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Chapter: Chapter 41: Assessment and Management of Patients with Diabetes Mellitus

Multiple Choice

1. The nursing instructor is discussing diabetes mellitus with the junior nursing class. What would the instructor tell the class may develop in the patient when ketone bodies accumulate in excessive amounts?A) HypovolemiaB) PolyuriaC) Diabetic ketoacidosisD) Blurred vision

Ans: CChapter: 41Client Needs: D-4Cognitive Level: ComprehensionDifficulty: EasyIntegrated Process: Teaching/LearningObjective: 9Page and Header: 1199, Diabetes

Feedback: Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. This will result in diabetic ketoacidosis. Signs and symptoms are abdominal pain, nausea, vomiting hyperventilation, fruity odor of breath, and if left

untreated, possible death. Excessive amounts of ketone bodies do not cause hypovolemia, polyuria or blurred vision.

2. A patient presents to the clinic complaining of symptoms that suggest diabetes mellitus. What criteria would support checking blood levels for the diagnosis of diabetes mellitus?A) Fasting plasma glucose greater than or equal to 126 mg/dLB) Random plasma glucose greater than 150 mg/dLC) Fasting plasma glucose greater than 100 mg/dLD) Random plasma glucose greater than 126 mg/dL

Ans: AChapter: 41Client Needs: D-4Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 4Page and Header: 1200, Diabetes

Feedback: Criteria for the diagnosis of diabetes mellitus include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL. Therefore options B, C, and D are incorrect.

3. A patient newly diagnosed with type 2 diabetes is attending a nutrition class specifically designed for type 2 diabetics. What general guideline would it be important to teach the patients at this class?A) Low fat generally indicates low sugar.B) Protein should constitute 35% of dietary intake.C) Control calorie intake to attain a reasonable body weight.D) Dietary fat should be eliminated from the diet.

Ans: CChapter: 41Client Needs: BCognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 5Page and Header: 1202, Diabetes

Feedback: In general, calorie distribution recommended is higher in carbohydrates than in fat and protein, and all carbohydrates should be eaten in moderation to avoid high postprandial blood glucose levels. The most important objective in the dietary management of diabetes is control of total calorie intake to attain or maintain reasonable body weight. Low fat does not automatically mean low sugar. Dietary fat does not need to be eliminated from the diet. Protein intake needs to keep calories within a reasonable amount.

4. The nurse is doing patient teaching with an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that what will decrease the body's need for insulin?A) SleepB) StressC) ExerciseD) Low-fat diet

Ans: CChapter: 41Client Needs: BCognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 6Page and Header: 1205, Diabetes

Feedback: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Stress increases the need for insulin. Insulin is generally taken to cover what is eaten at each meal. Sleep impacts the need for insulin because many patients forget to take their insulin dose prior to going to sleep.

5. The nurse is teaching a newly diagnosed diabetic about his insulin regimen. When administering Humalog insulin the nurse should teach the patient what?A) Have the patient's meal tray available.B) Have the patient begin the meal tray 30 minutes following the injection.C) Feed the patient prior to administering the dose of insulin.D) Watch for symptoms of hyperglycemia.

Ans: AChapter: 41Client Needs: D-2Cognitive Level: Analysis

Difficulty: ModerateIntegrated Process: Nursing ProcessObjective: 7Page and Header: 1209, Diabetes

Feedback: Humalog's onset of action is 10 to 15 minutes. Because of its rapid action, patients should be instructed not to wait the usual 30 minutes after injection to eat. You do not feed a patient before administering insulin. You always assess for symptoms of hyperglycemia.

6. A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient?A) SulfonylureaB) BiguanideC) ThiazolidinedioneD) Alpha glucosidase inhibitor

Ans: BChapter: 41Client Needs: D-2Cognitive Level: ComprehensionDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 8Page and Header: 1214, Diabetes

Feedback: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

7. The diabetic Nurse Educator is teaching a class for newly diagnosed diabetics and their families. In this class the Nurse Educator is teaching about “sick day rules.” What guideline applies to periods of illness (“sick day rules”) in a diabetic patient?A) Do not eliminate insulin when nauseated and vomiting.B) Report elevated glucose levels greater than 150 mg/dL.

C) Eat three meals a day.D) If nauseated, do not eat solid foods.

Ans: AChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 10Page and Header: 1226, Diabetic Ketoacidosis

Feedback: The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent small portions of food. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

8. The student nurses are studying for a test on diabetes mellitus. What should the students know is a complication of diabetes termed “macrovascular”?A) RetinopathyB) StrokeC) NephropathyD) Renal failure

Ans: BChapter: 41Client Needs: D-4Cognitive Level: ComprehensionDifficulty: DifficultIntegrated Process: Teaching/LearningObjective: 11Page and Header: 1230, Macrovascular Complications

Feedback: Myocardial infarction and stroke are considered macrovascular complications of diabetes mellitus, while peripheral neuropathy is related to the effects of elevated blood glucose levels over a period of years directly affecting the nerves. Microvascular complications include diabetic retinopathy and nephropathy.

9. The school nurse is teaching the senior health class about risk factors for diabetes mellitus. What risk factor for diabetes mellitus cannot be modified by the patient?A) Poor control of blood glucose levelsB) Inappropriate foot careC) Current or recent foot traumaD) Advanced age

Ans: DChapter: 41Client Needs: D-3Cognitive Level: AnalysisDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 3Page and Header: 1197, Diabetes

Feedback: Nonmodifiable risk factors are ones that aren't in the patient's ability to change. Therefore, advanced age is the answer. The other choices are factors over which the patient can exert some control. Therefore options A, B, and C are incorrect.

10. A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia. A diagnosis of diabetes mellitus is made. What classification will be used to describe a 15-year-old child with diabetes who requires daily insulin injections?A) Type 1 diabetesB) Type 2 diabetesC) Juvenile diabetesD) Prediabetes

Ans: AChapter: 41Client Needs: D-4Cognitive Level: ComprehensionDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Page and Header: 1198, Diabetes

Feedback: Once classified as juvenile diabetes or juvenile-onset diabetes, the current classification for children with diabetes is type 1 diabetes. Type 2 diabetes is characterized by onset of the condition during adulthood and insulin may or may not be required. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

11. A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. The nurse is explaining to the patient the etiology of type 1 diabetes. Which of the following explanations is appropriate?A) “The tissues in the body are resistant to the action of insulin, making insulin less effective in the body.”B) “The formation of an acidic substance when the liver breaks down fatty acids because of the lack of insulin in the body.”C) “The secretion of placental hormones causes the body to be resistant to insulin.”D) “Destruction of special cells in the pancreas causes a decrease in insulin production and the level of glucose (sugar) in the bloodstream increases because the body lacks insulin to break down the glucose.”

Ans: DChapter: 41Client Needs: D-4Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 2Page and Header: 1198, Diabetes

Feedback: Type 1 diabetes is characterized by the destruction of pancreatic beta cells resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood and leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. Gestational diabetes is defined as any degree of glucose intolerance with its onset during pregnancy and is caused by the secretion of placental hormones. Ketosis is the formation of a highly acidic substance when the liver breaks down free fatty acids in the absence of insulin.

12. A student nurse is caring for a patient with type 1 diabetes who also has glycosuria. The nursing instructor asks this student nurse what the patient's urine should look like. What would be the student's best response?A) Concentrated urineB) Dilute urineC) Elevated specific gravityD) Cloudy urine

Ans: BChapter: 41

Client Needs: D-4Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 3Page and Header: 1199, Diabetes

Feedback: When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. The urine will be dilute due to the osmotic diuresis. While the urine may be cloudy if the patient has a urinary tract infection, the best answer related to glycosuria is the excretion of dilute urine. A concentrated urine or urine with an elevated specific gravity occurs when the body is conserving fluid and is the opposite of diuresis.

