CDE Practice Exam 1 fully solved & updated

A community pharmacy wants to offer a fee-for-service diabetes patient education program to its customers. Which of the following is the MOST appropriate way to market this new program? A. Place an ad in the regional paper B. Place flyers in every prescription bag C. Send out letters to local hospital administrators D. Contact the top 3 insurance companies in the state - ANSWER-B. Place flyers in every prescription bag In a fee-for-service environment, where patients pay out-of-pocket, the most efficient advertising needs to be directly to the consumer. A 35 year-old woman with T1DM present to the clinic for f/u of self monitoring blood glucose. Her A1c is 12%, and during the interview she reports that she thinks her boyfriend is interested in a younger, thinner woman. Which of the following is the best f/u question related to this patient's concerns? A. Do you think that your boyfriend might stay with you if you become blind? B. Are you afraid that insulin might cause you to gain weight? C. Do your parents know that your blood glucose levels are poorly controlled? D. What time of the day do you check your glucose? - ANSWER-B. Are you afraid that insulin might cause you to gain weight? The question's focus is on assessment and screening for eating disorders, of which intentional insulin omission is one. Effective assessments reveal lifestyle issues and facts, are patient centered, and facilitate honest self-disclosure. Routine labs for a patient with a history of normal glucose tolerance revealed a fasting glucose level of 113 mg/dL. What does the result indicate? A. Normal blood glucose B. Impaired fasting glucose C. Diabetes D. Gestational diabetes - ANSWER-B. Impaired fasting glucose A blood glucose level between 100 and 125 mg/dL indicates impaired fasting glucose. A normal fasting glucose is 100 gm/dL and diabetes is indicated by a fasting blood glucose of 126 mg/dL. SQ presents for a routine visit. While performing a foot exam you note "dependent rubber" (swelling and redness) when his feet are in a dependent position and pallor on elevation. You suspect: A. diabetic neuropathy B. peripheral arterial disease C. varicose veins D. Charcot joint - ANSWER-B. peripheral arterial disease Swelling and redness when the feet hang down are signs of poor circulation and peripheral vascular disease. Diabetic neuropathy may accompany peripheral vascular disease; however these visually observable changes are not usually present. Varicose veins and Charcot joint are also not usual causes of foot swelling and redness. An individual newly diagnosed with T2DM presents for education. What should the educator do first? A. Provide a detailed overview of the pathophysiology of T2DM. B. Assess the individual's interests, needs, and problems C. Discuss chronic complication risk D. Review a carbohydrate counting meal plan - ANSWER-B. Assess the individual's interests, needs, and problems Assessment is the first step in the process of providing diabetes education. By understanding what the interests, needs, and problems of the person with diabetes are, the educator is more likely to provide appropriate and useful information that will assist the individual to meet desired outcomes. The other choices may well become part of the education plan, but this follows assessment. Which of the following medications should NOT be used in pregnancy? A. Human insulin B. Metformin C. Methlydopa D. HMG-CoA reducates inhibitors - ANSWER-D. HMG-CoA reductase inhibitors Statin drugs are category X and should not be used in pregnant women. Insulin, metformin, and methyldopa have adequate safety date to support use during pregnancy. A patient tells you that he wants to verify the accuracy of his meter. You tell him that the testing (meter vs laboratory determination) A. should be done in a fasting state B. is valid as long as he performs the testing 1 hour or less apart C. result will be ~15% higher than the laboratory value if his meter reports whole blood glucose level values D. should be done simultaneously using a drop of blood from the venipuncture - ANSWER-A. should be done in a fasting state When verifying the accuracy of a meter, the bg meter results should be compared against a laboratory value, not another meter. Only fasting values can be measured since postal values will differ between the capillary blood (as measured on the meter) and the venous blood (as measure in the lab). These should be done at the same time. The meter result would be ~15% LOWER than the laboratory result if the meter reports whole blood glucose values. Applying a drop of blood from the venipuncture needle is not acceptable, as the meter strips will give false reading if venous blood is used. FN has T1DM. When is testing for ketones the most appropriate? A. Daily in the morning after an overnight fast B. Prior to a decrease in insulin dosage C. With consistently elevated bg D. Prior to exercise - ANSWER-C. with consistently elevated bg Ketone testing is appropriate during illness, when bg levels are consistently elevated, during weight loss and pregnancy. A 73 year old man with T2DM presents to the clinic complaining that he cannot pay for his medications any longer. He reports that one of his prescriptions went up from $5 to $100. Which of the following additional questions would be MOST helpful in assessing this problem? A. Did you go to a different chain pharmacy? B. Did you recently change insurance? C. When was the last time you had any prescriptions filled? D. Did you ask for a 3-month supply? - ANSWER-B. Did you recently change insurance? Effective assessments should reveal potential barriers to self-mgmt. Financial concerns and a alack of adequate insurance represent a major obstacle to care and therefore would be the appropriate place to begin. A single mother with T2DM is treated with 3 oral agents plus a bedtime injection of glargine. She presents to the clinic appearing disheveled. Her bg log reveals widely fluctuating bg values day to day. She states that her days are filled with transporting her 3 children from one activity to another and that she does not have time for herself. Which of the following is the best way to address her fluctuating bg values? A. Increase the bedtime insulin and monitor bg frequently B. Simplify her diabetes treatment plan to avoid missed doses C. Switch from oral agents and insulin injections to insulin pump therapy D. Ask the patient to keep a 3 month food diary - ANSWER-B. Simplify her diabetes treatment plan to avoid missed doses The key problem is time pressure and diabetes treatment plan complexity. The instructional team for a diabetes self-management education program MUST include, at least a A. physician and a registered nurse B. registered nurse and a social worker C. registered dietitian and an exercise physiologist D. registered nurse, a registered dietitian, or a registered pharmacist - ANSWER-D. registered nurse, a registered dietitian, or a registered pharmacist The National Standards for Diabetes Self-Management Education/Training specify in Standard 5 that at least one of the program's instructors must be a RN, RD, or pharmacist. An 86 year old woman presents for an initial diabetes education evaluation. She lives in an assisted living environment and is unaccompanied today. She reports taking 15 medications each day but does not know their names or their indications. Which of the following is the best sources of an additional medication history information? A. Contact the local pharmacy that fills her prescriptions B. Call the podiatrist that she visits each month C. Contact her daughter at work D. Have the patient identity drug pictures in the Physician's Desk Reference - ANSWER-A. Contact the local pharmacy that fills her prescription The local pharmacy will be able to provide objective data and estimates of long-term adherence. A 45 year old Hispanic man with T2DM for 10 years refuses to start insulin after failing oral agents. Which of the following is the MOST appropriate response for the educator? A. Educate the patient on the increased risk of microvascular complications B. Ask the patient why he does not want to start insulin C. Reassure the patient that insulin injections won't hurt D. Ask the patient if he has any family members with diabetes complications - ANSWER-B. Ask the patient why he does not want to start insulin The educational process always begins with assessment, ie, in this case understanding why the patient does not want to start insulin. The other choice assumed what the problem - lack of knowledge, fear of pain, and experienced of family members - may be without involving the patient in the process and therefore are not correct choices. A spotless blood glucose log from the past 2 months reveals twice daily checks, with all results neatly written in blue ink and falling between 80 mg/dL and 125 mg/dL. An A1C drawn the week prior was 9.8%. Which of the following best summarizes the findings? A. The results correlate as expected B. The A1C is lower than expected C. The blood glucose values are not accurate D. The A1C was not fasting - ANSWER-C. The blood glucose values are not accurate Clues to fabricated home blood glucose values include daily testing at exactly the same time without missed days, absence of blood smears on the pages with neatly written numbers in the same ink, frequently repeated values, and values all with the desired range. Sad mood, lack of interest or pleasure, unintentional weight or appetite changes, fatigue, and worsening blood glucose control indicate the need for further evaluation of which of the following? A. An eating disorder B. Depression C. An anxiety disorder D. Anger management - ANSWER-B. Depression These are all symptoms of depression. Weight loss with an eating disorder would be intentional, major symptoms of anxiety disorder include sweating, tremulousness, weakness, lack of concentration, irritability, and restlessness; anger would be characterized by outbursts. A 60 year-old man with cognitive deficits and dominant handed weakness from a past cerebral vascular accident presents to learn how to inject insulin. Which of the following is the MOST appropriate method to assess insulin education successfulness? A. Ask the patient to describe the injection steps B. Have the patient write out the procedure C. Provide the patient with a pamphlet to take home D. Have the patient demonstrate an injection - ANSWER-D. Have the patient demonstrate an injection The focus of this question is assessment of psychomotor skills. Demonstration of an injection by the educator, then return demonstration by the patient, allows for active learning. Which of the following is the MOST effective way to determine the health literacy level of a person with diabetes who has been referred to you? A. Ask the patient how well he or she reads B. Obtain information about the patient's education level C. Gauge the reading level based on the newspapers and magazines the individual reads D. Ask the patient to read an educational pamphlet on diabetes and explain its meaning - ANSWER-D. Ask the patient to read an educational pamphlet on diabetes and explain its meaning Most adults who are illiterate have learned to hide their literacy deficit and manage to compensate for this deficit and function in society. People do not tend to reveal that they are illiterate, number of years of schooling is not an indicator, and neither is types of magazines or books read. At the end of a nutrition counseling session, the diabetes educator asks the patient to pretend that the educator is a waitress and the patient is ordering a meal that would fit into her meal plan. This teaching format is called: A. games B. discussion C. role-playing D. demonstration - ANSWER-C. role-playing By definition, role-playing is a form of active learning that allows the learner to practice, express, explore, discuss, and share. The prioritization of learning objectives should be based on: A. review of the medical record B. recommendations of the referring physician C. diabetes education curriculum D. patient's identified interests or needs - ANSWER-D. patient's identified interests or needs According to adult learning theory, adults learn best when they feel the need to know, when it is personally relevant, and when it is active. A 24 year-old college student with T1DM presents to the pharmacist educator for insulin dose adjustments. She reports injecting the same amount of rapid-acting insulin with each meal and never making any changes. Her recent A1c was 8.7%. Which of the following is the most appropriate approach for this patient? A. Advise the patient to search the internet for information on meal planning B. Consult a registered dietitian to educate the patient about carbohydrate counting C. Telephone the patient's family to enlist their help and support D. Provide the patient with written materials to take home - ANSWER-B. Consult a RD to educate the patient on carbohydrate counting This patient could benefit from a consult with an RD for education on carbohydrate counting and using insulin to carbohydrate ratios. Which of the following is the most appropriate sick-day management guideline? A. Omit insulin when vomiting occurs B. Increase frequency of blood glucose monitoring C. Drink larger amounts of carbohydrate-containing liquids D. Call healthcare professionals only if urine ketones are positive - ANSWER-B. Increase frequency of bg monitoring Increasing frequency of bg monitoring is important for sick-day mgmt because the signs and symptoms fo developing acute illness can be preceded by elevated blood glucose levels and ketone levels. Insulin doses should continue as able and adjusted to correct hyperglycemia. Individuals should drink beverages with 15g carbohydrates. Healthcare professionals should be contacted when the individual has episodes of vomiting, diarrhea, or elevated bg that are not responsive to insulin and fluids or has moderate or large urine ketones or blood ketones 0.6 mmol/L "Record food intake, physical activity, and blood glucose results in a logbook 5 days a week for 6 weeks" is an example of a: A. assessment B. learning objective C. behavioral objective D. goal - ANSWER-C. behavioral objective SMART goal is a behavior objective or planned change. A learning objective relates to the completion of a teaching session, although learning