1. 20
Nursing Care of Patients with Diabetes Mellitus

2. Directory
NCLEX-RN® REVIEW Test Questions
Lecture Note Presentation

3. NCLEX-RN® REVIEW Test Questions

4. NCLEX-RN® REVIEW Test Question 1
Increased susceptibility to the development of type 1 DM is indicated by which of the following?
genetic markers that determine immune response
persistent obesity throughout the adolescent years
delivery of a baby that weighs less than 6 lb
excessive amounts of plasma glucagon

5. NCLEX-RN® REVIEW Test Question 1 Response
Increased susceptibility to the development of type 1 DM is indicated by which of the following?
genetic markers that determine immune response
persistent obesity throughout the adolescent years
delivery of a baby that weighs less than 6 lb
excessive amounts of plasma glucagon

6. NCLEX-RN® REVIEW Test Question 1 Rationale
Ninety-five percent of patients diagnosed with type 1 DM have genetic markers indicating increased susceptibility for the development of type 1 DM.

7. NCLEX-RN® REVIEW Test Question 2
Diabetic ketoacidosis is the result of which pathologic process?
An excess amount of insulin drives all glucose into the cells.
A decreased amount of glucagon causes low protein levels.
A deficit of insulin causes fat stores to be used as an energy source.
An increase occurs in the breakdown of glucose molecules with hypoglycemia.

8. NCLEX-RN® REVIEW Test Question 2 Response
Diabetic ketoacidosis is the result of which pathologic process?
An excess amount of insulin drives all glucose into the cells.
A decreased amount of glucagon causes low protein levels.
A deficit of insulin causes fat stores to be used as an energy source.
An increase occurs in the breakdown of glucose molecules with hypoglycemia.

9. NCLEX-RN® REVIEW Test Question 2 Rationale
A deficit of insulin increases the liver’s production of ketone bodies and increased release of free fatty acids. Bicarbonate production is decreased and acid buffering is impaired, resulting in metabolic acidosis.

10. NCLEX-RN® REVIEW Test Question 3
Which of the following patients would be most at risk for the development of type 2 DM?
young adult who is a professional basketball player
middle-aged man who maintains normal weight
middle-aged woman who is the sole caretaker of her parents
woman over age 70 who is overweight and sedentary

11. NCLEX-RN® REVIEW Test Question 3 Response
Which of the following patients would be most at risk for the development of type 2 DM?
young adult who is a professional basketball player
middle-aged man who maintains normal weight
middle-aged woman who is the sole caretaker of her parents
woman over age 70 who is overweight and sedentary

12. NCLEX-RN® REVIEW Test Question 3 Rationale
Caloric need decreases with aging; unless dietary intake also decreases (and exercise increases), weight gain ensues. Obesity is a risk factor for the development of type 2 DM.

13. NCLEX-RN® REVIEW Test Question 4
A nurse notes that a patient has a nursing diagnosis of Peripheral Neurovascular Dysfunction involving both feet. Which of the following assessments would support this diagnosis?
normal sensation to touch
loss of normal reflexes
states “I can’t feel my feet anymore.”
states “I have been having chest pain.”

14. NCLEX-RN® REVIEW Test Question 4 Response
A nurse notes that a patient has a nursing diagnosis of Peripheral Neurovascular Dysfunction involving both feet. Which of the following assessments would support this diagnosis?
normal sensation to touch
loss of normal reflexes
states “I can’t feel my feet anymore.”
states “I have been having chest pain.”

15. NCLEX-RN® REVIEW Test Question 4 Rationale
Changes in sensation, such as numbness or tingling, support this diagnosis.

16. NCLEX-RN® REVIEW Test Question 5
Which of the following statements would indicate that a patient understands teaching about foot care at home?
“I will walk barefooted as long as I am in the house.”
“I always buy my shoes as soon as the stores open.”
“I will check my feet for cuts and bruises every night.”
“If I get a blister, I just put alcohol on it and bandage it.”

17. NCLEX-RN® REVIEW Test Question 5 Response
Which of the following statements would indicate that a patient understands teaching about foot care at home?
“I will walk barefooted as long as I am in the house.”
“I always buy my shoes as soon as the stores open.”
“I will check my feet for cuts and bruises every night.”
“If I get a blister, I just put alcohol on it and bandage it.”

18. NCLEX-RN® REVIEW Test Question 5 Rationale
Visual inspection of the feet each day is important in preventing more serious complications.

19. NCLEX-RN® REVIEW Test Question 6
Lantus and detemir insulin, long-acting insulins, have a unique insulin characteristic that increases the risk for administration error. The nurse understands that which of the following applies to this long-acting insulin?
It is combined with glucose to raise energy levels.
It is subject to being inactivated by light and must be kept cold.
It is a clear solution like regular insulin, unlike other intermediate and long-acting insulins.
It is activated by vigorous agitation.

