Nokea
The nurse is admitting a client with the diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) following steroid therapy. Which sign(s) and symptom(s) would the nurse likely note? Select all that apply.
- A. High blood pressure
- B. Extreme thirst
- C. Bradycardia
- D. Poor skin turgor
- E. Acidosis
- F. Hypoglycemia
Correct Answer: B,D
Rationale: HHNKS presents with extreme thirst and dehydration (poor skin turgor) due to severe hyperglycemia and fluid shifts. High blood pressure is unlikely (hypotension is more common), bradycardia is incorrect (tachycardia occurs), acidosis is not typical (unlike DKA), and hypoglycemia is not associated with HHNKS.
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The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?
- A. It carries glucose into body cells
- B. It aids in the process of gluconeogenesis.
- C. It stimulates the pancreatic hormone cells.
- D. It decreases the intestinal absorption of glucose.
Correct Answer: A
Rationale: Insulin's primary role is to facilitate glucose transport into cells for energy use and promote glycogen storage in the liver, inhibiting glycogen breakdown. It does not promote gluconeogenesis, stimulate pancreatic hormone cells, or affect intestinal glucose absorption.
A client asks why pancreas transplantation is not an option offered to all insulin-dependent clients with diabetes. Which is the best response by the nurse?
- A. Type 1 diabetes can be managed in most clients with insulin.
- B. Pancreas transplant is becoming more common.
- C. There is a long waiting list to receive a new pancreas.
- D. For every transplant, two deceased donors are needed.
Correct Answer: A
Rationale: Type 1 diabetes is manageable with insulin, and the risks of lifelong immunosuppression from transplantation often outweigh benefits. Pancreas transplants are not increasingly common, waiting lists are not the primary issue, and only one donor is needed.
A client newly diagnosed with type 1 diabetes asks the nurse why injection site rotation is important. What is the nurse's best response?
- A. Avoid infection.
- B. Promote absorption.
- C. Minimize discomfort.
- D. Prevent muscle destruction.
Correct Answer: B
Rationale: Rotating injection sites prevents lipodystrophy (fat buildup or breakdown), ensuring consistent insulin absorption. While infection and discomfort are concerns, they are not the primary reasons. Insulin is not injected into muscle, so muscle destruction is irrelevant.
On initial nursing rounds, the diabetic client reports 'not feeling well.' Later, the nurse finds the client to be diaphoretic and in a stuporous state. Which is the immediate action taken by the nurse?
- A. Call the physician.
- B. Obtain a glucometer reading.
- C. Administer fruit juice.
- D. Start an IV of dextrose.
Correct Answer: B
Rationale: A glucometer reading is critical to differentiate between hypoglycemia and diabetic ketoacidosis in a stuporous diabetic client. Administering juice or IV dextrose without confirming hypoglycemia risks worsening hyperglycemia, and calling the physician is secondary to obtaining a glucose level.
The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?
- A. Increases ability for glucose to get into the cell and lowers blood sugar
- B. Creates an overall feeling of well-being and lowers risk of depression
- C. Decreases need for pancreas to produce more cells
- D. Decreases risk of developing insulin resistance and hyperglycemia
Correct Answer: A
Rationale: Exercise enhances glucose uptake by increasing transmembrane glucose transporters in muscles, lowering blood sugar levels. While it may improve well-being and reduce insulin resistance, the primary benefit for diabetes management is improved glucose transport into cells.