13. The Diabetic Educator is teaching a patient about type 2 diabetes. The Educator recognizes the patient understands the primary treatment for type 2 diabetes when the patient states what?A) “A pancreas transplant will provide a cure for my diabetes.”B) “I will take my oral antidiabetic agents when my morning blood sugar is high.”C) “I will follow the weight loss plan designed by the dietitian.”D) “I will make sure I call the Diabetic Educator when I have questions about my insulin.”

Ans: CChapter: 41Client Needs: D-4Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 6Page and Header: 1202, Diabetes

Feedback: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis, or on a temporary basis during times of acute psychological stress. Pancreas transplantation is performed on a limited basis and is often performed in conjunction with kidney transplantation.

14. A Diabetes Nurse Educator is providing a class on diabetes for the dieticians and staff nurses. The nurse educator discusses the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA's recommendations include?

A) 0% of calories from carbohydrates, 50% from fat, and the remaining 50% from proteinB) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from proteinC) 20% to 30% of calories from carbohydrates, 50% to 60% from fat and the remaining, 10% to 20% from proteinD) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

Ans: DChapter: 41Client Needs: D-4Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 5Page and Header: 1203, Diabetes

Feedback: Currently, the ADA and the American Dietetic Association recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. These recommendations are also consistent with the American Heart Association, American Cancer Society, and the U.S. Department of Agriculture.

15. An 88-year-old patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. What nursing action would be a priority?A) Administration of anti-hypertensive medicationsB) Administering sodium bicarbonate intravenously for low bicarbonate levelsC) Reversing acidosis by administering insulinD) Fluid and electrolyte replacement

Ans: DChapter: 41Client Needs: D-2Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 9Page and Header: 1228, Hyperglycemic Hyperosmolar Nonketotic Syndrome

Feedback: The overall approach to HHNS includes fluid replacement, correction of electrolyte imbalances and insulin administration. Insulin administration plays a less important role in the treatment of HHNS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA). Sodium bicarbonate is not administered to patients with HHNS, as their plasma bicarbonate level is usually normal. Also, anti-hypertensive medications are not indicated, as hypotension generally accompanies HHNS due to dehydration.

16. The nurse is caring for a type 1 diabetic patient who is being discharged home tomorrow. Patient teaching includes assessing the patient's self-care skills to determine if further diabetes teaching is required. What is the best way to assess the patient's ability to prepare and give insulin?A) Ask the patient to describe the self-care skillB) Direct observation of the self-care skillC) Ask the family to describe the patient's ability to perform the self-care skillD) Consult the home health nurse to discuss self-care skills

Ans: BChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 12Page and Header: 1239, Management of Hospitalized Patients with Diabetes

Feedback: Nurses should assess the patient's ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether patients require further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the patient performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the patient or family members about these skills without actually observing performance of the skill is not sufficient.

17. An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient?A) An elderly patient with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy.

B) Avoiding the complications associated with foot ulcers may mean the difference between institutionalization and continued independent living.C) Hypoglycemia is a dangerous situation and it may lead to unsteadiness of the feet and falls.D) Drugs that the patients are required to take for their diabetic condition often decrease circulation to the lower extremities.

Ans: BChapter: 41Client Needs: D-2Cognitive Level: ComprehensionDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 12Page and Header: 1217, Diabetes

Feedback: The nurse recognizes that providing information on the long-term complications, especially foot and eye problems, associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Patients with foot ulcers may not realize that they have a foot ulcer because the patient has diminished sensation due to diabetic polyneuropathy and pain is generally absent. The nurse is correct to recognize that patients with diabetes are at risk for decreased circulation to the lower extremities, but should understand that the decrease in circulation is related to vascular changes and is not associated with drugs administered for the condition.

