Chapter 24: Endocrine and Immune Disorders

Touhy: Ebersole & Hess' Toward Healthy Aging, 9th Edition

Multiple Choice

1. A client is newly diagnosed with type 2 diabetes mellitus. Which diagnostic test will best evaluate the management plan prescribed for this client?

a. A yearly funduscopic examination by an ophthalmologist b. Regular foot examinations by a podiatrist c. Quarterly hemoglobin A 1C d. Biannual cholesterol testing

ANS: C

Quarterly or biannual hemoglobin A 1C (Hb A 1C ) is designed to provide information regarding the averaged glucose levels for a 3-month period of time. The periodic measurement of a glycated hemoglobin test (Hb A 1C ) is the best measure of ongoing glycemic control. Eye examinations are important, but proper blood sugar control will help prevent the damaging effects of diabetes to the eyes. Proper foot care is important, but good blood sugar control will help prevent the damaging effects of diabetes on the feet. Biannual cholesterol testing is not relevant to the evaluation of type 2 diabetes mellitus.

DIF: Cognitive Level: Applying REF: p. 313

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Presenting symptoms occur very quickly. b. The disease rarely occurs in older adults. c. The classic symptoms may not be present in older adults. d. There are no recognizable symptoms; it is a “silent killer.”

2. Which is the most likely reason that type 2 diabetes mellitus is often difficult to diagnose in older adults?

ANS: C

The symptoms are also often masked by normal aging changes and conditions common in older adults. Polydipsia often does not occur due to the decreased thirst mechanism in older adults, polyphagia is often not recognized due to normal appetite declines associated with aging, and polyuria is often not recognized due to frequent urinary tract infections in older adults. Presenting symptoms usually occur very slowly. Type 2 diabetes mellitus is very common in older adults. There are symptoms of diabetes mellitus in older adults; however, they may be different than those seen in younger adults.

DIF: Cognitive Level: Applying REF: pp. 309–310

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. There is a higher tolerance for elevated levels of circulating glucose in older adults. b. Older adults tend to metabolize glucose at a faster rate than younger adults. c. Fingerstick glucose monitoring is inaccurate in older adults. d. The classic signs of elevated glucose levels, polyuria, polyphagia, and polydipsia are rarely present in older adults.

3. Hyperglycemia is harder to detect in older adults due to which of the following?

ANS: A

Hyperglycemia in older adults is harder to detect than in a younger adult. With aging there is a higher tolerance for elevated levels of circulating glucose. It is not unusual to find persons with fasting glucose levels of 200-600 mg/dL or higher. It is not true that older adults metabolize glucose at a faster rate than younger adults or that fingerstick glucose monitoring is inaccurate in older adults. While it is true that older adults usually do not have the classic symptoms of elevated glucose levels, this does not explain why hyperglycemia is harder to detect in older adults.

DIF: Cognitive Level: Understanding REF: p. 311

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Insulin b. Sulfonylureas c. Metformin d. Chlorpropramide

4. A nurse is caring for an older adult who is diagnosed with type 2 Diabetes. The patient is prescribed oral medication for diabetes. The nurse can expect that which of the following medications is prescribed as a first-line therapy?

ANS: C

Metformin (Glucophage) is commonly prescribed as first-line therapy; it does not cause hypoglycemia or weight gain. Sulfonylureas were used for many years as first-line agents for all persons with type 2 DM. However, they are associated with hypoglycemia and can only be used in persons who can either be aware of the signs themselves or who have a caregiver capable of doing so; therefore, Metformin is considered the first line of therapy. Insulin is used for individuals with type 2 DM; however, it is not first-line therapy. Chlorpropramide is contraindicated due to a long half-life and the fact that it can cause prolonged hypoglycemia.

DIF: Cognitive Level: Understanding REF: p. 313

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. A walking program is not recommended for an older adult with diabetes. b. The walking regimen needs to be done on a regularly scheduled basis. c. Regular exercise should not exceed 30 minutes three times a week. d. Insulin can most probably be discontinued if the individual adheres to the walking program.

5. An older adult with type 2 DM who is being treated with insulin wants to increase his activity level and begin a walking program. What recommendations should the nurse provide to this patient?

ANS: B

If the person is using insulin, exercise needs to be done on a regular rather than an erratic basis. Exercise is an important part of diabetes self-management. In some cases, exercise in conjunction with an appropriate diet may be sufficient to maintain blood glucose levels within normal levels; however, it is not likely that insulin will be able to be discontinued.

