A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose

See also the separate Diabetes Education and Self-management Programmes article.

Patients with diabetes frequently attend their healthcare practitioners, either specifically for diabetes-related issues, for complications of their chronic illness, or for unrelated problems. They may see their GP, practice nurse, hospital diabetologist, diabetes specialist nurse, dietician and many others, from time to time. Each visit can be viewed as an opportunity to assess and improve the patient's understanding of their illness, and their ability to control the disease.

This article provides a summary of the areas of assessment relevant to type 1 diabetes and type 2 diabetes, which will need to be adapted, depending on an individual patient's type of diabetes.

To educate the patient and enable them to monitor and manage their diabetes as well as possible.
To assess any problems in glycaemic control and address them to improve it.
To detect any complications of diabetes and treat them as appropriate.
To educate and reinforce healthy lifestyle advice.
To assess the patient's overall health and to treat any associated or coincidental illness, physical or mental.
To provide support and advice to the patient on how to cope with living with a chronic illness and how they can best alter their lifestyle to maintain their health.

There is much to cover if all the information below is to be discussed at the review:

Education and self-management:
- How is the patient coping with self-care and self-management of their diabetes?
- Does the patient consider that they eat a healthy diabetic diet and do they feel sufficiently informed about how to manage their diet and its relationship to their insulin regimen?
- Have they received, or would they like to receive, any educational input to help them improve their understanding of their condition and its self-management? For example, Dose Adjustment for Normal Eating (DAFNE), Diabetes Self Management for Ongoing and Diagnosed (DESMOND), dietetic input, exercise and activity programmes.
- Is the patient a smoker? If so, what help would they like to become a non-smoker and are they aware of the importance of stopping smoking?
- Ensure the patient knows what to do if they become unwell for any reason. See the article on Diabetes and Intercurrent Illness.
Complications:
- Has the patient with diabetes had any hospital admissions in the preceding year for diabetic decompensations such as hypoglycaemia, diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state?
- Has the patient had any treatment or hospital admissions for complications of their diabetes in the preceding year? For example, angina/myocardial infarction, cerebrovascular event/transient ischaemic attack (TIA), diabetic nephropathy, diabetic retinopathy, diabetic neuropathy or diabetes foot problems.
- Has the patient had any symptoms of cardiovascular, cerebrovascular, renal, ophthalmological or neurological complications of diabetes?
- Has the patient had any problems with sexual function? Ask specifically about erectile dysfunction.
- Has the patient been otherwise well, or had any other illness of note over the preceding year for which they have consulted their GP or other healthcare services?
- How has their mood been? Has there been any problem with, or treatment for, depression?
Treatment:
- How is the patient coping with and complying with their medication regimen for diabetes? Have there been any problems with injection of insulin? Have there been any problems with timing of insulin or oral medication? Do they miss injections or medication regularly?
Monitoring:
- Are there any problems with the equipment that they have to monitor their capillary glucose? When did they last calibrate their glucose monitoring equipment?
- Do they have their records of their blood glucose monitoring?
Pregnancy and pre-pregnancy:
- See the separate Diabetes in Pregnancy article.
- Are they pregnant or planning on having any children? It is essential to ensure effective pre-pregnancy care and care during the pregnancy[1]. See also the Pre-pregnancy Counselling article.

Weight, abdominal circumference, height and BMI.
Urinalysis for ketones, protein and nitrite (evidence of infection).
Inspect injection sites of patients with type 1 diabetes, looking for evidence of lipoatrophy and lipodystrophy/lipohypertrophy.
Cardiovascular:
- Check pulse and blood pressure.
- Listen for carotid bruits and to heart sounds/lung fields if there is any history consistent with cerebrovascular or cardiac illness.
- Palpate and record the peripheral pulses of the feet.
Eyes:
- Ensure regular attendance and appropriate follow-up for diabetes eye screening.
- Inspect eyes, looking for any evidence of xanthelasmata, cataract formation or ophthalmoplegia.
- Check visual acuity, with distance vision glasses, if worn.
- Carry out ophthalmoscopy, preferably with dilated eyes, unless this has already been done as part of the patient's diabetes ophthalmological screening and digital retinal photography programme.
Neuropathy:
- Examine the legs for evidence of diabetic amyotrophy.
- Check peripheral limb sensation - eg, using a 10 g nylon monofilament probe[2].
- Check ankle and knee reflexes using a tendon hammer.
- Inspect footwear (for suitability) and the feet carefully for any evidence of peripheral neuropathy causing deformity and ulceration, or hypoperfusion due to peripheral arterial disease.

HbA1c; or check when last done.
Home capillary glucose monitoring results.
Frequency and severity of hypoglycaemic episodes.
Non-fasting lipid profile.
Estimated glomerular filtration rate to look for diabetic nephropathy (in addition to urine testing for microalbuminuria and albumin:creatinine ratio - ACR).

See also the separate articles on Management of Type 1 Diabetes and Management of Type 2 Diabetes.

Current diabetic medication and doses - insulin (short- and long-acting), biguanides, sulfonylureas and thiazolidinediones.
Current medication for other conditions, especially those designed to ameliorate cardiovascular risk such as diuretics, antihypertensives, angiotensin-converting enzyme (ACE) inhibitors, aspirin, beta-blockers, etc.

See also the separate Diabetes Diet and Exercise article.

What is the patient's current level of physical activity and can this be improved if thought necessary? Are there any local physical activity programmes in which they could be enrolled?
Has the patient received adequate education in respect of their diabetes, both in their and in your view? Would they like to receive more advice on self-management of their diabetes? Should they be enrolled into a local diabetes education delivery programme such as DAFNE (type 1 patients) or DESMOND (type 2 patients).

Glycaemic control and how to improve it.
Smoking status and how to stop smoking if needed.
Dietary patterns and how to modify them (can help with improving glycaemic control).
Exercise and how to incorporate regular physical exertion into one's life.
Lipid status and any lifestyle modifications or medication required to improve it.
Blood pressure and how to improve its control with medication and lifestyle modification.
Avoiding weight gain or losing weight (pertinent to both type 1 and type 2 patients).

Ideally, where the annual diabetic review is carried out as a 'one-stop' service where the patient has had their blood tests in advance of the appointment, the meaning of the results should be discussed with the patient there and then.
Any change in management that is needed should be outlined and agreed and it should be clear to the patient what the 'medical' and what the 'self-managed' changes need to be.
Where blood results and other useful information that will determine management are not available until later, a useful practice is to send to the patient a copy of the clinic letter sent to the GP, discussing the results, what they mean and what needs to change as a result of the annual review.
Where patients are seen exclusively in primary care, a further appointment should be offered to discuss what the ongoing treatment plan is and ensure that the patient is clear about it and knows how to proceed.
Arrange referrals to other practitioners as appropriate - eg, ophthalmologist, dietician, footcare team, educational support.

See the separate Audit and Audit Cycle and Audit of Diabetes Care articles.

The nurse admits a client diagnosed with a new onset of Type 1 diabetes mellitus. Which symptoms should the nurse expect to find during his initial physical assessment?1. polydipsia, polyuria, and weight loss2. weight gain, tiredness, and bradycardia3. Irritability, diaphoresis, and tachycardia

4. Diarrhea, abdominal pain, and weigh loss

1. polydipsia, polyuria, and weight loss

A client presents with diaphoresis, palpitations and tachycardia approximately two hours after receiving 20 units of insulin regular. What is the nurses's most appropriate intervention?1. Administer 15 grams of a simple carbohydrate2. Administer additional insulin based on a sliding scale3. Administer lorazepam per PRN order

4. Draw blood for a glucose level

1. Administer 15 grams of a simple carbohydrate

The nurse is caring for a preoperative client who has type 1 diabetes mellitus. Which action should the nurse take on the morning of the surgery?1. Clarify the insulin dose with the healthcare provider2. hold all insulin for the day3. Administer oral anti-diabetic agents only

4. Administer the full daily insulin dose

1. Clarify the insulin dose with the healthcare provider

The nurse is teaching health promotion to a group of adults in the community. Which action would the nurse advise to decrease the risk factors for type 2 diabetes mellitus?1. Following a fat free diet and non impact exercise three times a week2. Maintaining an ideal weight and participating in daily exercise3. Following a very low carbohydrate diet that includes moderate amounts of fat

4. Smoking cessation and a diet high in protein and fat

2. Maintaining an ideal weight and participating in daily exercise

The nurse is caring for a client with type 2 diabetes mellitus. One hour after taking an oral diabetic medication, the client becomes nauseous and commits. The nurse should:1. administer another dose of the drug2. administer subcutaneous insulin3. monitor blood glucose closely, and assess for signs of hypoglycemia

4. monitor blood glucose closely, and assess for signs of hyperglycemia

3. monitor blood glucose closely, and assess for signs of hypoglycemia

What priority information regarding diet and exercise should the nurse teach a client newly diagnosed with type 1 diabetes mellitus?1. Exercise will increase blood glucose2. Fluid, protein, and electrolytes should be managed3. Calorie intake should be reduced prior to exercise

4. Dietary goals, dietary composition, and physical activity are key

A nurse is teaching a client recently diagnosed with type 1 diabetes mellitus about chronic complications associated with the disease. Which information should the nurse include?1. Buy shoes that are half a size larger2. Schedule yearly eye examination3. Exercise will increase insulin resistance

4. Podiatry visits are necessary every five years

2. Schedule yearly eye examination

The nurse is teaching a client newly diagnosed with type 1 diabetes mellitus about the rotation of insulin injection sites. The nurse determines that teaching was effective when the client states:1. rotate injection sites within on anatomical region2. Rotate injection sites from one anatomic region to another3. rotation of injection sites does not affect speed of absorption

4. rotation of injection sites does not prevent lipohypertrophy

1. rotate injection sites within on anatomical region

The nurse is providing education to a group of clients newly diagnosed with type 1 diabetes mellitus. One client asks why the glycosylated hemoglobin blood test (HbA1c) is done. What is the nurses's best response?1. HbA1c measures hemoglobin level in addition to blood glucose level2. HbA1c is used to assess long-term glycemic control3. HbA1c provides information about conditions that effect a red blood cell's life span

4. HbA1c provides information about serum protein and albumin

2. HbA1c is used to assess long-term glycemic control

The nurse is providing diabetes education to a group of clients previously diagnosed with type 1 diabetes mellitus. One of the clients asks about the advantage of using a continuous subcutaneous insulin infusion (CSII) pump. Whats nurse's best response would be:1. CSII is easy to use, and requires very little education2. CSII eliminates the potential for ketoacidosis3. CSII is cheaper to use than traditional insulin injections

4. CSII allows for flexibility in meal timing

The nurse is admitting a client with a diagnosis of myxedema. During the initial assessment, which findings would the nurse be most concerned about?1. Hypertension and weight loss2. Heat Intolerance and emotional lability3. Corneal ulcerations and increased appetite

4. Bradycardia and decreased intellectual function

The nurse is caring for a client who is on day postoperative from a total thyroidectomy. Which symptoms would prompt the nurse to immediately call the rapid response team (RRT) of intervention?1.Blood pressure of 150/92mmHg2.Harsh, high-pitched respiratory sounds3.Weak voice or hoarseness

4.Decreased deep tendon reflexes

2.Harsh, high-pitched respiratory sounds

The nurse admits a client with a diagnosis of chronic adrenal insufficiency. Which assessment findings confirm the diagnosis? Select all that apply.1.Hyponatremia2. Hyperkalemia3. Hyperglycemia4.Hypercalcemia

5. Hypocalcemia

A nurse is caring for a client diagnosed with diabetes insipidus. Which laboratory value is most important for the nurse to monitor?1. Glucose2. Hemoglobin3. Creatinine

4. Sodium

A client diagnosed with Addisons disease is concerned about dark areas of skin around his knees and elbows. . The nurse's best response would be:1. This finding is not related to Addison's disease. I will refer you to a dermatologist2.This skin change is related to your medication therapy, and should subside in a few weeks3.This is related to hormonal changes caused by Addisons disease

4.This change is related to sun exposure and should not be a concern

3.This is related to hormonal changes caused by Addisons disease

The nurse is caring for a postoperative client who has undergone a transsphenoidal hypophysectomy. Which assessments would be most important for this client? Select all that apply.1.Urinary output2. Psychological status3.Fluid and electrolyte balance4.gastrointestinal status

5.visual assessment

The nurse is caring for a postoperative client who has undergone surgical removal of the pituitary gland (hypophysectomy), and has now developed diabetes insipidus (DI). The nurse should assess for: 1.hypertension and bradycardia2.glucosuria and weight gain3.fluid overload and hyponatremia

4.severe dehydration and hypernatremia

The nurse is caring for a client with diabetes insidious (DI). What is the nurse's priority intervention?1. watching for signs and symptoms of septic shock2. Maintaining adequate hydration3. Checking weight every three days

4. Monitoring urine for specific gravity >1.030

2. Maintaining adequate hydration

The nurse has completed an assessment of a client who has a head injury. Which assessment finding requires intervention?1.The client states she is not thirsty

2.The clients urine has a specific gravity <1.005
3.The client has a mild headache
4.The clients potassium level is 3.5 meq/L

2.The clients urine has a specific gravity <1.005>

A client was diabetes insipidus (DI) is receiving desmopressin. Which symptom would require immediate intervention?1.rash and difficulty breathing2.abdominal cramping3.buring at the injection site

4.headache

1.rash and difficulty breathing

The nurse caring for a client who is diagnosed with diabetes insidious (DI). The nurse should carefully assess this client to prevent:1.decreased hemoglobin and hyponatremia2.hypertension and bradycardia3.hypotension and increased urine output4. high urine specific gravity and hypertension

3.hypotension and increased urine output

The nurse is a admitting a client suspected of having Addison's disease. An initial serum chemistry test is done. Which findings should the nurse expect?1.hyponatremia and hyperkalemia2.hypernatremia and hypokalemia3.hyperglycemia and hypernatremia

4.hypercalcemia and hyperglycemia

1.hyponatremia and hyperkalemia

Which assessment findings should the nurse expect in a patient with Addisons disease?1.weight gain and loss of skin pigment2.fatigue and muscle weakness3.hypertension and hypernatremia

4.increased appetite and hypokalemia

2.fatigue and muscle weakness

The nurse is caring for a client with Addisons disease. Which laboratory value would indicate the treatment has been effective?1. Sodium of 147 meq/L2.Potassium of 2.9 meq/L3. Sodium of 142 meq/L

4.Potassium of 6.0 meq/L

The nurse caring for a client admitted with Addisonian crisis. Which outcome is he priority?1.Preventing irreversible shock2. Preventing infection3. Relieving anxiety

4. Lowering blood pressure

1.Preventing irreversible shock

What assessment finding is expected for a client diagnosed with Addisons disease?1.Fatigue2. Edema3. Heat intolerance

4. Respiratory acidosis

The nurse is planning care for a client with Addisons disease. What is an appropriate outcome for this client?1.Fluid intact of less than 1000 mL a day2.Participating in daily relaxation techniques3.Ambulating in the hall five to six times per day

4.Choosing low sodium foods

2.Participating in daily relaxation techniques

The nurse is providing education about disease management to a client with Addisons disease. The nurse's teaching should include:1.eating a low-sodium diet2.decreasing fluids to 1000ml/day3.wearing medic-alert bracelet

4.taking daily cortisone on an empty stomach

3.wearing medic-alert bracelet

The nurse is admitting a client to the unit with Cushing's syndrome. The nurse is likely to find which signs or symptoms during his initial assessment?1."Moon face" and truncal obesity2.Weight loss and heat intolerance 3.Changes in skin texture and low body temperature

4.Polyuria and dehydration

1."Moon face" and truncal obesity

The nurse is planning care for a client diagnosed with Cushing's syndrome. Which potential complication should the nurse instruct this client about?1.Dehydration2.Infections3.Breathing difficulty

4.Acute pain

The nurse is aware that the client with Cushing's syndrome is at risk for:1.hypoglycemia and dehydration2. hypotension and hyperkalemia hyperglycemia3. hyponatremia and dehydration

4. hypertension and heart failure

The nurse is admitting a client with newly diagnosed Cushing's syndrome. Which laboratory values should the nurse expect to find?1. decreased sodium and decreased glucose2. decreased cortisol and decreased glucose3. increased cortisol and decreased sodium

4. increased cortisol and increased sodium

The nurse is caring for a client who is diagnosed with Cushing's syndrome. What is the priority assessment?1.serum glucose2.daily weight3.urinary output

4.abdominal girth

The nurse is caring for a client in the post anesthesia care unit following an adrenalectomy. What is the nurse's priority action?1.assessing serum potassium2.assessing blood pressure3.administering dextrose in water

4.administering opioids

2.assessing blood pressure

Th nurse is caring for a client recently diagnosed with Cushings syndrome. Which assessment finding should the nurse expect to find?1.bruising and hypotension2.truncal obesity and abdominal striae3.hypertension and emanciation

4.Weight loss and "moon face"

2.truncal obesity and abdominal striae

The nurse providing education for a client with Cushing's syndrome. Which information would the nurse include in the teaching plan?1.dietary sodium should increased2.physical changes are disease related3.high fluid intake is important

4.dietary protein should be restricted

2.physical changes are disease related

The nurse is providing community education to a group of clients about the prevention of type 2 diabetes mellitus.Which client would be a highest risk for the development of diabetes mellitus?1.A young adult who plays basketball regularly2.an elderly woman who is sedentary3.a middle-age woman who delivers mail

4.a middle-age man with a basal metabolic rate within normal limits

2.an elderly woman who is sedentary

A client with type 1 diabetes mellitus often skips his ordered dose of insulin. What priority information should the nurse give to this client regarding the omission of insulin doses? 1. may lead to ketoacidosis2. may cause hypoglycemic coma3. may lead to pancreatitis

4. may cause diabetes insidious

1. may lead to ketoacidosis

A client with type 1 diabetes mellitus presents with poluphagia, polydipsia, and polyuria. Further assessment shows signs of dehydration. The nurse determines that this client may be experiencing:1.Diabetes insipidus2.diabetic ketoacidosis3.hypoglycemia

4.syndrom of inappropriate antidiuretic hormone (SIADH)

A client with type 1 diabetes mellitus is exhibiting Kussmaul's respirations, abdominal discomfort, and lethargy. What interventions should the nurse perform?1. assess complete blood count (CBC)2. administer insulin as ordered3. start an intravenous infusion of dextrose

4. assess neurological status

2. administer insulin as ordered

The nurse is admitting a client diagnosed with diabetic ketoacidosis (DKA). What is the nurse's priority intervention?1.subcutaneous glucagon administration2.transfusion of whole blood3.glucocorticoid administration

4.inrtravenous insulin

The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). The client is receiving insulin and IV fluids. Which laboratory test would be a priority for the nurse to monitor?1.Serum potassium2.Hemoglobin A1C (HbA1c)3.serum calcium

4.serum nitrogen

The home health nurse is visiting a client newly diagnosed with type 1 diabetes mellitus. The client reports nausea and abdominal pain. The nurse observes dehydration and dry skin. What question should the nurse ask the client?1.what did you drink today?2.are you taking your insulin daily?3.when is the last time you had a checkup?

4.Did you weigh yourself today?

2. are you taking your insulin daily?

