MUST READ NIGHT BEFORE EXAM

Which of the following should be used with caution in patients with hypoglycemia unawareness? Beta-blockers Angiotensin converting enzyme inhibitors Statins Aspirin

A - Beta-blockers is correct. Patients with hypoglycemia unawareness may experience a blunted response to epinephrine in response to falling blood glucose levels. Normally, epinephrine causes tachycardia and stimulates glucagon release; however, concurrent therapy with beta-blockers may further blunt these compensatory responses. Of note, sweating is a sympathetic response that is not blunted by beta-blockers. Other common cardiovascular agents: angiotensin converting enzyme inhibitors (Answer B), statins (Answer C) and aspirin (Answer D) do not affect sympathetic response to hypoglycemia.

A 55-year old woman with diabetes asks whether she should start taking an aspirin 81mg daily as primary prevention for ASCVD. Which of the following criteria would be necessary for the benefits of aspirin therapy to outweigh the risks? Cigarette smoking History of gastroesophageal reflux Albumin to creatinine ratio of 20mg/g Family history of mother with diabetes

A - Cigarette smoking is correct. Aspirin therapy with 75mg to 162mg daily should be considered for patients with type 1 or type 2 diabetes at increased risk of cardiovascular disease. Patients at increased risk include those with a calculated 10-year risk >10%, or those >50-years-old with at least one additional major ASCVD risk factor (family history of premature atherosclerotic cardiovascular disease (Answer D), hypertension, smoking, dyslipidemia, or albuminuria (>30mg/g, Answer C)). While peptic ulcer disease might prohibit initiation of aspirin therapy, gastrointestinal reflux is considered safe (Answer B).

Which of the following signs of hypoglycemia are unaffected by concomitant therapy with a beta-blocker? Diaphoresis Tachycardia Nervousness/anxiety Tremors

A - Diaphoresis is correct. Beta-blockers may block signs and symptoms of hypoglycemia that are mediated by adrenergic/sympathetic activation. Diaphoresis is not affected by beta-blockers as this response is mediated by nicotinic receptor activation.

A 29-year-old caucasian male patient with type 1 diabetes and newly diagnosed hypertension presents for evaluation. Which of the following would be the most appropriate as initial therapy for this patient? Lisinopril Furosemide Clorthalidone Doxazosin

A - Lisinopril is correct. The 2016 ADA guidelines recommend that angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), but not both are preferred for patients with diabetes and hypertension. Loop diuretics (furosemide, Answer B) is useful for patients with heart failure to maintain fluid balance, but has less effect on systemic blood pressure control. Thiazide diuretics (chlorthalidone and hydrochlorothiazide, Answer C) are often required in addition to ACE-I and ARBs. Alpha blockers (doxazosin, Answer D) are reserved for patients with resistant hypertension already on recommended first line agents.

Which of the following occur more frequently in caucasian patients with diabetes than with African American patients? Myocardial infarction Hypertension Peripheral Neuropathy Diabetic Kidney Disease

A - Myocardial infarction is correct. The rates of hypertension (Answer B), neuropathy (Answer C) and nephropathy (Answer D) are higher in African American compared with caucasian patients with diabetes.

What impact does diabetes have on the development of coronary artery disease in women compared with men? Women have a higher risk than men Men have a higher risk than women The risk is minimal in both sexes The risk is the same for both sexes

A - Women have a higher risk than men. Although premenopausal women without diabetes have a lower risk of coronary artery disease compared with men, having diabetes eliminates the protective effect of estrogen.

Which of the following lab values is most consistent with the presentation of diabetic ketoacidosis? pH 7.0 Bicarbonate 20 mEq/L Glucose 200 mg/dL Anion gap 10 mmol/L

A - pH 7.0 is correct. Patients with diabetic ketoacidosis present with blood pH <7.30, serum bicarbonate <18 meq="" l="" answer="" b="" glucose="">250 mg/dL (Answer C), and anion gap >12 (Answer D) with moderate or severe ketoacidosis.

Ketoacidosis in adolescents can be caused by the following except: Excessive intake of sweets Emotional disturbances Insulin omission Illness

A is the correct answer. DKA is the result of a relative or absolute insulin deficiency and can be seen in the presence of a physical illness, severe emotional distress or if insulin is omitted.

The current testing recommendations for diagnosing gestational diabetes include all of the following except: Every pregnant woman should have a risk assessment for the development of gestational diabetes at 24 to 28 weeks' gestational age A fasting plasma glucose of >126 mg/dL (7.0 mmol/L) or a casual plasma glucose of >200 mg/dL (11.1 mmol/L) is suggestive of diabetes and warrants immediate follow-up Having a 100g-OGTT (oral glucose tolerance test) The diagnosis of gestational diabetes can be made with either a 1-step 75-g oral glucose tolerance test or the 2-step process using a 50-g glucose screen and, if abnormal, a 100-g oral glucose tolerance test

A is the correct answer. Every pregnant woman should be screened and tested for GDM at 24 to 28 weeks gestation.