DIF: Cognitive Level: Applying REF: p. 314

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

Multiple Response

1. A nurse is educating an older adult with diabetes mellitus on minimizing the risk of cardiovascular disease. The nurse focuses on lipid levels. Which of the following are the recommended goals for lipid levels? (Select all that apply.)

a. Cholesterol <200 b. Low-density lipoprotein (LDL) >100 c. High-density lipoprotein (HDL) >40 (men), >50 (women) d. Hb A 1C value of ≥6.5% e. Triglycerides <150

ANS: A, C, E

Goals for acceptable lipid levels include: Cholesterol <200, LDL <100, HDL >40 (men), >50, (women) and triglycerides <150. Hb A 1C levels are not a measure of lipids.

DIF: Cognitive Level: Understanding REF: p. 312, Box 24-11

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. promoting cardiovascular health has the potential to minimize the complications of DM. b. there is little evidence that demonstrates that the course of DM can be altered in an older adult. c. the benefits of better control of blood pressure and lipid levels are seen much quicker than the benefits of better glycemic control. d. older adults are less receptive to teaching about diabetes than they are to teaching about cardiovascular disease. e. diabetes is not a common chronic condition in older adults.

2. An older patient asks a nurse: “I went to my diabetes doctor and everything was stable. The nurse practitioner spent the entire time teaching me about decreasing my risks of heart disease. It seemed odd that she did not focus on teaching me how to better control my diabetes. Do you know why?” The nurse formulates a response based on the understanding that: (Select all that apply.)

ANS: A, C

While glycemic control is important, more emphasis is now on the prevention and treatment of cardiovascular diseases. Research has indicated that it may take 8 years of glycemic control before benefits are seen while the benefits of better control of blood pressure and lipids are seen as early as 2-3 years. Promoting cardiovascular health has the potential to be the most efficacious in the minimization of complications in the persons with DM. Education on self-management of diabetes is important for patients of all ages. Diabetes is a common chronic condition in older adults.

DIF: Cognitive Level: Understanding REF: p. 311

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Glucose levels that are higher than normal b. Increased waist circumference c. Blood pressure that is lower than normal d. Increased blood cholesterol levels e. Decreased triglyceride levels

3. A nurse is caring for an older adult who has metabolic syndrome. The nurse knows that the following conditions are common in persons with metabolic syndrome: (Select all that apply.)

ANS: A, B, D

Metabolic syndrome is characterized by higher than normal glucose levels, increased waist size due to excess abdominal fat, high blood pressure, and abnormal levels of cholesterol and triglycerides in the blood.

DIF: Cognitive Level: Understanding REF: p. 310, Box 24-6

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Monitoring weight and BP b. Inspecting the feet c. Obtaining hemoglobin A 1C d. Reviewing self-management skills e. Obtaining fasting lipid profile and serum creatinine

4. A nurse works in an outpatient diabetes clinic. The nurse knows that the minimum standard of care for a patient with diabetes includes the following at each visit: (Select all that apply.)

ANS: A, B, D

Minimum standards of care for an individual with diabetes include the following at each visit: Monitoring weight and BP, inspecting feet, reviewing self-monitoring glucose record, reviewing/adjusting medications as needed, reviewing self-management skills/goals, assessing mood, counseling on tobacco and alcohol use. Obtaining hemoglobin A 1C is recommended at quarterly intervals and obtaining fasting lipid profile and serum creatinine is recommended annually.

DIF: Cognitive Level: Understanding REF: p. 312, Box 24-10

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. demonstrate the technique for obtaining a blood sample. b. verbalize actions to take when results indicate an error on the machine. c. state the correct timing of blood glucose monitoring. d. state the signs and symptoms of both hyperglycemia and hypoglycemia. e. demonstrate technique for storing and transporting insulin correctly.

5. A nurse is educating an older adult with diabetes on glucose self-monitoring. When developing the teaching plan, the nurse includes which of the following goals in the teaching plan? The patient will: (Select all that apply.)

ANS: A, B, C

Option D is important for an older person with diabetes; however, it is not directly related to glucose self-monitoring. Option E is important for a person who is taking insulin, however is not directly related to glucose self-monitoring.

DIF: Cognitive Level: Understanding REF: p. 314, Box 24-13

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation