.8 fever, mild rash, and minor upper respiratory symptoms two weeks ago, but have since improved. What is the cause of the patient's symptoms? A.Viral URI and Pancreatic beta cell destruction B. Bacterial URI and increased insulin resistance C. Viral URI and Dehydration D. Bacterial URI and Dehydration Answer is A. Page 1122 Joe presents in the hospital with Diabetic Ketoacidosis, what is the first action of the nurse? A. Begin IV fluid of 0.45% NaCl B. Contact the physician C. Hook the patient up to a EKG for monitoring D. Being IV fluid of 0.20% NaCl Oh the correct answer is A. Page 1144 on right side of page A 35 year old Asian male comes into the clinic experiencing symptoms of weakness and fatigue,but does not show clear symptoms of hyperglycemia. He obtains an A1C of 7.1% with a two-hour plasma glucose level of 210mg/dL. As soon as the diagnostic studies are back the HCP orders the patient to be on Levemir to maintain his blood glucose levels in between meals and overnight. What would be the correct response as a nurse? (Select all that apply) A. give the patient the Levemir B. Question the patient further about any other hyperglycemic symptoms C. Repeat the lab tests D. Question the HCP as to why Levemir was ordered E. Question the patient if he has recently taken Acetaminophen Answers: B, C, D, E Rationale: pg. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning." answer C- rational page 1132 above drug alert A patient has been recently diagnosed with Type 2 Diabetes. Which of the following statements by the patient indicates that they have received adequate patient teaching? A. Drinking beer will not effect my glucose levels B. Physical Activity is off limits C. I do not need to use an alcohol swab to clean the injection site prior to insulin administration D. Cold and clammy skin could indicate that my glucose is too high Answer: C Rationales on pages 1128, 1134, 1142, 1143 When teaching a patient about insulin administration what are some key points the patient should know? (Select all that apply.) A. Avoid injecting insulin IM. B. Caution the patient about injecting into a site that is to be exercised. C. Tell the patient to avoid rotating the injection sites. D. For cloudy insulins you should shake the bottle to agitate it. E. Once you have injected the insulin, leave the needle in place for 5 seconds, then remove. Answer: A, B, and E Rationale on pages 1127 and 1128 A patient with diabetes mellitus reports being hyperglycemia in the morning. You suspect it is due to the Somogyi effect. What is the best way to find out if you are correct? A. Increase the dose of insulin to lower the patient's blood glucose level B. Check the patients blood glucose level between 2-4 am for hypoglycemia. C. Nothing, this is a normal finding. D. Tell the patient to eat a high fiber diet for breakfast to help with constipation Answer: B, rationale on page . 1129 When giving a patient insulin before a meal who needs rapid acting insulin, which insulin types can you give the patient? (Select all that apply) A. glargine (Lantus) B. aspart (Novolog) C. NPH (Humulin N, Novolin N) D. lispro (Humalog) E. glulisine (Apidra) F. regular (Humulin R, Novolin R) (ANSWERS: B, D, E) (Rationale on pg., or table 48-3) COLLAPSE A patient comes in to the clinic for a check up and begins to list the problems they have been having. You suspect diabetes. What symptoms would the patient have discussed with you? Select all that apply. A. Weight gain B. Polyuria C. Polydipsia D. Weight loss E. Polyphagia Answer: B,C,D,E Rationale: pg.1124 under clinical manifestations An A1C of ____ or higher indicates diabetes mellitus. 6.5% (Pg. 1124) What are good diet recommendations for a patient with Diabetes Mellitus? Select all that apply: 1. Limit the amount of alcohol you drink 2. Take on fad diets to help with weight loss 3. Limit regular soda and fruit juice 4. Eat regular meals at regular times 5. Choose foods low in saturated and trans fat Answers: 1,3,4,5 A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. What do you suspect is occurring in the patient and what is your course of treatment? A. Hyperglycemia: administer prescribed insulin aspart (NovoLog) B. Hypoglycemia: administer 20-50 mL of 50% Dextrose IV push C. Hyperglycemia: administer prescribed insulin glargine (Lantus) D. Hypoglycemia: have patient eat or drink 15g of quick-acting carbohydrate e.g.(4-6oz of soda/orange juice or 5-8 LifeSavers hard candy) Answer: B Rationale: Page 1146-47, knowing the symptoms differences in hypo- and hyper- -glycemia you can get rid of both A and C. Choosing between B and D you notice that the patient is unresponsive so you should not put anything in their mouths because it is a choking hazard. If a patient has diabetic ketoacidosis (DKA) it is imperative that they receive potassium supplements as hypokalemia can lead to: A. bradycardia B. cardiac dysrhythmias C. excessive sweating D. numbness or tingling Answer: B Upon assessment of a patient admitted to the emergency department, the nurse immediately suspects Diabetic Ketoacidosis. What signs or symptoms is this patient experiencing? A. Nausea and vomiting B. Serum glucose 225 mg/dL C. Exophthalmos D. Rapid, weak pulse E. Fever *Answers A, D, E Rationale Table 48-18 pg. 1144 A patient has Type 1 Diabetes