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Diabetes Type I
Lara Fielding, a 20-year-old college student, comes to the student health center with a 4-day history of flu-like symptoms. She reports feeling increasing fatigue, thirst, and nausea over the last 24 hours. Further assessment and lab work indicate that Lara is experiencing diabetic ketoacidosis (DKA). She is transferred to an acute care facility for treatment.
Assessment: The nurse notes that Lara's breath has a fruity odor, and she is exhibiting Kussmaul respirations.
1. What is the mechanism that results in Kussmaul respirations?
A) To compensate for metabolic acidosis, the respirations are deep and rapid.
Lab work reveals that Lara's blood glucose level is 370 mg/dl, plasma bicarbonate is 8 mEq/L, potassium is
5.2 mEq/L, and she has elevated ketones in her urine. Goals of treatment in DKA include correcting fluid
imbalance and restoring normal pH, electrolytes, and glucose.
2. To achieve the goal of restoring Lara's fluid volume, the nurse would expect to implement which intervention?
C) Maintain an infusion of normal saline solution.
3. To restore Lara's blood glucose to a normal level, what should the nurse prepare to administer?
A) An IV infusion containing regular insulin.
4. In addition to monitoring Lara's blood glucose level, what additional serum lab value should the nurse monitor carefully?
D) Potassium.
Ethical-Legal Issues: Patient Information: Lara's blood glucose level stabilizes, and she begins taking oral
fluids. Her IV solutions are switched to D5.45 at a keep-open rate, and the insulin infusion is discontinued.
While hospitalized, family members and many of Lara's college friends call the nursing unit to check on her
condition.
5. The nurse's decision about what to tell these callers should be based on what primary consideration?
D) Lara's right to privacy regarding her health information.
A student nurse is assigned to work with the charge nurse in caring for Lara during her acute illness. The
student tells the nurse that she plans to present information about Lara to her fellow students during a
post-clinical conference, and asks the charge nurse for permission to copy Lara's lab data to take to the
conference.
6. Which response is best for the charge nurse to provide?
B) "The lab values can be copied as long as there is no identifying client data."
Manifestations: Once the acute ketoacidosis is controlled, Lara is told that she has Type 1 diabetes
mellitus. The nurse obtains Lara's history. Lara states that prior to the flu, she had been healthy. However,
she had noticed that she had been eating more than normal, but had not been gaining any weight. Lara
also states that she had been drinking a lot of diet colas and that she got up at night frequently to go to the
bathroom.
7. The nurse identifies that Lara has experienced classic symptoms of diabetes, which are:
B) Polyuria, polyphagia, and polydipsia.
Lara tells the nurse, "I know that diabetes is a chronic condition, so I've probably had this for a while. Why
didn't I experience any symptoms before now?"
8. How should the nurse respond?
D) "The symptoms have an abrupt onset that is often brought on by a viral illness, like the flu."
Therapeutic Communication: Lara states, "I wish I hadn't gotten the flu. Then, this diabetes wouldn't have
been discovered, and I could keep having a normal life."
9. What is the best initial response by the nurse?
D) "It must be quite a shock to learn that you have diabetes."
Lara starts to cry and says, "You have no idea how awful this is. I want to be by myself now. Please leave
me alone."
10. What is the best response by the nurse?
A) "I'll leave you alone for now, but I will stop back by in 30 minutes."
Insulin: The goal of treatment with hypoglycemic agents is the maintenance of stable blood glucose levels
to prevent the acute complications of hypoglycemia and hyperglycemia, and the long-term complications
associated with hyperglycemia. Lara will initially be taking Humulin N/Humulin R 70/30 insulin
subcutaneously every a.m., a sliding-scale dose of regular insulin subcutaneously before lunch and dinner,
and Humulin N insulin at bedtime.
11. Which statement made by Lara indicates that she correctly understands self-administration of insulin?
B) "The amount of short-acting insulin I take every day is based on my blood sugar readings."
The nurse observes as Lara administers her morning dose of insulin. Lara pinches the skin on the front of
her thigh and inserts the needle at a 90-degree angle.
12. What action should the nurse implement?
D) Encourage Lara to inject the insulin with the needle in place, as inserted.
An hour before the next dose of sliding-scale insulin is scheduled, Lara tells the nurse, "I guess I'm really
nervous about giving myself insulin injections. Look how shaky and sweaty I am."
13. What is the priority nursing action?
B) Check Lara's blood glucose.
Management: Priorities: Once she is feeling better, Lara does practice injection skills and later states that
she feels more comfortable about giving herself the injections.
The next morning, Lara is preparing to administer her insulin with the nurse's supervision. However, the
nurse is called back to the desk by the unit clerk where she learns that several patients are having problems
that require attention.
14. Which action should the nurse take first?
C) Administer IV dextrose to a diabetic client with a blood glucose level of 25 mg/dl.
When returning to Lara's room, the nurse learns that breakfast trays have not yet arrived on the unit and
all the other patients with diabetes have already received insulin.
15. What action should the nurse take first?
A) Ask the unit clerk to find out when the trays will be available.
Lifestyle Modifications: Lara attends a series of classes on management of her diabetes. She learns that
the goals of diet therapy for patients with Type 1 diabetes are to consume all essential nutrients, achieve
and maintain ideal body weight, and maintain blood glucose levels as near normal as possible. Lara tells the
nurse that she understands the importance of a well-balanced diet, and states, "You know I am in college,
and I know I'll want to go out for a beer every now and again. I understand that a can of beer has a lot of
calories, so I'll watch what I eat if I am going to have a drink."
16. What is the best response by the nurse?
B) "Alcohol does contain a lot of empty calories, but it is also likely to cause your blood glucose to decrease."
Lara tells the nurse that she will make sure she drinks plenty of water and will take a little extra regular
insulin before beginning strenuous exercise.
17. What is the best response by the nurse?
C) Advise Lara that extra insulin should not generally be taken before exercise.
A Complication Occurs: Lara is discharged with controlled blood glucose levels and sufficient knowledge of
diet and insulin therapy. She will continue to attend the series of classes on diabetes management offered
at the hospital by the diabetes educator.
Two months later, Lara's college roommate calls the nurse late at night in a panic and reports that Lara
described feeling like "my heart is beating out of my chest." Lara was weak and shaky, so the roommate
brought her some juice. Lara became confused and lethargic before she could drink it, and now she will not
wake up.
18. What is the best nursing action?
C) Ask the roommate if Lara has emergency supplies such as Glucagon or cake icing available.
19. Once Lara is more alert, what instructions should the nurse provide the roommate?
A) Give Lara some crackers and milk while waiting for the emergency transport.
Lara's blood glucose level is stabilized, and she is transported to the acute care facility where her blood
glucose is monitored carefully. The admitting physician suspects that Lara is experiencing Somogyi's
phenomenon.
20. What technique should the nurse use to assess for this occurrence?
D) Monitor blood glucose levels during the night and before breakfast.
Diagnostic Tests: After discharge, Lara is scheduled for a follow-up evaluation at the outpatient clinic. A
glycosylated Hgb level is drawn, and the results were 11%.
21. Which statement by Lara reflects understanding of glycosylated Hgb?
D) "At least I won't have this done again for 3 months. I will really work at following my diet between now and then."
Lara tells the nurse that her 15-year-old sister had a fasting blood glucose test last week, because she felt
that she had some of the same symptoms that Lara had before being diagnosed with diabetes. Lara states
her sister's results were 135 mg/dl.
22. How should the nurse respond?
A) "She needs a second test performed before a diagnosis is made."
Sick Day Management: Lara talks to the nurse about what to do if she gets sick. She states, "It just doesn't
make sense to take my insulin when I feel sick, knowing I won't want to eat anything."
23. How should the nurse respond?
C) "Being sick increases your blood sugar. Taking your usual insulin dose is important."
Classifications of Diabetes: Lara states that her grandmother became diabetic after she retired, but that
her mother had gestational diabetes mellitus (GDM) when she was pregnant with Lara. Lara asks the nurse
if this is related to her condition now.
24. How should the nurse respond?
B) "There is no direct correlation, but family history is important in diabetes."
Lara asks the nurse why her mother does not have diabetes, since it developed while she was pregnant
25. What is the best response?
C) "Women with gestational diabetes are at high risk for developing diabetes after pregnancy, but not all will get the disease."
Acute Problems of Diabetes: Lara tells the nurse that her grandmother was very sick after her gallbladder
was removed last year. She said she was in a coma and was diagnosed with hyperglycemic-hyperosmolar
nonketotic syndrome (HHNS). She asks the nurse to describe differences in HHNS and DKA.
26. How should the nurse respond?
C) HHNS is caused by persistent hyperglycemia, but ketosis does not occur.
Lara tells the nurse, "I hope I never get HHNS. My grandmother's blood glucose level was almost 1,000
mg/dl. My blood glucose level was only 370 mg/dl, and I was really sick. It's pretty amazing my
grandmother didn't die!"
27. What intervention should the nurse implement?
B) Tell Lara that HHNS is less likely to occur in Type 1 diabetes than in Type 2 diabetes.
Long-Term Complications: Lara learns that there are a number of things she can do to reduce her risk for
the numerous long-term complications associated with diabetes. She understands that cardiovascular
complications are a major cause of death in diabetics.
28. Which lab value indicates that Lara is working to reduce her risk for cardiovascular disease?
C) Low-density lipoprotein (LDL) cholesterol of 80 mg/dl.
29. Which finding indicates that Lara is experiencing a complication of diabetes?
A) Burning sensation in her toes.
Lara learns about good foot care and the importance of regular monitoring of her vision, kidney function,
cardiovascular, and cerebrovascular systems. She is aware of problems associated with neuropathies that
can occur, both peripheral and autonomic. Lara recognizes that she will be part of a collaborative
healthcare team to manage her diabetes. She states, "The single most important thing I can do is make
sure my blood glucose level is well controlled."
30. What response should the nurse make?
A) "You're absolutely right, and your healthcare team will be there to help you."
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