18. The Diabetic Educator is discussing “sick day rules” with a newly diagnosed type 1 diabetic. The Educator is aware that the patient will require further teaching when the patient states what?A) “I will not take my insulin on the days when I am sick, but I will check my blood sugar every 2 hours.”B) “If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day.”C) “I will call the doctor, if I am not able to keep liquids in my body due to vomiting or diarrhea.”D) “I will call the doctor if my blood sugar is over 300 (mg/dL) or if I have ketones in my urine.”

Ans: AChapter: 41Client Needs: D-4Cognitive Level: ApplicationDifficulty: Difficult

Integrated Process: Teaching/LearningObjective: 10Page and Header: 1226, Diabetic Ketoacidosis

Feedback: The nurse must explanation the “sick day rules” again to the patient. The nurse should emphasize that the patient should take insulin agents as usual and test their blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup and pudding. If vomiting, diarrhea or fever persists, the patient should have an intake of liquids every 1/2 hour to hour to prevent dehydration. Fluid loss is dangerous and nausea, vomiting, and diarrhea should be reported to the physician. Patients with type 1 diabetes who cannot retain oral fluids may need hospitalization to avoid diabetic ketoacidosis and possibly coma.

19. You are caring for four patients, all diagnosed with type 1 diabetes. Based upon components of managing diabetes, which patient will likely have the greatest success in maintaining tight glucose control of type 1 diabetes?A) A patient who skips breakfast when his or her morning fingerstick glucose reading is greater than 220 mg/dLB) A patient who never deviates from his or her prescribed dose of insulinC) A patient who adheres to a meal plan and meal scheduleD) A patient who eliminates carbohydrates from his or her daily intake

Ans: CChapter: 41Client Needs: D-4Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 5Page and Header: 1201, Diabetes

Feedback: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for an insulin-dependent diabetic.

20. A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test. The patient asks the nurse what results indicate gestational diabetes. The nurse should respond that the minimum parameter for indication of gestational diabetes is a 2-hour blood glucose level greater than what?A) 120 mg/dLB) 150 mg/dLC) 200 mg/dLD) 250 mg/dL

Ans: CChapter: 41Client Needs: D-4Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 4Page and Header: 1200, Diabetes

Feedback: A glucose tolerance test indicates a diagnosis of gestational diabetes when the 2-hour blood glucose level is greater than 200 mg/dL. Confirmation occurs when at least one subsequent result is greater than 200 mg/dL. Options A and B are incorrect because they're below the minimum parameter; option D is incorrect because it's above the minimum parameter.

21. In what patients does hyperosmolar nonketotic syndrome occur?A) Patients with no known history of diabetesB) Patients with either type 1 diabetes or no known history of diabetesC) Adolescents with type 2 diabetes or no known history of diabetesD) Older people with either type 2 diabetes or no known history of diabetes

Ans: DChapter: 41Client Needs: A-1Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Page and Header: 1228, Hyperglycemic Hyperosmolar Nonketotic Syndrome

Feedback: HHNS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. Therefore options A, B, and C are incorrect.

22. You are caring for a newly diagnosed type 2 diabetic. The patient is 67 years old and has been found to have what long-term complication of diabetes mellitus?A) Cardiovascular diseaseB) Renal diseaseC) Retinal damageD) Hypertension

Ans: AChapter: 41Client Needs: D-3Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 1Page and Header: 1230, Long-Term Complications of Diabetes

Feedback: Long-term complications are seen in both type 1 and type 2 diabetes but usually do not occur within the first 5 to 10 years after diagnosis. However, evidence of these complications may be present at the time of diagnosis of type 2 diabetes, because patients may have had undiagnosed diabetes for many years. Renal (microvascular) disease is more prevalent in patients with type 1 diabetes, and cardiovascular (macrovascular) complications are more prevalent in older patients with type 2 diabetes.