Which of the following metabolic changes occurs during puberty which leads to deterioration of glycemic control? Increased insulin resistance Decreased insulin resistance Decreased epinephrine responses Elevated ketone production

A is the correct answer. Insulin resistance increases during puberty because of increased hormone levels

The factor that makes the most significant difference when deciding whether to use a lecture method or a group discussion approach to learning is Relevance of the material to the learner Educator facilitation skills Opportunities to reinforce learning Availability of audiovisual resources

A is the correct answer. Patients are more likely to remember information that they see as relevant to them. Information should be presented in a way that individuals with diabetes can immediately understand how the information and self-care tasks directly apply to themselves.

Which of the following is NOT a usual symptom of acute coronary insufficiency? Angina Flushing Diaphoresis Anxiety

B - Flushing is correct. Symptoms of acute coronary insufficiency may include angina (Answer A), diaphoresis (Answer C), anxiety (Answer D), nausea and vomiting.

Which of the following would be the most appropriate blood pressure goal for a pregnant woman with chronic hypertension? <110/65 mmHg 110-129/65-79 mmHg 130-149/80-89 mmHg 140-159/90-99 mmH

B - 110-129/65-79 mmHg is correct. The 2016 ADA guidelines recommend a blood pressure goal of 110-129/65-79 mmHg for pregnant patients with diabetes and chronic hypertension to optimize long-term maternal health and minimize impaired fetal growth

A 45-year-old man with type 2 diabetes recently started atorvastatin 40mg daily to lower his cholesterol. Which of the following is the most appropriate frequency to recheck the fasting lipid profile? 1 to 3 weeks 4 to 12 weeks 6 to 9 months Yearly

B - 4 to 12 weeks is correct. The 2013 ACC/AHA Cholesterol Guidelines for ASCVD Risk Reduction in Adults recommends that a repeat fasting lipid panel be checked within 4 to 12 months after statin initiation or dose adjustment. Once patients the dose is stabilized, then follow-up can be set to every 3 to 12 months thereafter.

Which of the following is the most appropriate daily protein intake for a patient with nondialysis-dependent diabetic kidney disease who weighs 121 lb. (55 kg)? 35 g 44 g 50 g 55 g

B - 44 g is correct. The 2016 ADA guidelines recommend that dietary protein intake should be 0.8 g/kg body weight per day for patient with nondialysis-dependent diabetic kidney disease. Excess protein intake can worsen albuminuria and further reduce glomerular filtration rate in patients with diabetic kidney disease.

A 35-year-old patient with type 2 diabetes presents for follow-up of her glycemic control. Her current medications include: metformin 1g twice daily and glargine 46 units at bedtime with a recent A1C of 7.7% (goal <7%). She eats a granola bar for breakfast, has a sandwich and water at lunch, then a large evening meal. She denies symptoms of hypoglycemia. She weighs 156 pounds (BMI 26 kg/m^2) and her average preprandial self-monitored blood glucose levels are: 152 mg/dL at 8AM, 160 mg/dL at noon, 146 mg/dL at 6 PM, and 220 mg/dL at 10 PM. Her provider decides to start glulisine before the evening meal (at 6 PM). Which of the following would be the most appropriate recommendation for this patient? 1 unit 5 units 15 units 20 units

B - 5 units is correct. Both the ADA and AACE guidelines recommend adding bolus insulin at a dose of either 10% of the current basal dose, or 0.1 units/kg, or 5 units. Subsequent dose adjustments can be made in 1 to 2 unit increments or 10% to 15% of the dose.

A 28-year old woman with Type 1 diabetes for 10 years needs to re-calculate a mealtime (insulin to carbohydrate ratio) bolus based on her new insulin regimen. Her current total daily dose (TDD) of insulin is 60 units. Which of the following best estimates the amount of carbohydrates matched by 1 unit of insulin? 3 g 8 g 25 g 30 g

B - 8 g is correct. The Rule of 500 estimates the amount of carbohydrates matched by 1 unit of insulin. This patient takes a total daily dose (TDD) of 60 units (500 divided by 60 units = 8 g of carbohydrate). A general rule of thumb is that 1 unit of insulin is necessary for every 15 g of carbohydrate.

A 52-year-old male with diabetes, CAD, hypertension and dyslipidemia presents to clinic to follow-up on his fasting laboratory values (see labs below). His medical history is significant for MI (2009, 2011, 2014), PTCA (2009, 2014), and CABG (2011). His current medications include rosuvastatin 20 mg daily, empagliflozin 25 mg daily, amlodipine 10 mg daily, valsartan/HCTZ 320/12.5 mg daily, isosorbide mononitrate 30 mg daily, and metoprolol XL 100 mg daily. His fasting laboratory values are as follows: total cholesterol 298 mg/dL, triglyceride 187 mg/dL, HDL-cholesterol 35 mg/dL, LDL-cholesterol 225 mg/dL. Which of the following represents the most appropriate drug therapy option for this patient? Increase rosuvastatin to 40 mg daily Add alirocumab 75 mg every 2 weeks Switch to fluvastatin 80 mg daily Add fenofibrate 145 mg dail

B - Add alirocumab 75 mg every 2 weeks is correct. This patient at very high ASCVD continues to have significantly elevated LDLcholesterol and non-HDL-cholesterol, therefore would benefit most from adding a PCSK9 inhibitor. Increasing rosuvastatin to 40 mg daily (Answer A) will only lower his LDL-cholesterol by another 6% to 7%; whereas adding alirocumab will lower his LDL-cholesterol by 58% and non-HDL-cholesterol by 50%. Switching from a high-intensity statin to a moderate-intensity statin (Answer C) is not appropriate in this patient with high ASCVD risk. Adding fenofibrate (Answer D) is also not appropriate because his triglycerides are <204 mg/dL based on the ACCORD data.

