Chapter 47 Diabetes Mellitus PDF

Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 47: Management of Clients with Diabetes Mellitus
MULTIPLE CHOICE
1. The nurse explains that the most common type of diabetes is

a. type 1.
b. type 2.
c. juvenile.
d. gestational.
ANS: b
The most common form of diabetes, type 2, affects 90% to 95% of people who have diabetes and
is usually diagnosed after age 40.
DIF: Cognitive Level: Knowledge REF: Text Reference: 1243

TOP: Nursing Process Step: N/A MSC: NCLEX: N/A
2. The nurse participating in a screening program for persons at risk for diabetes should
have a high index of suspicion for
a. a 44-year-old man who is 6 feet tall and weighs 190 pounds.
b. a young man complaining of weight loss and joint pain.
c. a young woman who has had two babies weighing 7 pounds each.
d. an adolescent whose mother has type 2 diabetes.
ANS: d
Screening of high-risk individuals should include those who have first-degree relatives with type
2 diabetes; obese individuals; members of high-risk races; persons older than 40 years with any
other risk factor; individuals with hypertension or hyperlipidemia; those with previous impaired
glucose tolerance (IGT); women with previous gestational diabetes mellitus (GDM) or history of
a baby weighing greater than 9 pounds; and individuals with a history of recurrent infections.
DIF: Cognitive Level: Analysis REF: Text Reference: 1251, Box 47-2;
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
3. A client with diabetes mellitus recently discharged from the hospital calls the nursing
unit to report that she is nauseated and cannot remember what she has to do about her
insulin injection. The nurse should remind the client to
a. call the physician at once.
b. review the material she was given at the hospital.
c. take her insulin and monitor her blood sugar frequently.
d. omit her insulin until she is able to eat her normal diet.
ANS: c
Elsevier items and derived items  2005 by Elsevier Inc.

Chapter 47: Management of Clients with Diabetes Mellitus 2
More frequent self-monitoring of blood glucose level, often every 2 to 4 hours, is important
during illness. The client should not stop taking insulin, even if vomiting and unable to eat.
Additional regular insulin may be needed, depending on blood glucose level.
DIF: Cognitive Level: Application

REF: Text Reference: 1257, Client Education Guide - Sick Day Management for Diabetes
Mellitus; TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity
4. Evaluating a young man with diabetes who reports a number of clinical

manifestations, the nurse would consider a classic clinical manifestation of diabetes to
be the client’s
a. overwhelming fatigue.
b. excessive thirst.
c. recurrent blurred vision.
d. gradual weight gain.
ANS: b
The cardinal manifestations of diabetes are polyuria, polydipsia, and polyphagia.
DIF: Cognitive Level: Application REF: Text Reference: 1249

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse evaluating the laboratory studies of a 46-year-old client would recognize
that the laboratory report most suggestive of the presence of diabetes mellitus is
a. a morning blood glucose level of 80 mg that rises to 110 mg in the evening.
b. a glucose tolerance test that does not return to normal levels for 2 hours.
c. a fasting blood glucose level of 151 mg/dl.
d. high urine ketone levels with +2 glycosuria.
ANS: c
A fasting blood glucose level greater than 126 mg/dl is diagnostic of diabetes. “Fasting” is
defined as no caloric intake for at least 8 hours.

6. The nurse explains to a client that the results of a glycosylated hemoglobin study
provide information about the client’s control of blood sugar over the last
a. week.
b. month.
c. 3 months.
d. 6 months.
ANS: c
The results of the glycosylated hemoglobin test show a diabetic client’s average blood glucose
control over the past 3 months.


TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
7. In a teaching plan about dietary concerns for a diabetic client, the nurse would include
that the new guidelines for the percentage of calories from carbohydrates is
a. 10%.
b. 25%.
c. 60%.
d. 75%.
ANS: c
Clinical guidelines suggest that 50% to 60% of the calories in the diet should consist of
carbohydrates, either in simple or complex form.
DIF: Cognitive Level: Comprehension REF: Text Reference: 1260

TOP: Nursing Process Step: Intervention
8. The nurse teaching a type 2 diabetic client how to manage the disease while on a
prescribed diet and taking an oral antidiabetic agent would recognize that the client
has an accurate understanding of diabetes management when the client states
a. “I must exercise at least 1 hour daily to help bring down my sugar.”
b. “I’m really happy I can take insulin pills; it’s much easier than an injection.”
c. “I must decrease my total daily fat intake to less than 45% of my total calories.”
d. “I can use oral medications for my diabetes as long as my pancreas can still
produce insulin.”
ANS: d
Oral antidiabetic agents are not insulin and can work only if the pancreatic beta cells are able to
produce insulin. Oral hypoglycemic agents are effective in clients with type 2 diabetes after
nutrition and exercise therapy have failed. Clients should exercise for 20 to 45 minutes at the
desired heart rate at least three times a week. The general recommendation for the U.S.
population is to decrease total dietary fat to 30% or less of total calories.

TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
9. The nurse tells a client that the regular insulin the client has taken this morning will
begin to act in
a. a few minutes.
b. 30 minutes to 1 hour.
c. 2 to 4 hours.
d. 6 to 8 hours.
ANS: b
The onset of action of short-acting, regular insulin is 30 minutes to 1 hour.
DIF: Cognitive Level: Knowledge REF: Text Reference: 1254, Table 47-3;

10. The nurse should most closely observe a client receiving NPH insulin at 7 AM for
manifestations of an insulin reaction at
a. 7:30 AM.
b. 9 AM.
c. 2 PM.
d. 8 PM.
ANS: c
The peak action for intermediate-acting NPH is 4 to 10 hours after administration.
DIF: Cognitive Level: Analysis REF: Text Reference: 1254, Table 47-3;
11. A client who has been taking pork insulin for many years tells the nurse he is
considering changing to human insulin because he heard it was absorbed better. The
nurse’s most appropriate response would be
a. “You shouldn’t change an insulin regimen that has been used for years.”
b. “Human insulin may have a different duration of action. You should check with
your prescribing health care provider before making a switch.”
c. “Human insulin is much more expensive than animal insulins. Have you
considered that in your plans?”
d. “Lantus insulin is readily available. Have you considered using that type?”
ANS: b
Compared with animal insulin, human insulin peaks more precisely and predictably and has a
shorter duration of action.

12. A client frustrated with self-monitoring his blood glucose levels tells the nurse he
wants an insulin pump. The nurse’s most helpful response would be
a. “Pumps don’t monitor blood glucose levels. You will still need to do that
yourself.”
b. “The pump must be calibrated several times a day, but you will not need to
monitor your blood glucose levels anymore.”
c. “Pumps are still experimental, and there are many problems associated with them.”
d. “If you are willing to make a commitment to good aseptic technique, you should
like the pump.”
ANS: a
Insulin pumps often improve blood glucose control by means of continuous subcutaneous insulin
infusion. However, pumps do not have a built-in feedback mechanism for monitoring blood
glucose levels.

13. The nurse caring for a client with a history of experiencing the Somogyi effect would
monitor the client’s blood sugar level between
a. 2 AM and 7 AM.
b. 10 AM and 3 PM.
c. 12 PM and 6 PM.
d. 5 PM and 12 AM.
ANS: a
Nocturnal rebound hyperglycemia (Somogyi phenomenon) should be investigated by monitoring
blood glucose levels between 2 and 4 AM and again at 7 AM.
DIF: Cognitive Level: Analysis REF: Text Reference: 1278

14. The nurse counseling a 60-year-old woman with diabetes about establishing an
exercise program would encourage
a. swimming.
b. running.
c. playing tennis.
d. walking.
ANS: d
The client should be helped to choose an exercise regimen and to set reasonable goals, because
any increase in activity level is beneficial. Walking is usually well tolerated.

15. When a client asks if he can use the disposable insulin syringe more than once, the
nurse’s most appropriate reply would be
a. “No; the equipment is designed for single use only.”
b. “Yes; make sure the needle is straight and sharp.”
c. “No; insulin from the previous dose will alter the next dose.”
d. “Yes; make sure to cap the needle to prevent infection.”
ANS: d
Althought the equipment is designed for single use, many clients use the syringes until the needle
is dull. If the needle is capped securely and not brought into contact with any object other than
the client’s skin, the narrow gauge of the needle and the bacteriostatic qualities of the insulin
would allow multiple use of one syringe.

REF: Text Reference: 1263, Client Education Guide - Self-Injection of Insulin

16. The nurse caring for a client admitted for treatment of diabetic ketoacidosis (DKA)
assesses Kussmaul’s respirations, which are
a. rapid and short.
b. slow and shallow.
c. irregular and gasping.
d. fast and deep.
ANS: d
Respirations increase in rate and depth (Kussmaul’s respirations) in clients with DKA, and the
breath has a “fruity” or acetone odor.
DIF: Cognitive Level: Application REF: Text Reference: 1269, Box 47-4;
17. The nurse must carefully monitor the client who is being aggressively treated for
DKA for the common, immediate complication of
a. dehydration.
b. pulmonary infarction.
c. premature ventricular contractions.
d. respiratory infection.
ANS: a
Clients with DKA lose fluids from several sources. Severe dehydration resulting from these fluid
losses may be followed by hypovolemic shock and lactic acidosis.