objectives are also measurable. A goal is a big-picture directional guide, the focal point for and the end results of meeting the learning and behavioral objectives. Specific, measurable, achievable, realistic, and time-bound (SMART) are characteristics of a well developed: A. learning objective B. behavioral objective C. action plan D. evaluation - ANSWER-B. behavioral objective SMART is a simple acronym to guide educators in assessing the completeness of their behavioral objectives. A behavioral objective is a planned change in behavior that is expected to result in improved health or quality of life. TW is a 65 year-old man with newly diagnosed T2DM and low literacy skills. Which of the following strategies would be most appropriate to implement? A. Use the same teaching approach as for all other individuals with diabetes B. State major learning points C. Use audiovisual teaching aides to cover all major points D. Include only TW in the educational session to avoid distraction by family members/support persons - ANSWER-C. Use audiovisual teaching aides to cover all major points Methods of instruction that focus on non-print media are more effective for individuals with low literacy skills. Which meal planning approach would best suit a 16 year-old with T1DM and normal body weight for height? A. 1800 calorie meal pattern B. Carbohydrate counting C. 1300 calorie meal pattern D. MyPyramid - ANSWER-B. carbohydrate counting The primary nutrition goal for individuals with T1DM is to establish an insulin plan that fits into their preferred eating routine and lifestyle. The Toal and type of carbohydrates in meals and snacks directly affects blood glucose levels, so this is the primary area of focus. Those individuals on a fixed insulin plan should strive for consistency in carbohydrate intake, while those on a flexible insulin plan or insulin pump should adjust their insulin and food based on their insulin to carb ratio. Which of the following teaching strategies/formats best provides opportunity for on-demand, self-directed learning and problem solving? A. Discussion B. Print materials C. Role-playing D. Computers - ANSWER-D. computers Appropriately designed computer programs are well suited for on-demand, self-directed learning. Discussions with patients are useful, but may not be as convenient as computer resources. Print resources are useful to convey information, but tend to be very linear in their presentation. Role-playing is also useful to reinforce problem-solving strategies, but may not be convenient for patients with busy schedules. After 2 previous cancellations, a 67 year-old man with diabetes presents for bg monitoring education. He states several times that he's only at the appointment to satisfy his doctor; however, he is fairly attentive and engaged until the blood glucose monitor is removed from the package. At this point, he begins to fidget and appears agitated. Based on this information, what would be the educator's best assessment of this man's behavior? A. Hypoglycemia B. Hyperglycemia C. Needle panic D. Short attention span - ANSWER-C. Needle panic Needle anxiety occurs in almost everyone to varying degrees. If severe or persistent and left unresolved, diabetes control can suffer because of missed injections, inadequate testing, and avoidance of healthcare follow-up visits. A skilled diabetes educator will learn to match and individualize the presentation of the BG monitoring so that the fears of the person with diabetes may be alleviated. Which teaching method is particularly effective in a group education setting? A. Lecture B. Use of computer programs C. Distribution of print materials D. Role-playing - ANSWER-D. Role-playing Role-playing is an active form of learning that facilitates the sharing of information and therefore works well in a group setting. A 19 year-old patient complains of unexplained weight loss and extreme hunger over the past month. Which of the following is the MOST useful information to confirm diagnosis of diabetes? A. Reports of polyuria B. An A1C of 5.1-6.4% C. Fasting plasma glucose 100-125 mg/dL D. Random plasma glucose 200 mg/dL with polyuria - ANSWER-D. Random plasma glucose 200 mg/dL with polyuria According to the ADA's 2015 Clinical Practice Recommendations: Diagnosis and Classification of DM, the criteria for diagnosis of diabetes are as follows: Fasting plasma glucose 126 mg/dL OR Symptoms of hyperglycemia and a casual plasma glucose 200 mg/dL OR 2-hour plasma glucose 200 mg/dL during a 75g oral GTT. Polyuria is a symptom of hyperglycemia, but cannot be used as diagnostic criteria, A1C 5.1-6.4% would be prediabetes, and a fasting plasma glucose of 100-125 mg/dL would indicate impaired fasting glucose. A 53 year old man whose mother and brother have T2DM presents at a health screening. He asks, "How does the doctor know if I have diabetes?" What is the MOST appropriate response to this question? A. Your doctor may use an A1C test of 6.0% or greater to diagnose diabetes B. T2DM must be diagnosed by HLA sub typing C. Your doctor may use 2 fasting bg values over 126 mg/dL D. T1DM can be diagnosed only if you are admitted with ketoacidosis - ANSWER-C. Your doctor may use 2 fasting bg values over 126 mg/dL Diabetes can be diagnosed by acute symptoms plus casual plasma glucose 200 mg/dL or by OGTT testing (2 hr 200 mg/dL). The HLA genotype is strongly associated with the occurrence of T1DM but again is not diagnostic. Although some individuals are diagnosed with T1DM when they develop DKA, it is not a criterion for diagnosis. In a post absorptive state (4 to 15.9 hours after food consumption) A. plasma insulin levels decrease and glucagon levels begin to rise B. insulin inhibits breakdown of glycogen and triglyceride reservoirs C. counter-regulatory hormone secretion is stimulated D. excess glucose is stored in hepatic, muscle, adipose, and other tissue reservoirs - ANSWER-A. plasma insulin levels decrease and glucagon levels begin to rise The focus of this question is normal fuel homeostasis, which occurs in 5 phases. Phase II of fuel homeostasis, is the post absorptive state. During this phase, blood glucose originates from glycogen breakdown and hepatic gluconeogenesis. Plasma insulin levels decrease and glucagon levels begin to rise. Energy storage ends and energy production begins. Carbohydrate and lipid stores are mobilized. Hepatic glycogen breakdown provides maintenance of plasma glucose and ensures an adequate supply of glucose for the brain and other tissues. Adipocyte triglyceride begins to breakdown and free fatty acids are released into circulation and used by the liver and skeletal muscle as a primary energy sources and as a substrate for gluconeogenesis. The brain continues to use glucose, provided mainly by gluconeogenesis, because of its inability to use free fatty acids as fuel. Insulin inhibits breakdown of glycogen and triglyceride reservoirs during Phase I; counter-regulatory hormone secretion is stimulated during Phase IV; and excess glucose is stored in hepatic, muscle, adipose, and other tissue reservoirs in Phase I. LT comes to you for counseling. Her bg levels are poorly controlled, she has stopped monitoring her bg levels, and she reports sleep disturbances and difficulty concentrating. You should first: A. screen her for depression B. encourage her to enroll in a diabetes self-mgmt program C. reinforce the importance of self-monitoring bg D. work with her to set realistic self-care goals - ANSWER-A. screen her for depression LT displays several common symptoms of depression including lack of interest, sleep disturbances, and difficulty concentrating. Mental health issues such as depression may interfere with diabetes self-mgmt and diabetes control and therefore should be addressed first. Which of the following islet cell antibodies is the best predictor of future T1DM? A. Heat shock protein 65 B. Islet antigen A2 and A2 beta C. Glutamic acid decarboxylase D. Insulin autoantibodies - ANSWER-C. Glutamic acid decarboxylase Early T1Dm is first identified by the appearance of active autoimmunity direct against pancreatic beta cells and their products. Glutamic acid decarboxylase appears to be the best immunologic predictor for the future development of T1DM. These islet cell antibodies may play a permissive or pathologic role in the causation of T1DM, but are not the best predictor. An overweight 52 year-old man presents complaining of polyuria, polydipsia, and fatigue. His fasting blood glucose is 326 mg/dL and his urine is negative for ketones. Which fo the following best describes the clinical presentation of this patient? A. Impaired fasting glucose B. T1DM C. T2DM D. Impaired glucose tolerance - ANSWER-C. T2DM Although many patients are diagnosed with T2DM based on 2 fasting plasma glucose values above 126 mg/dL, patients with hyperglycemic symptoms may also be diagnosed with a random plasma glucose value above 200 mg/dL. Impaired fasting glucose is defined as values between 100 and 125 mg/dL, whereas impaired glucose tolerance is defined as a 2 hour postprandial plasma glucose above 140 mg/dL but less than 200 mg/dL. The age of the patient and absence of ketones with this degree of elevation are not consistent with T1DM. Evaluation of patient satisfaction with a DSME program is an example of which of the following outcomes? A. Process B. Long-term C. Immediate D. Intermediate - ANSWER-A. Process Process outcomes, which focus on program value, include program reach, participation examination rates, and in this case patient satisfaction. Long-term outcomes include improved health states; intermediate outcomes refer to behavior change; and immediate outcomes refer to knowledge. A woman at 27 weeks' gestation with previous normal plasma glucose levels undergoes a 100-g oral glucose tolerance test with results of 92 mg/dL fasting, 196 mg/dL at 1 hour, 171 mg/dL at 2 hours and 152 mg/dL at 3 hours. Which of the following diagnoses best describes the results of the test? A. Normal oral glucose tolerance test (OGTT) B. Inconclusive results C. Gestational diabetes D. T1DM - ANSWER-C. Gestational diabetes A normal oral glucose tolerance test would be characterized by a 1 hour peak less than 180 mg/dL and a return to less than 140 mg/dL after 3 hours. This test demonstrated consistently elevated bg levels throughout the evaluation period. This patient does not have T1DM as evidenced by her ability to maintain a normal fasting bg level. A 14 year-old girl with T1DM presents accompanied by her mother. The girl sits quietly while her mother expresses concerns about her daughter's rising A1C. She adds that her daughter is tired all the time. "Instead of talking with her friends on the telephone, she just sleeps on the couch after school since not being selected for the school cheerleading squad 2 months ago." Which of the following best supports the diagnosis of adjustments disorder with depressed mood in this patient? A. Unintentional changes in weight or appetite B. Continuation of symptoms for more than 2 months C. Early morning awakening for at least 1 week D. Presence of manic symptoms (excessive euphoria) - ANSWER-B. Continuation of symptoms for more than 2 months Adjustment disorder with depressed mood is defined by the American Psychiatric Association as the development of depressive symptoms (eg sleeping after school, withdrawing from friends) within a 3 months period time following a stressor (eg not making cheer squad). With this disorder, depressive symptoms cause impairment in social, occupational, or other areas of functioning OR are in excess of what would be expected from exposure to the stressor. Symptoms are expected to remit within 6 months of the time of onset. A traveling salesman with T2DM for many years remains poorly controlled on 3 oral agents. He understands that high blood glucose is bad for him, but states that he does not want to start insulin. Which of the following is the MOST appropriate response to his proclamation? A. Do you think that you will lose your job if you start insulin? B. Are you afraid of giving yourself injections? C. What is it that concerns you most about starting insulin? D. Have you ever given yourself an injection with a syringe? - ANSWER-C. What is it that concerns you most about starting insulin? The educator should seek first to understand patient concerns from the patient himself rather than imposing predetermined values. What should be the caregiver's role in diabetes management of a 14 year-old with T1DM? A. Drawing up insulin dose B. Providing physical and mental support C. Planning foods to be consumed at each meal/snack D. Perform blood glucose checks - ANSWER-B. Providing physical and mental support The question focuses on assessment of diabetes self-care considering age-related traits of youth and delegation of diabetes care responsibilities. Youth ages 12-15 are increasingly independent. The caregiver's responsibility is to continue delegation of diabetes self-mgmt tasks and to provide physical and mental support as needed. How often should individuals with diabetes have a dental checkup? A. Every 3 months B. Every 6 months C. Every 6 months and more often if periodontal disease is present D. Once a year - ANSWER-C. Every 6 months and more often if periodontal disease is present You are seeing AK for counseling. She has a 10-year history of T1DM and a 1% increase in her A1C since her last medical visit. She tells you that she became divorced 2 months ago and has been having difficulty functioning at work and following her self-management plan for several weeks now. Which of the following is the MOST likely diagnosis to accompany these symptoms? A. Major depressive disorder B. Adjustment disorder with depressed mood C. Dysthymic disorder D. Adjustment disorder with anxiety - ANSWER-B. Adjustment disorder with depressed mood This patient reports an identifiable cause of her depression. Major depressive disorder and dysthymic disorder are not associated with an identifiable cause of the psychological response. This patient's adjustment disorder is characterized by tearfulness, which is consistent with depression, rather than nervousness, worry, or jitteriness expected with anxiety. An individual with intense fear of becoming fat, even though he or she may be at normal weight or underweight, is characteristically of A. anorexia nervosa B. bulimia nervosa C. binge-eating disorder D. purging - ANSWER-A. anorexia nervosa Intense fear of gaining weight or becoming fat, even though underweight is one fo the criteria for anorexia nervosa. Bulimia is characertized by repeated episodes of binge-eating and involving a loss of control and compensatory behaviors to prevent weight gain, eg, self-induced vomiting, fasting. Binge-eating disorder is characterized by repeated episodes of binge-eating as in bulimia, but in the absence of compensatory behaviors to prevent weight gain. Purging is a compensatory behavior often used to prevent weight gain. A woman taking glipizide before breakfast and supper feels shaky, weak, and sweaty after walking for 30 minutes before lunch. She does not check her bg routinely. She returns to the office, eats, and feels better after lunch. Which of the following is the MOST likely explanation of the symptoms? A. Hyperglycemia B. Hypoglycemia C. Overexertion D. Ketoacidosis - ANSWER-B. Hypoglycemia The combination of exercise, delayed eating, and a sulfonylurea increases the likelihood of hypoglycemia. A patient on metformin mono therapy complains to his pharmacist about the high cost of the bg test strips and asks why he needs to test his bg at home. Which of the following is the most appropriate response? A. All patients with diabetes should test their bg at least twice daily. B. Self-monitored bg is only useful for patients on insulin C. Self-monitored bg lets patients see how food affects their glycemic control D. Urine testing is more appropriate for patients on oral agents for diabetes - ANSWER-C. Self-monitored bg lets patients see how food affects their glycemic control Patients who reach their glycemic control on oral drug therapy only need to test their bg a few times each week. Patients who are poorly controlled, changing therapy, or on insulin should test their bg levels at least 1 or 2 times daily. Which of the following is the MOST frequent cause of inaccurate results from self monitoring of blood glucose? A. Operator technique B. Improper calibration C. Expired or defective test strips D. Inadequate blood sample - ANSWER-A. Operator technique Inaccurate results from self-monitoring of bg can come from a variety of sources; however, the most common is operator technique. Many newer bg meters are self-calibrating and do not start the test until an adequate sample is applied. Using expired or defective test strips may also cause inaccurate results; however, newer testing methodologies make this error less significant. MP was recently diagnosed with T2DM. Her doctor placed her on thiazolidinediones (TZDs) 1 month ago. MP is discouraged because, despite taking the TZDs as prescribed, her glucose levels remain elevated. Which of the following choices would be the best first step for a diabetes educator to do? A. Review her diet and exercise programs B. Remind her that it can take as long as 8 to 12 weeks of TZD use to see an effect C. Refer her back to her doctor for an addition of another oral agent D. Reduce the calories in her meal plan - ANSWER-B. Remind her that it can take as long as 8 to 12 weeks of TZD use to see an effect Persons taking a TZD should be told that the maximum glucose-lowering effect of these medications may not be apparent until 8 to 12 weeks of use. Since the patient only has been on the TZD for a month, it is a logical first step to wait to see if the medications have an effect on glucose levels before looking to make changes in diet and exercise or referring to the doctor for additional medication. You are counseling NZ, who is on a basal/bolus insulin regimen. When evaluating her blood glucose records, which of the following would be MOST helpful to evaluate her basal insulin doses? A. 1-hour postprandial glucose B. Fasting and premeal glucose C. 2-hour postprandial glucose D. 4-hour postprandial glucose - ANSWER-B. Fasting and premeal glucose The basal insulin dose controls bg levels in between meals when the individual is not eating. Therefore premeal glucose and fasting glucose data are the best indicators of the appropriateness of the basal insulin dose. Postprandial glucose levels best reflect the effect of the bolus regimen. A guitar player with T1DM does not test his bg frequently because sore fingers interfere with playing. Which of the following solutions is the best recommendation for this patient? A. Use a glucose sensor instead of capillary testing B. Avoid testing 12 hours before a concert C. Use urine test strips instead of a bg meter D. Use a bg meter with alternate test site testing capabilities - ANSWER-D. Use a bg meter with alternate test site testing capabilities Although a glucose sensor may be useful to augment capillary testing, the sensors must be calibrated each day with several finger sticks. Because stress can affect bg, this patient may need to test more often before a concert to appropriately adjust his insulin dose. A patient's blood pressure reading in the office is 147/88 mm HG. What is the most appropriate plan of action? A. Blood pressure is in the acceptable range, so no action is necessary B. Recheck blood pressure at 3-month follow-up appointment C. Confirm blood pressure on a separate day in the office or through home monitoring D. Initiate drug therapy - ANSWER-C. Confirm blood pressure on a separate day in the office or through home monitoring According to the Standards of Medical Care in Diabetes 2014, if systolic bg is 140 mm Hg or diastolic 80 mm Hg, blood pressure should be confirmed on a separate day. Repeat readings over 140/80 mm Hg confirms as diagnosis of HTN. A 40 year-old man with T2DM for 3 years presents on his lunch break for diabetes education. Which of the following is MOST important for the diabetes educator to review with the patient at this initial visit? A. Economic impact of diabetes on the healthcare system B. Patient's family history of diabetes C. Patient expectations and personal education goals D. Pathophysiology of diabetes and its complications - ANSWER-C. Patient expectations and personal education goals Assessment is the first step in the process of providing diabetes education. By understanding what the interests, needs, and problems of the person with diabetes are, the educator is more likely to provide appropriate and useful information that will assist the individual to meet desired outcomes. A 12 year-old girl, accompanied by her mother, presents to the registered dietitian for meal planning. Which of the following is the most important consideration when developing her meal plan? A. Use the term "diet" instead of "meal plan" to emphasize weight loss urgency B. Schedule a separate session with the mother to review grocery selection C. Adjust the meal plan to meet energy requirements for growth and activity D. Suggest a plan that avoids intake of nutrient-dense foods - ANSWER-C. Adjust the meal plan to meet energy requirements for growth and activity A 47 year-old woman with T2DM returns for a 3 month f/u evaluation. She reports improved bg and a 10 lb weight loss since her last visit. She states, "I feel great!" She continues to eat 3 meals daily and her exercise routine is unchanged. Which of the following additional questions would be MOST helpful in evaluating the cause of her weight loss? A. Did you stop taking your glipizide? B. Did you start taking a multivitamin? C. How much television did you watch each day? D. Have you recently made any changes in your beverage choices? - ANSWER-D. Have you recently made any changes in your beverage choices? This question tests assessment skills. Key information noted includes improved bg, significant wt loss, continuation of 3 meals/day, and no change to exercise. Beverage choices could significantly impact bg and weight via reduced carbohydrates and calorie intake. Which of the following tools is most useful to assess lifestyle activity? A. Blood glucose meter B. Pedometer C. Blood pressure cuff D. Holter monitor - ANSWER-B. Pedometer A pedometer records steps/day, a lifestyle activity. An overweight 11 year-old Hispanic boy with T2DM presents to the registered dietitian for meal planning. His mother and father accompany him. Both are obese and have type 2 diabetes. Which of the following is the MOST appropriate advice for this patient? A. Avoid eating fast food B. Eliminate high-fat, calorie dense foods C. Get involved in a soccer, basketball, or baseball league D. Aim for at least 60 minutes of moderate intensity physical activity daily - ANSWER-D. Aim for at least 60 minutes of moderate intensity physical activity daily The Dietary Guidelines for Americans recommend at least 60 minutes of moderate intensity physical activity daily for children and adolescents. When addressing lifestyle intervention in children and adolescents, the focus must be one of substitution and reduction rather than elimination. Instead of recommending avoidance of fast-food, the suggestion might be to learn to make healthier choices; reduce consumption of fatty, calorie-dense foods; competitive sports may not be appropriate. The Nutrition Facts panel on a food package revels 16g of total carbohydrates per serving. How many carbohydrate choices (servings) do 2 servings of the food item contain? A. 1/2 B. 1 C. 2 D. 3 - ANSWER-C. 2 You wish to conduct an evaluation of your diabetes self-management education program. Your major outcomes of interest are program sustainability and its long-term effects on individual outcomes. Which of the following tools/frameworks would best meet your needs? A. Continuous Quality Improvement (CQI) B. Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) C. Penetration, Implementation, Participation, and Effectiveness (PIPE) D. National Diabetes Education Outcomes System (NDEOS) - ANSWER-B. Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) RE-AIM is the one evaluation tool that includes the dimensions of effectiveness (in terms of the primary outcome) and maintenance (or program sustainability). CQI is incorrect because it is a management approach that attempts to correct program shortcomings. The PIPE model provides a global estimate of impact and influence of the program. This evaluation framework does address effectiveness but most sustainability. The NDEOS is incorrect because it is a system that gathers, tracks, and aggregates outcomes measures unique to diabetes education and supports its integration into care. Olive oil and canola oil are sources of A. monounsaturated fat B. polyunsaturated fat C. saturated fat D. trans fat - ANSWER-A. monounsaturated fat Other sources of monounsaturated fats include avocados, almonds, pecans, and peanuts. When substituted for saturated fats, monounsaturated fats can decrease LDL, triglycerides without decreasing HDL. When developing a diabetes self-management program, assessment of the target population should include assessment of educational needs, ethic background, formal education level, reading ability, and A. knowledge about diabetes B. attendance at medical appointments C. social or family support D. barriers to participation in education - ANSWER-D. barriers to participation in education Assessment of the target population should not be limited to individuals who frequently attend medical appointments, but encompass all individuals with diabetes. Knowledge about diabetes or social support is not an assessment criteria. An 62 year old woman with a history of T2DM and cardiovascular disease contacts the diabetes educator for advise on exercise. Her physician advised her to begin a resistance program following a recent diagosis of osteopenia. Which of the following is the most appropriate exercise recommendation for the patient? Advise her to A. check her blood pressure and pulse frequently B. focus on aerobic exercise to strengthen her bones C. hold her breath while lifting to stimulate coronary perfusion D. complete repetitions as quickly as possible - ANSWER-A. check her blood pressure and pulse frequently Individuals with cardiovascular disease must focus particular attention on blood pressure and heart rate response during resistance training. The heart rate and bp need to remain within the limits established by an exercise stress test, and, therefore, need to be monitored throughout the training session. Starting with lighter resistance and choosing exercises that use a smaller amount of muscle mass help decrease the myocardial oxygen demand on the heart. In the absence of contraindications, all patients with diabetes should be encouraged to engage in resistance training at least twice per week. Recommended duration of resistance training is 1 to 3 sets of 8-20 repetitions. An educator is hired to develop a new diabetes education program for an inner-city, hospital based clinic. Which of the following is the MOST appropriate first step for this educator? A. Contact local drug industry representatives for education material B. Post flyers in the hospital waiting rooms announcing the education program C. Send out a memo to all hospital staff asking for referrals to the program D. Contact the hospital billing office to review patient demographic information - ANSWER-D. Contact the hospital billing office to review patient demographic information One of the first steps in the development of a new education program is to assess the target population and determine their educational needs. An obese 45 yearly patient expresses an interest in losing weight and asks for advice on exercise. Which of the following is the MOST appropriate exercise recommendation for this patient? A. Advise him that the real focus should be on meal planning, not exercise B. Encourage the patient to work up to walking 45 to 60 minutes for 5 to 7 days weekly C. Advise the patient that swimming is the best method to induce weight loss D. Recommend high-intensity exercise, such as running, for maximum weight loss - ANSWER-B. Encourage the patient to work up to walking 45 to 60 minutes for 5 to 7 days weekly The physical activity guideline for obese individuals is 45 to 60 minus of moderate intensity activity 5 to 7 days per week. Which of the following describes the normal hormonal response and acute metabolic effects of physical activity? A. Insulin levels increase to reduce free fatty acid production B. Glucagon rises and hepatic glucose production is increased C. Both epinephrine and norepinephrine are reduced, and free fatty acids production is inhibited D. Growth hormone and cortisol are decreased, and insulin-stimulated glucose uptake is enhanced - ANSWER-B. Glucagon rises and hepatic glucose production is increased Immediately following exercise, the body attempts to make more energy available. Increasing insulin secretion would be counterproductive to making more glucose available. Epinephrine and growth hormone levels increase immediately after exercise. Which of the following should NOT be considered when assessing the physical capabilities and limitations of an individual with diabetes? A. Hearing B. Visual acuity C. Mobility D. Literacy - ANSWER-D. Literacy Literacy is a factor that influences learning, while the others are physical factors. A patient with T1DM notes that her bg prior to 1 hour step aerobics class is 278 mg/dL. She has not taken any insulin since her last mealtime bolus. What is the most appropriate plan of action? A. Consume a 15g carb snack to prevent hypoglycemia during the class B. Continue with the class because the exercise will lower the bg C. Check for urine ketones and continue only if ketones are negative D. Skip the class - ANSWER-C. Check for urine ketones and continue only if ketones are negative Worsening of hyperglycemia and ketosis can occur in the presence of absolute insulin deficiency. As a rule of thumb, ketone levels should be checked with bg levels above 250 mg/dL. If ketones are present, then the elevated bg level is a result of insulin deficiency and corrective action should be taken immediately. In the absence of ketones, this higher value should not pose a medical threat, however, some people experience bad headaches, blurry vision, or lack of energy with higher levels, and may avoid exercise. A new billing clerk asks the diabetes educator for clarification about a Medicare patient. After an initial assessment, the educator indicates that the patient should be scheduled for an individual session instead of the usual group education class. According to Medicare regulations, which of the following is an acceptable reason to schedule this patient for individual diabetes education? The patient: A. prefers one-on-one education B. is blind and reads Braille C. takes insulin for diabetes D. wears a hearing aid in one ear - ANSWER-B. is blind and reads Braille Although Medicare regulations dictate that most patients receive their education in a group setting in order to qualify for reimbursement, the following are exceptions: No group session available within 2 months of the date education is ordered; the individual has severe vision, language, or hearing limitations or other conditions identified by the treating healthcare provider. Acarbose is added to glipizide to treat a patient with T2DM. Which of the following is the MOST appropriate recommendation to treat hypoglycemia in this patient? A. Orange juice B. low-fat or skim milk C. Hard candy D. Regular soda - ANSWER-B. low-fat or skim milk Acarbose inhibits the enzyme alpha-glucosidase, which is responsible for breaking down complex carbohydrates in the proximal portion of the small intestine. Lactose is not affected by acarbose, so milk is absorbed at its normal rate. Fructose and sucrose found in juice, hard candy, and regular soda would all experience delayed metabolism in the presence of acarbose. When collecting outcome data, a diabetes patient education program must ensure that personal health information is always stored, analyzed, and reported in a manner that protects the identification of individuals as dictated by which of the following? A. Agency for Healthcare Research and Quality (AHRQ) B. American Diabetes Association (ADA) C. Health Insurance Portability and Accountability Act (HIPPA) D. Centers for Medicare and Medicaid Services (CMS) - ANSWER-C. Health Insurance Portability and Accountability Act (HIPPA) A physician is considering adding metformin to a patient's regimen, but is unsure of how it improves glycemic control. Which of the following is the most appropriate description of the primary mechanism of action for metformin? A. Increased insulin sensitivity B. Inhibition of hepatic glucose release C. Delated absorption fo carbohydrates form the GI tract D. Enhanced insulin secretion from the islet cells of the pancreas - ANSWER-B. Inhibition of hepatic glucose release Thiazolidinediones improve insulin sensitivity in skeletal muscle. Alpha-glucosidase inhiibitors delay absorption of carbohydrates from the GI tract. Sulphonylureas and meglitinides enhance insulin secretion from the islet cells of the pancreas. A postal worker who walks a route every day is newly diagnosed with T2DM. Which of the following is MOST likely to cause hypoglycemic symptoms while he is delivering mail? A. Meglitinides B. Thiazolidinediones C. Biguanides D. DPP-IV inhibitors - ANSWER-A. Meglitinides Although less likely than longer-acting insulin secretagogues, meglitinides are more likely to cause hypoglycemia than other oral agents. TZDs, biguanides, and DPP-IV inhibitors are not likely to cause hypoglycemia and would be better choices for this patient. Quality improvement in a diabetes education program A. is a systemic review of process and outcome data to measure the effectiveness of the education and support and to correct program shortcomings B. is conducted by management staff only C. focuses exclusively on patient outcomes D. is not a process recommended in the National Standards for Diabetes Self-Management Education and Support - ANSWER-A. is a systemic review of process and outcome data to measure the effectiveness of the education and support and to correct program shortcomings A QI process is a systemic review of process and outcome data to measure the effectiveness of the education and support and looks for ways to improve any identified gaps in service or service quality. The process includes staff from a variety of levels and department that are relevant to the specific QI project. A QI project can select a number of groups as the customer, including patients with diabetes, third-party mayors, regulatory agencies, etc. Implementing a QI process in a DSME program is recommended in Standard 10 of the National Standards. A 32 year-old woman with polycystic ovarian syndrome and newly diagnosed T2DM begins pioglitazone plus metformin. Which of the following should be included in her initial medication counseling? A. Use of contraception B. Hypoglycemia risk C. Risk for diabetic ketoacidosis D. Potential for disulfiram-like reaction - ANSWER-A. Use of contraception Resolution of hyperglycemia with metformin in patents with PCOS often restores menstruation and ability to become pregnant. TZDs and biguanides are not associated with hypoglycemia. Disulfiram-like reactions are associated with first generation sulfonylureas, bot not with the patient's regimen. Marked dawn phenomenon or frequent, unpredictable hypoglycemia in a patient on multiple daily injections warrants considerations of A. carbohydrate counting B. increased basal dose C. more frequent bg monitoring D. insulin pump therapy - ANSWER-D. insulin pump therapy With insulin pump therapy the dawn phenomenon effects are easier to manage because a variable basal rate can be set to accommodate fluctuations in insulin requirements overnight. Basal rates can be lowered during periods of low physiological requirements, which can minimize nocturnal or daytime hypoglycemia. Serum glucose of 734 mg/dL, loss of 13% body weight, lethargy, mild confusion, and negative ketones are indicative of A. hyperosmolar hyperglycemia nonketonic syndrome (HHNS) B. diabetic ketoacidosis (DKA) C. insufficient insulin in T1DM D. steptococcus infection - ANSWER-A. hyperosmolar hyperglycemia nonketonic syndrome (HHNS) A bg greater than 600 mg/dL, without significant ketones, characterizes hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Extreme dehydration, more than profound insulin deficiency, is the primary precipitating factor. HHNS develops slowly and does not cause the GI pain and Kussmaul respirations associated with DKA. A middle school principal is concerned about the apparent rise in the number of obese children at her school. She has heard the reports in the media lately about the increasing incidence of T2DM in overweight children, so she contacts the local diabetes educator for recommendations. Which of the following is the MOST appropriate recommendation to prevent diabetes in the children? A. Organize a school assembly with presentations by a dialysis nurse and patient B. Encourage daily physical education and modify cafeteria food choices C. Write a letter to the parents of the children linking obesity and diabetes D. Offer a plasma glucose screening of parents at the school - ANSWER-B. Encourage daily physical education and modify cafeteria food choices This question addresses lifestyle interventions to help prevent T2DM in overweight children. Schools are organizations that are especially pertinent to diabetes prevention. Successful school-based interventions have focused on multiple levels of intervention including environmental change (such as cafeteria food choices), encouraging daily physical activity, classroom instruction by teachers, and family involvement. The absence of warning signs of impending neuroglycopenia is known as A. servere hypoglycemia B. hypoglycemia unawareness C. multifocal neuropathy D. amyotrophy - ANSWER-B. hypoglycemia unawareness In addition to increased serum ketones, diabetic ketoacidosis is characterized by: A. dehydration B. decreased blood urea nitrogen and serum creatinine C. decreased serum osmolality D. increased arterial pH - ANSWER-A. dehydration BUN and serum creatinine would be elevated secondary to the dehydration. Serum osmolality is increased and the arterial pH is reduced as the result of acidosis. Which of the following oral agents is contraindicated in patients with New York Heart Association Class III or IV heart failure? A. Meglitinides B. Thiazolidinediones C. Alpha-glucosidase inhibitors D. Sulfonylureas - ANSWER-B. Thiazolidinediones Thiazolidinediones or glitazones increase plasma volume, which may be particularly dangerous for patients with New York Heart Association Class III or IV heart failure. Meglitinides, alpha-glucosidase inhibitors, and sulfonylureas are all safe to use in patients with heart failure. Which of the following is the MOST appropriate initial treatment goal for both diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome? A. Adequate insulin to restore glucose metabolism B. Correction of electrolytes C. Rehydration D. Glucose replacement - ANSWER-C. Rehydration Adequate rehydration of patients suffering from diabetic ketoacidosis of hyperglycemic hyperosmolar syndrome is an essential first step to restore appropriate glucose levels. Correction of electrolyte deficits usually follows rehydration and is accompanied by balanced administration of insulin and glucose replacement. Which is the MOST appropriate treatment for mild to moderate hypoglycemia? A. 12-oz can regular soda B. 4 oz juice C. 4 oz juice with 1 tablespoon sugar D. 1/2 peanut butter sandwich - ANSWER-B. 4 oz juice Which of the following best describes a patient with serum glucose of 359 mg/dL, arterial pH of 7.1, Kussmaul respirations, and electrolyte imbalance? A. New T2DM B. Hyperosmolar hyperglycemia nonketotic syndrome (HHNS) C. Renal disease D. Diabetic ketoacidosis (DKA) - ANSWER-D. Diabetic ketoacidosis (DKA) Newly dx T2DM may have high glucose levels, but without changes in acid-base status. This presentation is also not consistent with blood glucose levels higher than 400 mg/dL. Finally, elevated bg levels are not characteristic of patients with renal disease. A patient with T1DM telephones the diabetes educator stating that she has the flu. Her self-monitored bg values are ranging 250-280 mg/dL, which is much higher than usual. She reports vomiting once, but now tolerates fluids well. Her husband just returned from the store with new urine ketone test strips. Which of the following is the MOST appropriate advise for this patient? A. Consume at least 8 oz of fluid per hour B. Make an urgent appoint with the endocrinologist C. Arrange for transportation to the local emergency department D. Contact primary care provider if urine is positive for small ketones - ANSWER-A. Consume at least 8 oz of fluid per hour This question is assessing knowledge of appropriate sick-day mgmt for use in prevention of DKA. Early recognition of hyperglycemia and appropriate treatment during illness are essential to prevent DKA. To maintain hydration during illness, 8 oz of fluid per hour is required. Every third hour, the 8 oz of fluid should be a sodium rich fluid such as bouillon. Including family members, friends, or significant others in the diabetes education session can help assess A. motivation B. long-term outcomes C. community support D. social support - ANSWER-D. social support An individual with diabetes is training for a half marathon. During a training run lasting about 2 hours, what carbohydrate replacement, if any, is needed? A. Carbohydrate replacement is not likely needed B. 15 g of carbohydrate each hour C. 30 to 50 g carbohydrate each hour D. 75 g of carbohydrate each hour - ANSWER-C. 30 to 50 g carbohydrate each hour To prevent hypoglycemia, the body generally requires 30-50 grams of carbohydrate replacement each hour for high-intensity physical activity with duration 60 minutes. A 15 g carb replacement each hour would be recommended for moderate-intensity exercise of 30-60 minutes. A young nurse on a medical floor calls the diabetes educator to clarify why her patient with diabetic ketoacidosis is receiving potassium and insulin. Which of the following is the best rationale to provide the nurse? A. Suggest the low potassium levels usually resolve without supplementation B. Advise her that potassium should not be co-administered with insulin C. Insulin causes cells to take potassium from the plasma D. Potassium is an essential cofactor for glucose metabolism - ANSWER-C. Insulin causes cells to take potassium from the plasma Insulin administration to patients with DKA drives potassium into cells from the plasma. To avoid hypokalemia, potassium supplementation may be given with insulin. Potassium is important for many cellular functions, including insulin release from pancreatic islet cells; however, potassium is not considered an essential cofactor for glucose metabolism.