A 64-year-old man with type 2 diabetes, cardiovascular disease and heart failure returns to clinic on metformin 1g twice daily plus glargine 65 units at bedtime. His fasting glucose is 162 mg/dL with an A1C of 8.1% and eGFR 50 mL/min/1.73m2. Which of the following would be the most appropriate recommendation for this patient? Increase metformin Add empagliflozin Add pioglitazone Add dapagliflozin

B - Add empagliflozin is correct. Based on data from the EMPA-REG trial, adding empagliflozin to background therapy in patients with established cardiovascular disease decreases heart failure hospitalizations by 35%, cardiovascular death by 38% and all-cause mortality by 32%. The optimal dose of metformin is 2g per day, increasing the dose offers no additional A1C reduction but does increase side effects (Answer A). Adding pioglitazone in this patient would not be ideal considering his history of heart failure (Answer C). It is uncertain whether the beneficial effects observed in EMPA-REG are restricted to empagliflozin or represent a class effect; however, dapagliflozin (Answer D) is not recommended in patients with an eGFR <60 mL/min/1.73m

A 29-year-old patient with type 1 diabetes and no evidence of retinopathy on the last 2 eye examinations presents for follow-up. Which of the following would be the most appropriate frequency of dilated eye exams this patient? Annually Every 2 years Annually starting after A1C >9% As needed based on changes in visual acuity

B - Every 2 years is correct. According to the ADA 2016 Standards of Care, patients without evidence of retinopathy on one or more annual eye exams may have the frequency extended to every 2 years. Eye exams performed by an ophthalmologist or optometrist at least annually (Answer A) is appropriate in all patients with diabetes (type 1 or 2) with any level of retinopathy. Eye exam frequency is not determined by glycemic control (Answer C) or patient symptoms (Answer D).

After taking atorvastatin 40 mg daily for 6 weeks, a 62-year-old male patient with type 2 diabetes and history of myocardial infarction returns for follow-up. His laboratory values are as follows: total cholesterol 190 mg/dL, triglyceride 175 mg/dL, HDL-cholesterol 27 mg/dL, LDL-cholesterol 128 mg/dL. Which of the following represents the most appropriate drug therapy change for this patient? Increase atorvastatin to 80 mg daily Add ezetimibe 10 mg at daily Switch to simvastatin 40 mg daily Add gemfibrozil 600 mg twice daily

B - Add ezetimibe 10 mg at daily is correct. The non-HDL-cholesterol goal for this patient is <100 mg/dL. Increasing atorvastatin to 80 mg daily (Answer A) will only lower his LDL-cholesterol by another 6% to 7%; whereas adding ezetimibe will lower his LDL-cholesterol by 18%. Switching from a high-intensity statin to a moderate-intensity statin (Answer C) is not appropriate in this patient with high ASCVD risk. Adding gemfibrozil (Answer D) is also not appropriate because his triglycerides are <204 mg/dL based on the ACCORD data, and gemfibrozil is contraindicated with atorvastatin.

A 38-year-old female patient with type 2 diabetes presents for evaluation. She currently metformin 1g twice daily and rosuvastatin 20mg daily. In clinic today her weight is 200 pounds (90kg); laboratory values include: A1C 9.4%, serum creatinine 0.7mg/dL, total cholesterol 196mg/dL, triglycerides 350mg/dL, HDL-cholesterol 36mg/dL, LDL-cholesterol 90mg/dL. Which of the following would be the most appropriate recommendation to address the hypertriglyceridemia in this patient? Add colestipol 6 g daily Add glargine 18 units daily Switch rosuvastatin to lovastatin 20 mg daily Switch metformin to glipizide 10 mg twice daily

B - Add glargine 18 units daily is correct. Patients with elevated fasting triglyceride levels less than 500 mg/dL should optimize their glycemic control prior to adding medical therapy such as omega-3 fatty acids (fish oil), fibrates or niacin. Addition of bile acid sequestrants (colestipol, Answer A) will lower total and LDL-cholesterol but may raise triglyceride levels. Switching to a low intensitystatin (lovastatin, Answer C) would not be appropriate for this high risk patient already on a high-intensity agent. Switching from metformin to glipizide (Answer D) offers no therapeutic advantage in this patient who is already far from her A1C goal of <7%.