20. NCLEX-RN® REVIEW Test Question 6 Response
Lantus and detemir insulin, long-acting insulins, have a unique insulin characteristic that increases the risk for administration error. The nurse understands that which of the following applies to this long-acting insulin?
It is combined with glucose to raise energy levels.
It is subject to being inactivated by light and must be kept cold.
It is a clear solution like regular insulin, unlike other intermediate and long-acting insulins.
It is activated by vigorous agitation.

21. NCLEX-RN® REVIEW Test Question 6 Rationale
Since it is clear, Lantus (glargine) could be confused with regular insulin. Regular insulin is short acting in 4 to 6 hours and Lantus is long acting in 24 to 28 hours.

22. NCLEX-RN® REVIEW Test Question 7
The nurse is preparing an insulin infusion for a patient in diabetic ketoacidosis (DKA). She is careful to select which type of insulin that can be administered intravenously?
glargine
NPH
regular
Humalog

23. NCLEX-RN® REVIEW Test Question 7 Response
The nurse is preparing an insulin infusion for a patient in diabetic ketoacidosis (DKA). She is careful to select which type of insulin that can be administered intravenously?
glargine
NPH
regular
Humalog

24. NCLEX-RN® REVIEW Test Question 7 Rationale
Only regular insulin can safely be administered intravenously for diabetic ketoacidosis.

25. NCLEX-RN® REVIEW Test Question 8
Glycosylated hemoglobin (A1C) is useful for evaluating the degree of blood glucose control the patient with DM has been maintaining for the previous 2 to 3 months.The ADA recommends a diagnosis of DM at what A1C level?
> 15%
> 9%
> 6.5%
> 2.25%

26. NCLEX-RN® REVIEW Test Question 8 Response
Glycosylated hemoglobin (A1C) is useful for evaluating the degree of blood glucose control the patient with DM has been maintaining for the previous 2 to 3 months.The ADA recommends a diagnosis of DM at what A1C level?
> 15%
> 9%
> 6.5%
> 2.25%

27. NCLEX-RN® REVIEW Test Question 8 Rationale
Levels of Hgb A1C greater than 6.5% demonstrate elevated or erratic glucose control over time and support a diagnosis of DM.

28. NCLEX-RN® REVIEW Test Question 9
A patient with increased ACTH levels and Addison’s disease is likely to manifest which of the following?
It should be given intravenously.
It should be chilled to slow absorption.
It should be given with intravenous glucose.
It should be combined with long-acting insulin.

29. NCLEX-RN® REVIEW Test Question 9 Response
A patient with increased ACTH levels and Addison’s disease is likely to manifest which of the following?
It should be given intravenously.
It should be chilled to slow absorption.
It should be given with intravenous glucose.
It should be combined with long-acting insulin.

30. NCLEX-RN® REVIEW Test Question 9 Rationale
No intermediate- or long-acting insulin is given the day of surgery since dietary intake postoperatively is uncertain. IV glucose (5%) and regular insulin in equally divided doses will compensate for the increase in serum glucose until the patient is eating and drinking normally.

31. NCLEX-RN® REVIEW Test Question 10
Subcutaneous injections of insulin can be made in several locations in the body. The nurse teaches the patient that the most rapid absorption occurs in which of the following?
hip
thigh
deltoid
abdomen

32. NCLEX-RN® REVIEW Test Question 10 Response
Subcutaneous injections of insulin can be made in several locations in the body. The nurse teaches the patient that the most rapid absorption occurs in which of the following?
hip
thigh
deltoid
abdomen

33. NCLEX-RN® REVIEW Test Question 10 Rationale
Insulin is absorbed more rapidly when injected subcutaneously in the abdomen.

34. Lecture Note Presentation

35. Learning Outcome 1
Describe the prevalence and incidence of DM.

36. Diabetes Mellitus
Diabetes is a group of chronic disorders resulting in hyperglycemia.
Type 1 DM characterized by a total deficit of circulating insulin
Type 2 DM characterized by insulin resistance
One of the major roles of the nurse in diabetes management is education of the diabetic patient.

37. Diabetes Mellitus
Nursing care and educational plans for the diabetic patient need to be individualized based on:
Type of diabetes
Length since diagnosis
Prior knowledge
The patient’s individual health and socioeconomic circumstances

38. Diabetes Mellitus Prevalence, incidence, and economic impact of DM
DM is widespread, and is the sixth-leading cause of death in the United States.
Ninety percent of patients with diabetes have type 2 DM.
10% have type 1 DM.

39. Diabetes Mellitus
Type 2 diabetes is most common among these populations:
American Indian
Alaska native
Latino
There has been a sharp increase in type 2 diabetes related to rates of obesity in the United States.