18. The nurse is preparing to care for a client with DKA (pulse 100, blood pressure
140/80, temperature 98.2) being admitted from the emergency department (ED). The
nurse would anticipate using an intravenous (IV) solution of
a. isotonic saline.
b. Ringer’s solution.
c. serum albumin.
d. half-strength saline.
ANS: a
IV infusions of isotonic saline are started immediately. Usually the client receives 1000 ml of
isotonic solution in the first hour, followed by 2000 to 8000 ml more over the next 24 hours.

19. A client admitted to the hospital 3 hours ago for treatment of acidosis has an order
for parenteral potassium in his IV infusion. Before hanging the potassium, the nurse
would assess for
a. chest pain.

b. persistent elevation in blood glucose levels.

c. urine output.
d. tachypnea.
ANS: c
The nurse should frequently assess and measure urine output. Potassium should not be
administered to a client with low urine output because dangerous hyperkalemia may develop.

20. For a client with DKA receiving insulin to correct hyperglycemia, the nurse knows
that the most appropriate route of administration would be
a. intramuscular.
b. intradermal.
c. intravenous.
d. subcutaneous.
ANS: d
Insulin should never be given subcutaneously to a client with DKA, because the subcutaneous
tissues are dehydrated and poorly perfused with blood from dehydration and hypovolemic shock.
Traditionally, the hyperglycemia associated with DKA is treated with an IV bolus of regular
insulin, with an insulin drip then started.

21. A client is being admitted to the nursing unit with hyperglycemic hyperosmolar
nonketotic coma (HHNK). The nurse would explain that compared with the care of
DKA clients, the care of HHNK clients differs in that
a. insulin is usually administered at a lower rate.
b. treatment for dehydration will not be needed.
c. assessments must be constant.
d. parenteral hyperalimentation will be needed.
ANS: a
In clients with HHNK, insulin is given by infusion pump but usually at lower dosages than used
in DKA clients because the HHNK client is producing some insulin.

22. An ambulatory care client with diabetes mellitus is being scheduled for a fasting
blood glucose level. If the blood sample will be drawn at 7 AM, the nurse would
instruct the client only to drink water after
a. 5 PM the night before.
b. 11 PM the night before.
c. 12 midnight before the test.

d. 4 AM on the day of the test.

ANS: b
The client should not have ingested any nutrients other than water for 8 to 12 hours before a
fasting blood glucose sample is drawn.

23. The nurse educating a client about an upcoming oral glucose tolerance test would
include information relevant to
a. eating at least 500 g of carbohydrate for 3 days before the test.
b. the first blood sample being drawn 1 hour after drinking a glucose-containing
beverage.
c. not eating or drinking anything else during the test.
d. exercising during the test to relieve boredom.
ANS: c
The client needs a diet that offers at least 150 g of carbohydrate daily for at least 3 days before
the oral glucose tolerance test. A sample is drawn to measure fasting blood glucose, then a 75-g
glucose beverage is given to the client to drink. The client then waits, and blood samples are
taken at intervals, often at 1 and 2 hours. The client may not eat or drink during the test.

24. The nurse teaches a client newly diagnosed with insulin-dependent diabetes to
perform glucose self-monitoring after exercising for
a. excessive urination.
b. unusual thirst.
c. shakiness.
d. sudden anorexia.
ANS: c
Hypoglycemia is a significant risk for clients who exercise while taking insulin or oral therapy.
Shakiness is a manifestation of hypoglycemia, whereas polyuria and polydipsia occur with
hyperglycemia.

25. The nurse would assess for lactic acidosis as an adverse effect in the client taking the
oral antidiabetic agent
a. glipizide (Glucotrol).
b. metformin (Glucophage).
c. acarbose (Precose).
d. repaglinide (Prandin).

ANS: b
In following the nursing implications of oral antidiabetic medication, the nurse should monitor
the client taking metformin (Glucophage) for lactic acidosis.

26. The nurse providing education to a client newly diagnosed with diabetes mellitus
about an exercise program would remind the client to
a. reduce fluid intake before exercising.
b. ensure that blood sugar level is above 100.
c. refrain from eating until 30 minutes after exercising.
d. set exercise periods for different times during the day.
ANS: b
The diabetic client should ensure that the blood sugar level is above 100 mg/dl because exercise
utilizes glucose. Adequate intake of fluid before and during exercise will combat dehydration.
Exercise periods should be at the same time each day, and a snack is advisable after exercise.