Mellitus. Which statement by the patient indicates more teaching is required? Select all that apply. A. My body does not produce insulin B. My body is resistant to insulin C. My diabetes can be sucessfully managed with diet and lifestyle modifications D. My diabetes puts me at higher risk for MI E. As long as I keep my blood glucose levels below 150 mg/dL I will be in a safe rage. ANS: B, C, E Rationale: pg. A patient who is a type 2 diabetic comes into the emergency department exhibiting symptoms of hyperglycemia. What symptoms might he have? Select all that apply. A. Cold, clammy skin B. Increase in urination C. Slurred speech D. Blurred vision E. Abdominal cramps F. Nausea and vomiting Answers: B, D, E, F Bob is a type 2 diabetic. He sees the hot light is on at Krispy Kreme. He decided to eat twelve donuts. He experiences a spell of hyperglycemia and needs insulin. Which of the following could help him? Select All That Apply lispro (Humalog) aspart (Novolog) glulisine (Apidra) NPH (Humulin N, Novolin N) Glargine (Lantus) Answer= lispro, aspart, glulisine A patient diagnosed with type 2 Diabetes is experiencing symptoms of Hypoglycemia. What is the next course of action for the nurse to take? A. Wait 15 minutes and check blood glucose levels B. IM injection of 1mg of Glucagon C. Immediately check the blood glucose levels D. Notify the health care provider Answer. C. Rationale pg.1146 Which of the following are nursing responsibilities when administering insulin to a patient? Select all that apply. A. rotate quadrants if giving in the abdomen B. rub the area after administration C. store insulin in the refrigerator D. agitate both regular and NPH insulin before withdrawing into the syringe E. give rapid-onset insulin 15 minutes before meals ... A female patient was just diagnosed with type 2 diabetes. Which of the statements below lead you to believe your patient needs more teaching? (Select All That Apply) A. "I need to lose about 15% of my body weight to help my blood glucose levels." B. "I'll take my medication until my blood glucose is normal of at least 9 consecutive days." C. "I need to moderately cut back my calorie intake and increase calorie expenditure." D. "My attitude and the attitude of the people around me has no effect on my life style changes." E. "I am so excited I still get have my daily glass of wine after work." Rationale: Pg 1133 ... A patient with no prior diagnosis of diabetes has an A1C of 8.0%. What is the next course of action? A. Prepare to administer a rapid-acting insulin B. Repeat the blood test C. Tell the patient they likely have diabetes mellitus D. Ask the patient about what they ate for breakfast The correct answer is B. On page 1124, the book says that if any lab test is performed where the A1C, fasting plasma glucose, or two-hour plasma glucose levels are high, the test must be repeated to rule out any suspicion of error in the lab test. In order for the lab retest to be accurate, the same lab value that was elevated before must elevated a second time. A nurse is assessing a patient who is at risk for type 2 diabetes because he has metabolic syndrome. Which of the following characteristics does he have: (Select All That Apply) a) decreased GI motility b) elevated glucose levels c) high levels of HDL's d) high levels of triglycerides e) elevated BP answer: b, d, e rationale: pg 1123 description of metabolic syndrome A patient who is a type 1 diabetic must be aware of which of these in monitoring blood glucose? A. Checking their blood glucose before meals B. Checking blood glucose 2 hours after the first bite of food C. During times of illness, the patient should check glucose levels every 6 hours D. Monitor glucose levels before and after exercise E. If obese, glucose levels should be monitors more frequently Rational: page 1136, A, B, D Which of the following are true of patient teaching of insulin therapy? (Select all that Apply) A. Shake the cloudy insulin bottle. B. Push the needle into the skin at a 90-degree angle. C. Do not agitate clear insulin. D. Give the injection into highly exercised areas. E. Give faster-absorbing insulin into faster absorbing sites and vice versa. Correct answers: B, C, E Rationale: Page 1128 table 48-5 and paragraph above it. A male just diagnosed with Type 2 Diabetes Mellitus has asked the nurse how to maintain a healthy diet. The nurse's general recommendations for his nutrient balance are: A. alcohol B. fats C. insulin D. carbohydrates E. protein Answer: A,B,D,E Rationale: pg.1133 What would you expect to see ordered in a patient that has a blood glucose level of 650 mg/dL, an increased serum osmolality, and minimal ketones present? Select all that apply. A. Immediate IV insulin administration B. Fluid replacement C. Exogenous ketone supplementation D. Place them O2 via nasal cannula E. Monitor electrolytes *A,B,E page 1145 interprofessional care When caring for a patient with Diabetes Mellitus, the LPN can: (select all that apply) A) Administer OAs and routinely scheduled insulin regimens B) Assess for risk factors for prediabetes and type 1 and 2 diabetes mellitus C) Teach the patient and caregiver about self-management of DM D) Report concerns with patient self-management in the home setting E) Monitor the patient for symptoms of hypoglycemia, DKA, and HHS