23. A 35-year-old female patient with type 1 diabetes has come to the clinic because she just doesn't feel well. The patient confides in the nurse that she is going through a divorce and a custody battle for her children ages 2 and 4. She has started drinking and has lost her job. What would the nurse suspect is causing this patient to feel poorly?A) HypoglycemiaB) KetoacidosisC) HypernatremiaD) Fluid overload

Ans: BChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1

Page and Header: 1238, Patients with Diabetes Who Are Undergoing Surgery

Feedback: Patients with type 1 diabetes also risk developing ketoacidosis during periods of stress. The scenario describes a very stressful time in this patient's life. Hypoglycemia is a concern when the patient is undergoing surgery. Hypernatremia and fluid overload would not be a concern with a diabetic patient under stress.

24. The physician has explained to the patient that he has developed diabetic neuropathy in his right foot. Later that day the patient calls the nurse and asks what causes diabetic neuropathy. What would be the nurse's best response?A) “Research has shown that diabetic neuropathy is caused by hyperglycemia that has gone on for years.”B) “The cause is not known for sure but it is thought to have something to do with ketoacidosis.”C) “The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years.”D) “Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels.”

Ans: CChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Communication and DocumentationObjective: 2Page and Header: 1235, Diabetic Neuropathies

Feedback: The etiology of neuropathy may involve elevated blood glucose levels over a period of years.

25. An adolescent, newly diagnosed with type 1 diabetes, asks the nurse what caused the diabetes. What would be the nurse's best response?A) “Type 1 diabetes has a variety of causes that work together to cause the disease.”B) “It is thought to be caused by environmental factors like a virus.”C) “Part of the cause of diabetes is immunologic. That means your body is destroying itself.”D) “The causes of type 1 diabetes are genetic, immunologic, and environmental.”

Ans: DChapter: 41

Client Needs: BCognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Communication and DocumentationObjective: 2Page and Header: 1197, Diabetes

Feedback: The etiology of type 1 diabetes mellitus includes genetic, immunologic, and environmental factors (eg, virus). Option C is not something you would say to a patient without further explanation. Options A and B are not complete answers to the patient's question.

26. The nursing instructor is quizzing one of her students who is caring for a diabetic in the clinical area. The instructor asks the student what is a contributing cause of ulcers to the foot in the diabetic patient. What should the student answer?A) Insensitive feetB) Arterial insufficiencyC) GoutD) Smoking

Ans: AChapter: 41Client Needs: D-4Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Page and Header: 1236, Foot and Leg Problems

Feedback: Patients with an insensitive foot do not feel injuries, which may be thermal (eg, from using heating pads, walking barefoot on hot concrete, testing bath water with the foot), chemical (eg, burning the foot while using caustic agents on calluses, corns, or bunions), or traumatic (eg, injuring skin while cutting nails, walking with an undetected foreign object in the shoe, or wearing ill-fitting shoes and socks). Arterial insufficiency, gout and smoking are not considered contributing causes of foot ulcers in the diabetic patient.

27. The Diabetic Educator is teaching a class on complications of diabetes for newly diagnosed diabetic children and their parents. The diabetic Educator would define hypoglycemia as what blood glucose level?A) Below 60 mg/dLB) Between 60 and 120 mg/dL

C) Between 120 and 180 mg/dLD) Above 180 mg/dL

Ans: AChapter: 41Client Needs: D-3Cognitive Level: KnowledgeDifficulty: EasyIntegrated Process: Teaching/LearningObjective: 4Page and Header: 1222, Hypoglycemia (Insulin Reactions)

Feedback: Hypoglycemia occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L), because of too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity.

28. The diabetic nurse is working for the summer at a camp for diabetic adolescents. When providing information on the prevention of hypoglycemia, what criteria would best help to prevent hypoglycemia?A) Always carry a form of fast-acting sugar.B) Exercise should be done prior to eating.C) Eat a meal or snack every 8 hours.D) Check blood sugar every 24 hours.