27. The nurse would encourage the client who is attempting to loose weight to reduce the
intake of
a. broccoli.
b. oranges.
c. chicken.
d. cheese.
ANS: d
Reduction of fat calories may be a good initial modification.

28. The nurse teaching a diabetic client who has just started insulin therapy would
include the instruction to
a. shake short-acting insulin vigorously to mix it.
b. draw up short-acting insulin before longer-acting insulin.
c. routinely aspirate before injecting.
d. inject at a 30-degree angle.
ANS: b
The client should shake insulin vials to resuspend all forms except short-acting insulins. The
prescribed amount of short-acting insulin is aspirated first. Routine aspiration is not necessary.
Injection should be at a 90-degree angle, or a 45-degree angle if the client is thin or has loose
skin.


29. The nurse would instruct a client who is on a rowing team to avoid injecting insulin
in his arms on rowing practice days because
a. the arms have increased muscle mass.
b. the arms will become painful.
c. increased circulation in the arms will dilute the insulin.
d. exercise increases the absorption rate of insulin.
ANS: d
The nurse should tell clients to avoid sites above muscles that will be exercised heavily that day,
because exercise increases the rate of insulin absorption.

30. The nurse assesses a diabetic client and finds a blood sugar level of 280 mg/dl, low
blood pressure, nausea and vomiting, and erratic pulse. The nurse would suspect the
electrolyte abnormality of
a. hypernatremia.
b. hypocalcemia.
c. hypokalemia.
d. hypermagnesemia.
ANS: c
Electrolyte imbalances such as hyponatremia and hyperkalemia or hypokalemia accompany
acute hyperglycemia, with clinical manifestations of nausea and vomiting, diarrhea, ectopic
beats, and hypotension.
DIF: Cognitive Level: Analysis REF: Text Reference: 1276, Table 47-7;
31. In a client who needs fluid replacement therapy for DKA, the nurse would evaluate
the best indicator of dehydration as
a. intake and output.
b. weight deviation from baseline.
c. skin turgor.
d. dryness of tongue and mucous membranes.
ANS: b
The best indication of the degree of dehydration in the DKA client is weight loss, which may be
determined if the client’s baseline weight is known; loss may be 10% of total body weight.


32. The nurse explains that diabetic retinopathy, the leading cause of blindness in the
United States, results when the retina
a. detaches from the inner chamber wall.
b. hemorrhages and loses it ability to function.
c. is obstructed by protein plaque.
d. is deprived of oxygen.
ANS: d
As the microangiography progresses into the chamber of the eyes, the vessels gradually occlude,
depleting the retina of oxygen; the retina depends on oxygen to function.

33. The ED nurse who is giving insulin by continuous IV infusion to a client with DKA
would plan to monitor the client’s blood glucose level every
a. 10 minutes.
b. 30 minutes.
c. hour.
d. 2 hours.
ANS: b
Blood glucose levels need to be monitored every 30 minutes initially, preferably with a blood
glucose meter.

34. The nurse would be most vigilant in assessing for hypoglycemia in a client taking the
oral antidiabetic agent
a. chlorpropamide (Diabinese).
b. metformin (Glucophage).
c. acarbose (Precose).
d. repaglinide (Prandin).
ANS: a
Most recorded cases of hypoglycemia have been in clients receiving chlorpropamide
(Diabinese), which has a duration of action of 24 to 72 hours.

35. The nurse suspects hypoglycemia in a client with diabetes who is difficult to arouse.
To reverse this condition, the nurse knows that the best therapy would be
a. graham crackers.
b. orange juice.
c. 4 teaspoons granulated sugar.

d. glucagon.
ANS: d
The nurse should never force an unconscious or semi-conscious client to drink liquids, because
fluid may be aspirated into the lungs. Glucagon or IV glucose can be administered in the event of
a serious hypoglycemic episode.

36. The nurse would recognize that the trend in the lipid levels of a client with diabetes
follows the pattern that accompanies macrovascular disease, which is
a. decreased very-low-density lipoproteins.
b. decreased low-density lipoproteins.
c. increased high-density lipoproteins.
d. increased triglyceride levels.
ANS: d
Typically, very-low-density and low-density lipoproteins are increased and high-density
lipoproteins are decreased. The most characteristic lipid abnormality in diabetes is an elevated
triglyceride level.

