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DM Med/ Surg Practice Questions

(Using notes and book)


1) On a cellular level, what is the difference found between Type 1 and Type 2
DM? Beta cell (insulin) destruction is seen in Type 1, whereas insulin
resistance is seen in Type 2
2) Where is insulin produced? In the Beta cells of the Islets of Langerhans
located in the pancreas.
3) What are the actions of insulin? Controls the level of glucose in the blood by
regulating the production and storage of glucose. It is necessary for
metabolism of carbs, proteins, and fats
4) Why are the terms insulin-dependent diabetes and non-insulin dependant
diabetes no longer used? Because they focus on the basis of treatment of
diabetes rather than the underlying cause
5) What percentage of Americans are DM pts? 20%
6) What percentage of Americans is considered pre-diabetic? 40%
7) What are some risk factors for developing diabetes? Family Hx. Of diabetes,
Obesity esp. abdominal and visceral adiposity, BMI> 27%, Race/Ethnicity,
GDM or babies > 9 lbs., HTN > 140/90 mm Hg, Triglycerides > 200mg/dL,
Prev. impaired glucose tolerance
8) There are 3 metabolic processes that are important in ensuring adequate
glucose for body fuel. These 3 are glycolysis, glycogenolysis and
gluconeogenesis. Give a description of each process Glycolysis: breakdown
of glucose into water and carbon dioxide form. Glycogenolysis: breakdown of
glycogen into glucose by the liver. Gluconeogenesis: building of glucose from
new sources
9) What hormones stimulate gluconeogenesis? glucagon , glucocorticoid
hormones, thyroid hormones
10) Another hormone is found in the Beta cells of the pancreas that works along
with insulin to decrease glucose levels. What is this hormone? Amylin
11) So when blood sugar is too high, insulin is secreted. What is secreted when
blood sugar is too low? Glucagon
12) Where is glucagon produced? The alpha cells of the pancreas
13) Two catecholamines help maintain glucose levels during stressful times.
They inhibit insulin release, promote glycogenolysis and conserve energy.
What are they? Epinephrine and norepinephrine
14) This hormone, made in the delta cells of the pancreas, inhibits insulin
secretion. What is it called? Somatostatin
15) What are the 2 main problems with insulin seen in Type 2 DM? Impaired
insulin secretion, and insulin resistance.
16) What lab tests are used to diagnose DM? FPG-Fasting Plasma Glucose8hrs after fasting; Casual (random) glucose- no regard to food; OGTT- oral
glucose tolerance test- 2 hours after glucose taken ; HgbA1C- glucose levels for
past 120 days; **The fasting plasma glucose is the most popular
17) What levels diagnose DM in each of these tests?

FPG- >equal to- 126mg/Dl


Random - >/equal to 200mg/dl
OGTT >/ equal to 200mg/dl
Hba1c> 7%
18) What does post-prandial mean? Blood sugar level 2 hrs after eating
19) What occurs to cause gestational diabetes? Hormones needed for placental
growth can also block insulins actions leading to high serum glucose levels.
This is what cause glucose intolerance over time.
20)
What are the goal blood sugars we should see in pregnant women 1hr
before meals and 2 hrs post- prandially? 1hr before meals: 105mg/dl; 2hrs
after meals: 130-140mg/dl
21) When should pregnant women be screened for gestational DM? During 2428wks of pregnancy
22)So if the ideal post-prandial blood sugar for a pregnant women is 130140mg/dl, what level would diagnose GDM? Level of 155 or greater.
23)What causes Secondary DM? Any type of damage/injury/ or interference to
the pancreas
24)
Secondary DM can be resolved when the underlying cause is treated.
What disease processes could lead to Secondary DM? Renal failure, CAD,
Cushings, hyperthyroidism, recurrent pancreatitis, use of parenteral nutrition
25) What medications could cause DM? Corticosteroids, thiazides, dilantin,
anti psychotics
26)
What are some s/s of Type 1 (acute onset) DM? 3 Ps Polydipsia,
polyuria, polyphagia, weight loss, weakness
27) What are some s/s of Type 2 (gradual onset) DM? Fatigue, Recurrent yeast
infections and poor wound healing (bacteria loves sugar) , visual changes
28) What would you expect to see in a physical assessment of a person with DM?
Blood pressure (sitting and standing), BMI, foot eye- neuro- oral exams
29) What lab tests would you expect to perform for a diabetic? HbA1C, lipid
levels, serum creatinine, UA, Ekg
30) What is the #1 predictor of Type 2 DM? Obesity
31) Some risk factors for Metabolic syndrome are: central obesity,
westernization, sedentary lifestyle, certain ethnic groups
32) Why should we use U-100 syringes instead of Tuberculin syringes?
Tuberculin syringes could increase risk for insulin med error
33) What are the 2 types of insulin? Natural (human), modified (synthetic)
34) What are the 3 groups of insulin?1) Short acting (a) rapid (b) slower acting
2) Intermediate, 3) Long- acting
Ok just study these and know that you gotta make sure your pt has eaten 30min
within giving insulin.

Types of Insulin (Rapid )


Insulin
(rapid)

Onset

Peak
(hrs)

Duration
(hrs)

Types of Insulin (Intermediate)


Insulin

Onset

Peak

Duration

NPH

1-2

4-8

10-20

Humulin N

1-2

4-8

10-20

Novolin N

1-2

4-8

10-20

Levemir
intermediate
/long acting

1-2

6-8

12-24

(intermediate)

Regular
HumulinR

30-60 min.

Aspart
Novolog

10-20 min.

1-3

3-5

Lispro
Humalog

15-30 min.

1-2

3-6

Glulisine
Apidra

10-15 min.

3-5

2-4

6-10

Types of Insulin (long-acting)


Glargine
(Lantus)

Onset
1-2

Ultralente

Onset
2-4

Peak
Flat

Duration
24

Peak

Duration
16-20

Not
Predictable

35) What should you remember when storing insulin? It can be stored for 30
days @ room temp, may be refrigerated until exp. Date, pre-filled pens can be @
room temp or refrigerated for 30 days.
36) What are the dos and donts storing of insulin Avoid temperature
extremes (dont freeze or heat), inspect for flocculation (frosted whitish coating),
always keep a spare insulin
37) When selecting insulin injection sites what are some things to take into
consideration? Always rotate sites to prevent lipodystrophy, dont use the same
site more than once in 2-3 weeks, always space injections at least 1 inch apart,
dont inject a limb that you are about to exercise
38) Insulin should always be given with an insulin or U-100 syringe rather than a
Tuberculin syringe to help prevent insulin med errors. It also should always be
given @ a 45 degree angle. What sites are appropriate to give SQ insulin
injections? Arms (posterior), thighs (anterior), abdomen, hips
39) What are some complications of insulin therapy? lipodystrophy (atrophy of
tissue), local rxn (itching, burning around injection site), systemic rxn
(anaphylactic shock, urticaria or hives)
40) What is the dawn phenomenon The dawn phenomenon is hyperglycemia
upon awakening. This occurs with the release of counterregulatory hormones that
rise in pre-dawn hours.
41) How can we treat it? By adjusting the time insulin is taken @ night or
increasing the dose
42) What is the Somogyi effect? rebound elevation of glucose brought on by
hypoglycemia. This may lead to ketosis or coma
43) Thiazolidnedones (Avandia) and Biguanides (Metformin) help to decrease
overall glucose production and decrease insulin resistance. What is the main
action of Sulfonylurias (Glipizide) and Meglitinides (Prandin)? They stimulate
the pancreas to make insulin
44) What are the actions of alpha glucosidase inhibitors (Precose)? They slow the
absorption of starches
45) Byetta and Symalin SQ injections that delay gastric emptying, increase
satiety, and decrease glucagon secretion. What is the main action that differs
them? Byetta stimulates insulin release and Symalin decrease glucose output
by liver
46) What is the key to nutritional treatment for Type 2 DM weight loss
47) What BMI is considered overweight? Obese? Overweight= 24-29; Obese
>30
48) When meal planning for a diabetic, ethnic backgrounds, insulin timing, diet
history, lifestyle and eating habits, and weight changes and maintenance are all
factors. In dealing with caloric intake, what % of calories should come from carbs,
proteins, and fats? 50-60% from carbs, 10-20%from proteins and 20-30% from
fats.
49) What is the recommended daily cholesterol for a DM pt? <300mg

50) Why are sat. fats and moderate to high amounts of protein not
recommended for the DM pt? It causes unnecessary stress on kidneys to
excrete excess nitrogen
51) What are the benefits of exercise for DM pt? Lowers blood glucose and
decreases risk for CVD. It increases HDLs and decreases triglyceride and
cholesterol levels
52) What type of exercise increases lean muscle mass and metabolism and
decreases weight and stress? Resistance strength training
53) Exercise will also raise blood glucose levels. Should a person continue to
exercise with a blood glucose >250 and ketones in their urine? No. They
shouldnt exercise until levels are acceptable (80-120mg/dl) and urine is free of
ketones
54) Exercise has different effects on each 2 types of diabetics. In Type 2 it is
encouraged to help lose weight and decrease insulin resistance. On the other
hand, in Type 1 hypoglycemia can be more severe and occur up to 48 hrs after
exercise due to loss of glycogen. What can we teach our Type 1 patients?
Monitor blood sugar before, during, and after exercise and keep carb snacks
available.
55) What can we recommend to the DM pt on exercise? Exercise @ the same
time of the day for the same amount of time, may need stress test if pt has cardiac
dysrythm., high BP may aggravate retinopathy, start slow and gradually increase.
56) What is the cornerstone in DM mgmt? Blood glucose monitoring
When self- monitoring glucose at home these are the levels you would want
to have 1 hr before eating, 2hrs after eating, and before bedtime
1hr before eating: 30-90mg/dl- before
2 hours after eating: 100-140mg/dl after
Bedtime: 140- 180mg/dl @HS
57) What can we teach our patients to avoid false blood sugar readings? Teach
to get enough blood on the strip. Old meters need to be cleaned manually. Make
sure reagent strips are not out of date, teach to program strip control # to glucose
monitor if needed. If on insulin pt should test 4x a day, if on oral hypoglycemic 23x a day. Keep and take a logbook to all Dr. appts.
58) There are 2 types of hypoglycemic states, mild and moderate. What happens
in the body during each state? Mild- SNS is stimulated and catecholamines are
released. Moderate- brain cells are deprived of glucose.
59) What are the s/s of each? Mild- sweating, tremor, tachycardia,
palpitations, nervousness, and hunger. Moderate- inability to concentrate,
headache, lightheadness, confusion, memory lapse, numbness of the lips and
tongue, slurred speech, impaired coordination, emotional changes, irrational
or combative behavior, double vision and drowsiness
60) What is the Rule of 15 that we can teach our patients to prevent
hypoglycemia? For every 30min of exercise done eat 15gm of carbs

61) What is autonomic neuropathy? neuropathy that occurs in the nerves


controlling certain organs that function involuntarily. (MedicineNet.com)
Gastrophoresis (when the stomach doesnt empty all the way) is one
symptom of this type of DM.
62) Hyperglycemia, dehydration, electrolyte loss, illness, infection, missed
insulin, and undiagnosed or untreated DM can cause DKA to occur. On a
cellular level what causes DKA? extremely low to no insulin production.
Seen usually in Type 1
63) S/S of DKA re due to Na and K+ loss. What are the s/s of DKA? Kussmaul
respirations (deep and rapid), sweet fruity breath, extreme drowsiness,
weakness, n/v (from lactic acid build up), cardiac arrhythmias, tachycardia,
and hypotension
64) What is the first line of treatment for DKA pts? Replace fluid loss with
IVF, then begin insulin drip
65) What could occur if fluids are replaced too fast in DKA? fluid overloead,
cerebral edema, hypokalemia
66) What does HHNS stand for Hyperglycemic hyperosmolar nonketontic
syndrome. This is also a medical emergency.
67) What would the blood sugar of a pt. With HHNS look like? 8001000mg/dl
68) What is the main difference between HHNS and DKA? Ketosis is minimal
or absent
69) Persistant hyperglycemia will lead to osmotic diuresis. What will this result
in? Loss of water and electrolytes.
70) What are the s/s of HHNS? Hypotension, Profound dehydration,
Tachycardia, Variable neurological signs ; Morality rate- 10% to 40%
71) What is the treatment fro HHNS? fluid replacement and correct
electrolytes
72) What is an example of macrovascular (medium to large vessel) damage in
DM? CVD
73) What are examples of microvascular (capillary bed thickening) damage in
DM? neuropathy, nephropathy, retinopathy, amputation situations,
erectile dysfunction
74) What is the leading cause of death in DM pts? #1- CVD, high risk for HTN,
CVA, MI also.
**Prevention is Key for long term complications of DM! Control blood sugar, BP,
stop smoking.
75) What is the #1 cause of renal failure for DM pts? Nephropathy
76) There are 2 types of diabetic retinopathy, non-proliferate and proliferate.
What is occuring in each type? Non- proliferate- partial occlusive of blood
vessels in eye; Proliferate- full occlusion of vessels in eye or hemorrhages
seen
77) What BP meds are very kidney protectant and used in decreasing risk for
nephropathy?Ace inhibitors!.. but ARBS and Beta blockers can also be
used

78) What are 3 options for the pt in ESRD? Hemodialysis, Peritoneal dialysis
and Kidney transplant
What can we teach to our pt with DM neuropathy regarding foot care? Teach to
perform monofilament test on foot. If pt can feel the monofilament poke then
they still have sensation to this area, if not, these areas are problem areas that
have increase risk for breakdown. Diabetics CANNOT go barefoot and teach to
check foot meticulously, wear thick white socks, teach patient to look at feet with
a mirror, daily self foot exams for pt, dont put lotion in between toes or cut
toenail too short--> these could cause infection
Blisters may cause sores overnight!

Essentials of Foot Care


Examination
Annually for all patients
Patients with neuropathy - visual inspection of feet at
every visit with a health care professional

Advise patients to:

Use lotion to prevent dryness and cracking


File calluses with a pumice stone
Cut toenails weekly or as needed
Always wear socks and well-fitting shoes
Notify their health care provider immediately if any
foot problems occur

What are the treatments for foot ulcers? - Abx, bed rest, debridement, blood
sugar control
79) What is Sudomotor neuropathy? absence of sweating of the extremities
with a compensatory increase in upper body sweating
80) Remember that bacteria love sugar. Increased and prolonged blood sugar
increases risk for infections. Stress also increases BG levels
81) What is seen in the DM pt with acanthosis nigricans? Dark, coarse,
thickened skin on the neck.
82) Should insulin be given the morning of surgery? usually not to prevent
hypoglycemia from occurring
**If client is NPO- insulin dose may need to be changed for type 2
Type 1 may need to administer insulin
Frequent blood glucose monitoring.
Clear liquids need to be caloric
Tube feeding-important to administer insulin at regular intervals.