40. Diabetes Mellitus
Complications such as acute myocardial infarction, stroke, renal failure, blindness, and traumatic amputations are common among diabetics with poor glycemic control.
According to the American Diabetes Association, health care costs related to diabetes exceeded $132 billion per year in 2002.

41. Learning Outcome 2
Explain the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM.

42. Type 1 and Type 2 DM All patients with DM experience hyperglycemia.
The signs and symptoms of hyperglycemia include
Polyuria
Polydipsia
Polyphagia.

43. Type 1 and Type 2 DM
Type 1 DM
Autoimmune destruction of the pancreatic islet cells
No insulin produced
Occurs in childhood/adolescence
Genetic predisposition plus environmental factors such as onset following viral illness
Includes 5–10% of all patients with DM

44. Type 1 and Type 2 DM
Type 1 DM
Rapid onset
Risk factors

45. Type 1 and Type 2 DM Type 2 DM Results from insulin resistance
Occurs at any age
Heredity plays an important role, along with obesity
Includes 90–95% of all patients with DM
Gradual onset
Risk factors

46. Type 1 and Type 2 DM
Diabetic complications result from chronic hyperglycemia
Chronic complications:
Result of endothelial inflammation and thickening

47. Learning Outcome 3
Provide rationale for the diagnostic tests used for screening, diagnosis, and monitoring of DM.

48. Screening Tests for DM Casual plasma glucose (PG)
Fasting plasma glucose (FPG)
Oral glucose tolerance test (OGTT)

49. Screening Tests for DM
Screening tests to determine diabetes management
FBG (fasting blood glucose)
A1C (glycosylated hemoglobin (c))
Urine glucose and ketone levels
Urine tests, serum cholesterol, and serum electrolytes

50. Learning Outcome 4
Discuss the nursing implications for insulin and oral hypoglycemic agents used to treat patients with DM.

51. Treating DM The patient with type 1 DM requires exogenous insulin.
The patient with type 2 DM may take oral medications or may take insulin.

52. Treating DM Types of insulins: Rapid-acting Short-acting
Intermediate-acting
Long-acting

53. Treating DM Teaching the patient to give insulin:
Measurement of blood glucose
Syringe and needle selection
Preparing the injection
Sites of injection
Mixing insulins
Storage of insulin
Food intake with insulin

54. Treating DM
Nursing considerations for patients taking either insulin or oral agents:
Assessment of therapeutic response
Monitoring blood glucose levels
Signs of hypo- or hyperglycemia
Patient Education:
Safe medication practices

55. Treating DM Nursing Implications:
Assessing response to medications, especially in first 7 days
Assess for signs of hypoglycemia
Assess for signs of hyperglycemia

56. Learning Outcome 5
Discuss best practices of self-care management of DM related to diet planning, sick day management, and exercise.

57. The Goals of Diabetes Treatment
Prevent hypo- and hyperglycemia
Maintain glucose levels close to normal

58. The Goals of Diabetes Treatment
Dietary management of DM
Carbohydrates
Protein
Fats
Fiber
Sodium
Sweeteners
Alcohol

59. The Goals of Diabetes Treatment
Dietary management of DM
Meal Planning
Diet plan for the older adult
Sick day management:
Increased need for insulin
Hyperglycemia
Continuing medications important
Food intake
Frequent monitoring

60. The Goals of Diabetes Treatment
Exercise
Exercise is important to maintain glycemic control.
The person with DM should be assessed for potential health risks prior to beginning an exercise program.
Exercise can cause hypoglycemia as well as hyperglycemia.
Responses to exercise should be monitored carefully and treated as needed.

61. The Goals of Diabetes Treatment
Exercise
Glycemic control improves with a regular exercise program.
Glycemic responses to exercise should be monitored.

62. The Goals of Diabetes Treatment
Variables:
Type of DM
Intensity of exercise
Duration of exercise
The time of day

63. Learning Outcome 6
Compare and contrast the manifestations of hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state.

64. Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) develops when there is an absolute deficiency of circulating insulin

65. Diabetic Ketoacidosis
Manifestations of diabetic ketoacidosis
Hyperosmolarity (from hyperglycemia)
Metabolic acidosis from ketoacids and lactic acids
Volume depletion from osmotic diuresis as a result of hyperosmolarity
Electrolyte imbalances from osmotic diuresis

66. Diabetic Ketoacidosis
Manifestations of Hyperosmolar Hyperglycemic State (HHS)
Hyperosmolarity from hyperglycemia (often more severe than in DKA)
Volume depletion from osmotic diuresis as a result of hyperosmolarity
Electrolyte imbalances from osmotic diuresis

67. Diabetic Ketoacidosis
Hypoglycemia is more common in diabetics who are insulin dependent.
Signs and symptoms of hypoglycemia result from responses of the autonomic nervous system (release of stress hormones), and from a deficiency of circulating glucose available for normal brain function.