A 64-year-old man with type 2 diabetes and cardiovascular disease (myocardial infarction 5 years ago) returns to clinic on metformin 1g twice daily plus glargine 34 units at bedtime. He continues to work as an automobile mechanic and enjoys gardening. His fasting glucose is 140 mg/dL with an A1C of 8.2%. Which of the following would be the most appropriate recommendation for this patient? Make no change Add liraglutide once daily Switch glargine to NPH insulin Add regular insulin before meals

B - Add liraglutide once daily is correct. In the LEADER study, patients with diabetes at high risk of cardiovascular events were randomized to liraglutide or standard (non-incretin) therapy plus usual care. Patients in the liraglutide group had a 15% reduction in all-cause mortality and 22% reduction in cardiovascular related death. Liraglutide was also associated with lower A1C, body weight and hypoglycemia compared with the standard therapy group. Although less intensive A1C goals are appropriate for some older patients, this patient continues to perform vigorous work and would likely benefit from tighter glycemic control (Answer A). Switching from glargine to NPH insulin provides no improvement in glycemic control and may increase the risk of nocturnal hypoglycemia (Answer C). Adding rapid-acting insulin before meals is an option for this patient, but regular insulin (Answer D) would likely increase the risk of late hypoglycemia.

Which of the following GLP-1 receptor agonists requires that the patient mix and wait 15 to 30 minutes before injecting? Dulaglutide Albiglutide Liraglutide Exenatide

B - Albiglutide is correct. Albiglutide comes in two strengths; after mixing, the patient must wait 15 minutes for the 30mg pen, and 30 minutes for 50mg pen. Exenatide LAR (Bydureon) must also be mixed; however, the other GLP-1 receptor agonists are provided as pens containing premixed solutions.

An obese 45-year-old woman with type 2 diabetes with an A1C of 7.6% is considering with her provider to add a new medicine. She is very interested in improving her diet and losing weight. Which of the following would be the LEAST helpful in her quest to improve her glycemic control and lose weight? Liraglutide Albiglutide Dulaglutide Exenatide

B - Albiglutide is correct. All of the GLP-1 receptor agonists generally promote weight loss of 2 to 3kg after 6 months of therapy. However, in its package labeling patients randomized to albiglutide only lost 0.6kg at 32 weeks compared with 2.2kg for patients randomized to liraglutide

Which of the following would be the most appropriate initial lipid-lowering therapy for a 46-year-old patient with clinical atherosclerotic cardiovascular disease (ASCVD)? Simvastatin 40mg Atorvastatin 40mg Rosumvastatin 5mg Atorvastatin 20mg + Ezetimibe 10mg

B - Atorvastatin 40mg is correct. The 2016 ADA guidelines recommend a high-intensity statin for adults ages 40 to 75 with clinical ASCVD (atorvastatin 40mg to 80mg or rosuvastatin 20mg to 40mg). Moderate-intensity statins (simvastatin 40mg, Answer A; rosuvastatin 5mg, Answer C) are suggested for patients between ages 40 to 75 without risk factors or clinical ASCVD. For patients who do tolerate a high-intensity statin, the guidelines recommend a moderate-intensity statin plus ezetimibe (Answer D).

A 64-year-old patient with type 2 diabetes and history of an myocardial infarction 3-years ago returns to clinic. He complains of muscle pain in his thighs and calves that occurs during exercise. He previously tolerated atorvastatin but noticed the pain after the dose was increased from 20mg to 40mg daily 2-weeks ago. Which of the following would be the most appropriate recommendation for this patient? Switch from atorvastatin to alirocumab Change to atorvastatin 20mg plus ezetimibe Switch from atorvastatin to pravastatin 40mg Change to atorvastatin 20mg plus gemfibrozil

B - Change to atorvastatin 20mg plus ezetimibe is correct. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) randomized patients who were >50-years-old and experienced acute coronary syndrome (ACS) within the preceding 10 days to simvastatin plus ezetimibe or simvastatin alone. Patients in the combination therapy group showed a significant reduction in major adverse cardiovascular events. Consequently, the 2016 ADA guidelines suggest adding ezetimibe to moderate-intensity statins for those patients with ACS who cannot tolerate high-intensity statin therapy. The PCSK9 inhibitors (alirocumab, Answer A) are indicated for patients with ASCVD on maximally tolerated statin therapy. Switching to a low intensity-statin (pravastatin, Answer C) would not be appropriate for this high risk patient. Adding gemfibrozil (Answer D) to atorvastatin would not be appropriate due to the increased risk of myopathy of combination therapy, especially in this patient with a history of statin-induced myositis

A 45-year-old patient presents to clinic complaining of fatigue, frequent urination and a skin infection on his lower leg that is slow to heal. Laboratory values at the visit are as follows: A1C 9.5%, fasting plasma glucose 256mg/dL, serum creatinine 0.7mg/dL. The diabetes care team decides to start this patient on metformin. Which of the following would be the most appropriate addition to metformin therapy based on the 2016 AACE guidelines? Acarbose Glargine Pioglitazone Glimepiride

B - Glargine is correct. Unlike the 2016 ADA guidelines, the 2016 AACE guidelines recommend drug therapy based on A1C level at entry. Insulin is recommended with or without metformin for patients with an A1C >9% plus symptoms. Alpha glucosidase inhibitors (acarbos, Answer A), thiazolidinediones (pioglitazone, Answer C) and sulfonylureas (glimepiride, Answer D) are reserved as second and third line options for patients with A1C levels <9%.