37. The nurse would explain to a client diagnosed with diabetes and hypertension that
the most likely prescribed medication will be a(n)
a. beta-adrenergic blocker.
b. diuretic.
c. angiotensin-converting enzyme (ACE) inhibitor.
d. direct-acting vasodilator.
ANS: c
ACE inhibitors and calcium channel blockers are the agents of choice for treatment of diabetic
clients with hypertension. Beta-blockers and diuretics may increase glucose tolerance and lipid
levels.
DIF: Cognitive Level: Knowledge REF: Text Reference: 1279, Table 47-8;
38. The nurse would counsel a diabetic client who has developed nephropathy that the
best dietary alteration to manage this complication is a
a. low-protein diet.
b. high-calorie diet.
c. high-fat diet.
d. low-mineral diet.
ANS: a

Clients with nephropathy are taught to eat a low-protein diet and to avoid nephrotoxic drugs
(e.g., gentamicin). The protein component of the diet should be less than 10%.

39. A client with diabetes who has properly learned the principles of foot care would be
most likely to say
a. “I should wear nice, tight shoes for firm support.”
b. “A mirror will be very helpful so I can look at all parts of my feet each day.”
c. “I should limit walking barefoot to a half hour a day.”
d. “The best method of testing bath temperature is with the toes.”
ANS: b
The feet should be inspected daily for any trauma (a mirror may be needed). The diabetic client
should wear properly fitting, nonrestrictive shoes; avoid walking barefoot; and test water
temperature with the elbow before bathing.

REF: Text Reference: 1283, Bridge to Home Health Care Box;
TOP: Nursing Process Step: Evaluation
40. For a client with diabetes mellitus scheduled for surgery at 8 AM, the nurse would
plan to check the client’s blood glucose level on the day of surgery between
a. 12 and 2 AM.
b. 2 and 4 AM.
c. 4 and 6 AM.
d. 7 and 8 AM.
ANS: d
A blood glucose determination should be performed and reported to the physician within 1 hour
before surgery to ensure that the client (who has been NPO since midnight) will not develop
hypoglycemia during surgery.

41. In a teaching plan for clients newly diagnosed with diabetes, the nurse would include
some basic facts relative to the pathophysiology of diabetes mellitus, such as
a. insulin must be present to convert glucose to glycogen.
b. insulin assists in metabolizing fats for energy.
c. urine output increases to excrete by-products of fat metabolism.
d. the liver is capable of producing adequate insulin levels.
ANS: a
Insulin is the key that turns glucose into glycogen, which can be stored in the muscles.

DIF: Cognitive Level: Comprehension REF: Text Reference: 1257

42. The nurse counsels a client that in the beta cell destruction process toward type 1
diabetes, the client may experience a “honeymoon period,” during which the
pancreas
a. regenerates and produces adequate amounts of insulin indefinitely.
b. becomes desensitized to high levels of blood glucose.
c. produces proinsulin in greater quantities for about 3 months.
d. compensates with adequate amounts of insulin for 3 to 12 months.
ANS: d
In the decline toward type 1 diabetes, the pancreas compensates and produces a normal level of
insulin for 3 to 12 months, but then becomes overwhelmed.

43. For a diabetic client weighing 80 pounds, the nurse would anticipate that the starting
dose of insulin will be
a. 72 units.
b. 54 units.
c. 36 units.
d. 18 units.
ANS: d
The rule is that initial insulin should be ordered at .5 unit/kg/day: 80  2.2 = 36.36  .5 = 18.18
units.

44. The nurse cautions a diabetic client taking ginseng that to avoid a drop in blood
sugar, ginseng should be taken
a. 1 hour after meals.
b. during meals.
c. 30 minutes before meals
d. between meals.
ANS: b
Studies have found that ginseng taken with meals will not profoundly decrease blood sugar level.

REF: Text Reference: 1258, Complementary and Alternative Therapy Box - Ginseng
Supplements and Blood Glucose; TOP: Nursing Process Step: Intervention

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Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, 7th Edition

Chapter 47: Management of Clients with Diabetes Mellitus

1. The nurse explains that the most common type of diabetes is

DIF: Cognitive Level: Knowledge REF: Text Reference: 1243

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application

4. Evaluating a young man with diabetes who reports a number of clinical

DIF: Cognitive Level: Application REF: Text Reference: 1249

DIF: Cognitive Level: Knowledge REF: Text Reference: 1249

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DIF: Cognitive Level: Knowledge REF: Text Reference: 1251

DIF: Cognitive Level: Comprehension REF: Text Reference: 1260

DIF: Cognitive Level: Application REF: Text Reference: 1253

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TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

DIF: Cognitive Level: Application REF: Text Reference: 1254

DIF: Cognitive Level: Application REF: Text Reference: 1255

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TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

DIF: Cognitive Level: Analysis REF: Text Reference: 1278

DIF: Cognitive Level: Application REF: Text Reference: 1258

DIF: Cognitive Level: Application

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b. persistent elevation in blood glucose levels.

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d. 4 AM on the day of the test.

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