Ans: AChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 6Page and Header: 1225, Hypoglycemia (Insulin Reactions)

Feedback: The following should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.

29. You are teaching basic information to a newly diagnosed type 1 diabetic. What would the basic information include?A) Traveling

B) “Sick day” kitsC) Surgery and stressD) How to mix insulin

Ans: DChapter: 41Client Needs: BCognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Teaching/LearningObjective: 7Page and Header: 1219, Diabetes

Feedback: Insulin injections are self-administered into the subcutaneous tissue with the use of special insulin syringes. Basic information includes explanations of the equipment, insulins, and syringes, and how to mix insulin. Therefore options A, B, and C are incorrect.

30. You are conducting a class on how to self-manage insulin regimens. A patient asks you how long a vial of insulin can be stored at room temperature before it “goes bad.” What would be your best answer?A) If you are going to use up the vial within 1 month it can be kept at room temperature.B) If a vial of insulin will be used up within 21 days, it may be kept at room temperature.C) If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature.D) If a vial of insulin will be used up within 1 week, it may be kept at room temperature.

Ans: AChapter: 41Client Needs: D-2Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 7Page and Header: 1219, Diabetes

Feedback: If a vial of insulin will be used up within 1 month, it may be kept at room temperature.

31. In pharmacology class the student nurses are learning about oral antidiabetic agents. What category of oral antidiabetic agents would the students learn enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas?

A) SulfonylureasB) BiguanidesC) ThiazolidinedionesD) Alpha glucosidase inhibitors

Ans: CChapter: 41Client Needs: D-2Cognitive Level: ComprehensionDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 8Page and Header: 1216, Diabetes

Feedback: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides facilitate insulin's action on peripheral receptor sites. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

32. An adolescent patient tells the nurse at school that he is feeling nervous and hungry. The school nurse assesses the patient and finds he has tachycardia and is diaphoretic. What should the school nurse administer?A) Non-diet soda, 1 ozB) Three hard candies (eg, Life Savers)C) Fruit juice, 4 to 6 ozD) Honey, 1 tsp

Ans: CChapter: 41Client Needs: D-1Cognitive Level: ApplicationDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 9Page and Header: 1224, Hypoglycemia (Insulin Reactions)

Feedback: The usual recommendation for treatment of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally, such as three or four commercially prepared glucose tablets; 4 to 6 oz of fruit juice or regular soda; 6 to 10 Life Savers or other hard candies; or 2 to 3 tsp of sugar or honey. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice,

because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.

Multiple Selection

33. The Diabetic Nurse Educator is teaching a class for newly diagnosed diabetics and their families. The Nurse Educator is talking about “sick day” kits. What would the Nurse Educator tell the people attending the class to put in their “sick day” kits? Mark all that apply.)A) Concentrated proteinsB) Urine test stripsC) Nutritious pastriesD) Baby orange juiceE) Blood glucose test strips

Ans: B, D, EChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 10Page and Header: 1226, Diabetic KetoacidosisFeedback: Patients are taught to have foods available for use on sick days. In addition, a supply of urine test strips (for ketone testing) and blood glucose test strips should be available. The patient must know how to contact his or her physician 24 hours a day. These materials should be assembled in a “sick day” kit. Concentrated proteins would not be included in the kit. Nutritious pastries is an oxymoron and would not be included in the kit.

Multiple Choice

34. What is another name for diabetic microvascular disease?A) Diabetic microangiopathyB) Diabetic microcapillary diseaseC) Diabetic microcellular disease

D) Diabetic micromembranous disease

Ans: AChapter: 41Client Needs: D-3Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 11Page and Header: 1231, Microvascular Complications

Feedback: Diabetic microvascular disease (or microangiopathy) is characterized by capillary basement membrane thickening. The basement membrane surrounds the endothelial cells of the capillary. Researchers believe that increased blood glucose levels react through a series of biochemical responses to thicken the basement membrane to several times its normal thickness. Two areas affected by these changes are the retina and the kidneys. Options B, C, and D are detractors for this question.

35. A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient?A) Examine feet once per week for redness, blisters, and abrasions.B) Apply lotion to dry feet, especially between the toes.C) Avoid hot-water bottles and heating pads.D) Dry feet vigorously after each bath.

Ans: CChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 11Page and Header: 1237, Foot and Leg Problems

Feedback: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury.

36. The Diabetic Educator is assessing a hospitalized patient to see if it is necessary to reinforce parts of the patient's knowledge of basic diabetic self-care skills. What would be an appropriate way for the Diabetic Educator to assess the patient's knowledge of nutritional therapy in diabetes mellitus?A) Ask the patient's roommate.B) Monitor the patient's daily food menus.C) Ask the patient's family what they eat at home.D) Ask the nursing staff what the patient is eating.

Ans: BChapter: 41Client Needs: BCognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 12Page and Header: 1239, Management of Hospitalized Patients with Diabetes

Feedback: The patient's knowledge about diet can be assessed with the help of a dietitian through direct questioning and review of the patient's menu choices.

37. The nursing instructor is teaching his students about foot care for the diabetic patient. The instructor teaches the students what general guidelines regarding foot care?A) Wash feet in warm water.B) Rub a thin coat of lotion between the toes.C) Walk barefoot only at the beach.D) Do not wear socks to bed.

Ans: AChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 12Page and Header: 1237, Foot and Leg Problems

Feedback: Feet should be washed in warm water, and lotion should be applied to the tops and bottoms of the feet, but not between the toes. The patient should never walk barefoot. Patient may wear socks to bed if the feet are cold.

38. You are a Family Nurse Practitioner performing a preoperative physical examination. The patient is a diabetic and you note a decrease in deep tendon reflexes in the right leg that make you suspect diabetic neuropathy. The patient has no history of diabetic neuropathies. What other indication of diabetic neuropathy might the Nurse Practitioner expect to find if the patient does have a diabetic neuropathy?A) Decreased sensation of dullnessB) Lack of sensation of sharpnessC) Increased sensation of painD) Decreased vibratory sensation

Ans: DChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 11Page and Header: 1235, Diabetic Neuropathies

Feedback: On physical examination, a decrease in deep tendon reflexes and vibratory sensation is found. For patients who have few or no symptoms of neuropathy, these physical findings may be the only indication of neuropathic changes. Options A, B, and C are incorrect. Patients with diabetic neuropathy do not have a sensation of pain or sharpness, and if they feel at all, everything feels dull.

39. A diabetic patient calls the clinic complaining of having a “flu bug.” The nurse tells him to take his regular dose of insulin. What else would the nurse tell the patient?A) Eat as you regularly would.B) Try drinking juice, regular soda, and eating gelatin frequently and in small portions.C) Check your blood glucose every hour.D) Check your urine ketones every 8 hours.

Ans: BChapter: 41Client Needs: D-3Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 10Page and Header: 1226, Diabetic Ketoacidosis

Feedback: For prevention of DKA related to illness, “sick day” rules for managing diabetes when ill (Chart 41-9) should be reviewed. The most important concept in this is to never eliminate insulin doses when nausea and vomiting occur. Instead, the patient should take the usual insulin dose (or previously prescribed special “sick day” doses) and then attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

Multiple Selection

40. A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is in HHNS. What are the components of HHNS? (Mark all that apply.)A) Too much insulinB) GlycosuriaC) DehydrationD) HyponatremiaE) Hyperglycemia

Ans: B, C, EChapter: 41Client Needs: D-4Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 9Page and Header: 1227, Hyperglycemic Hyperosmolar Nonketotic SyndromeFeedback: HHNS is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is usually minimal or absent. The basic biochemical defect is lack of effective insulin (ie, insulin resistance). Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur.