CDCES practice questions

PR has type 2 diabetes and enjoys an occasional drink. What is considered a moderate alcohol intake for a woman? A. one 12 oz beer B. two 12 oz beer C. one 8 oz glass wine. D. two small shots of spirits.

✅ A. one 12 oz beer Explanation: According to the Dietary Guidelines for Americans and the American Diabetes Association (ADA): Moderate alcohol intake for women is defined as no more than 1 standard drink per day. A standard drink is typically: 12 oz beer (about 5% alcohol) 5 oz wine (about 12% alcohol) 1.5 oz distilled spirits (about 40% alcohol) ❌ Why the other options are incorrect: B. Two 12 oz beers = exceeds moderate intake for women. C. One 8 oz glass of wine is more than a standard drink (5 oz is standard). D. Two small shots of spirits = 3 oz total, which exceeds the 1.5 oz moderate guideline.

LS is interested in eating healthier and wants to decrease the intake of saturated fat. which of the following foods contains saturated fat? A. almonds B. avocado C. sour cream D. olives.

✅ C. sour cream Explanation: Saturated fat is primarily found in animal products and some tropical oils. A. Almonds - Contain mostly unsaturated fats (heart-healthy fats). B. Avocado - Rich in monounsaturated fats, not saturated. C. Sour cream - Made from animal dairy, and contains a notable amount of saturated fat. D. Olives - Like avocados, they are high in monounsaturated fats. Tip for LS: To reduce saturated fat, suggest limiting: Fatty cuts of meat, butter, full-fat dairy (like sour cream, cheese), Fried foods and baked goods made with shortening or palm oil And focus on: Nuts, seeds, olive oil, avocados, and fatty fish (for omega-3s)

RJ is 52 with type 1 diabetes and a minor stroke last year. RJ takes an ACE Inhibitor, insulin, and a statin. According to ADA Standards of Care 2021, what is the blood pressure target for RJ? A. 120/70. B. 130/80. C. 140/90. D. 135/85.

B. 130/80. According to the American Diabetes Association (ADA) Standards of Care 2021, the blood pressure target for people with diabetes and high cardiovascular risk — such as RJ, who has a history of stroke — is: <130/80 mmHg, if it can be safely achieved without undue treatment burden.

AR is a 39-year-old on an insulin pump and CGM. AR's basal rates are: 1.7 units from 10 pm to 6 am and 1.6 units from 6 am to 10 pm. AR's insulin to carb ratio is 1:15 and the correction is 1:50 with a blood sugar target of 100-120. When looking at AR's report, they are bolusing for meals at 7 am, 12 pm, and 7 pm. AR is experiencing blood sugars of 60 -70 around 10 am and 3 pm every day. Based on this data, what is the best recommendation? A. Adjust the 6 am to 10 pm basal rate. B. Encourage a 15 gm snack at 9:30 am and 2:30 pm. C. Make adjustments to the insulin to carb ratio. D. Recalculate the correction bolus ratio.

A. Adjust the 6 am to 10 pm basal rate. Rationale: AR is consistently having low blood sugars (60-70 mg/dL) at 10 am and 3 pm, both occurring several hours after meals (7 am and 12 pm). This pattern suggests the basal insulin during the day may be too high, causing hypoglycemia between meals when there's no active food bolus insulin remaining. The basal rate from 6 am to 10 pm is 1.6 units/hr, and it's active during the times the lows occur. ❌ Why not the others? B. Encourage a snack: While this might treat the symptom, it doesn't fix the underlying issue—basal insulin is likely too high. C. Adjust insulin-to-carb ratio: There's no indication of post-meal highs, which would suggest over-bolusing. The issue is not meal-related. D. Recalculate correction factor: There's no mention of correction boluses being used or resulting in lows. The lows are occurring between meals, not after corrections.

Based on the nutrition recommendations outlined by the American Diabetes Association, which of the following is an accurate statement for people with diabetes? A. Avoid sugar sweetened beverages B. consumed less than 30% of calories from fat C. incorporate at least 3 servings of fiber daily. D. limit coffee to no more than 2 cups a day.

A. Avoid sugar sweetened beverages The American Diabetes Association (ADA) strongly recommends that people with diabetes avoid sugar-sweetened beverages (SSBs) such as soda, sweet tea, energy drinks, and sweetened coffee drinks. SSBs cause rapid spikes in blood glucose with no nutritional benefit, increasing the risk of hyperglycemia and weight gain. ❌ Why the other options are incorrect or outdated: B. Consume less than 30% of calories from fat ❌🔻 This guideline is outdated. The ADA no longer recommends a specific percentage of calories from fat but instead emphasizes the quality of fats (favoring unsaturated over saturated/trans fats). C. Incorporate at least 3 servings of fiber daily ❌🔻 The ADA recommends 14 grams of fiber per 1,000 calories — this equates to about 25-30 grams/day, not just 3 servings (which is vague and may not meet the target). D. Limit coffee to no more than 2 cups a day ❌🔻 There is no ADA recommendation that limits coffee to 2 cups per day. Moderate coffee consumption is generally considered safe, and some studies even suggest it may have protective effects.

What best describes the difference between a Certified Diabetes Care and Education Specialist (CDCES) and a person Board Certified in Advanced Diabetes Management (BC-ADM)? A. BC-ADMs are responsible for increased complexity in decision making. B. A bachelor's degree or higher is required to obtain a CDCES. C. The main difference is that BC-ADM's prescribe medications based on diagnosis. D. With an advanced degree, BC-ADM's are qualified to set up an independent practice.

A. BC-ADMs are responsible for increased complexity in decision making. Rationale: The BC-ADM (Board Certified-Advanced Diabetes Management) credential is designed for advanced-level clinicians, such as nurse practitioners, clinical nurse specialists, pharmacists, and dietitians with advanced training. They often manage more complex cases, including adjusting medications, developing comprehensive care plans, and sometimes initiating or modifying therapy under prescriptive authority (depending on licensure and state laws). In contrast, a CDCES (Certified Diabetes Care and Education Specialist) focuses on education, support, and behavioral change strategies to help individuals with diabetes manage their condition. ❌ Why not the others? B. A bachelor's degree or higher is required to obtain a CDCES: While this is true, it doesn't describe the difference between CDCES and BC-ADM. It's a general eligibility fact, not a comparative distinction. C. The main difference is that BC-ADM's prescribe medications based on diagnosis: This is misleading. Prescriptive authority is not granted by the BC-ADM credential itself; it depends on the individual's professional license (e.g., NP, PharmD, etc.). D. With an advanced degree, BC-ADM's are qualified to set up an independent practice: This is not universally true. Independent practice depends on state scope of practice laws, not the BC-ADM certification.

RT is 33 years old and has had diabetes for the past 20 years. RT uses an insulin pump and CGM and works hard to keep A1cs less than 7%. Their most recent A1c increased to 7.9% and RT sets up an appointment with the diabetes specialist for help. After downloading the report, the specialist thinks they have discovered the reason behind the increasing A1c. Which of the following would most likely explain the A1c increase? A. Carbohydrate bolus insulin omissions. B. Basal insulin rate set too high. C. Bolus insulin given 15 minutes before meal. D. CGM sensor malfunction.

A. Carbohydrate bolus insulin omissions. Rationale: RT: - Is 33 years old, has had type 1 diabetes for 20 years - Uses an insulin pump and CGM - Has been working hard to keep A1c <7%, but it recently rose to 7.9% - Made an appointment for support, and the specialist identified a likely reason after reviewing download data Most likely explanation: Bolus insulin omissions for meals are a common cause of increasing A1c in people using pumps, especially when: - Basal insulin is still running (so fasting BG looks okay) - But post-meal glucose levels are elevated - Patient may be skipping or delaying boluses due to lifestyle demands, burnout, or underestimating carbs Why not the other options? B. Basal insulin rate set too high→ Would more likely cause hypoglycemia, not an elevated A1c C. Bolus insulin given 15 minutes before meal→ This is actually recommended timing for rapid-acting insulins. It helps prevent post-meal spikes, so it's not a problem. D. CGM sensor malfunction→ Would affect glucose visibility but not directly increase A1c, unless it led to missed insulin adjustments. It's also unlikely that a one-off CGM issue would explain a sustained A1c increase.

The health of our gut microbiome has been linked to the overall health of our body. Which of the following statements is true about our gut microbiome? A. Eating a wide variety of fiber foods increases the availability of the short chain fatty acids in the intestine. B. On average, the gut microbiome weighs about a pound. C. Taking proton pump inhibitors (PPIs) is associated with increased microbial diversity. D. Regular consumption of probiotics capsules has been shown to increase levels of prevotella.

A. Eating a wide variety of fiber foods increases the availability of the short chain fatty acids in the intestine. Eating a diverse range of fiber-rich plant foods (like legumes, whole grains, fruits, and vegetables) helps nourish gut bacteria, which in turn produce short-chain fatty acids (SCFAs) like butyrate, acetate, and propionate. These SCFAs support: Gut lining health Reduced inflammation Immune function ❌ Why the others are incorrect: B. ❌ The gut microbiome actually weighs about 2-5 pounds, not 1. C. ❌ Proton pump inhibitors (PPIs) are associated with reduced microbial diversity and increased risk of infections like Clostridioides difficile. D. ❌ While probiotics can benefit the microbiome, current research does not consistently show that capsules increase specific genera like Prevotella, especially without dietary changes.

You are working with KS, a 57-year-old with type 2 diabetes, who wants to join the water aerobics program at their local YMCA. KS has a history of hypothyroidism and has an LDL cholesterol of 98 mg/dl. KS's medications include levothyroxine and metformin XR 1000 mg BID. According to the ADA and the American College of Sports Medicine, what would be the best recommendation? A. Encourage KS to join the water aerobics program. B. Recommend that KS get an EKG before starting this new activity. C. Ask KS's provider to order a stress test. D. Make sure KS monitors blood glucose before and after exercise class.

A. Encourage KS to join the water aerobics program. According to the ADA (American Diabetes Association) and the American College of Sports Medicine (ACSM) guidelines: Most people with type 2 diabetes do not need medical clearance or stress testing before starting low- to moderate-intensity activities, like water aerobics. Regular physical activity is strongly encouraged as it improves insulin sensitivity, cardiovascular health, and overall well-being. Water aerobics is a low-impact, moderate-intensity activity, especially appropriate for older adults or those with joint issues. ❌ Why not the other options? B. Recommend EKG - Not necessary for starting moderate-intensity exercise unless the patient has active cardiac symptoms (like chest pain or shortness of breath on exertion). C. Ask for a stress test - Also not needed for starting this type of activity unless there are cardiac risk factors with symptoms. D. Monitor BG before/after exercise - This is helpful for insulin users or those at risk of hypoglycemia, but KS is on metformin only, so hypoglycemia risk is minimal.

JL is a 17-year-old with type 1 diabetes and takes insulin via syringe 4 times a day. JL lives with his uncle who has a history of intravenous drug usage. JL tells you he is worried that his uncle will use his insulin needles. Considering the empowerment model, what is the educator's best response? A. Explore possible solutions to the situation with JL. B. Empower JL to move out of his uncle's house. C. Suggest JL clean his needles with alcohol wipes before using. D. Educator mindfully volunteers to contact the uncle to evaluate the situation.

A. Explore possible solutions to the situation with JL. Rationale: It aligns with the empowerment model, which focuses on collaboration, respect, and supporting the individual's problem-solving abilities. It allows JL to participate actively in finding a safe, realistic solution that fits his circumstances. It acknowledges JL's concerns without judgment and builds trust and self-efficacy. ❌ Why the others are less appropriate: B: Telling JL to move out is unrealistic and directive—it doesn't empower him to find his own solution. C: Suggesting he clean needles implies reuse, which is unsafe and not recommended. D: Contacting the uncle without JL's consent could violate confidentiality and trust.

JL is 65 years old and has diabetes. JL tells you they had two different pneumonia vaccines in the past, but they are wondering what vaccinations they need this year. What is the BEST answer? A. Flu and Pneumonia PPSV23 [Pneumovax] B. Hepatitis B and Flu vaccine C. Pneumonia PCV13 [Prevnar] and Human Papilloma Virus (HPV) D. Zoster and Hepatitis B vaccine

A. Flu and Pneumonia PPSV23 [Pneumovax] JL is a 65-year-old adult with diabetes, and: Annual influenza vaccination is strongly recommended for all adults, especially those with chronic conditions like diabetes. The 2021 ADA standards - people with diabetes need a flu vaccine yearly and a pneumonia vaccine, PPSV23, after they turn 65 regardless of previous pneumonia vaccines history.

JR has type 2 diabetes for 28 years. He injects aspart (novolog) before meals and glargine (basaglar) at night. when you ask if he brought a log book he says "i can just tell how much aspart insulin i need." what is the best response? A. how has this strategy worked so far? B. checking your BG is important to prevent hypoglycemia C. Did you know that insulin dosing is usually based on blood sugar levels? D. sounds like you know how you feel

A. How has this strategy worked so far? Rationale: This is a nonjudgmental, open-ended question that encourages JR to reflect on the effectiveness of his current approach. It respects his experience and autonomy, which helps build trust and opens the door for collaborative problem-solving. From there, you can guide him toward evidence-based insulin dosing while aligning with his lived experience. ❌ Why the other options are less effective: B. Checking your BG is important to prevent hypoglycemia⚠️ While true, this is more of a directive and can come off as paternalistic, especially if JR feels confident in his method. It may shut down the conversation. C. Did you know that insulin dosing is usually based on blood sugar levels?❌ This sounds didactic and might feel condescending, especially to someone who's been managing diabetes for 28 years. JR likely does know this — he may just be relying on personal cues. D. Sounds like you know how you feel✅ Empathetic, but too passive. It doesn't encourage reflection or create an opportunity for education or improvement in care.

JL has had diabetes for 16 years and lost 9 pounds over the past 3 months, after meeting with the diabetes educator and determining weight loss strategies, which of the following is an appropriate response from the diabetes educator? A. I am so proud of JL, she really stuck to her goals and had success B. I knew my plan would work and look at her success! C. Without our team of educators, JL would have not met her goals. D. I got her to decrease her intake of sodas and she lost 9 pounds.

A. I am so proud of JL, she really stuck to her goals and had success. Why A is best: It centers JL as the one taking action and achieving success. It recognizes her effort and commitment to her own goals. It uses strengths-based, respectful, and empowering language, consistent with ADCES and ADA recommendations for communicating with people living with diabetes. ❌ Why the others are less appropriate: B: Centers the educator's plan, not JL's efforts. C: Minimizes JL's role and credits the team rather than the individual. D: Uses "I got her to..." which implies coercion or lack of collaboration, rather than a shared, person-centered approach.

JZ is excited for 2021 and wants to work on some New Years resolutions. Which of the following would be considered a SMART behavioral goal for the New Year? A. I will check my sugars every other day before breakfast for one month. B. I will exercise or lift weights even if I don't feel motivated, for the next year. C. I plan to avoid sugary drinks, chips and candy and junk foods. D. I commit to taking all of my medications daily and losing 3 pounds.

A. I will check my sugars every other day before breakfast for one month. Rationale: This goal follows the SMART criteria: Specific: Check blood sugars before breakfast. Measurable: Every other day. Achievable: Checking every other day is a realistic goal. Relevant: Blood glucose monitoring is relevant to diabetes management. Time-bound: For one month.

LR has type 2 diabetes, BMI of 29.1, takes metformin 1000 mg and 20 units of glargine at home daily. A1c of 8.2%. LR is admitted to the hospital for an urgent coronary artery bypass surgery. Which of the following is an accurate statement? A. LR may need up to double his usual insulin home dose post-op day 1 and 2 B. LR is at low risk of a sternal wound infection C. LR is very insulin sensitive and at high risk for hypoglycemia D. LR will need to go on basal bolus therapy after discharge.

