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Diabetes Mellitus Complications (HHNS and DKA) NCLEX ScienceMedicineNursing student_257 Save Diabetes, DKA, HHNS NCLEX REVIE...15 terms ellie_201Preview Thyroid Storm NCLEX Questions

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kitty0303Preview Cushings/Addison's Practice Questi...44 terms alexisvu99Preview SIADH 10 terms flor The elderly patient with type 2 diabetes mellitus presents to the clinic with a fever and productive cough. The diagnosis of pneumonia is made.You notice tenting skin, deep tongue furrows, and vital signs of 110/80 mm Hg, 120 beats/minute, and 24 breaths/minute. What assessment is important for you to obtain?

• Blood glucose
• Orthostatic blood pressures
• Urine ketones
• Temperature
• Blood glucose

HHS is typically seen in patients with type 2 diabetes and infection, such as pneumonia. The main presenting sign is a glucose level above 600 mg/dL. Enough evidence of dehydration already exists that orthostatic vital sign assessments are not a priority, and they are often inaccurate in the elderly due to poor vascular tone. Patients with HHS do not have elevated ketone levels, which is a key distinction between HHS and DKA.Temperature will eventually be taken but is often blunted in the elderly and diabetics. An infectious diagnosis has already been made. The glucose level for appropriate fluid and insulin treatment is the priority.The patient with HHS presented with a glucose level of 800 mg/dL and is started on IV fluids and insulin. What action do you anticipate when the patient's glucose reaches 250 mg/dL?

• Administer an intravenous (IV) solution with 5% dextrose.
• Administer sodium polystyrene sulfate (Kayexalate).
• Slow the IV infusion rate to 40 mL/hour.
• Assess cardiac monitoring for peaked T waves.
• Administer an intravenous (IV) solution with 5% dextrose.

When blood glucose levels fall to approximately 250 mg/dL, IV fluids containing glucose are administered to prevent hypoglycemia. Kayexalate (for cation exchange) is used in the treatment of hyperkalemia, which causes peaked T waves on cardiac monitoring. In HHS hypokalemia may result from insulin moving the potassium intracellularly. Fluid replacement remains a priority, but it is given with dextrose. The infusion rate of 40 mL/hour keeps the vein open, but it is not the appropriate replacement rate.

What is a typical finding of hyperosmolar hyperglycemic syndrome (HHS)?

• Occurs in type 1 diabetes as the presenting symptom
• Slow onset resulting in a blood glucose level greater than 600 mg/dL
• Ketone bodies higher than 4+ in urine
• Signs and symptoms of diabetes insipidus
• Slow onset resulting in a blood glucose level greater than 600 mg/dL

HHS has a slower onset than diabetic ketoacidosis. HHS is often related to impaired thirst sensation, inadequate fluid intake, or functional inability to replace fluids. Because of the slower onset, the blood glucose levels can be quite high (more than 600 mg/dL) before diagnosis.HHS is seen in type 2 diabetics, and there is enough circulating insulin to prevent ketoacidosis. Diabetes insipidus is related to inadequate antidiuretic hormone secretion or kidney response with dilute, frequent urination. It is not related to HHS.A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessment of the patient, you suspect DKA rather than HHS based on the finding of

• polyuria.
• severe dehydration.
• rapid, deep respirations.
• decreased serum potassium.
• rapid, deep respirations.

Rapid, deep respirations are Kussmaul's and are are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Kussmaul respirations (rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through exhalation of excess carbon dioxide. Acetone is detected on the breath as a sweet, fruity odor.What is a finding in DKA that is not seen in hyperosmolar hyperglycemic syndrome (HHS)?

• Glucose level above 400 mg/dL
• Hyperkalemia
• Ketones in blood
• Urine output of 30 mL/hr
• Ketones in blood

The main difference between the two conditions is that ketone bodies are absent or minimal in HHS because the body has enough insulin to prevent ketoacidosis. Both have high glucose levels, although the level in HHS tends to be higher (above 600 mg/dL). Hypokalemia is possible in both, although it is more likely and serious in DKA. Urine output of 30 mL/hr is normal obligatory output; both conditions are likely to have dehydration and decreased output.Which assessment is the most sensitive indicator that the IV fluid administration may be too rapid when treating a patient with DKA and a history of renal disease?

• Pedal edema
• Tachypnea
• Urine output of 40 mL/hour
• Change in the level of consciousness
• Change in the level of consciousness

Too rapid fluid replacement can lead to hyponatremia and cerebral edema. Pedal edema is a later and relatively insignificant sign. In a bedridden patient, edema is more evident in the sacral area. The Kussmaul respirations are expected; crackles auscultated in the lungs are a more sensitive indicator. The desired urine output for adequate hydration is 30 to 60 mL/hr.

The patient presents to the emergency department with a glucose level of 400 mg/dL, ketone result of 2+, and rapid respirations with a fruity odor. What finding do you anticipate?

• pH below 7.30
• Urine specific gravity below 1.005
• High sodium bicarbonate levels
• Low blood urea nitrogen (BUN) level
• pH below 7.30

The patient is in metabolic acidosis, which is a pH below 7.35. Dehydration results in a high urine specific gravity (at the upper end of the normal range, or above 1.025 to 1.030). Sodium bicarbonate levels are low in metabolic acidosis. The dehydration that occurs with DKA elevates the BUN level.The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor?

• Magnesium (Mg)
• Hemoglobin (Hb)
• White blood cells (WBCs)
• Potassium (K)
• Potassium (K)

Even if the patient has normal potassium levels, there can be significant hypokalemia when insulin is administered as it pushes the serum potassium intracellularly. This can lead to life-threatening hypokalemia. The other options are not as significant.The patient with type 1 diabetes arrives in the emergency department with a glucose level of 390 mg/dL and positive result for ketones. Vital signs are 110/70 mm Hg, 120 beats/minute, and 28 deep, sighing respirations/minute. What is the priority need for the patient?

• Oxygen
• Intravenous (IV) fluids
• Albuterol (Ventolin)
• Metformin (Glucophage)
• Intravenous (IV) fluids

A patient in diabetic ketoacidosis (DKA) needs IV fluids and insulin to stop the tissue breakdown resulting in ketone bodies and acidosis. The initial goal is fluid and electrolyte balance. Kussmaul respirations indicate the body is attempting to compensate by blowing off the carbon dioxide, but it is ineffective as long as the body continues to break down the ketone bodies and remains in metabolic acidosis.The patient has type 1 diabetes mellitus and is found unresponsive with cool and clammy skin. What action is a priority?

• Obtain a serum glucose level.
• Give hard candy under the tongue.
• Administer glucagon per standing order.
• Notify the health care provider.
• Administer glucagon per standing order.

The patient has signs and symptoms of hypoglycemia for which treatment should be the priority. Glucagon stimulates a strong hepatic response to convert glycogen to glucose and therefore makes glucose rapidly available. Waiting for a serum result (up to an hour) is improper because brain cells continue to die from a lack of glucose. Nothing solid should be placed in the mouth when the patient has an altered level of consciousness and can aspirate. With obvious symptoms, emergent treatment takes priority over notifying the health care provider.

The patient had a hypoglycemic episode and is treated with a concentrated glucose oral tablet. Fifteen minutes later the capillary glucose level (Accu-Check) is 150 mg/dL. What action should you take?

• Administer a second bolus of glucose solution.
• Administer regular insulin per sliding scale.
• Have the patient eat peanut butter and toast.
• Obtain a serum glucose level.
• Have the patient eat peanut butter and toast.

The patient has had an appropriate response to the glucose. Now a complex carbohydrate is needed to prevent hypoglycemia from reoccurring. There is no need for a second bolus of glucose because the result is within normal range. Insulin is not given, even though the glucose level is slightly elevated. The short-acting glucose is metabolized and insulin administration can increase the risk of a second hypoglycemic reaction. A serum confirmation of the level can be obtained but is not the priority.The patient is managed with NPH and regular insulin injections before breakfast and before dinner. When is the patient most likely to have a hypoglycemic reaction?

• After breakfast
• Before lunch
• During lunch
• After lunch
• Before lunch

The regular insulin peak occurs about 2 to 3 hours with a duration of 5 to 6 hours. If too much insulin or not enough food is given, the most likely time of hypoglycemia is before lunch, when the regular insulin is still present, the NPH has its onset, and the breakfast food has been metabolized.Which symptoms reported by a patient with diabetes mellitus are most important to follow-up?

• "My vision has been getting fuzzier over the past year."
• "I cannot read the small print anymore."
• "There is something like a veil of blackness coming across my vision."
• "I have yellow discharge from one eye."
• "There is something like a veil of blackness coming across my vision."

Diabetic retinopathy, particularly proliferative retinopathy, can cause retinal detachment, which has the classic new symptom of a veil coming across the field of vision. This requires emergency treatment. Chronic blurry vision can be cataracts and is not emergent. Change in the ability to read things near to the eye (presbyopia or farsightedness) is an age-related change and not emergent. Conjunctivitis needs treatment but is not as emergent as retinal detachment.What is the best teaching for a patient who is newly diagnosed with diabetes mellitus type 2?

• Read a Snellen chart yearly.
• Be checked out for presbycusis.
• Notify the doctor if your vision has color distortion.
• See an ophthalmologist for a dilated eye examination yearly.
• See an ophthalmologist for a dilated eye examination yearly.

The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Because of this, the patient with type 2 diabetes should have a dilated eye examination by an ophthalmologist at the time of diagnosis and annually thereafter for early detection and treatment.