The nurse is preparing to administer IV insulin to a client diagnosed with diabetic ketoacidosis (DKA). What will the nurse monitor while the client is receiving this intervention?1.hypokalemia and hypoglycemia2.hypocalcemia and hyperkalemia3.hyperkalemia and hyperglycemia

4.hypernatremia and hypercalcemia

1.hypokalemia and hypoglycemia

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is most at risk for the development of :1.infection2.confusion3.dehydration

4.skin breakdown

The nurse teaches a client diagnosed with hyperglycemic hyperosmolar state (HHS) how to monitor his condition . What is a potential warning sign of this condition?1.symptoms of hyperglycemia2.symptoms of hypoglycemia3.ketones in the urine

4.rapid and deep respirations

1. symptoms of hyperglycemia

The nurse is administering an insulin infusion for a client diagnosed with diabetic ketoacidosis (DKA). Which outcome indicates that treatment has been effective?1.lowered blood glucose level to normal limits within one hour2.the replacement of fluids during the first 24 hours3.an increase in anion gap within 24 hours

4.an increase in blood glucose levels within the first three hours

2.the replacement of fluids during the first 24 hours

A client with type 2 diabetes mellitus comes to the emergency department with weakness, thirst, and an inability to concentrate. What should the nurse assess?1.thyroid hormones 2.weight3.apical pulse

4.blood glucose

The nurse is providing sick day rules to a group of clients with type 1 diabetes mellitus. Which information is appropriate to include?1.monitor blood glucose at lease once a day 2.do not take insulin until you feel well3.drink 8-12 oz of fluid each waking hour

4.if nauseous, do not eat or drink

3.drink 8-12 oz of fluid each waking hour

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment being received for SIADH is effective? Select all that apply.1.decrease in body weight2.rise in blood pressure; drop in heart rate3.absence of wheezes in the lungs4.increase in urine output

5.decrease in urine osmolarity

A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements would indicate that the nurse's teaching has been effective? Select all that apply.1.i hat to take my steroids for 10 days 2.i need to weigh myself daily to be sue i don't eat too many calories 3.I need to call my healthcare provider to discuss my steroid needs before I have dental work 4.I will call the healthcare provider if I start to feel fatigues, weak, or dizzy5. if i feel like i have the flu, I'll carry on as usual because this is an expected response

6. I need to obtain and wear a medical alert bracelet

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drink is initiated with 50 unites of insulin in 100 ml of normal saline solution. The IV is being infused via an infusion pump, and th pump is currently set at 10 ml/hr. How many units of insulin each hour is this client receiving?

The nurse is providing education for a client diagnosed with Cushing's syndrome. Which statement indicates an understanding of the disease?1. My blood sugar is low, so I don't need to watch my diet2. I should increase my fluid intake to three liters a day3. I will weigh myself daily and report any gain

4. With this disease process, it is okay to increase my sodium intake.

`3. I will weigh myself daily and report any gain

An adolescent client who has type 1 diabetes mellitus has a decreased level of 45. Which is the priority nursing intervention?1. Placing a Salem sump tube and providing tube feedings2. Administering 500 ml bolus of normal saline solution3. Administering 1mg of glucagon intramuscularly or subcutaneously

4. Calling the healthcare provider for orders

3. Administering 1mg of glucagon intramuscularly or subcutaneously

A client diagnosed with diabetic ketoacidosis (DKA) had a serum glucose level of 485 mg/dL. After treatment, the serum glucose level dropped to 185 mg/dL. The client developed an irregular heart rate. Which assessment finding most likely caused this irregularity?1. Decreased serum chloride level2. Decreased serum potassium level3. Elevated serum glucose level

4. Elevated serum sodium level

2. Decreased serum potassium level

A client is being treated for Addisonian crisis. Which laboratory values are most important for the nurse to monitor?1. Serum bicarbonate and sodium2. serum glucose and ketones3. serum sodium and potassium

4. serum calcium and magnesium

3. serum sodium and potassium

The nurse is providing education for a client newly diagnosed with Addison's disease. The client is receiving a maintenance dose of steroids. What priority information should the nurse include?1. Fluid maintenance2. Symptoms of hypo and hyperglycemia3. Taking steroids exactly as prescribed

4. Exercise schedule

3. Taking steroids exactly as prescribed

A client has developed diabetic ketoacidosis (DKA), secondary to infection. The nurse should assess for which potential problems?1. Kussmaul's respirations and a fruity odor to the breath2. Shallow respirations and sever abdominal pain3. Decreased respirations and increased urine output

4. Cheyne-Stokes respirations and foul-smelling urine

1. Kussmaul's respirations and a fruity odor to the breath