A. LR may need up to double his usual insulin home dose post-op day 1 and 2 Explanation: After major surgery like coronary artery bypass graft (CABG), patients with diabetes often experience increased insulin resistance due to: - Surgical stress - Inflammation - Use of glucocorticoids or vasopressors - Infection or trauma As a result, insulin requirements typically increase in the first 1-2 days after surgery. It is not uncommon for patients to require up to 2x their usual home insulin dose during this period. ❌ Why the other options are incorrect: B. LR is at low risk of a sternal wound infection❌ Incorrect — People with type 2 diabetes are actually at higher risk of post-op infections, including sternal wound infections, especially after cardiac surgery. C. LR is very insulin sensitive and at high risk for hypoglycemia❌ Incorrect — With a BMI of 29.1 (overweight) and an A1c of 8.2%, LR is more likely to have insulin resistance, not insulin sensitivity. D. LR will need to go on basal bolus therapy after discharge❌ Not necessarily — Post-discharge insulin needs depend on several factors. LR may or may not require bolus insulin depending on how he recovers, his nutrition, and glycemic control. This is a clinical decision based on close follow-up.

JR has had prediabetes for several years, with A1c's of 6.0-6.4%. JR is now experiencing sudden hyperglycemia and an A1c is 9.2%, GAD is positive, transglutaminase is negative and TSH is 1.4. What is the most likely diagnosis? A. Latent autoimmune diabetes. B. Hyperglycemia due to secondary causes. C. Celiac induced hyperglycemia. D. Type 1 diabetes.

A. Latent autoimmune diabetes. Rationale: Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressing form of autoimmune diabetes, often initially misdiagnosed as type 2 diabetes or prediabetes. Key features in this case: A1c jumped from prediabetic levels (6.0-6.4%) to 9.2%, indicating rapid worsening of glycemic control. Positive GAD antibodies = clear evidence of autoimmune beta-cell destruction. Age and progression pattern are consistent with LADA. Negative transglutaminase and normal TSH help rule out celiac disease or thyroid-related secondary causes. ❌ Why not the others: B. Hyperglycemia due to secondary causes - ❌ Labs don't suggest another cause (e.g., steroid use, Cushing's, etc.). C. Celiac induced hyperglycemia - ❌ Transglutaminase is negative, so celiac disease is unlikely. D. Type 1 diabetes - ❌ LADA is a form of type 1, but occurs later in life and progresses more slowly. Classic type 1 typically presents with faster onset and often DKA in younger individuals.

Which of the following is an accurate recommendation according to the nutrition principles as outlined by the American Diabetes Association Standards of Care? A. Maintain pleasure of eating by taking a non-judgmental approach. B. Limit added sugar intake to less than 6 teaspoons a day. C. Include cinnamon in meal plan to reduce glucose levels. D. Encourage people with diabetes to reach BMI goal of less than 25

A. Maintain pleasure of eating by taking a non-judgmental approach. The American Diabetes Association (ADA) Standards of Care emphasizes that nutrition therapy should be individualized and that people with diabetes should be supported in making enjoyable, sustainable dietary changes. The ADA promotes a non-judgmental, collaborative approach that helps individuals maintain the pleasure of eating, while making informed food choices to improve overall health and manage diabetes. ❌ Why the other options are incorrect: B. Limit added sugar intake to less than 6 teaspoons a day ❌🔻 While it's true that added sugars should be minimized, the ADA does not specify an exact teaspoon limit. That recommendation comes from the American Heart Association, not the ADA. C. Include cinnamon in meal plan to reduce glucose levels ❌🔻 Evidence on cinnamon's glucose-lowering effect is inconclusive and not strong enough to recommend it as a treatment. The ADA does not endorse cinnamon as part of evidence-based medical nutrition therapy. D. Encourage people with diabetes to reach BMI goal of less than 25 ❌🔻 While weight loss may benefit many people with type 2 diabetes, the ADA does not require or emphasize a strict BMI < 25 for all. The focus is on modest weight loss (5-10%), achievable and sustainable lifestyle changes, and health improvements over specific numbers.

ML has had type two diabetes for 12 years, a BMI of 33.7, an A1 C of 8.3%, and elevated triglycerides and LDL cholesterol levels. You notice ML's palms are deeply red. Which of the following conditions is ML most likely experiencing in addition to diabetes? A. Non-alcoholic fatty liver disease. B. Dermatomyositis secondary to inflammation. C. Auto immune renal hypertension. D. Acanthosis Nigricans of the palmar surface.

A. Non-alcoholic fatty liver disease. Up to 20% of people with diabetes are living with non alcoholic steatohepatitis (NASH) which can lead to cirrhosis, liver failure and cancer. Risk factors associated with NASH include hyperlipidemia, hyperglycemia, and a BMI of 30 or greater. People with NASH may have elevated liver enzymes including ALT and AST. Physical symptoms include acanthosis nigricans, abdominal pain, sense of fullness, facial spider angiomas and red palms. The major focus of treatment includes weight loss, increased activity, aggressive management of lipids and glucose. Some research also indicates that Actos, Vitamin E and liraglutide may improve liver histology. Join our Critical Assessment Course to learn more about NASH and other diabetes co-conditions.

A person living with diabetes is currently taking metformin, Glyburide and an evening basal dose of insulin. After discussing how best to achieve better glycemic control, he has agreed to add a pre-meal insulin dose. which modification should be made with addition of the prandial dose? A. discontinue the glyburide B. discontinue the metformin C. No modification should be made D. discontinue the metformin, glyburide, and evening insulin

A. discontinue the glyburide Explanation: When prandial (mealtime) insulin is added to a regimen that already includes basal insulin, it is appropriate to discontinue sulfonylureas like glyburide for several reasons: ✅ Why discontinue glyburide: Redundant mechanism: Sulfonylureas stimulate insulin secretion. Once rapid-acting insulin is given before meals, glyburide becomes unnecessary. Increased risk of hypoglycemia: Combining glyburide with both basal and bolus insulin significantly increases the risk of low blood sugar. No added benefit: There's limited additional glycemic benefit when using sulfonylureas alongside a full insulin regimen. ✅ Continue metformin: Metformin helps reduce insulin resistance and does not cause hypoglycemia. It can help minimize weight gain associated with insulin therapy. ❌ Discontinue everything (D): That would remove beneficial therapies and result in poor glycemic control. ❌ No modification (C): Keeping glyburide increases hypoglycemia risk unnecessarily.

JR is on metformin 2000mg, empagliflozin 25mg, semaglutide 1.0mg and 100 units of glargline insulin. A1C is 8.9% and JR weighs 100kg. What best describes this clinical picture? A. Overbasalization. B. Non-compliance. C. Fear of hypoglycemia. D. Clinical inaction.

A. Overbasalization Rationale: JR is on: - Metformin 2000 mg - standard first-line agent - Empagliflozin 25 mg (SGLT-2 inhibitor) - improves glucose excretion - Semaglutide 1.0 mg (GLP-1 receptor agonist) - enhances insulin secretion and reduces appetite - Glargine insulin 100 units daily - a very high dose of basal insulin Despite this, JR still has: A1C of 8.9% → Above target Weight: 100 kg → Glargine dose is 1 unit/kg, which is at the upper limit for basal insulin effectiveness This suggests: JR has likely exceeded the effective ceiling of basal insulin. When basal insulin exceeds 0.5-1.0 units/kg/day without A1c reaching goal, this is called overbasalization — meaning: Adding more basal insulin isn't helping anymore, and further control should come from mealtime insulin or non-insulin therapies (which JR already has). ❌ Why not the other options: B. Non-compliance - There's no indication JR is not taking medications; rather, the treatment regimen is not optimized. C. Fear of hypoglycemia - Not mentioned or implied in the case. D. Clinical inaction - Not correct because multiple therapies have already been added. However, not addressing overbasalization soon could lead to future clinical inertia. Summary: JR is maxed out on basal insulin (100 units = 1 unit/kg), yet A1C is still 8.9%. This strongly suggests overbasalization, and treatment should shift to adding prandial insulin or re-evaluating insulin timing/dosing.

JR is 27 with Type 1 diabetes and is very worried about getting COVID-19 since they work in a local grocery store. They ask you what they should do if they get COVID-19? Which of the following statements is accurate regarding sick day management with COVID-19? A. Seek immediate medical attention if lips or face become bluish. B. Report to the emergency room if temperature is 101 degrees or greater. C. Reduce insulin intake by 10-20% if experiencing diarrhea. D. Use glucose fingersticks instead of continuous glucose monitoring when febrile to improve accuracy.

A. Seek immediate medical attention if lips or face become bluish. Blue lips or face are signs of low oxygen levels and may indicate severe COVID-19 illness or respiratory distress. This is considered a medical emergency, and immediate medical attention is required. ❌ Why not the other options? B. Report to ER if temp is 101°F or greater → ❌ Not necessarily. A fever alone is not always an emergency. Patients should monitor symptoms and follow sick day protocols, but emergency care is typically based on more severe signs, such as breathing difficulty or altered mental status. C. Reduce insulin intake by 10-20% if experiencing diarrhea → ❌ This is risky. During illness (even with reduced food intake or diarrhea), people with type 1 diabetes usually need the same or even more insulin to prevent diabetic ketoacidosis (DKA). Never reduce insulin without monitoring and medical guidance. D. Use glucose fingersticks instead of CGM when febrile to improve accuracy → ❌ Not necessarily. Modern CGMs remain reasonably accurate during fever, though confirming with fingersticks if readings seem off is a good practice. But there's no blanket recommendation to stop using CGM during fever.

A 59 year old with type 2 diabetes, A1c of 7.2%, takes bolus insulin before meals, plus basal insulin at night and metformin. They ask you how to best work in a piece of birthday cake for their grandchild's upcoming birthday celebration. What is the best advice? A. Take additional bolus insulin to cover the extra carbs. B. Accept the cake but don't actually eat it. C, Increase their nighttime basal insulin to prevent hyperglycemia. D. Skip the previous meal to allow for the extra cake carbs.

A. Take additional bolus insulin to cover the extra carbs. Rationale: This patient is already on intensive insulin therapy—a basal-bolus regimen—which is designed to offer flexibility in managing blood glucose around meals and special events. The core principle of this approach is carbohydrate counting, enabling precise bolus insulin dosing based on the carbohydrate content of foods. A piece of birthday cake is high in carbohydrates and simple sugars, which can cause a rapid postprandial glucose spike. The appropriate clinical strategy is to calculate the carbohydrate content of the cake and administer an additional bolus insulin dose using their established insulin-to-carb ratio (ICR). ❌ Why the other options are inappropriate: B. Accept the cake but don't actually eat it. This approach undermines quality of life and does not reflect patient-centered care. Diabetes management should allow for real-life flexibility, especially for special occasions, using available tools like insulin adjustments. C. Increase nighttime basal insulin to prevent hyperglycemia. Basal insulin addresses fasting and between-meal glucose, not postprandial spikes. Increasing basal insulin to offset food-related hyperglycemia is ineffective and increases the risk of nocturnal hypoglycemia. D. Skip the previous meal to allow for the extra cake carbs. This is outdated and potentially dangerous advice. Skipping meals can lead to hypoglycemia and erratic glucose control. Moreover, it ignores the physiologic purpose of bolus insulin—to match food intake.

LS is 26 weeks pregnant and just discovered she has gestational diabetes. LS asks you what type of meal planning approach will help keep her and the baby healthy. According to the ADA Standards of Care, what is the most accurate response? A. To promote healthy fetal development, consume about 175 gms of carb a day. B. Try to eliminate simple carbohydrates to decrease risk of reactive hypoglycemia. C. Consume the majority of carbs in the morning when you are most insulin resistant. D. Eat no more than one serving of fruit a day to prevent hepatic fructose toxicity.

A. To promote healthy fetal development, consume about 175 gms of carb a day. Explanation: The 2022 ADA Standards of Care recommend about 175 grams of carbohydrates daily for pregnant people with gestational diabetes to support fetal growth and maternal energy needs. Restricting carbs too much can harm the baby's development. Balanced carb distribution throughout the day is important, but total carbohydrate intake around 175 g/day is key. ❌ Why other options are less accurate: B. Try to eliminate simple carbohydrates to decrease risk of reactive hypoglycemia.Not recommended; completely eliminating simple carbs is not advised during pregnancy and can cause nutritional imbalance. C. Consume the majority of carbs in the morning when you are most insulin resistant.Pregnant people often experience higher insulin resistance later in the day, so the majority of carbs are usually recommended earlier, not later. This option is misleading. D. Eat no more than one serving of fruit a day to prevent hepatic fructose toxicity.There is no ADA guideline restricting fruit to one serving due to fructose toxicity during pregnancy.

MS has type 1 diabetes and is on a low carb diet to help her keep her weight on target. She has a BMI of 24.3. MS has a friend with type 1 who is taking a SGLT-2 in addition to insulin to help with weight management. MS wants to know if she could add on a SGLT-2 to her insulin treatment plan. What is the Diabetes Specialist's best response? A. We don't recommend adding on a SGLT-2 for people with type 1 on a low carb diet. B. Your BMI of 24.3 is right on target. C. I'm sorry, but oral medications don't work for people with type 1 diabetes. D. Do you think you might be struggling with disordered eating?

A. We don't recommend adding on a SGLT-2 for people with type 1 on a low carb diet. Rationale: SGLT-2 inhibitors are not FDA-approved for people with type 1 diabetes in the U.S., although they are sometimes prescribed off-label in other countries. While these medications can lower glucose and support weight management, they carry serious risks in people with type 1 diabetes—especially: Euglycemic Diabetic Ketoacidosis (euDKA):This potentially life-threatening condition can occur even with normal blood glucose levels and is more likely when paired with low-carb diets, dehydration, or illness. Low-carb diets + SGLT-2s = higher DKA riskA low-carb diet promotes ketone production, and SGLT-2 inhibitors increase ketone formation, compounding the risk. ❌ Why the Other Options Are Incorrect: B. "Your BMI of 24.3 is right on target."While true, it doesn't address the safety concern MS raised about adding an SGLT-2 to a low-carb diet. C. "Oral medications don't work for people with type 1 diabetes."This is outdated and inaccurate. Some oral or non-insulin injectables are used off-label or in research for T1D, including SGLT-2s and GLP-1s, but with caution. D. "Do you think you might be struggling with disordered eating?"This may be relevant if other red flags exist, but it's not the appropriate response based solely on this inquiry. It may stigmatize or shut down the conversation unnecessarily.

AJ is motivated to decrease weight. AJ eats an egg sandwich and hash browns 5 times a week. You look up the calories on an app and find that the egg sandwich has 370 calories and the medium hash browns have 390 calories. If AJ doesn't eat the hash browns for one month, how much weight would AJ lose? A. 3.1 pounds B. 2.2 pounds C. 2.1 pounds D. 4.3 pounds

B. 2.2 pounds Step 1: Calculate Weekly Calorie Reduction AJ eats hash browns 5 times a week, and each serving has 390 calories: 390 calories × 5 days = 1,950 calories/week Step 2: Calculate Monthly Calorie Reduction Assuming 1 month ≈ 4 weeks: 1,950 calories/week × 4 weeks = 7,800 calories/month Step 3: Convert Calories to Pounds There are approximately 3,500 calories in one pound of body weight: 7,800 ÷ 3,500 = 2.23 pounds

JR is 24 years old and uses an insulin pen for their basal insulin injections each evening. JR takes 30 units a night and each insulin pen holds 300 units of insulin. How many insulin pens would JR need for one month? A. 3 pens. B. 4 pens. C. 10 pens. D. 1 box.

B. 4 pens. Rationale: JR takes 30 units of basal insulin a night. We know that JR needs to prime their insulin pen with a 2 unit air shot before each injection. To make sure the insulin pen and needle are working correctly, we instruct people to use a new pen needle and to prime it before injection. This means that JR will use 32 units of insulin each night (30 units for the injection, 2 units to prime the pen). 32 units x 30 days = 960 units. If each pen holds 300 units, JR will need 4 insulin pens for the month.

As a Diabetes Specialist in a rural clinic, you are asked to consult on a 49-year-old female with type 2 diabetes and a BMI of 27. Blood pressure is 132/74 with the following lab values; A1c of 7.6%, LDL of 97 mg/dl, triglycerides 138, and GFR of 69. Her medications include: Metformin 850 mg three times a day, levothyroxine 100 mcg a day, and cetirizine 10mg daily. According to the ADA Cardiovascular Standards of Care, what other medication therapy needs to be added? A. Basal insulin. B. A statin. C. Aspirin therapy. D. An ACE Inhibitor or Angiotensin Renin Blocker (ARB).

B. A statin. According to the American Diabetes Association (ADA) Standards of Care, statin therapy is recommended for people with diabetes aged 40-75 years, regardless of baseline LDL, if they have additional cardiovascular risk factors — and diabetes itself is considered a risk factor. Per ADA guidelines: For patients aged 40-75 with diabetes but no ASCVD, moderate-intensity statin therapy is recommended.If other risk factors are present, consider high-intensity statin. ❌ Why not the other options? A. Basal insulin → ❌ Not needed. Her A1c is 7.6%, and she's already on metformin — insulin isn't the next logical step. A GLP-1 or SGLT-2 might be next before insulin, depending on comorbidities. C. Aspirin therapy → ❌ Aspirin is only recommended for secondary prevention or for primary prevention if elevated ASCVD risk and low bleeding risk. No history of ASCVD is given. D. ACE Inhibitor/ARB → ❌ Her blood pressure is <140/90 and no albuminuria or kidney damage is noted. These aren't needed solely for diabetes prevention here.

JR is 53 yrs old with type 2 diabetes, BMI of 24.3 and is recovering from a COVID infection. In addition to metformin, a SGLT-2i and a weekly GLP-1 RA, JR is on daily prednisone. Morning blood glucose levels are in the low 100's, lunch and dinner blood glucose levels are in the 250-300 range. Which of the following is the best treatment intervention to get lunch and dinner blood glucose levels to goal? A. Initiate a low carb meal plan. B. Add NPH or 70/30 insulin in morning. C. Start evening basal insulin and gradually increase. D. Ask provider to stop or reduce prednisone dose.

B. Add NPH or 70/30 insulin in morning. NPH insulin peaks in 4-6 hours and lasts about 12-16 hours → matches prednisone's glucose-raising effect. 70/30 insulin (70% NPH, 30% regular insulin) given in the morning also addresses both basal and prandial needs during the day. This approach specifically targets prednisone-induced hyperglycemia during lunch and dinner. ❌ Why not the other choices? A. Low carb meal plan - May help overall, but not enough to counteract steroid-induced glucose spikes alone. C. Start evening basal insulin - Won't address daytime hyperglycemia, as the issue is with blood sugars after lunch and dinner, not fasting. D. Reduce prednisone - Might seem logical, but not always possible depending on the medical need for it (e.g., post-COVID inflammation). It's not the diabetes educator's or patient's role to stop a needed steroid.

COVID cases are surging throughout the United States. Providing the best care for people with diabetes is especially important during this crisis. Which of the following statements regarding diabetes and COVID is most accurate? A. Avoid use of ACE inhibitors during illness, especially during the critical phase. B. Administration of sitagliptin (Januvia) during hospitalization may be associated with improved outcomes. C. Steroid use during acute illness should be avoided to prevent hypoglycemic or hyperglycemic crisis. D. Supine positioning during the acute phase is associated with improved oxygen saturation.

B. Administration of sitagliptin (Januvia) during hospitalization may be associated with improved outcomes. Rationale: Recent studies have suggested that use of sitagliptin (a DPP-4 inhibitor) in patients with type 2 diabetes hospitalized with COVID-19 may be associated with better outcomes, including reduced mortality and improved clinical status. While more research is ongoing, this has been a notable area of interest and cautious optimism. ❌ Why not the others? A. Avoid use of ACE inhibitors during illness... - ❌ This is not recommended. The ADA, AHA, and other organizations advise continuing ACE inhibitors/ARBs during COVID-19 unless there are specific contraindications like hypotension or acute kidney injury. In fact, stopping these medications abruptly can be harmful. C. Steroid use... should be avoided... - ❌ Steroids may be necessary for treatment of severe COVID-19 (e.g., dexamethasone in patients requiring oxygen). Though they can cause hyperglycemia, this is managed, not a reason to avoid them when clinically indicated. D. Supine positioning... improves oxygen saturation - ❌ This is incorrect. For patients with respiratory distress, prone positioning (lying on the stomach) — not supine — has been shown to improve oxygenation in COVID-19. Summary: In the context of diabetes and COVID-19, sitagliptin may offer additional benefits when used during hospitalization, according to emerging evidence.

LR loves going to the gym 3 times a week. LR is 78, with Latent Autoimmune Diabetes (LADA) and is on basal bolus insulin. LR also takes a statin and ACE Inhibitor. LR has a history of retinopathy and peripheral neuropathy. During your assessment, LR proudly shares that when on the treadmill, their heart rate never goes above 100 beats per minute. What best explains this heart rate? A. Excellent cardiovascular health from regular exercise. B. Cardiac autonomic neuropathy. C. Stiff heart syndrome. D. ACE Inhibitors can contribute to lower heart rates.

B. Cardiac autonomic neuropathy. Explanation: LR is an older adult with LADA, a form of type 1 diabetes with autoimmune destruction of beta cells. LR has a history of retinopathy and peripheral neuropathy, which are complications of diabetes and can be accompanied by autonomic neuropathy. Cardiac autonomic neuropathy (CAN) can blunt heart rate response during exercise, resulting in an abnormally low maximal heart rate despite physical activity. A heart rate that does not increase appropriately with exercise (like staying below 100 bpm on a treadmill) is a classic sign of CAN. ❌ Why other options are less likely: A. Excellent cardiovascular health: This would typically result in a normal or appropriately increased heart rate during exercise, not a low or blunted response. C. Stiff heart syndrome: This refers more to diastolic dysfunction or restrictive cardiomyopathy, which does not directly explain a low heart rate response on exertion. D. ACE Inhibitors: These medications do not typically cause bradycardia or limit heart rate increase during exercise.

LS takes 20 units 70/30 insulin twice daily with an insulin pen. LS states that blood sugars are usually on target, but over the past week, blood sugars have suddenly increased. LS confirms that they are taking insulin on a regular basis. Which factor could be contributing to this sudden blood glucose rise? A. 70/30 insulin is no longer effective for LS. B. Check where LS is keeping the insulin pens. C. Remind LS to shake the insulin to assure adequate mixing. D. Verify that LS is doing a 3-unit air shot before each injection.

B. Check where LS is keeping the insulin pens. Rationale: Insulin is temperature-sensitive. If LS is storing insulin in a place that's too hot or too cold (like in a car, near a heater, or in the freezer), it can become inactive, leading to increased blood glucose even if dosing is consistent. ❌ Why the Other Options Are Incorrect: A. 70/30 insulin is no longer effective for LS.❌ Insulin doesn't just "stop working" unless it's mishandled or expired. There is no indication that a change in insulin formulation is needed yet. C. Remind LS to shake the insulin to assure adequate mixing.❌ While 70/30 insulin (a mix of NPH and regular insulin) does require gentle rolling, not shaking, improper mixing would lead to inconsistent results—not a sustained increase in blood glucose. D. Verify that LS is doing a 3-unit air shot before each injection.❌ The air shot ensures dose accuracy, but forgetting it occasionally doesn't typically lead to sustained hyperglycemia. It's more about avoiding injection device malfunction. ✅ Bottom Line: Improper insulin storage is a common cause of unexpected hyperglycemia. Always verify how and where patients are storing their insulin.

LS has a BMI of 29 with type 2 diabetes with an A1c of 8.7%. LS is smoking a pack of cigarettes a day and states, "I don't know if I am ready to quit." According to the transtheoretical theory, what best describe her statement? A. Denial B. Contemplation. C. Bargaining, D. Internal locus of control.

B. Contemplation. Rationale: The transtheoretical model (stages of change) defines the contemplation stage as when a person is aware of a problem and is thinking about making a change, but has not yet committed to action. LS's statement, "I don't know if I'm ready to quit," reflects ambivalence, a hallmark of the contemplation stage. ❌ Why the others are incorrect: A. Denial: Would imply LS is unaware that smoking is a problem, which is not the case here. C. Bargaining: This is more of a term from grief theory (e.g., Kübler-Ross model), not a stage in the transtheoretical model. D. Internal locus of control: Refers to the belief that one's actions influence outcomes, which is not what LS is expressing.

JR is a 38 yr old who received a kidney transplant 3 months ago and has a GFR >60 and creatinine of 0.9. JR takes prednisone 10mg daily as part of the post-transplant protocol. JR's most recent A1c came back at 7.9% and the provider asks the Diabetes Specialist what intervention is recommended. Which of the following is the best response? A. Refer to a kidney specialist for a thorough workup. B. Encourage referral for medical nutrition therapy. C. Evaluate if JR can cut the prednisone dose in half. D. Instruct JR to start a very low-calorie diet to reverse hyperglycemia.

B. Encourage referral for medical nutrition therapy. ✅ Explanation: Post-transplant diabetes (sometimes referred to as new-onset diabetes after transplant, or NODAT) is a common complication, especially in patients on glucocorticoids like prednisone, which can raise blood glucose levels. With a relatively mildly elevated A1c of 7.9% in someone who's only 3 months post-kidney transplant, the first-line and safest intervention is Medical Nutrition Therapy (MNT) with a Registered Dietitian (RD/RDN) to help manage steroid-induced hyperglycemia. ❌ Why the other options are incorrect: A. Refer to a kidney specialist: JR already has a normal GFR and creatinine, and has had a successful transplant. There's no sign of renal dysfunction requiring urgent nephrology input. C. Evaluate if JR can cut the prednisone dose in half: Prednisone tapering decisions must be made by the transplant team and are not typically altered for glucose control alone without risking transplant rejection. D. Very low-calorie diet: Not appropriate post-transplant, especially while healing and on immunosuppressive therapy. It may also not be sustainable or safe without close supervision.

LS has type 1 diabetes and reports to clinic with unusually frequent hypoglycemia and some weight loss. LS appears distraught and says that since the pandemic, their work hours have been dramatically reduced and paying bills has been a struggle. Based on this information, which of the following topics would the diabetes specialist most want to explore further? A. Disordered eating. B. Food insecurity. C. Insulin rationing. D. Diabetes distress.

B. Food insecurity. Rationale: LS: - Has type 1 diabetes - Reports frequent hypoglycemia - Has experienced weight loss - Is under financial strain since the pandemic - Says paying bills has been a struggle These clues point strongly toward food insecurity, which is: Limited or uncertain access to adequate food, especially due to financial constraints. How food insecurity can explain the symptoms: - Skipping or delaying meals due to lack of food → leads to hypoglycemia, especially when still taking insulin. - Weight loss from not eating enough - Emotional distress and unpredictability in glucose control ❌ Why not the other options in this case? C. Insulin rationing→ Very plausible in type 1 diabetes with financial struggles, but frequent hypoglycemia is less consistent with insulin underuse (more often leads to hyperglycemia or DKA).In contrast, hypoglycemia fits more with not having food when insulin is still active. A. Disordered eating→ No evidence in the vignette (e.g., no body image concerns or insulin omission for weight loss). D. Diabetes distress→ Likely present, but it's a broader emotional state. The specific pattern of symptoms aligns more directly with food insecurity.

LR is 12 years old with type 2 diabetes. His weight is greater than the 95th percentile for his age. LR's dad asks you for strategies to help with weight management. which of the following recommendations are most useful? A. check LR's room for empty candy wrapper adn provider gentle coaching. B. Have fresh fruits and vegetables on display and easily accessible. C. Remove all processed and junk food from the house D. Encourage LR to engage in a least 2 hours of exercise daily.

B. Have fresh fruits and vegetables on display and easily accessible. Rationale: This approach is practical, positive, and supportive. It encourages healthy eating habits without shame or restriction. Making healthy foods visible and easy to grab increases the likelihood that LR will choose them. ❌ Why the other options are incorrect: A. Check LR's room for empty candy wrappers and provide gentle coaching⛔ Not ideal — This can feel invasive and shaming, potentially damaging trust and increasing secretive eating behaviors. C. Remove all processed and junk food from the house⚠️ Too extreme — While reducing junk food is good, eliminating all of it can feel restrictive and trigger rebellious or binge eating, especially in adolescents. D. Encourage LR to engage in at least 2 hours of exercise daily⚠️ Unrealistic — The current CDC recommendation is at least 60 minutes per day of moderate to vigorous physical activity for children. Two hours might be discouraging or unsustainable.

RL has type 2 diabetes on metformin (Glucophage) and is struggling to lose weight. RL has tried many different diets without success. However, RL arrives to the appointment excited about a new low carbohydrate "ketogenic" diet they are on and states they have lost 4 pounds in the last month. What is the diabetes educator's best response? A. Please check your urine ketones at least once a week. B. It seems like this approach is working for you? C. Good job, however, the recommended daily intake of carbohydrate is 140 gm per day. D. Even though you are losing weight, there can be issues with kidney function

B. It seems like this approach is working for you? Rationale: This option reflects the principles of motivational interviewing and patient-centered care. It: Acknowledges RL's success and enthusiasm Keeps the conversation open and non-judgmental Encourages further dialogue to explore what's working and how to support sustainable behavior change As a diabetes educator, showing interest and curiosity rather than immediately correcting or cautioning helps build rapport and encourages continued engagement. ❌ Why the other options are incorrect: A. May cause unnecessary worry — ketone testing is typically more relevant for type 1 diabetes or if someone is ill. C. Corrects the patient too soon, which might feel dismissive of their effort and success. D. Jumps to a cautionary message without first exploring the patient's understanding, goals, and experiences.

RJ is 67 years old with a 40+ year history of type 1 diabetes. GFR is 62, UACR is < 30, A1c is 6.7%, B/P is 132/72, LDL cholesterol is 98, his BMI is 28.6. RJ uses multiple daily injections and CGM to manage his diabetes. RJs other medications include: Levothyroxine 100mcg daily, atorvastatin 40mg daily, Aspirin 81 mg daily and a multivitamin. Based on your assessment, which of the following interventions would improve RJs outcome? A. Add an ACE Inhibitor B. Lifestyle intervention C. Suggest addition of an ARB D. Increase atorvastatin dose

B. Lifestyle intervention RJ is a 67-year-old with long-standing type 1 diabetes and an excellent A1c (6.7%), normal kidney function (GFR 62 and UACR <30), controlled blood pressure (132/72), and an LDL of 98 mg/dL while already taking atorvastatin 40 mg. His BMI is 28.6, which is overweight (but not obese), and modest lifestyle changes could improve weight, cardiovascular risk, and insulin sensitivity. ❌ Why not the other options? Add an ACE Inhibitor → ❌ Not necessary. RJ's UACR is <30 (no albuminuria) and BP is <140/90, so ACE inhibitors aren't currently indicated for kidney or blood pressure protection. Suggest addition of an ARB → ❌ Same reasoning as above. ARBs are alternatives to ACE inhibitors — not used in combination and not indicated here. Increase atorvastatin dose → ❌ Atorvastatin 40 mg is already considered a high-intensity statin (along with 80 mg). LDL is at goal for someone with diabetes and no known atherosclerotic cardiovascular disease (ASCVD).

MJ, a 49-year-old with type 1 diabetes, states during your telehealth session that they are not feeling very well and are worried about getting COVID-19. Which of the following is an accurate statement? A. People with diabetes are at higher risk of getting COVID-19 B. People with diabetes have the same risk of getting COVID-19 as the general population C. People with type 1 diabetes have a slightly higher risk of getting COVID-19 than those with type 2 diabetes D. Regardless of the type of diabetes, COVID-19 rates are slightly lower

B. People with diabetes have the same risk of getting COVID-19 as the general population People with diabetes are not more likely to contract COVID-19 than others — the risk of infection is similar to the general population. However, if someone with diabetes becomes infected, they may have a higher risk of severe illness, complications, or hospitalization, especially if blood sugars are not well-controlled.

RT has type 1 diabetes and is going to turn 18 years old in a month and is heading off to college. Which of the following would most help with the transition? A. Make sure to set up an appointment with a trusted endocrinologist within 6 months. B. Problem solving situations that RT might encounter at college. C. Reinforce the risk associated with taking drugs and blood glucose control. D. Create a meal and exercise plan for RT to follow.

B. Problem solving situations that RT might encounter at college. Rationale: It helps build RT's self-management and decision-making skills, which are essential for a successful transition to independent living and diabetes care in college. It aligns with transition-of-care best practices, which emphasize preparing young adults to handle real-life situations such as erratic schedules, managing supplies, social pressures, sick day care, and communicating with new providers. It supports autonomy and empowerment, key elements in adolescent and young adult diabetes education. ❌ Why the others are less ideal: A: While important, waiting 6 months for an endocrinology appointment is too long—a proactive plan before leaving for college is better. C: Risk education is valuable but not as developmentally empowering or comprehensive as problem-solving practice. D: Creating a rigid plan for RT doesn't promote independence or flexibility, which is needed in a college environment.

AJ is admitted to the hospital for the second time this month for DKA. The 28-year-old has type 1 diabetes, wears a CGM, and uses insulin pen injections. AJs last A1c was 11.3%. AJs admitting glucose is 498 mg/dl, his pH is 7.05, and is anion gap is above 12. What are the next steps? A. Give AJ 20 units of rapid-acting insulin IV push. B. Start IV fluids and evaluate electrolytes before starting IV insulin. C. Start IV insulin at 0.5 units/kg/hour. D. Initiate basal-bolus insulin.

B. Start IV fluids and evaluate electrolytes before starting IV insulin. AJ is presenting with Diabetic Ketoacidosis (DKA) Standard DKA Management (ADA Guidelines) 1. Start IV Fluids FIRST Usually 0.9% NaCl (normal saline) to restore perfusion Correct volume depletion and support renal function 2. Evaluate Electrolytes Especially potassium (K⁺) If K⁺ < 3.3 mEq/L, insulin must be delayed until potassium is corrected Insulin drives potassium into cells and may worsen hypokalemia 3. Start IV Insulin AFTER fluid resuscitation and potassium status is known Typically 0.1 units/kg/hour, not 0.5 units/kg/hr ❌ Why the Other Options Are Incorrect: A. 20 units of rapid-acting insulin IV push Too much insulin and not guideline-based; boluses are no longer recommended in most cases C. Start IV insulin at 0.5 units/kg/hour Too high; standard rate is 0.1 units/kg/hour D. Initiate basal-bolus insulin Not appropriate during active DKA Basal-bolus insulin is used after resolution of DKA and transition from IV insulin

LT is 43 with new type 2 diabetes and smokes a pack of cigarettes daily. He is on metformin (glucophage) 2500 mg daily. In spite of attending a DSMES program and making lifestyle changes, LT's A1C is 8.4%, GFR is greater than 60. According to the ADA Type 2 management guidelines, which of the following would be the preferred action? A. Start LT on a low dose sulfonylurea B. Start LT on empaglifozin (Jardiance) C. Gently encourage LT to stop smoking. D. Start LT on low dose basal insulin

B. Start LT on empaglifozin (Jardiance) Explanation: LT has: Type 2 diabetes A1c of 8.4% despite max-dose metformin and lifestyle changes GFR > 60 (normal kidney function) History of smoking (increased cardiovascular risk) 🔑 ADA 2024 Standards of Care recommend: For people with Type 2 diabetes who are not at A1c target on metformin, the next step depends on comorbidities, especially cardiovascular risk: ➡️ If ASCVD risk is present (e.g., smoking, hypertension, etc.), initiate an SGLT2 inhibitor (like empagliflozin) or a GLP-1 receptor agonist with proven cardiovascular benefit, even if A1c reduction is modest, because of cardioprotective effects. Empagliflozin (Jardiance) is an SGLT2 inhibitor shown to reduce cardiovascular events and is approved for people with GFR > 30, so it is safe here. ❌ Why the other options are incorrect: A. Start LT on a low dose sulfonylurea-Not preferred due to risk of hypoglycemia and weight gain, and no cardiovascular benefit. C. Gently encourage LT to stop smoking-While smoking cessation is crucial, it is not the preferred pharmacologic next step in this context. D. Start LT on low dose basal insulin-Insulin may eventually be needed, but guidelines recommend adding oral or non-insulin agents with proven benefit first, especially in those with cardiovascular risk.

Which of the following is accurate regarding cystic fibrosis related diabetes (CFRD)? A. A1c testing is the preferred diagnostic tool to detect cystic fibrosis-related diabetes (CFRD). B. Start annual screening for diabetes at age 10 for those with cystic fibrosis-related diabetes (CFRD). C. People with cystic fibrosis-related diabetes (CFRD) benefit from intensive carbohydrate intake reduction. D. Best treatment strategy for people with cystic fibrosis-related diabetes (CFRD) includes GLP-1s to support gut hormone production.

B. Start annual screening for diabetes at age 10 for those with cystic fibrosis-related diabetes (CFRD). Rationale: Cystic Fibrosis-Related Diabetes (CFRD) is a distinct form of diabetes that shares features of both type 1 and type 2 diabetes but is primarily caused by insulin insufficiency due to pancreatic damage from cystic fibrosis. Annual screening for CFRD is recommended beginning at age 10 using an oral glucose tolerance test (OGTT) — this is the most sensitive method for detecting early glucose abnormalities in CF patients. ❌ Why the other options are incorrect: A. A1c testing is the preferred diagnostic tool - ❌ Incorrect. A1c is not reliable in cystic fibrosis due to altered red blood cell turnover and may underestimate glycemia. The OGTT is preferred. C. Benefit from intensive carbohydrate intake reduction - ❌ CF patients often have high caloric needs and should not restrict carbohydrates severely. The goal is to maintain weight and nutritional status. D. GLP-1s are best for CFRD - ❌ There is no evidence that GLP-1 receptor agonists are effective or recommended in CFRD. Insulin therapy remains the standard and most effective treatment.

CT was diagnosed with type 2 diabetes three years ago. The current medication regimen includes 1000 mg of metformin twice daily and 70 units of glargine at night. CT wears an intermittent sensor, and you look at the glucose trends together on CT's phone app. You both agree that there are consistent postmeal spikes up to 250 almost every day after lunch and dinner. The lowest blood sugar readings are in the 100s. BMI is 33.8 and CT says, "I never feel full". The most recent A1C is 8.2%, urinary albumin creatinine ratio less than 30. Based on this information, what intervention would be most likely help CT get to recommended ADA targets? A. Add on low-dose sulfonylurea to prevent hypoglycemia. B. Suggest adding a GLP-1 Receptor Agonist. C. Hold metformin, and switch to basal-bolus therapy. D. Encourage CT to get more active, especially after meals.

B. Suggest adding a GLP-1 Receptor Agonist. Rationale: CT has: Type 2 diabetes, diagnosed 3 years ago Currently on max dose of metformin and 70 units of glargine (basal insulin) Still has an A1C of 8.2% (above ADA target of <7%) Post-meal glucose spikes to 250 after lunch and dinner BMI 33.8 (obese) Says "I never feel full", suggesting increased appetite or poor satiety No significant kidney issues (UACR <30) Why a GLP-1 receptor agonist is ideal: - Targets postprandial glucose: GLP-1 RAs slow gastric emptying and reduce post-meal spikes. - Promotes satiety: Helps with appetite control and weight loss—addressing "never feeling full." Weight benefit: Beneficial in a patient with BMI >30. - Cardiometabolic benefit: Even greater if there's any CV risk. - Avoids hypoglycemia: Unlike sulfonylureas or prandial insulin. This aligns with ADA Standards of Care, which recommend GLP-1 RAs before starting mealtime insulin in patients already on basal insulin and not at A1C goal. ❌ Why not the other choices? A. Add low-dose sulfonylurea→ Sulfonylureas increase risk of hypoglycemia and weight gain, and are not first-line when post-meal spikes are the main issue in someone already on basal insulin. C. Hold metformin and switch to basal-bolus→ Metformin should be continued unless contraindicated. Also, basal-bolus insulin is more complex and usually not the next step before trying GLP-1 RAs or SGLT-2 inhibitors. D. Encourage more activity→ Always good advice, but alone it's not enough to address significant post-meal spikes and A1C above goal.

Language use while interviewing someone with diabetes can have a profound impact on the meaningfulness of the interaction. Which of the following comments uses a person-centered approach and exemplifies the use of updated diabetes language? A. We don't recommend avoiding breakfast. B. Tell me more about skipping your afternoon insulin. C. I notice you haven't tested your blood sugars daily. D. Exercise is important because it helps control your glucose levels.

B. Tell me more about skipping your afternoon insulin. Rationale: This response uses person-centered, nonjudgmental language that invites open dialogue and supports shared decision-making. It: Avoids blame or shame. Focuses on understanding behavior, not judging it. Uses neutral, compassionate language. Aligns with the ADA/ADCES recommendations for respectful, strengths-based communication in diabetes care. ❌ Why the other choices are less appropriate: A. "We don't recommend avoiding breakfast."- ❌ Directive and paternalistic in tone; lacks exploration or collaboration. C. "I notice you haven't tested your blood sugars daily."- ❌ Uses compliance-based language and focuses on what's "missing," which may feel critical or accusatory. D. "Exercise is important because it helps control your glucose levels."- ❌ The term "control" can feel judgmental and imply success/failure. Preferred alternatives are "manage" or "support glucose levels."

Intestinal health and diabetes are co-related. Which of the following statements is true? A. High levels of intestinal butyrate indicate excess inflammation and increased glucose levels. B. Thicker intestinal mucous lining is correlated with a lower risk of diabetes. C. In diabetes, there is an inverse correlation between food diversity and gut bacteria diversity. D. Decreasing the prevalence of mucin-producing bacteria decreases diabetes risk.

B. Thicker intestinal mucous lining is correlated with a lower risk of diabetes. Rationale: The intestinal mucus layer acts as a protective barrier between gut microbes and the intestinal epithelium. A thicker mucous lining helps prevent inflammation, supports gut integrity, and is associated with a healthier metabolic profile, including reduced risk of insulin resistance and type 2 diabetes. ❌Why the others are incorrect: A. High levels of intestinal butyrate indicate excess inflammation and increased glucose levels - ❌ Incorrect. Butyrate, a short-chain fatty acid produced by gut bacteria, is anti-inflammatory and beneficial for blood glucose regulation and gut health. C. In diabetes, there is an inverse correlation between food diversity and gut bacteria diversity - ❌ False. Greater dietary diversity generally increases gut microbiome diversity, which is protective against diabetes and metabolic disorders. D. Decreasing the prevalence of mucin-producing bacteria decreases diabetes risk - ❌ Opposite is true. Mucin-producing bacteria help maintain the gut barrier. Decreased mucin producers are linked to increased gut permeability and inflammation, raising the risk of diabetes.

JR has type 2 diabetes and is trying to lose weight by eating less and moving more. JR asks your advice about drinking diet sodas. Based on this information, what intervention would be most likely help CT get to recommended ADA targets? A. Sodas that contain non-nutritive sweeteners help with weight loss and increase sugar cravings. B. Try to decrease intake of beverages with non-nutritive sweeteners and increase water intake. C. Drinking beverages with non-nutritive sweeteners is better than drinking sugary beverages. D. Research has found that drinking beverages with nonnutritive sweeteners decreases diabetes risk.

B. Try to decrease intake of beverages with non-nutritive sweeteners and increase water intake. Explanation: While diet sodas (with non-nutritive sweeteners) may be better than sugary drinks in terms of calories and blood sugar, some evidence suggests they may still negatively affect metabolism, appetite, or gut microbiota, potentially making weight loss or glucose control harder. Increasing water intake is the healthiest option for hydration and blood sugar control. Therefore, encouraging reducing diet soda consumption and replacing it with water is a balanced, evidence-informed approach. ❌ Why the other options are less suitable: A. Sodas that contain non-nutritive sweeteners help with weight loss and increase sugar cravings.This statement is contradictory and confusing. Non-nutritive sweeteners don't directly promote weight loss; they may increase sugar cravings in some individuals, but this is not a clear benefit. C. Drinking beverages with non-nutritive sweeteners is better than drinking sugary beverages.This is true but incomplete and could encourage ongoing diet soda consumption, which isn't ideal for weight loss or metabolic health. D. Research has found that drinking beverages with nonnutritive sweeteners decreases diabetes risk.This is inaccurate; research is mixed, and no conclusive evidence shows that non-nutritive sweeteners reduce diabetes risk.

LT, a 59-year old with type 2 diabetes presents to the hospital in a hyperglycemic crisis. LT has a history of hypertension, peripheral vascular disease and smokes a pack per day. LT states they have been taking 1000mg metformin BID and 10 units basaglar every night as usual. LT tells you they are stressed out and concerned about a foot sore that doesn't seem to be getting better. LT is trying to stay home and avoid other people, to prevent getting COVID. LT's A1C is 8.8%. What is the most likely cause of this sudden hyperglycemia? A. Stress eating due to isolation. B. Untreated infection. C. Rationing medications due to financial hardship. D. Insulin resistance secondary to cigarette smoking.

B. Untreated infection. Rationale: Hyperglycemic crises (such as DKA or HHS) are often triggered by acute illness or infection in people with diabetes. LT reports a foot sore that's not healing — in a patient with peripheral vascular disease and diabetes, this strongly raises concern for foot infection, even if LT hasn't been diagnosed or treated for one yet. Infection increases insulin resistance and leads to elevated counter-regulatory hormones, which can dramatically worsen blood glucose levels. ❌ Why not the others? A. Stress eating due to isolation: Possible, but unlikely to cause a hyperglycemic crisis by itself. C. Rationing medications: There's no indication LT has stopped or reduced medications—LT says they're taking them as usual. D. Insulin resistance due to smoking: Smoking contributes to chronic insulin resistance but is not a likely trigger for an acute crisis.

A 9 year old with type 2 diabetes tell you that they don't want to walk for a half-hour every day. What would be the most appropriate response? A. Are you nervous about walking? B. What outside games do you like to play? C. It sounds like you are not ready to start exercising D. Don't say anything, but document that they refuse to exercise.

B. What outside games do you like to play? Why B is best: It uses motivational interviewing techniques to explore the child's interests rather than imposing a specific behavior. It shifts the conversation toward fun, age-appropriate physical activity instead of framing it as "exercise," which can feel like a chore. It respects the child's autonomy while helping them identify enjoyable alternatives to structured exercise. ❌ Why the others are less appropriate: A: While open-ended, it assumes fear and may not engage the child in a positive way. C: Makes a judgment about readiness and could shut down further conversation. D: Misses an opportunity for engagement, education, and rapport-building.

You are counseling a person about carb counting and matching bolus insulin dose to meals consumed. They ask, if i eat a fatty meal, how will that affect my blood glucose? what is the best response? A. A high fat meal will cause an initial blood glucose spike, followed by a sudden drop. B. You might experience a delayed post prandial elevation. C. if you are consuming a high fat meal, avoid saturated fats and include polyunsaturated fats. D. Most people need to increase insulin dose by 25% to prevent post meal excursions.

B. You might experience a delayed post prandial elevation. Rationale: High-fat meals delay gastric emptying, which can result in: Slower absorption of carbohydrates A delayed rise in postprandial (after-meal) blood glucose levels Potential mismatch with rapid-acting insulin if timing is not adjusted This can make blood glucose management more complex for people using bolus insulin. ❌ Why the other options are incorrect: A. ❌ High-fat meals don't typically cause an initial spike followed by a sudden drop — they delay the rise instead. C. ❌ While the quality of fat matters for cardiovascular health, it does not directly answer the blood glucose impact question. D. ❌ Insulin adjustments should be individualized. Suggesting a blanket 25% increase could be inaccurate or unsafe without careful monitoring or provider guidance.

Which of the following phrases uses recommended language when working with or discussing people with diabetes? A. MJ is really suffering with her diabetes and ongoing hyperglycemia B. would you like to consider checking your blood sugar daily? C. We don't recommend you skip breakfast. D. Normal people have A1c less than 5.7%

B. would you like to consider checking your blood sugar daily? Why B is best: It uses person-centered, collaborative language. It invites choice and promotes shared decision-making. It is respectful and nonjudgmental, aligning with the ADCES/ADA recommendations for communication with people living with diabetes. ❌ Why the others are less appropriate: A: "Suffering" is a negative and emotionally loaded term that implies helplessness. C: "We don't recommend you skip breakfast" is directive and could feel prescriptive or paternalistic. D: "Normal people" is stigmatizing. The preferred term is "people without diabetes" or "individuals in the non-diabetes range."

JR wants to lose weight in the next 30 days by drinking less juice. There are 100 calories per glass of juice and JR usually drinks 3 glasses a day. How much weight would JR lose by only drinking 1 glass a day? A. 0.85 pounds. B. It depends on the type of juice. C. 1.7 pounds. D. 3000 calories.

C. 1.7 pounds Step-by-step: Calories saved per day:JR currently drinks 3 glasses/day → 3 × 100 = 300 calories/dayIf JR reduces to 1 glass/day → 1 × 100 = 100 calories/daySo, calories saved per day = 300 - 100 = 200 calories/day Over 30 days:200 calories/day × 30 days = 6,000 calories saved Calories per pound of fat:~3,500 calories = 1 pound of body fat Estimated weight loss:6,000 ÷ 3,500 ≈ 1.7 pounds

JR is going to stay home for Thanksgiving and decided to prepare a fantastic dinner. JR has type 1 diabetes and injects bolus insulin before each meal. JR takes 1 unit of insulin for each 10 gms of carbohydrates. Using myfitnesspal to calculate JRs carb intake for the following festive meal, how much insulin would JR need to take? ½ cup cranberry sauce ½ cup mashed potatoes ½ cup of buttered corn 1 small dinner roll A big scoop of green beans 4 ounces of turkey breast ½ cup of stuffing 5 ounces Vendagne Chardonnay A. 11.8 units. B. 12.3 units. C. 11 units. D. 10.8 units. E. I have no idea, pass the pumpkin pie.

C. 11 units. Rationale: The most important feature of this question is "how much insulin would JR need to inject?" Since he is injecting insulin, no syringe or pen would allow him to inject 1/10th of a unit. Based on this info, the only plausible answer is 11 units or answer 3. But, for fun, here is the carb calculation. JR will be eating 109 gms of carb. His insulin to carb ratio is 1/10. 109 / 10 = 10.9 units of insulin, then round up to 11 units. ½ cup cranberry sauce - 40 gms ½ cup mashed potatoes - 15 gms ½ cup of buttered corn - 11gms 1 small dinner roll - 15 gms A big scoop of green beans - 7gms 4 ounces of turkey breast - 0 ½ cup of stuffing - 21 gms 5 ounces Vendagne Chardonnay - Total carb = 109 gms Insulin needed 109 / 10 = 10.9 units. Then round up to 11 unit injection.

SZ has type 1 diabetes and uses an insulin pump. SZ wants to celebrate her 21st birthday with friends and asked about drinking alcohol. Which of the following is a correct statement? A. since alcohol causes hyperglycemia, make sure to avoid mixed drinks. B. check glucose 1-2 hours post drink to see if extra insulin is needed. C. 5 oz of wine is about one serving of alcohol. D. White wine affects blood glucose more than red wine.

C. 5 oz of wine is about one serving of alcohol. Standard alcohol serving sizes: Beer: 12 oz Wine: 5 oz Liquor: 1.5 oz of 80-proof spirits This is important for someone with diabetes to understand how much alcohol they're consuming. ❌ Why the other options are incorrect: A. Since alcohol causes hyperglycemia, make sure to avoid mixed drinks. ❌🔻 Incorrect. Alcohol does not cause hyperglycemia — it more commonly leads to hypoglycemia, especially several hours after drinking.Mixed drinks can spike blood sugar due to added sugar in mixers, but the main concern with alcohol itself is low blood sugar, not high. B. Check glucose 1-2 hours post drink to see if extra insulin is needed. ❌🔻 Incorrect. Alcohol can lower blood glucose, especially several hours after drinking, by impairing the liver's ability to release glucose.Giving extra insulin can be dangerous. The focus should be on monitoring for hypoglycemia, not adding insulin. D. White wine affects blood glucose more than red wine. ❌🔻 Not a general rule. The impact on blood glucose varies more with sugar content, not the color of the wine. Dry wines (white or red) have minimal carbs; sweet wines can raise blood sugar. There's no consistent evidence that white wine affects glucose more than red.

Based on the new ADCES (formerly AADE) recommendations regarding language in diabetes care and education, which of the following statements best reflect the preferred approach when addressing people living with diabetes? A. Diabetic person living with diabetes can live long healthy lives by taking charge of their blood sugar level B. You can control your diabetes by making small changes in your daily life C. Testing your blood sugar empowers your self-care decisions. D. In our diabetes program, we will share strategies to help you manage your diabetes.

D. In our diabetes program, we will share strategies to help you manage your diabetes. It uses collaborative, nonjudgmental language, inviting participation ("we will share strategies") rather than commanding or implying failure. It replaces "control" with "manage," aligning with ADCES's move away from blame-focused terminology. It still centers the person's experience ("help you manage your diabetes") and fosters partnership.

JR is 78, lives alone and manages their diabetes with bolus insulin at breakfast and dinner and basal insulin at night. For the past few months, JR has had trouble remembering to take insulin with meals and JR's most recent A1c is above 9%. Which of the following is most likely contributing to this change of behavior for JR? A. Increased frequency of hypoglycemia. B. Nonalcoholic fatty liver disease. C. Alzheimer dementia. D. Adjustment of statin dose.

C. Alzheimer dementia. Explanation: Memory issues and difficulty with routine tasks like taking insulin on time in an elderly person can indicate cognitive decline or dementia, including Alzheimer's disease. Poor adherence due to memory problems is common in dementia and can worsen glycemic control. ❌ The other options are less likely to directly cause forgetting insulin doses: A. Increased hypoglycemia might cause fear or dose adjustment but not necessarily forgetting. B. Nonalcoholic fatty liver disease usually does not impair memory. D. Adjustment of statin dose would not typically cause memory loss or forgetting medications.

JT, a 17-year-old recently hospitalized with a new diagnosis of type 1 diabetes, is using Multiple Daily Injections (MDI) therapy. JT uses fingerstick blood glucose monitoring but wants to move to a CGM. JT's mother wants to know how long fingerstick monitoring must be used before a CGM can be started. According to the ADA 2025 Standards of Care, when can a CGM be initiated after a type 1 diabetes diagnosis? A. CGM is to be initiated when an individual with type 1 diabetes does not meet glycemic targets. B. CGM is to be initiated only when an individual with type 1 diabetes is started on continuous subcutaneous insulin infusion (CSII) therapy. C. CGM can be initiated when an individual with type 1 diabetes is ready and able, and the individual or caregiver has been educated on its use, even at diagnosis. D. CGM is to be initiated when an individual with type 1 diabetes is over the age of 18.

C. CGM can be initiated when an individual with type 1 diabetes is ready and able, and the individual or caregiver has been educated on its use, even at diagnosis. Rationale: According to the American Diabetes Association (ADA) 2025 Standards of Care, continuous glucose monitoring (CGM) is recommended for all individuals with type 1 diabetes, including children, adolescents, and adults, and it can be initiated as early as diagnosis if: The individual is ready and able to use the device. The individual or caregiver has received appropriate education and training on how to use the CGM. This aligns with a person-centered approach and emphasizes early access to technology to improve outcomes and quality of life. ❌ Why the other options are incorrect: A. Only when glycemic targets are not met - ❌ Incorrect. Early CGM use is encouraged regardless of glycemic control. B. Only with CSII therapy - ❌ CGM can be used with MDI or pump therapy. D. Only over age 18 - ❌ CGM is approved and recommended for children, including those younger than 18.

JL is a 78-year-old with type 2 diabetes who has been taking metformin 1000mg BID for the past year. She checks her BG each morning and says it usually ranges from 100 - 138. Her most recent A1c came back at 9.6% and the provider started her on dapagliflozin (Farxiga) 5 mg daily two days ago. JL arrives at the clinic in a panic and says she has been checking her blood glucose 3 times a day it has "jumped up to 236 and 242". The diabetes specialist double-checked and verified random glucose of 249. What is the best explanation? A. Dapagliflozin is associated with transient hyperglycemia. B. Double-check kidney function to verify GFR is adequate. C. Discovery of hyperglycemia due to random BG checks. D. Hyperglycemia due to the initiation of steroid therapy.

C. Discovery of hyperglycemia due to random BG checks. Rationale: JL previously only checked fasting blood glucose, which ranged from 100-138 mg/dL — this may have missed high postprandial (after-meal) blood glucose values. Her A1c is 9.6%, indicating an average glucose around 230 mg/dL, which does not align with her fasting numbers. This suggests hyperglycemia at other times of the day was previously undetected. After starting Farxiga (dapagliflozin) and increasing monitoring to 3x/day, she is now seeing those previously hidden postprandial highs, which aligns with her elevated A1c. This is a discovery of existing hyperglycemia, not a new problem caused by the medication. ❌ Why not the others? A. Dapagliflozin is associated with transient hyperglycemia: Incorrect. Dapagliflozin typically lowers blood glucose, not raises it. B. Double-check kidney function: While kidney function is important for SGLT2 inhibitors, it's not the explanation for the sudden discovery of high glucose readings. D. Hyperglycemia due to steroids: There is no mention of JL being on steroids.

A 10-year-old child with newly diagnosed type 1 diabetes is being discharged from the hospital. Which of the following components is most critical to include in the initial outpatient diabetes management plan to reduce the risk of diabetic ketoacidosis (DKA) and hospital readmission? A. Initiate basal insulin therapy and MNT instruction, with follow-up in two weeks. B. Provide basic carbohydrate counting and bolus insulin instruction with a follow-up appointment within 30 days. C. Establish follow up with a specialist within a week and provide actions to take in case of glucose emergencies. D. Prescribe continuous glucose monitoring (CGM) and glucagon rescue medication and ask family to schedule a follow-up appointment after the sensor is delivered and set up.

C. Establish follow up with a specialist within a week and provide actions to take in case of glucose emergencies. Rationale: For a newly diagnosed 10-year-old with type 1 diabetes, early outpatient management is critical to prevent DKA and readmission. The most important elements include: Timely follow-up with a pediatric endocrinologist or diabetes care team within 1 week, which is recommended by the American Diabetes Association (ADA) and ISPAD guidelines. Clear education on recognizing and managing glucose emergencies (hypoglycemia and hyperglycemia), which empowers families to intervene early and avoid complications. While insulin initiation, nutrition therapy, carbohydrate counting, CGM, and glucagon prescription are also important, none of the other choices provide both timely follow-up and emergency management guidance, which are the most essential components for immediate safety and stabilization. ❌ Why the other options are less appropriate: A: Two-week follow-up is too delayed, and focusing only on basal insulin omits bolus insulin, which is vital for type 1 diabetes. B: A 30-day follow-up is much too long; it significantly increases the risk of DKA and complications. D: While CGM and glucagon are important tools, waiting for CGM setup before follow-up delays care and does not prioritize immediate emergency education or timely specialist evaluation.

RT is a 49-year-old with type 1 diabetes, admitted to a local hospital to treat Diabetes Ketoacidosis (DKA). RT is on an insulin drip, fluids and potassium replacement therapy and is getting hungry. The IV insulin is running at 2 units an hour and the RTs usual insulin dose at home is 12 units glargine at bedtime and 3-4 units of lispro before meals. Before stopping the IV insulin, what is the most important action? A. Maintenance of glucose less than 200 for at least 4 hours. B. Give 3 units of bolus insulin via IV and at least 6 units of glargine. C. Evaluate labs to make sure that RT is ketone negative. D. Determine if potassium replacement is still needed.

C. Evaluate labs to make sure that RT is ketone negative. Rationale: In the management of Diabetic Ketoacidosis (DKA), the primary goal is to correct metabolic derangements—especially ketoacidosis—not just blood glucose. Even if the blood glucose is normalized, stopping insulin before resolution of ketosis can lead to recurrent DKA. Key criteria before stopping IV insulin (ADA Guidelines): 1. Glucose < 200 mg/dL 2. AND two of the following: - Serum bicarbonate ≥ 15 mEq/L - Venous pH > 7.3 - Anion gap closed (typically ≤ 12) - Ketone clearance (usually measured via serum β-hydroxybutyrate or urine ketones) So the most critical action is confirming that ketones have cleared, signaling resolution of ketoacidosis, not just hyperglycemia. ❌ Why the other choices are incorrect: A. Maintenance of glucose < 200 for 4 hours→ Important, but not sufficient. Ketones may still be elevated despite normal glucose. B. Give 3 units of bolus insulin via IV and at least 6 units of glargine→ Not a standard practice. You do give subcutaneous long-acting insulin (like glargine) before stopping the drip, but the timing and dose depends on patient-specific factors. You must first confirm DKA is resolved. D. Determine if potassium replacement is still needed→ Potassium management is important during treatment, but it's not the key factor in deciding when to stop IV insulin.

LS is a 16-year-old with type 1 diabetes for the past 3 years. The most recent A1c is 9.3%. LS covers carbs using a 1:15 carb/insulin ratio and takes basal insulin at night. After the parents leave the room, LS tells you they are so tired of checking blood sugars and taking insulin four times a day, sometimes they just "fake it." What is the most appropriate action? A. Gently remind LS that not taking insulin on a regular basis can lead to complications. B. Download their meter results and ask them to start logging their carbs and insulin. C. Explore the possibility of trying Continuous Glucose Monitoring. D. Bring the parents in for a family meeting to stress the importance of getting A1c to goal.

C. Explore the possibility of trying Continuous Glucose Monitoring. LS is expressing diabetes burnout, which is common in teens managing type 1 diabetes. LS is already admitting to faking adherence due to fatigue with the routine. Rather than scolding or increasing demands (like logging more), a supportive, empowering solution is needed. Continuous Glucose Monitoring (CGM) can reduce the burden of finger sticks and provide real-time feedback, which may improve engagement, safety, and glycemic control. ❌ Why not the other options? "Gently remind LS..." - While education is important, LS already knows the risks and is overwhelmed; this could feel like guilt-tripping. "Download their meter results and ask them to start logging..." - More tasks may worsen burnout. "Bring the parents in..." - Not appropriate at this moment. LS confided privately, so preserving trust is key.

JR has prediabetes and is worried about his LDL cholesterol of 128 mg/dl, he asks you what changes would help to decrease his LDL. Which of the following is the best response? A. Decrease consumption of beef and pork B. Increase consumption of chicken and white meats, decrease intake of red meats. C. Increase consumption of Fiber rich food and decrease consumption of meat and dairy products. D. Eliminate all fat from diet.

C. Increase consumption of fiber-rich food and decrease consumption of meat and dairy products. Why C is best: Soluble fiber (found in oats, beans, lentils, fruits, and vegetables) helps lower LDL cholesterol by binding cholesterol in the digestive system. Reducing saturated fat intake from meat and dairy also helps lower LDL levels. This option provides evidence-based, comprehensive dietary guidance aligned with heart-healthy recommendations. ❌ Why the other options are less ideal: A. Decreasing beef and pork is helpful, but the recommendation is too narrow. B. Chicken and white meats may be lower in saturated fat, but this still includes animal fats, and does not mention fiber, which is critical for lowering LDL. D. Eliminating all fat is not recommended — healthy fats (like those in nuts, seeds, and fish) are beneficial and essential.

Which phrase represents the principles for communicating with and about people living with diabetes? A. John is non-adherent to his insulin regimen and is not taking his insulin as prescribed B. John is in denial about his diabetes and frequently skips his insulin C. John is taking his insulin about 50% of the time. D. John doesn't seem to care about his diabetes control at this time.

C. John is taking his insulin about 50% of the time. Here's why: This phrase reflects the ADCES (formerly AADE) and ADA recommendations for using neutral, factual, and nonjudgmental language when communicating about people living with diabetes. It: Describes behavior objectively without assigning blame. Avoids stigmatizing terms like "non-adherent," "in denial," or "doesn't care." Focuses on observable facts rather than assumptions or labels. ❌ Why the others are less preferred: A: "Non-adherent" is judgmental and implies willful failure. B: "In denial" is a psychological label that may not reflect the individual's reality and comes across as dismissive. D: "Doesn't seem to care" assumes intent and lacks empathy or a strengths-based perspective.

According to ADA standards of care, if the person living with diabetes is on the maximum dose of Metformin with a history CV disease and their A1c is not a target, which of the following medications should be added next? A. Sitagliptin (Januvia) B. Basal insulin C. Liraglutide (Victoza) D. Glipizide (Glucotrol)

C. Liraglutide (Victoza) Explanation: According to the American Diabetes Association (ADA) Standards of Care, if a person with type 2 diabetes is: Already on maximum dose of metformin Has established atherosclerotic cardiovascular disease (ASCVD) And their A1c is still not at target Then the preferred next agent is a medication with proven cardiovascular benefit. ✅ Why Liraglutide (Victoza): It is a GLP-1 receptor agonist with strong evidence for reducing major adverse cardiovascular events (MACE) in people with type 2 diabetes and ASCVD. ADA guidelines recommend GLP-1 RAs (like liraglutide, semaglutide, and dulaglutide) or SGLT2 inhibitors for patients with ASCVD independent of A1c. ❌ Why the other options are less appropriate: A. Sitagliptin (Januvia): A DPP-4 inhibitor with neutral cardiovascular outcomes — not preferred in patients with ASCVD. B. Basal insulin: Typically reserved for later stages or when glycemic targets aren't met with oral or non-insulin injectable agents. Insulin has no cardiovascular benefit. D. Glipizide (Glucotrol): A sulfonylurea with risk of hypoglycemia and weight gain, and no cardiovascular benefit.

AR is 16 years old and is struggling with weight. AR was diagnosed with type 2 diabetes and has met with the dietitian and diabetes specialist. In spite of eating healthier and a 3% weight loss, AR's A1c is increasing and is currently 7.6%. The provider decides to start AR on medication. Which of the following FDA approved medications should the provider prescribe? A. Metformin or SGLT-2 Inhibitor B. Basal insulin or sulfonylurea C. Liraglutide (Victoza) or Metformin D. Basal-bolus insulin

C. Liraglutide (Victoza) or Metformin In adolescents with type 2 diabetes, the FDA has approved only a few medications. The first-line medication is Metformin, and Liraglutide (Victoza) is another FDA-approved option for those aged 10 years and older when glycemic control is not achieved with lifestyle changes and Metformin alone. Medication Overview for Youth with T2D: Metformin - First-line treatment - FDA-approved for use in children ≥10 years old Liraglutide (Victoza) - A GLP-1 receptor agonist - FDA-approved for children ≥10 years old with type 2 diabetes - Helps with both glucose control and weight loss Insulin (basal or basal-bolus) - Used when A1c is significantly elevated (≥9%) or if there are symptoms of hyperglycemia SGLT-2 Inhibitors and Sulfonylureas - Not FDA-approved for use in youth under 18 with type 2 diabetes

According to the ADA standards of care, which of the following complementary therapies are recommended for older individuals with type 2 diabetes? A. Cinnamon. B. St. John's wort C. None D. Chromium

C. None Explanation: According to the American Diabetes Association (ADA) Standards of Care, no complementary therapies such as cinnamon, St. John's wort, or chromium are currently recommended for the treatment of type 2 diabetes in older adults due to: Lack of consistent evidence supporting their effectiveness Potential interactions with diabetes medications Safety concerns, especially in older populations who may have comorbidities or be on multiple medications (polypharmacy) ❌ Why the others are incorrect: A. Cinnamon: Some studies suggest a possible mild effect on blood glucose, but results are inconsistent, and it is not officially recommended by the ADA. B. St. John's Wort: Commonly used for depression, but it can interact dangerously with many medications, including those used for diabetes. D. Chromium: Has been studied, but evidence is insufficient to recommend routine use.

AR likes to take a "hand-on" approach to learning. Which one of these interventions would acknowledge this preference? A. Have them turn on and watch a video on glucose monitoring. B. Ask them to join the support group and address their questions to the group C. Provide a package with a label and have them determine how many grams of carb per serving D. Ask them to create a sick day management kit and bring it to the next appointment

C. Provide a package with a label and have them determine how many grams of carb per serving Determining carbohydrate content using a food label involves active engagement with real-world materials, which supports a hands-on or tactile learning style. It requires manipulating an object, analyzing the label, and applying numeracy — all of which are interactive and practical. This kind of task reflects real-life decision-making and reinforces functional skills in diabetes self-management.

JR is 49 with type 2 diabetes and is admitted to the hospital for congestive heart failure. His home diabetes medication includes metformin 2000 mg daily. GFR is 53 and JR's A1c is 8.1%. Upon discharge, which class of medication is recommended, according to the AACE Guidelines, in addition to the metformin to improve outcomes? A. Sulfonylurea. B. Meglitinide. C. SGLT-2 Inhibitor. D. Basal insulin.

C. SGLT-2 Inhibitor. According to the AACE (American Association of Clinical Endocrinology) Guidelines, for patients with type 2 diabetes and heart failure, SGLT-2 inhibitors are recommended in addition to metformin due to their proven cardiovascular and heart failure benefits, including: - Reducing hospitalization for heart failure - Lowering cardiovascular risk - Preserving kidney function ❌ Why not the others? A. Sulfonylurea: Increases risk of hypoglycemia, no cardiovascular benefit. B. Meglitinide: Short-acting secretagogue with no CV benefit, rarely used. D. Basal insulin: May be used if A1c is very high, but it's not the preferred second-line in this situation with heart failure and an A1c of 8.1%.

JR is 63, has diabetes and has a B/P of 162/94 which is repeated on a separate visit. JR also has albuminuria. What would be the recommended pharmacological approach based on the ADA Standards of Care? A. Start on DASH Diet plus one blood pressure medication. B. Start ACEi plus ARB. C. Start ACEi or ARB plus another blood pressure medication. D. Avoid diuretics if on an ACEi or ARB.

C. Start ACEi or ARB plus another blood pressure medication. Rationale (based on ADA Standards of Care): JR has confirmed hypertension (≥160/100 mmHg) and albuminuria (a marker of kidney damage). According to the ADA guidelines, if a person with diabetes has a blood pressure ≥160/100 mmHg, it is recommended to start two antihypertensive agents—one of which should be an ACE inhibitor or ARB, especially in the presence of albuminuria. The goal is to lower blood pressure more effectively and protect kidney function. ❌ Why not the others? A. DASH diet plus one med: Lifestyle changes are important but not sufficient when blood pressure is this high. This option under-treats the situation. B. ACEi plus ARB: Not recommended due to increased risk of hyperkalemia, hypotension, and kidney injury. D. Avoid diuretics if on ACEi/ARB: Incorrect—thiazide diuretics are commonly used alongside ACEi or ARBs, especially in cases of resistant or stage 2 hypertension.

MS is 63, has type 1 diabetes, and will be having knee surgery. In addition to using an insulin pump and CGM to manage their type 1 diabetes, MS also takes empagliflozin (Jardiance) 25 mg daily to improve glucose levels. In preparation for the upcoming surgery, which of the following is an accurate statement? A. Transition to insulin injections in preparation for surgery. B. Maintain perioperative glucose between 80-110. C. Stop empagliflozin (Jardiance) 3 days prior to surgery. D. Reduce basal insulin by half the night before surgery.

C. Stop empagliflozin (Jardiance) 3 days prior to surgery. ✅ Explanation: SGLT-2 inhibitors like empagliflozin (Jardiance) are associated with an increased risk of euglycemic diabetic ketoacidosis (DKA), particularly in settings of stress such as surgery, prolonged fasting, or acute illness. To minimize this risk, the American Diabetes Association (ADA) and surgical guidelines recommend stopping SGLT-2 inhibitors at least 3 days before surgery. ❌ Why the other options are incorrect: A. Transition to insulin injections: Not necessarily required. Patients on pumps may continue them during minor surgeries if safely managed, though some cases warrant switching to injections. It's not the first or most accurate recommendation. B. Maintain glucose 80-110: This target is too tight and increases the risk of hypoglycemia. Current ADA recommendations suggest a perioperative glucose target of 80-180 mg/dL. D. Reduce basal insulin by half: Insulin adjustments depend on individual needs and fasting periods, but blanket reductions can risk hyperglycemia or DKA in type 1 diabetes. This is not a standard or recommended approach without further evaluation.

BK is an 11 year old with a new diagnosis of type 2 diabetes. Both of her mom and dad are present for their first MNT appointment. BK's body weight is over the 100th percentile for her age. Which of the following would be beneficial for the educator to say or ask? A. Have you tried eating three meals a day? B. According to your records, weight is an issue that you have dealt with for a long time. C. What do you eat and drink on a typical day? D. if we don't get your weight to target, the provider may need to start you on medications.

C. What do you eat and drink on a typical day? Explanation: This open-ended, nonjudgmental question helps the educator: Build rapport with both BK and her parents Understand current habits without assigning blame Initiate a collaborative, patient-centered conversation It aligns with motivational interviewing principles and the ADCES guidance on respectful, strength-based language in diabetes education. ❌ Why the others are not ideal: A. ❌ Assumes BK isn't eating three meals and may come across as prescriptive without exploring current behaviors first. B. ❌ This phrase may feel blaming or shaming, especially in front of her parents, and isn't forward-focused. D. ❌ Puts pressure on weight as the only factor and may increase anxiety or resistance; medication decisions are multifactorial and should be addressed with shared decision-making.

JR is in stage 3 kidney failure with a GFR of 48. JR's primary care provider instructed them to see a RD, CDCES to learn how to limit protein intake. what is the best response? A. it is hard to limit your protein intake, but it gets easier over time. B. Limiting protein is an important step to preserving kidney function to prevent creatinine levels from increasing. C. we used to think limiting protein was helpful, but new research has brought that into question. D. it's been demonstrated that animal protein can accelerate kidney failure.

C. we used to think limiting protein was helpful, but new research has brought that into question. In the past, protein restriction was commonly recommended for people with CKD to slow the progression of kidney disease. However, more recent research — including guidelines from the National Kidney Foundation (KDOQI) and American Diabetes Association (ADA) — suggests that: Very low-protein diets do not significantly improve outcomes in non-dialysis CKD. The focus should now be on individualized nutrition plans rather than across-the-board protein limitation. Overly restricting protein can lead to malnutrition, especially in older adults or those with diabetes. Instead of rigid restriction, the current emphasis is on: High-quality protein sources Balanced intake tailored to the person's needs and nutritional status Other dietary factors like phosphorus, potassium, and sodium may play a bigger role depending on labs and symptoms ❌ Why the other choices aren't the best: A. Too vague and not educational B. 🔴 Outdated: It overstates the benefit of protein restriction for CKD stage 3 and may cause unnecessary fear. D. 🔴 Oversimplified and misleading: It wrongly blames animal protein as a blanket issue; quality and quantity both matter.

MJ takes 25 units of glargine at HS. She also takes lispro 5 units at each meal. Her A1c is 6.3%. Due to new insurance coverage she can't afford the insulin copay anymore. Her provider agrees to switch her to 70/30 (NPH/Regular Insulin) twice daily. What would be her new dose of 70/30 BID? A. 30 units am, 15 units before dinner B. 35 units am, 5 units at nighttime C. 25 units am, 10 units lunch and 10 units at dinner D. 20 units am and 12 units before dinner

D. 20 units am and 12 units before dinner When switching a patient from a basal-bolus insulin regimen (like glargine + lispro) to pre-mixed insulin (like 70/30 NPH/Regular), a common strategy is: 1. Calculate the total daily dose (TDD) of current insulin. 2. Reduce the TDD by ~20% to lower hypoglycemia risk during the transition. 3. Split the adjusted TDD into 2/3 in the morning and 1/3 in the evening. Step-by-step for MJ: Current insulin: Basal (glargine): 25 units Bolus (lispro): 5 units × 3 meals = 15 units Total Daily Dose (TDD) = 25 + 15 = 40 units Reduce by ~20% to safely transition to mixed insulin: 40 units × 0.8 = 32 units Split 32 units as follows: 2/3 in the morning: ~21 units 1/3 in the evening: ~11 units Closest available choice:

LS uses an insulin pump and the 500 rule for carbohydrate coverage. For breakfast, LS plans to eat ½ cup of oatmeal, 3/4 cup of blueberries, a cup of skim milk, a tablespoon of peanut butter, and a cup of coffee with a packet of Splenda. Her insulin to carb ratio is 1 to 12 for breakfast and lunch. Her insulin to carb ratio is 1 to 15 for dinner. How much insulin does LS need for breakfast? A. 3.0 units B. 2.8 units C. 4.0 units D. 3.5 units

D. 3.5 units Step 1: Estimate Total Carbohydrates in the Meal Here's a breakdown of the approximate carbohydrate content of each food item: ½ cup oatmeal ≈ 15 g carbs ¾ cup blueberries ≈ 15 g carbs 1 cup skim milk ≈ 12 g carbs 1 tbsp peanut butter 0 g carbs 1 cup coffee with Splenda ≈ 0 g carbs Total = 15 + 15 + 12 + 0 + 0 = 42 g carbs Step 2: Use the Insulin-to-Carb Ratio Breakfast insulin-to-carb ratio is 1 unit per 12 g carbs. Now calculate: 42 g carbs/12 g/unit=3.5 units

LS is 79 years old and their most recent A1c is 7.4%. LS takes metformin 1000 mg twice daily and sitagliptin (Januvia) plus 14 units of basaglar at before sleep at 2am. LS is excited that they started using a Freestyle Libre sensor and shows you the glucose trends. You notice that glucose levels rise to 250 - 350 in between noon to 4pm. What is the next best action? A. Start bolus insulin at breakfast. B. Increase basal insulin by 20%. C. Add a low dose sulfonylurea. D. Assess food timing and content.

D. Assess food timing and content. LS is an older adult (age 79) with type 2 diabetes, already on: - Metformin - lowers hepatic glucose output - Sitagliptin (Januvia) - improves post-meal insulin secretion - Basaglar (long-acting insulin) - targets fasting and between-meal glucose Despite these, LS is experiencing hyperglycemia between noon and 4 PM (250-350 mg/dL), not overnight or fasting, and the trend is visible on their Freestyle Libre sensor. Rationale: Glucose spikes in this window are most often postprandial, likely related to lunch or snacks. Before intensifying therapy, especially with older adults, it's essential to: - Review meal timing (Is lunch at 11 AM? Snacking later?) - Check carbohydrate load and glycemic index - Evaluate if high-sugar foods or large meals are being consumed. This approach follows ADA and ADCES guidelines to use continuous glucose monitoring (CGM) data to inform lifestyle and behavioral interventions first. ❌ Why not the others (yet): A. Start bolus insulin at breakfast - Not the right timing. The spike is after lunch, not breakfast. Also, adding mealtime insulin to an older adult requires caution due to hypoglycemia risk. B. Increase basal insulin by 20% - Basal insulin should cover fasting and background needs, not post-meal rises. Increasing it to fix post-lunch highs can cause overnight lows, especially since LS takes it at 2 AM. C. Add a low dose sulfonylurea - Sulfonylureas stimulate insulin regardless of meals and can increase hypoglycemia risk, especially in older adults. This class is generally avoided in geriatric patients unless other options are exhausted.

What is the common educator or provider barrier to care for the LGBTQ population? A. being aware of personal biases B. understanding those in a same-sex relationship may be concerned how an illness or its treatment will have on fertility. C. knowing that all people seeking care may wish to discuss relationship issues. D. Assuming person is straight or belongs to the LGBTQ population.

D. Assuming person is straight or belongs to the LGBTQ population. ❌ Why the other options are incorrect: A. Being aware of personal biases ❌ This is actually a strength or facilitator, not a barrier.A provider who is aware of their own biases is better equipped to provide affirming, equitable care — so this is not a barrier, but part of the solution. B. Understanding those in a same-sex relationship may be concerned how an illness or its treatment will have on fertility.❌ This is not a barrier, but rather an example of cultural competence or sensitivity that providers should have. C. Knowing that all people seeking care may wish to discuss relationship issues.❌ Again, this reflects good practice, not a barrier. It emphasizes treating LGBTQ individuals as whole people, but isn't itself a challenge providers typically face.

Which medication class(es) place asymptomatic people at increased risk of developing hyperglycemia? A. Atypical antipsychotics B. Glucocorticoids C. Aspirin D. Both A and B

D. Both A and B Rationale: ✅ Atypical Antipsychotics Examples: Olanzapine, Risperidone, Quetiapine Can cause insulin resistance, weight gain, and impaired glucose metabolism Associated with new-onset diabetes and worsening of existing hyperglycemia ✅ Glucocorticoids Examples: Prednisone, Dexamethasone Increase hepatic glucose production and peripheral insulin resistance Often cause transient or persistent hyperglycemia, especially in people with prediabetes or other risk factors ❌ Aspirin Does not cause hyperglycemia In fact, low-dose aspirin has sometimes been studied for its potential protective effects in cardiovascular health for people with diabetes, but it does not affect glucose metabolism directly

JR has type 2 diabetes and an A1c of 9.4%. He is on 3 medications for diabetes and now needs to start insulin. JR says, "I just don't know if insulin would help me. My brother took insulin and he had all kinds of problems." What best describes JR's stage of change using the transtheoretical model? A. Denial. B. Bargaining. C. Avoidance. D. Contemplation.

D. Contemplation Rationale: In the transtheoretical model (stages of change), the contemplation stage is when a person is aware of the need to change and is considering it, but also has ambivalence or concern. JR acknowledges the discussion of insulin ("I just don't know if insulin would help me"). He expresses doubt or fear based on his brother's experience ("he had all kinds of problems"). This indicates he is thinking about insulin, but not ready to act—a hallmark of contemplation. ❌ Why not the others? A. Denial: JR is not denying the need for insulin; he's questioning its value or safety. B. Bargaining: Bargaining is more applicable in grief stages, not the transtheoretical model. C. Avoidance: He is engaging in the conversation, not avoiding it—so this doesn't fit.

LS states that she is drinking 3 beers at night after dinner. She is on glargine (Lantus) 30 units at HS and 10 units lispro (Humalog) at each meal. Her GFR is 57 and her LDL is 93. What is your biggest concern? A. Chronic alcohol consumptions contribution to LDL cholesterol B. Increased risk of kidney failure secondary to alcohol intake C. Inability to withdraw insulin dose accurately at bedtime D. Decreased glycogenolysis increasing hypoglycemia risk

D. Decreased glycogenolysis increasing hypoglycemia risk 🔍 Explanation: LS drinks 3 beers nightly, is on basal (glargine) and bolus (lispro) insulin, and has a GFR of 57 (mildly decreased kidney function). ✅ Why D is correct: Alcohol inhibits gluconeogenesis (liver's ability to make glucose), especially when the liver is metabolizing alcohol. Glycogenolysis (breaking down stored glycogen) is also impaired with alcohol intake, especially during fasting/sleeping hours. Drinking alcohol without food increases risk of delayed or prolonged hypoglycemia, especially overnight. LS takes insulin at night, which increases this risk even more. Thus, the biggest concern is increased risk of hypoglycemia due to impaired hepatic glucose output during alcohol metabolism. ❌ Why the other options are incorrect: A. Chronic alcohol consumption's contribution to LDL cholesterol. While alcohol can impact lipids, her LDL is 93 (within target) — not the biggest concern. B. Increased risk of kidney failure secondary to alcohol intake. Her GFR is 57 — early stage CKD. Alcohol is not a primary cause of kidney failure unless in massive excess or due to comorbidities (e.g., hypertension). Not the top concern. C. Inability to withdraw insulin dose accurately at bedtime. No evidence in this scenario of dexterity or cognitive problems affecting insulin administration.

MT is 59 and her most recent A1c was 10.3%. The diabetes specialist suggested they add insulin to her other 3 oral diabetes medications to lower A1c. MT was not ready for insulin, so the specialist agreed that they would try adding on glipizide 5mg BID and evaluate the response for one month. After 2 weeks, MT calls and is very upset about her frequent low blood sugars (66, 68, 69) that are happening between 3pm and 6pm a few times a week. MT works in the field starting at 5am and gets her lunch break at 10am and eats her dinner again at 6pm. Which of the following is the best recommendation? A. Hold the glipizide for one week. B. Make sure MT has a glucagon emergency kit in the field. C. Inform her that she is protected under the American Disabilities Act. D. Encourage a 2 pm carbohydrate snack

D. Encourage a 2 pm carbohydrate snack Rationale: MT is experiencing mild hypoglycemia (66-69 mg/dL) in the afternoon (3-6 PM). This timing corresponds to the peak action of glipizide, a sulfonylurea that stimulates insulin secretion regardless of food intake. Additionally: She takes glipizide 5 mg BID - likely first thing in the morning and at dinner Lunch is at 10 AM, and dinner isn't until 6 PM, creating a long fasting window (8 hours) So, the afternoon lows are likely due to: - Increased insulin secretion from glipizide, combined with - Long period without food, especially while being physically active during work Why a 2 pm carbohydrate snack is best: It provides glycemic support during the window when glipizide is active and glucose is falling. It's a non-invasive, practical first step before changing medications. It can be evaluated in follow-up to see if it prevents hypoglycemia. ❌ Why not the other options (yet): A. Hold the glipizide for one week→ This could be considered if the snack doesn't help or if the hypoglycemia worsens. But first, try adjusting timing of food to counteract med action. B. Make sure MT has a glucagon kit→ Glucagon is for severe hypoglycemia (e.g., unconsciousness). MT's readings are mild, and the priority is prevention, not emergency prep. C. Inform her she is protected under the ADA→ True in a general sense, but not a direct solution to this acute clinical issue.

AJ is 89 years old with type 1 diabetes and is a caretaker for a partner with dementia. AJ is on an insulin pump and uses a meter to check blood glucose level 4-7 times a day. AJ mentions that they were surprised the other morning that their blood glucose was 59 mg/dl and they felt fine. Based on this, what is the best action? A. Discuss the possibility of stopping pump therapy due to safety concerns. B. Make sure AJ checks blood glucose every one-to-two hours during the night. C. Encourage AJ to have a carb plus protein snack at bedtime. D. Evaluate pump settings to see if basal insulin adjustment is needed.

D. Evaluate pump settings to see if basal insulin adjustment is needed. Rationale: AJ's blood glucose was 59 mg/dL in the morning, which indicates possible overnight hypoglycemia. The fact that AJ didn't feel symptoms suggests hypoglycemia unawareness, which increases the risk of severe hypoglycemia—especially concerning for an older adult who is a caretaker and may not be able to respond to a low appropriately. The first step should be a careful review of the pump's basal rates, especially overnight, to prevent future lows. ❌ Why not the others? A. Stopping pump therapy: This is too extreme as a first step. Pump therapy is beneficial for type 1 diabetes and should only be stopped after evaluating and trying to correct settings. B. Checking every 1-2 hours overnight: This is unrealistic and burdensome, especially for an 89-year-old caregiver. Also not a long-term solution. C. Carb + protein snack at bedtime: This might help temporarily, but it treats the symptom, not the cause. Basal insulin may simply be too high overnight, which is what needs to be addressed.

According to the AACE guidelines for pharmacologic management of type 2 diabetes, when should insulin therapy be initiated? A. For person living with diabetes with a decreased c-peptide level. B. For person living with diabetes who is on maximum dose of metformin C. For person living with diabetes with diabetes duration of 10 years or greater D. For person living with diabetes with A1c of 9% and hyperglycemic symptoms.

D. For person living with diabetes with A1c of 9% and hyperglycemic symptoms. Explanation: According to the American Association of Clinical Endocrinology (AACE) guidelines for the pharmacologic management of type 2 diabetes: Insulin therapy should be initiated when a person presents with A1c ≥9% accompanied by symptoms of hyperglycemia, such as: Polyuria (frequent urination) Polydipsia (increased thirst) Unintentional weight loss Fatigue or blurred vision This situation suggests significant beta-cell dysfunction and possibly glucotoxicity, where immediate glycemic control is crucial — and insulin is the most effective and rapid-acting option. ❌ Why the other options are incorrect: A. Decreased c-peptide level: This suggests low insulin production, but c-peptide is not routinely used as a trigger for initiating insulin in standard type 2 diabetes care. B. On maximum dose of metformin: If metformin alone is insufficient, other non-insulin agents (GLP-1 RAs, SGLT2 inhibitors, etc.) are typically added before insulin unless the person is severely hyperglycemic or symptomatic. C. Diabetes duration ≥10 years: Duration alone is not an automatic trigger for insulin. Glycemic control, symptoms, and other clinical indicators are more important.

A person living with diabetes newly diagnosed with type 2 diabetes is started on metformin, metformin should be titrated to minimize which side effect? A. Rebound hyperglycemia B. Reactive hypoglycemia C. Weight gain D. Gastrointestinal-side effects

D. Gastrointestinal-side effects Rationale: Metformin is the first-line medication for type 2 diabetes and is generally well tolerated, but gastrointestinal (GI) side effects are the most common issue, especially during initiation. ✅ GI side effects include: Nausea, Diarrhea, Abdominal discomfort, Bloating To reduce these side effects, metformin is typically titrated slowly—starting at a low dose (e.g., 500 mg once daily) and gradually increasing over 1-2 weeks. ❌ Why the other options are incorrect: A. Rebound hyperglycemia: Metformin does not cause rebound hyperglycemia. B. Reactive hypoglycemia: Metformin does not cause hypoglycemia, especially when used alone. C. Weight gain: Metformin is usually weight-neutral or may cause modest weight loss, not gain.

BT has had type 1 diabetes for 12 years and is complaining of feeling full and sometimes nauseated after meals, especially after consuming salads. Which of the following conditions is BT most likely experiencing? A. Food intolerance syndrome. B. Celiac disease. C. Chron's disease. D. Gastroparesis.

D. Gastroparesis BT has had type 1 diabetes for 12 years and is now reporting: - Feeling full quickly - Nausea after meals - Worse symptoms after eating high-fiber foods like salads These are classic symptoms of gastroparesis, a condition where the stomach empties too slowly due to autonomic nerve damage, commonly caused by long-standing diabetes. ❌ Why not the others? A. Food intolerance syndrome - Would typically involve specific food triggers (e.g., lactose, gluten) and not necessarily be related to meal size or diabetes duration. B. Celiac disease - More likely to cause diarrhea, weight loss, or malabsorption, not post-meal fullness and nausea, and while it is more common in people with type 1 diabetes, the symptoms here point elsewhere. C. Crohn's disease - An inflammatory bowel disease with symptoms like abdominal pain, diarrhea, and weight loss; not just early satiety or nausea after meals.

PZ arrives for their diabetes appointment with their food diary and glucose log book. PZ blood glucose levels have improved since last visit by about 20 points, with morning glucose levels in the 130 range and bedtime glucose in the 180 range. When you ask PZ about what changes they have made, PZ shrugs their shoulders and says, "I quit eating tortillas because my children said they are bad for me." What is the best response? A. Good for you, giving up tortillas is really hard. B. Your children sound like they are worried about your health? C. Yes, we don't recommend tortillas since they are high in starch. D. How are you feeling about giving up tortillas?

D. How are you feeling about giving up tortillas? Explanation: This response uses open-ended, empathetic communication to explore PZ's feelings and motivations about the dietary change. It encourages PZ to reflect on the impact of this change, which can foster engagement and support for sustained behavior change. It avoids judgment or assumptions, and instead invites dialogue. ❌ Why other options are less ideal: A. Good for you, giving up tortillas is really hard.This assumes giving up tortillas was difficult, but PZ shrugged and didn't express that; it might feel insincere or presumptive. B. Your children sound like they are worried about your health?This shifts focus away from PZ's own experience and may make PZ feel sidelined. C. Yes, we don't recommend tortillas since they are high in starch.This is lecturing and may alienate PZ; it doesn't explore PZ's feelings or encourage self-reflection.

A 42-year-old woman arrives with an A1c of 10.3%, BMI of 32 and states she is ready to take better care of her type 1 diabetes. She uses a Freestyle Libre Sensor and takes 3-4 injections of insulin a day. Both her parents have type 2 diabetes and she says her diabetes was diagnosed after her third pregnancy. During this pregnancy, she had gestational diabetes and after delivery, her blood sugars never improved. Given this history, which of the following lab tests would clarify the best diabetes treatment plan? A. A1c and OGTT. B. Transglutaminase. C. TSH and T4. D. ICA, IAA, GAD.

D. ICA, IAA, GAD. Rationale: This patient's history raises suspicion for latent autoimmune diabetes in adults (LADA) or misdiagnosed type 2 vs type 1 diabetes: She was diagnosed with "type 1 diabetes" after gestational diabetes and persistent hyperglycemia postpartum. She is on multiple daily injections and using a CGM, suggesting intensive insulin management. But she also has obesity (BMI 32) and a strong family history of type 2 diabetes, which could suggest insulin resistance or a different type of diabetes. To clarify her true type of diabetes, testing autoantibodies is appropriate: ICA = Islet Cell Antibodies IAA = Insulin Autoantibodies GAD = Glutamic Acid Decarboxylase Antibodies These markers help differentiate type 1 diabetes (autoimmune) from type 2 diabetes or LADA, which is crucial for selecting the most appropriate treatment plan (e.g., how aggressively to use insulin or whether to consider adjunct oral agents). ❌ Why not the others? A. A1c and OGTT: She already has a known diagnosis and high A1c. OGTT isn't needed now. B. Transglutaminase: Used to screen for celiac disease, which can co-occur with type 1, but not relevant to clarifying diabetes type. C. TSH and T4: Thyroid screening is important in type 1 diabetes, but again, not useful for clarifying which type of diabetes she has.

JR can't figure out why his blood glucose is running over 180 mg/dl after breakfast. he takes 20 units of glargine (basaglar) at bedtime and 3 units of aspart (novolog) at each meal. which of the following is the most likely cause of post-breakfast hyperglycemia? what is the best response? A. Too much basal insulin B. Tebound hyperglycemia C. Dawn phenomena D. Insulin timing.

D. Insulin timing. JR is taking 3 units of rapid-acting insulin (aspart/Novolog) at meals, but if he's injecting immediately before or after eating, it may not have enough time to act on the carbohydrate load — especially at breakfast when insulin resistance is naturally higher due to morning hormones (like cortisol). Timing matters. Rapid-acting insulin should ideally be taken 10-15 minutes before meals to better match the glucose rise after eating. ❌ Why the other choices are less likely: A. Too much basal insulin ❌🔻 This would increase the risk of hypoglycemia, not hyperglycemia. JR is on 20 units of glargine at bedtime, which is reasonable for basal insulin in many adults. B. Rebound hyperglycemia (Somogyi effect) ❌🔻 This occurs when overnight hypoglycemia triggers a hormone response that raises blood sugar too high by morning. However, JR's issue is after breakfast, not upon waking. C. Dawn phenomenon ⚠️🔻 The dawn phenomenon refers to an early morning rise in blood glucose before eating, due to natural hormone release. Again, JR's blood sugar is specifically high after breakfast, not before it.

JR is 19 years old with type 1 diabetes and uses a continuous glucose monitor and insulin pump to manage their diabetes. For the past few months, JRs' ambulatory glucose profile (AGP) indicates that JR runs above 80% time in range and less than 2% low and 1% very low. JRs' most recent A1c was 6.1%. What is the diabetes specialist's best response? A. We just need to increase your time in range to 85%. B. An A1c of 6.1% is too low and can be dangerous. C. Great job. Now let's see if we can achieve 0% low and very low. D. It seems like using technology is helping you reach your goals.

D. It seems like using technology is helping you reach your goals. JR's glucose data indicates excellent diabetes management: >80% Time in Range (TIR) (70-180 mg/dL) ✅ <2% Low and 1% Very Low ✅ A1c of 6.1% ✅ Uses CGM and insulin pump ✅ These metrics exceed the ADA-recommended targets and indicate safe and effective diabetes control without excessive hypoglycemia. ❌ Why the other choices are incorrect: A. "Increase TIR to 85%" → ❌ While 85% is an ideal stretch goal, JR is already doing very well. Pushing for perfection may lead to burnout or unnecessary stress, especially when current control is excellent. B. "A1c of 6.1% is too low and dangerous" → ❌ Not necessarily. An A1c of 6.1% is not dangerous if there's no significant hypoglycemia. JR's low/very low time is <3%, which is safe. C. "Let's achieve 0% low and very low" → ❌ Unrealistic. A small amount of low glucose readings is typical and sometimes unavoidable. Aiming for exactly 0% could lead to higher average glucose and A1c, which may be counterproductive.

JR is 16 years old with type 1 using an insulin pump. his creatinine 0.8 and his GFR is greater than 60. JR is worried about getting kidney failure, since JR's mom needed dialysis due to diabetes. JR's blood pressure is 128/72. Based on ADA standards, what is the most appropriate recommendation for JR to prevent diabetes kidney disease? A. Start JR on an ACE-inhibitor to protect kidney B. limit protein intake C. Maintain blood pressure less than 120/70 D. Keep A1c on target.

D. Keep A1c on target. According to the American Diabetes Association (ADA) Standards of Care, the most important strategy to prevent the onset and progression of diabetic kidney disease (DKD) in people with type 1 diabetes is: ✅ Maintaining blood glucose in the target range (A1c on target). Tight glycemic control has been shown to significantly reduce the risk of microvascular complications, including nephropathy. ❌ Why the other options are incorrect: A. Start JR on an ACE-inhibitor to protect kidney ❌🚫 ADA recommends ACE inhibitors or ARBs only if the patient has hypertension or albuminuria.JR's blood pressure and kidney labs are normal, so there's no indication to start this medication. B. Limit protein intake ❌🚫 The ADA does not recommend restricting protein intake below the Recommended Daily Allowance (RDA) to prevent kidney disease. There's no evidence that protein restriction helps in those without existing kidney disease. C. Maintain blood pressure less than 120/70 ❌🚫 This is lower than the ADA's recommended target, which is <140/90 for most people with diabetes, or <130/80 for those at high cardiovascular or renal risk.JR's BP (128/72) is within target, and there's no need to lower it further at this time.

AR has type 2 diabetes and an A1c of 6.7%. AR takes glipizide 40mg a day, empagliflozin 25mg, and metformin 850mg three times a day. AR says that they keep waking up with headaches and blood sugars less than 80. AR decided to only take the metformin once daily to "feel better." What would be the best response? A. We don't recommend decreasing medications without provider approval. B. Good job taking charge of your diabetes. C. Are you also experiencing diarrhea? D. Let's consider decreasing the glipizide.

D. Let's consider decreasing the glipizide. AR is likely experiencing hypoglycemia, especially overnight, as indicated by: Waking up with headaches, a common symptom of nocturnal hypoglycemia. Blood sugars less than 80 mg/dL upon waking. Self-adjusting medications to avoid symptoms (i.e., reducing metformin). Medication Insight: Glipizide is a sulfonylurea, which increases insulin secretion and has a known risk of hypoglycemia, especially when the dose is high. 40 mg/day is at the maximum dose, and likely contributing to these low blood sugars. Metformin does not cause hypoglycemia, even at full dose. Empagliflozin (SGLT-2 inhibitor) may cause mild glucose lowering but is not the primary concern here.

JL has diabetes and injects insulin 2-3 times a day. JL is at a holiday party and is struggling with wanting a holiday spirit. Which of the following is the best approach for JL? A. JL is on insulin and needs to avoid alcohol. B. JL needs to take extra insulin to cover alcohol. C. Wine is a better choice than a margarita. D. For every alcohol drink, JL needs to eat 15 gms of carb. E. Both C & D.

E. Both C & D. Rationale: People with diabetes can drink alcohol safely in moderation, but there are important considerations—especially for those who take insulin: ✅ C. Wine is a better choice than a margarita Wine has fewer carbs (especially dry varieties) compared to sugary mixed drinks like margaritas, which can cause significant glucose spikes. ✅ D. For every alcoholic drink, JL needs to eat 15 gms of carb Alcohol can cause delayed hypoglycemia, especially in those taking insulin. Consuming carbohydrates with alcohol can help prevent this. General advice is to pair alcohol with food and monitor glucose levels closely. ❌ Why not the others? A. JL is on insulin and needs to avoid alcohol - ❌ Not true. Alcohol isn't strictly prohibited; it just requires careful management. B. JL needs to take extra insulin to cover alcohol - ❌ Alcohol usually doesn't need extra insulin and can lower blood sugar, especially with fasting or late at night.

JR was recently diagnosed with type two diabetes. JR's A1 C was 13.9%, but now blood sugars are running in the 100 to 180 range. JR mentions that they have been noticing "black spots" floating in their eyes. What is the best response by the diabetes specialist? A. This is an expected finding when blood sugars drop rapidly. B. On a scale of 1 to 10, how much are these spots affecting your daily quality of life? C. That must be really scary. Make sure to mention this at your next provider visit. D. Let's get you scheduled in to see ophthalmology.

D. Let's get you scheduled in to see ophthalmology. Explanation: "Black spots" floating in the vision can indicate floaters, which are often a symptom of diabetic retinopathy or vitreous hemorrhage. Given JR's very high initial A1c (13.9%) and recent rapid blood sugar improvement, they are at increased risk for diabetic retinopathy progression. Prompt ophthalmologic evaluation is necessary to diagnose and manage any diabetic eye complications early to prevent vision loss. While empathizing is important, the priority here is urgent referral to ophthalmology. ❌ Why other options are less ideal: A. This is an expected finding when blood sugars drop rapidly.Not accurate; while rapid glucose lowering can transiently worsen retinopathy, "black spots" should always prompt urgent eye evaluation. B. On a scale of 1 to 10, how much are these spots affecting your daily quality of life?This downplays the urgency and misses the need for immediate eye care. C. That must be really scary. Make sure to mention this at your next provider visit.Waiting until the next routine visit risks delaying care for a potentially serious eye problem.

JL has prediabetes and wants to know if adding cinnamon to their diet will prevent them from getting type 2 diabetes. What is the Diabetes Ed Specialist's best response? A. Adding cinnamon to your meal plan lowers your risk of diabetes. B. The American Diabetes Association does not recommend nutritional supplements. C. It is better to take the cinnamon capsules, so you get a standardized dose. D. Many people find that cinnamon makes healthy foods taste better.

D. Many people find that cinnamon makes healthy foods taste better. As a Diabetes Education Specialist, it's important to provide a response that is evidence-based, supportive, and non-dismissive. Current scientific evidence does not strongly support cinnamon as a proven method to prevent type 2 diabetes. However, adding cinnamon as a flavor enhancer—especially to healthy, low-sugar foods like oatmeal or plain yogurt—can support healthy eating habits, which do help prevent diabetes. ❌ Why not the other options? A. "Lowers your risk of diabetes" → ❌ Not evidence-based. There is insufficient clinical evidence to claim cinnamon reduces diabetes risk. B. "ADA does not recommend supplements" → ❌ Too rigid. The ADA does not endorse or oppose specific supplements; they recommend focusing on proven lifestyle strategies. C. "Better to take capsules" → ❌ Not appropriate. Supplements can vary in potency, quality, and safety. There's no conclusive benefit to taking cinnamon capsules.

Which of the following insulins can you mix with dedgludec (Tresiba)? A. only aspart (novolog) B. regular insulin C. any of the insulin analogs D. None

D. None Explanation: Insulin degludec (Tresiba) is a long-acting basal insulin analog with a very long duration of action (up to 42 hours) and a unique formulation. Due to its formulation and pharmacokinetics, it should not be mixed with any other insulin.

RJ is 15 years old and starting on basal-bolus insulin. The diabetes specialist reviews the signs of hypoglycemia and provides information on glucagon rescue medications. Which of the following statements is most accurate? A. A glucagon is an injectable form of glucose. B. Injectable glucagon rescue medications are to be injected subcutaneously only. C. Nasal glucagon must be inhaled to increase glucose levels. D. Premixed glucagon liquid solution is approved for children two years and older.

D. Premixed glucagon liquid solution is approved for children two years and older. Glucagon is used as a rescue treatment for severe hypoglycemia when someone is unconscious or unable to swallow. In recent years, newer formulations have made it easier to administer. Premixed (ready-to-use) glucagon solutions, like Gvoke HypoPen and Baqsimi nasal glucagon, have been FDA-approved for children ≥ 2 years old, making administration faster and easier during emergencies. ❌ Why the other choices are incorrect: A. "A glucagon is an injectable form of glucose." → ❌ Incorrect. Glucagon is a hormone, not glucose. It works by stimulating the liver to release stored glucose into the bloodstream. B. "Injectable glucagon rescue medications are to be injected subcutaneously only." → ❌Not true. Glucagon can be injected subcutaneously, intramuscularly, or even intravenously depending on the formulation and situation. C. "Nasal glucagon must be inhaled to increase glucose levels." → ❌While nasal glucagon is administered via the nose, it is absorbed through the nasal mucosa, not inhaled into the lungs.

A 12-year-old with new-onset hyperglycemia presents to the Emergency Room with positive urine ketones and blood sugar of 283. What action is required most immediately? A. Contact dietitian to provide macronutrient review. B. Start a person with diabetes on Metformin (Glucophage). C. Draw ABGs and antibodies. D. Provide insulin therapy.

D. Provide insulin therapy. Rationale: A 12-year-old presenting with: New-onset hyperglycemia Positive urine ketones Blood glucose of 283 mg/dL This presentation is highly suggestive of new-onset type 1 diabetes, possibly with early diabetic ketoacidosis (DKA) or impending DKA. The most immediate priority is to correct the metabolic disturbance and prevent worsening acidosis, which requires: 👉 Insulin therapy. ❌ Why not the others? A. Contact dietitian: Important for long-term management, but not urgent in the acute phase. B. Start on Metformin: Metformin is not appropriate for type 1 diabetes or DKA; it's used for type 2 diabetes. C. Draw ABGs and antibodies: Useful for diagnosis and monitoring severity (e.g., if in DKA), but treatment should not be delayed while waiting for labs.

LR is 32 years old and just went for her first prenatal visit. She is 11 weeks pregnant and has a family history of type 2 diabetes. The provider checks her blood glucose levels and the result is a fasting blood glucose of 131 mg/dl and 128 mg/dl on 2 different days. Based on these findings, which of the following statements is correct for LR? A. She needs to be started on metformin or an SGLT-2 Inhibitor. B. She will need to do a 75 gm OGTT in the next few weeks to determine if she has gestational diabetes. C. She will need to go on a low carb, high protein diet to stop ketosis. D. She will need to be referred to a dietitian within 48 hours.

D. She will need to be referred to a dietitian within 48 hours. Rationale: LR's fasting blood glucose levels of 131 mg/dL and 128 mg/dL on two different days meet the diagnostic criteria for diabetes in pregnancy—not gestational diabetes. According to the American Diabetes Association (ADA) and ACOG guidelines: A fasting blood glucose ≥ 126 mg/dL on two occasions during early pregnancy (before 13 weeks) is diagnostic of overt diabetes in pregnancy (i.e., preexisting type 2 diabetes that was previously undiagnosed). Why D is Correct: Prompt referral to a registered dietitian or diabetes care and education specialist (DCES) is crucial—within 48 hours—to initiate: Medical nutrition therapy Glucose monitoring education Support for behavior changes Preventing complications for mother and baby ❌ Why the Other Options Are Incorrect: A. "She needs to be started on metformin or an SGLT-2 Inhibitor."🔺 SGLT-2 inhibitors are contraindicated in pregnancy due to risk to the fetus. Metformin may be used in some cases, but insulin is first-line therapy for overt diabetes in pregnancy. B. "She will need to do a 75 gm OGTT in the next few weeks..."Not necessary—she already meets diagnostic criteria for diabetes. OGTT is used later (24-28 weeks) for screening gestational diabetes, not overt diabetes. C. "She will need to go on a low carb, high protein diet to stop ketosis."This is not evidence-based guidance. Extreme low-carb diets are not recommended in pregnancy, and the immediate priority is comprehensive medical nutrition therapy, not a restrictive approach.

AJ takes 85 units of basaglar at bedtime and 10 -12 units of glulisine (Apridra) at meals, plus metformin and empagliflozin at maximum dose. Fasting blood sugars are 130 or greater and the rest of the day, AJs blood sugars are in the 200s. AJ has a BMI of 32 and an A1c of 9.3%. The diabetes specialist recommends adding semaglutide (Ozempic) 0.5 mg to the regimen. What teaching information is most important given the addition of this new medication? A. Report any muscle pain immediately. B. Semaglutide needs to be injected before eating. C. Make sure to evaluate liver enzymes after 3 months. D. Signs of hypoglycemia and appropriate action.

D. Signs of hypoglycemia and appropriate action. Rationale: Semaglutide (Ozempic) is a GLP-1 receptor agonist, which by itself has a low risk of hypoglycemia. However, AJ is on high-dose basal insulin (85 units) and mealtime insulin (glulisine), along with metformin and empagliflozin. The addition of semaglutide can enhance glucose-lowering, potentially increasing the risk of hypoglycemia when used with insulin or sulfonylureas. Therefore, AJ should be educated on recognizing hypoglycemia symptoms and how to treat it (e.g., 15g of fast-acting carbohydrate, recheck in 15 minutes, etc.). ❌ Why not the others? A. Report any muscle pain immediately: This is more associated with statins, not semaglutide. B. Inject before eating: Incorrect. Semaglutide is a once-weekly injection, not tied to meals. C. Check liver enzymes: Not routinely required for semaglutide. This is more relevant for certain medications like thiazolidinediones or statins.

SL is 17 years old, with type 1 diabetes. SL uses an insulin pump and checks glucose levels before meals and at bedtime. SL started track team at high school a week ago and noticed that they are waking up with vivid dreams and morning blood glucose levels are higher than usual. Which of the following is the best recommendation? A. Advise SL to consume at least 30 gms of carb during track workouts. B. Recommend increasing basal insulin by 10% during track season. C. Encourage SL to check blood glucose before track practice. D. Suggest ingesting additional carbs before bedtime.

D. Suggest ingesting additional carbs before bedtime. SL has type 1 diabetes, uses an insulin pump, and recently started track practice, which is increasing physical activity. Now, they're experiencing: Vivid dreams (a possible symptom of nocturnal hypoglycemia) Elevated morning blood glucose (a common rebound effect, also known as the Somogyi effect, where overnight hypoglycemia triggers a counter-regulatory hormone surge causing high morning BG) Recommendation Rationale: ➡️ Giving additional carbohydrates before bedtime can help prevent overnight hypoglycemia, especially after an active day, and reduce the risk of rebound hyperglycemia in the morning. ❌ Why not the others? A. 30g carbs during track workouts - May help prevent lows during exercise, but doesn't address the overnight issue. B. Increase basal insulin by 10% - Could worsen nocturnal lows if overnight lows are already happening. C. Check BG before track - Good routine practice, but doesn't address the nighttime/morning glucose pattern.

TS brings a logbook to the appointment, the am blood glucose levels for the last four days are recorded as 120, 115, 125, 110. TS's A1c is 10.2%. TS's BMI is 20. What is the best explanation? A. TS has numeral illiteracy. B. TS needs to perform quality control on the meter. C. TS may have disordered eating. D. TS is worried about disappointing providers and parents.

D. TS is worried about disappointing providers and parents. Why D is the best answer: The A1c of 10.2% indicates average blood glucose levels around 240 mg/dL, which significantly contradicts the normal morning values shown in the logbook. This suggests TS may be selectively recording or reporting "good" numbers, likely due to fear of judgment, shame, or a desire to please caregivers or healthcare providers. This aligns with common emotional responses in youth with diabetes, especially when they are struggling with self-management but want to avoid disappointing others.

JL observes Ramadan and fasts from sunrise to sunset. JL has type 2 diabetes and usually takes 4 units of bolus insulin three times a day with meals and 10 units of lantus at bedtime. What would be the best recommendation for JL? A. See if you can get a note from your doctor to allow eating during the day. B. Take 4 units of bolus insulin at lunch, then drink 8 oz of a clear juice. C. Monitor urine ketones at least twice a day. D. Take 4 units bolus insulin when JL eats a meals.

D. Take 4 units bolus insulin when JL eats a meals. During Ramadan, individuals with diabetes who choose to fast require adjustments to their insulin regimen to align with their new eating schedule (typically two meals daily, at suhoor before dawn and iftar after sunset). The bolus insulin should be taken with meals, not at fixed times, since meals are no longer spread throughout the day. D is correct because it adjusts insulin to the timing of food intake, which helps reduce the risk of hypoglycemia during fasting hours and maintains blood glucose control. ❌ Why the other options are incorrect: A. ❌ This does not respect JL's religious observance and may feel dismissive. B. ❌ There is no lunch during fasting, and juice during fasting hours would break the fast. C. ❌ While monitoring may be appropriate in some contexts (e.g., for those on SGLT2 inhibitors or risk of DKA), urine ketone testing is not typically required in type 2 diabetes unless blood glucose is very high or patient is ill.