Test Flashcards

A nurse is creating a plan of care for a client with hyperglycemia and diabetes mellitus. The following would be the top nursing diagnosis:

Answer: High risk for deficient fluid volume

Severe hyperglycemia leads to osmotic diuresis, where high glucose levels in the urine pull water from the body, resulting in significant fluid and electrolyte loss. This makes 'High risk for deficient fluid volume' a top nursing diagnosis for a client with hyperglycemia, as dehydration can rapidly become life-threatening. Addressing fluid balance is critical for patient safety.

The blood gases of a patient show diabetic acidosis. The nurse should prepare for:

Answer: Decreased HCO3

Diabetic acidosis, specifically diabetic ketoacidosis (DKA), is a metabolic acidosis. In this condition, the body produces excess acids (ketones), which consume bicarbonate (HCO3-) in the buffering process. Therefore, a key finding in arterial blood gases for diabetic acidosis is a decreased bicarbonate level.

When first admitted for treatment of hyperglycemia, a client with DM exhibits severe anxiety. The following would be the most effective intervention to lessen the client's anxiety:

Answer: Convey empathy, trust, and respect toward the client

When a client is experiencing severe anxiety, establishing a therapeutic relationship built on empathy, trust, and respect is the most effective intervention. This approach helps the client feel safe, understood, and supported, which can significantly reduce anxiety. Providing complex medical terms or ignoring symptoms would be counterproductive and increase distress.

A client with type 2 diabetes mellitus receives a physical evaluation from a nurse. Fasting blood glucose levels were 120 mg/dl, temperature was 101 °F, pulse rate was 88 bpm, respirations were 22 bpm, and blood pressure was 140/84 mmHg. Which finding would worry the nurse the most?

Answer: Temperature

A temperature of 101°F (38.3°C) indicates a fever, which is a significant concern for a patient with diabetes. Infections can rapidly lead to hyperglycemia and potentially trigger serious complications like diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The fever points to an acute issue requiring immediate attention and investigation.

The insulin that would be given to a patient who has diabetic ketoacidosis is:

Answer: Human regular insulin

Human regular insulin is the only type of insulin that can be administered intravenously. In diabetic ketoacidosis (DKA), rapid and precise insulin delivery is crucial to lower blood glucose and reverse acidosis. Intravenous regular insulin allows for immediate action and continuous titration based on the patient's response, making it the preferred choice.

When exercising, a client with type 1 diabetes phones the nurse frequently to report episodes of hypoglycemia. Which client comment revealed a lack of knowledge regarding the peak action of NPH insulin with exercise?

Answer: “The best time for me to exercise is every afternoon.”

NPH insulin is an intermediate-acting insulin with a peak action typically 6-14 hours after administration. If a client takes NPH in the morning, exercising in the afternoon would coincide with or be close to the insulin's peak action, significantly increasing the risk of hypoglycemia. Exercise itself lowers blood glucose, and combining it with peak insulin action can be dangerous.

An ER patient with DKA is being cared for by a nurse. The most important nursing action during the acute period is to get ready to:

Answer: Administer regular insulin intravenously

In the acute management of DKA, the most critical initial nursing action is to prepare for the administration of regular insulin intravenously. This is essential to rapidly lower blood glucose, stop ketone production, and reverse the acidosis. While fluid replacement and electrolyte correction are also vital, insulin is the primary treatment for the underlying metabolic derangement.

A cell needs glucose because it is largely used for the following functions:

Answer: Extraction of energy

Glucose is the primary and preferred energy source for most cells in the body, especially the brain. Through cellular respiration, glucose is broken down to produce ATP (adenosine triphosphate), which is the main energy currency used for various cellular functions and metabolic processes. This process is fundamental for sustaining life.

A patient with hypoglycemia is being admitted by the nurse. Describe the symptoms and indicators the nurse should look out for. Please check all that apply.

Answer: Palpitations

Hypoglycemia symptoms arise from the activation of the sympathetic nervous system and neuroglycopenia (lack of glucose to the brain). Palpitations and diaphoresis (sweating) are adrenergic symptoms, while slurred speech is a neuroglycopenic symptom indicating brain dysfunction due to low glucose. Hyperventilation and thirst are more characteristic of hyperglycemia or DKA.

A patient with diabetes mellitus goes to a clinic for medical attention. Glyburide (Diabeta), 5 mg PO daily, has previously been effective in controlling the client's diabetes, but more lately, the fasting blood glucose has been ranging between 180 and 200 mg/dl. What drug, if it had been added to the client's regimen, might have caused the hyperglycemia?

Answer: prednisone (Deltasone)

Prednisone, a corticosteroid, is well-known to cause hyperglycemia by increasing glucose production in the liver and decreasing insulin sensitivity in peripheral tissues. This can significantly elevate blood glucose levels, even in individuals whose diabetes was previously well-controlled. Its addition to a client's regimen would likely explain the recent increase in fasting blood glucose.

The nurse's top goal when a patient with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to offer:

Answer: Fluid replacement

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by extreme hyperglycemia, severe dehydration, and hyperosmolarity. The most critical initial intervention is aggressive intravenous fluid replacement to correct the profound dehydration and restore circulatory volume. This also helps to gradually lower blood glucose levels and improve overall patient stability.