Which of the following should be avoided in a patient with a history of severe angioedema with enalapril requiring hospitalization Doxazosin Irbesartan Metoprolol Chlorthalidone

B - Irbesartan is correct. Angioedema with angiotensin converting enzyme (ACE) inhibitors is idiosyncratic and can occur at any time during therapy. African-American patients tend to be higher risk of angioedema. For patients with severe reactions, angiotensin receptor blockers (ARB) should also be avoided if other options are available

A 62-year-old overweight woman is referred to your clinic as a new patient. Her PMH includes hypertension (5 year history), type 2 diabetes (2 year history), chronic kidney disease (Stage 4) and osteoporosis (4 years). She reports walking 2 miles daily without chest pain or shortness of breath. "I just cannot seem to lose weight." Which of the following conditions is the most compelling reason to avoid metformin in this patient? Unstable heart failure Renal dysfunction Osteoporosis Age >60 years old

B - Renal dysfunction is correct. Patients with Stage 4 kidney disease have severely reduced kidney function with glomerular filtration rates (GFR) <30 mL/min/1.73m . Specific serum creatinine levels to determine appropriateness of metformin therapy (<1.4 mg/dL for women; <1.5 mg/dL for men) have been replaced with estimates of GFR. The metformin dose should be limited to 1g in patients with a GFR of 30 to 45 mL/min/1.73m but should be discontinued in patients with a GFR <30 mL/min/1.73m . This patient is very active as evidenced by her daily exercise program so heart failure (Answer A) and age (Answer D) are not appropriate. Thiazolidinediones but not metformin may worsen osteoporosis symptoms (Answer C).

Which of the following lab parameters best correlates with mental functioning during HHS and DKA? Plasma sodium level Serum osmolality Blood pH Serum glucose

B - Serum osmolality. Although disturbances in sodium (Answer A), glucose (Answer D) and blood pH (Answer C) occur during HHS and DKA, serum osmolality has the greatest effect on mental functioning. Increased osmolality occurs with dehydration and overhydration may create a hypotonic state causing cells to fill and potentially lyse.

Which of the following is LEAST associated with nausea? Pramlintide Sitagliptin Metformin Exenatide

B - Sitagliptin is correct. The DPP-4 inhibitors, including sitagliptin, are very well tolerated and have a low incidence of gastrointestinal upset (1.4% with sitagliptin). Up to 48% of patients with type 1 diabetes and 23% of patients with type 2 diabetes report nausea with pramlintide (Answer A). One study reported rates of gastrointestinal upset of 26% with immediate release metformin that dropped to 11% with extended release metformin (Answer C). Nausea with exenatide occurs in 23% of patients (Answer D).

Which of the following was a significant benefit (occurred less often in intensive blood pressure treatment group) in the ACCORD trial? Nonfatal myocardial infarction Total and nonfatal stroke Cardiovascular death Hyperkalemia

B - Total and nonfatal stroke is correct. The ACCORD trial compared the effect of intensive systolic blood pressure goals (<120 mmHg) with standard care (130 to 140 mmHg) on cardiovascular events. The composite primary endpoint, nonfatal myocardial infarction (Answer A), cardiovascular death (Answer C) and all-cause mortality were not statistically different between the groups. Total and nonfatal stroke were lower in the intensive group but did not alter the primary composite endpoint. Patients in the intensive control group also experienced more orthostasis and hyperkalemia (Answer D).

Aspects of the empowerment perspective include: Providing skills training, prescribing a treatment regimen, and giving ongoing support and encouragement Providing skills training, giving ongoing support and encouragement, understanding and starting from the patient's perspective Providing skills training, giving ongoing support and encouragement, and increasing frequency of patient visits None of the above

B is the correct answer because a key aspect of the empowerment perspective includes supporting patient centered decision - making. With the empowerment approach it is the patient rather than the provider who evaluates outcome. This reinforces the concept that the health professional is not the judge of their efforts or behaviors

SS, a 44-year-old school teacher with type 2 diabetes, has just started an antianxiety agent for her symptoms. During your assessment, what potential adverse clinical concern would you have related to the medication? Skin rash Over-sedation Palpitations, tremors Loss of glycemic control

B is the correct answer. Antianxiety agents can have a sedative effect.

Which of the following metabolic changes does not occur in the second half of pregnancy? Insulin resistance results in higher and more prolonged postprandial blood glucose concentration than in the nonpregnant state Basal insulin levels decrease in relation to placental growth Insulin resistance appears to be related to placental hormones (e.g., human placental lactogen, prolactin, estrogen, and cortisol) Women are prone to the condition of accelerated starvation, which can result in elevated plasma and urinary ketone levels

B is the correct answer. Basal insulin levels increase throughout the second half of pregnancy.

A 36-year-old woman returns to clinic on metformin 1g twice daily plus detemir 60 units at bedtime. Her fasting self-monitored blood glucose values average 248 mg/dL for the past 2-weeks. Her fasting glucose goal is <130 mg/dL and she denies symptoms of hypoglycemia. Which of the following would be the most appropriate dose change for her detemir insulin? 2 units 6 units 12 units 24 units

C - 12 units is correct. Dose adjustments to basal insulin may be made in fixed or adjustable increments. Recommended fixed dose adjustments range from 2 units to 4 units every 2 to 3 days; however, for patients on large insulin doses, adjustable increments (10% for fasting blood glucose between 140 mg/dL and 180 mg/dL, or 20% for fasting blood glucose >180 mg/dL) may be more appropriate, especially if the patient is far from their glycemic target. This patient is on a large dose of insulin and is 100 mg/dL from the target, the most appropriate dose change would be 20% of the current dose (20% x 60 = 12 units)

A 28-year-old woman with Type 1 diabetes for 10 years presents for follow-up. Recent laboratory tests showed fasting plasma glucose of 194 mg/dl and a hemoglobin A1C of 10.3%. A spot urine was positive for microalbumin at 58. Blood pressure today is 118/64 without symptoms and all other laboratory values were within normal limits. Which of the following is the most appropriate blood pressure goal for this patient based on the 2016 ADA Standards of Care? < 140/90 mmHg < 140/80 mmHg < 130/80 mmHg < 120/75 mmHg

C - <130/80 mmHg is correct. The 2016 ADA guidelines recommend a blood pressure goal of <140/90 mmHg for most adults with diabetes. However, lower blood pressure targets are considered appropriate for younger patients whose potential duration of disease is longer; those with albuminuria suggesting presence of sustained kidney damage; and those in whom the burden of treatment is minimal. This young patient with type 1 diabetes would certainly be able to withstand the treatment burden and will likely reap benefits during her lifetime from tighter blood pressure control.

A 57-year-old woman with type 2 diabetes returns to clinic on metformin 1g twice daily. She exercises daily and has maintained a normal weight for the last 5-years. She recently finished a course of antibiotics for a urinary tract infection (the third in the last 18 months) and denies any symptoms today. She is tolerating the metformin well with an A1C of 7.8%. Which of the following would be the most appropriate recommendation for this patient? Add canagliflozin Add glyburide Add sitagliptin Add bromocriptin

C - Add sitagliptin is correct. Addition of a DPP-4 inhibitor (sitagliptin) would be a good choice for this patient because of the low risk of hypoglycemia, weight gain and ability to reach the A1C goal of <7%. Canagliflozin (an SGLT2 inhibitor, Answer A) also has a low risk of hypoglycemia but would not be the best choice given her history of frequent urinary tract infections. Glyburide (Answer B) and other sulfonylureas would help her achieve her A1C goal but may increase the risk of hypoglycemia during her daily exercise. Bromocriptine (Answer D) has a low risk of hypoglycemia, but is not considered a favorable second agent due to the dizziness, nausea and fatigue associated with the dopaminergic agent.

A 28-year-old woman with type 2 diabetes plans to get pregnant. Which of the following drugs should be discontinued prior to getting pregnant? Metformin Detemir Atorvastatin Clonidine

C - Atorvastatin is correct. Statins, angiotensin converting enzyme inhibitors and angiotensin receptor blockers are common therapies for patients with type 2 diabetes but may cause fetal damage and are contraindicated during pregnancy. About 50% of the metformin dose crosses the placenta but is not associated with adverse effects on the fetus (Answer A). Recombinant human NPH insulin is preferred during pregnancy; however, if insulin analogs are desired, then lispro, aspart or detemir (Answer B) are FDA Pregnancy Category B.

Which of the following was shown by the Diabetes Control and Complications Trial (DCCT) to be associated with tight glycemic control of diabetes? Decreased weight Increased nephropathy Decreased retinopathy Increased quality of life

C - Decreased retinopathy is correct. In the Diabetes Control and Complications Trial (DCCT) intensive therapy was associated with a 76% reduction in the adjusted mean risk of retinopathy and 56% reduction in the adjusted mean risk of nephropathy (Answer C). However, intensive therapy was also associated with a 33% increase in the adjusted risk of becoming overweight; after 5 years patients in the intensive therapy group gained an average for 4.6 kg more than conventional therapy patients. There were no significant differences in mean total scores on the quality-of-life questionnaire (Answer D).

What is the most appropriate frequency to obtain a lipid profile for screening purposes in adult patients with type 2 diabetes? Yearly Every 2 years Every 5 years Every 10 years

C - Every 5 years is correct. Adult patients with diabetes should have a lipid profile obtained at the time of diabetes diagnosis, then every 5 years thereafter in the absence of compelling indications.

A 46-year-old patient with type 2 diabetes presents for evaluation of his dyslipidemia. He reports two episodes of gout in the past but no history of ASCVD. He currently takes metformin ER 500mg daily and rosuvastatin 20mg daily. Laboratory values include: A1C 6.1%, serum creatinine 0.8mg/dL, total cholesterol 232mg/dL, triglycerides 550mg/dL, HDL-cholesterol 34mg/dL, LDL-cholesterol 88mg/dL. Which of the following would be the most appropriate addition to this patient's regimen? Niaspan Ezetimibe Fenofibrate Evolocumab

C - Fenofibrate is correct. This patient has significantly elevated triglyceride levels despite excellent glycemic control. Although the combination of simvastatin plus fenofibrate in the ACCORD trial did not improve ASCVD risk in the general population, patients with triglycerides >204mg/dL and HDL-cholesterol <34mg/dL did benefit. Likewise, cardiovascular data supporting combination therapy with statins plus niacin (Answer A) is also weak. Adding niacin might be an option considering the pancreatitis risk imparted by this patient's elevated triglycerides, but his history of gout makes niacin a less favorable choice. The PCSK9 inhibitors (evolocumab, Answer D) and ezetimibe (Answer B) primarily lower LDL-cholesterol and would not be appropriate in this patient with hypertriglyceridemia

A 62-year-old man with type 2 diabetes and chronic kidney disease presents for management of his diabetes. Recent laboratory values include the following: A1C 7.8%, serum creatinine 2.3 mg/dL. Which of the following DPP-4 inhibitors most appropriate for this patient? Sitagliptin Saxagliptin Linagliptin Alogliptin

C - Linagliptin is correct. Linagliptin is the only agent in the DPP-4 inhibitor class that does not require dose reduction in patients with renal impairment. Sitagliptin (Answer A) and Saxagliptin (Answer B) require dose reductions with CrCl <50mL/min. Alogliptin (Answer D) requires dose reduction with CrCl <60mL/min

Which of the following can precipitate Kussmaul breathing? Metabolic alkalosis Dehydration Metabolic acidosis Hypotension

C - Metabolic acidosis is correct. Kussmaul breathing is the physiological response to metabolic acidosis, usually as a result of diabetic ketoacidosis (DKA), and is characterized by deep labored breaths. This breathing response is an attempt to "blow off" carbon dioxide and raise pH levels (Answer A).

A 32-year-old pregnant female patient with type 1 diabetes and newly diagnosed hypertension presents for evaluation. Which of the following would be the most appropriate as initial therapy for this patient? Lisinopril Irbesartan Methyldopa Chlorthalidone

C - Methyldopa is correct. Angiotensin converting enzyme inhibitors (lisinopril, Answer A) and angiotensin receptor blockers (irbesartan, Answer B) may cause fetal damage and are contraindicated during pregnancy. Chronic use of diuretics (Answer D) during pregnancy may reduce plasma volume and also be harmful to the fetus. Drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin

A 42-year-old male patient with type 2 diabetes presents for evaluation of his dyslipidemia. Other than diabetes, he does not have any ASCVD risk factors. Which of the following would be the most appropriate recommendation in addition to lifestyle therapy for this patient based on the 2016 ADA guidelines? No statin therapy Low-intensity statin therapy Moderate-intensity statin therapy High-intensity statin therapy

C - Moderate-intensity statin therapy is correct. Patients with diabetes between age 40 and 75-years-old without atherosclerotic cardiovascular disease (ASCVD) risk factors should consider therapy with a moderate-intensity statin in addition to lifestyle therapy. Adult patients with diabetes are twice as likely to experience an ASCVD event as their age-matched peers without diabetes. Patients in this age group with ASCVD risk factors or overt disease should be treated with a high-intensity statin.

A 62-year-old patient with type 2 diabetes has noticed a 30-pound weight gain over the past 2 years. Which of the following drugs would most likely worsen her weight gain? Pramlintide Exenatide Rosiglitazone Saxagliptin

C - Rosiglitazone is correct. Thiazolidinediones (pioglitazone and rosiglitazone) activate PPAR-gamma receptors in the body. Activation of these receptors results in mobilization of visceral fat and promotes deposition in subcutaneous adipose tissue. Pramlintide and exenatide (Answers A and B) tend to promote weight loss, while saxagliptin (Answer D) is weight neutral.

A 78-year-old woman with type 2 diabetes and heart failure presents for evaluation. She reports frequently skipping meals because it is "too far to walk to the dining room" before getting short of breath. Her recent laboratory values include: A1C 7.8%, serum creatinine 1.2 mg/dL. Her vital signs today are as follows: weight 160 pounds (BMI 25 kg/m^2), blood pressure 118/68 mmHg, pulse 66 BPM. Which of the following would be the most appropriate recommendation? Metformin Saxagliptin Sitagliptin Pioglitazone

C - Sitagliptin is correct. This patient with symptomatic heart failure requires an agent with a low risk of hypoglycemia that will not worsen her heart failure symptoms. Saxagliptin and pioglitazone (Answers B and D) are contraindicated in patients with symptomatic heart failure. Metformin (Answer A) may be used with caution in patients at risk of decompensating, but sitagliptin would be a better choice

A 44-year-old overweight patient (BMI 28 kg/m^2) with type 2 diabetes takes 15 units twice daily of 70/30 biphasic insulin (NPH/regular). His A1C is 8.4% but he complains of hypoglycemia 3 to 4 times per week at 10 AM (about 3 hours after his morning dose). His diet consists of coffee for breakfast, a sandwich and small apple for lunch, and large hot meal at dinner. Which of the following would be the most appropriate recommendation for this patient? Decrease 70/30 insulin to 10 units at 7 AM and 15 units at 6 PM Advise him to eat 60g of carbohydrate for breakfast every day Switch to aspart 4 units at 6 PM plus glargine 30 units at bedtime Increase 70/30 insulin to 15 units at 7 AM and 20 units at 6 PM

C - Switch to aspart 4 units at 6 PM plus glargine 30 units at bedtime is correct. Because this patient does not eat breakfast, the fastacting portion of 70/30 insulin is not needed and is causing hypoglycemia. The challenge for the diabetes team is to adjust the insulin regimen to eliminate the hypoglycemic events while increasing the total daily dose (TDD) of insulin to lower his A1C to a goal <7%. Reducing the morning dose (Answer A) will help decrease the risk of hypoglycemia but will worsen the A1C; while increasing the evening dose may improve his A1C, but at a cost of increased hypoglycemia (Answer D). Advising overweight and obese patients to increase their calorie intake only worsens insulin resistance (Answer B). The best option is to select a semi-intensive insulin regimen with a basal insulin dose that avoids between meal hypoglycemia and a bolus targeted at the largest meal of the day.

A child should be expected to inject his or her insulin by what age? Age 8 Age 10 Age 12 No set age: individually determined

C is the correct answer. By the age of 10-12 years, children with diabetes are able to draw the insulin, mix doses and inject without assistance.

A bipolar disorder often involves a manic episode. Which of the following symptom s is not characteristic of manic behavior? Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week Abnormally and persistently elevated, expansive, or irritable mood that requires hospitalization in less than a week from the onset of symptoms Depressive symptom s that impair social, occupational, or other important areas of functioning Significant decrease in need to sleep

C is the correct answer. During a manic episode the patent will not suffer from depressive symptoms but quite the opposite will experience an abnormal and persistently elevated mood.

The incidence of psychological disorders in the population of persons with diabetes: Is likely to be detected earlier because of their more frequent interactions with health professionals Has the same incidence as in the general population Has a higher incidence than in the general population Is well understood and effectively treated by healthcare providers

C is the correct answer. Individuals with diabetes have a higher incidence of psychological disorders above the general population

The definition of overweight for children and adolescents is > 85th percentile of body mass index > 50th percentile of body mass index > 95th percentile of body mass index > 100th percentile of body mass index

C is the correct answer. Overweight for children and adolescents is based on > 95th percentile of body mass index for that age and gender.

With the diagnosis of gestational diabetes there are associated possible neonatal complications. Which of the following complications is not usually associated with gestational diabetes? Macrosomia and hypoglycemia Shoulder dystocia and polycythemia Small-for-gestational-age infants and birth defects Hyperbilirubinemia and macrosomia

C is the correct answer. Small for gestational age (SGA) infants and birth defects are usually associated with offspring of mothers with pre-existing diabetes. Birth defects are related to hyperglycemia during organogenesis (which is completed at about 7 weeks gestation) before GDM occurs. SGA is most common in offspring of women with vascular complications.

The empowerment approach: Focuses exclusively on the strengths of the person with diabetes Offers solutions to problems for the patient to choose Provides education to help patients make informed choices Enables the healthcare team to formulate an intervention plan early in the treatment process and have everyone follow it

C is the correct answer. The empowerment approach redefines the purpose of diabetes education, taking it from providing information so individuals will know why their behaviors need to change to providing information so individuals can make informed decisions about their behaviors.

A pregnant woman with past medical history of type 2 diabetes, ASCVD and hypercholesterolemia uncontrolled by TLC presents for evaluation. Which of the following drug therapy options would be the best choice for this patient? Niacin Rosuvastatin Fenofibrate Colesevelam

D - Colesevelam is correct. Treatment of dyslipidemia in pregnant patients should consider the welfare of the woman and the fetus. Bile acid sequestrants (colesevelam, colestipol, etc.) remain in the gastrointestinal tract and are not systemically absorbed. Statins (Answer B) are classified as FDA Pregnancy Category X which signifies that studies have shown they may cause birth defects and that the risks clearly outweigh any benefit. Niacin and fibrates (Answers A and C) are Pregnancy Category C.

Which of the following antidiabetic agents would be the safest in a patient with NYHA Class III heart failure? Metformin Pioglitazone Saxagliptin Empagliflozin

D - Empagliflozin is correct. Metformin (Answer A) is not a good choice due to the increased risk of lactic acidosis (hypoxemic state) in patients with heart failure and decreased kidney perfusion. Pioglitazone (Answer B) increases plasma fluid volume and may worsen symptoms of heart failure. In the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR) trial, patients taking saxagliptin had increased hospitalizations for heart failure. Conversely, empagliflozin (Answer D) reduced heart failure hospitalization by 35% and cardiovascular death by 38% in the EMPA-REG trial.

A 38-year-old man with type 2 diabetes and an A1C of 8.7% stopped taking metformin 500mg twice daily due to persistent diarrhea. Which of the following is most likely to achieve his A1C goal of less than 7%? Liraglutide Canagliflozin Saxagliptin Glimepiride

D - Glimepiride is correct. Biguanides and sulfonylureas lower A1C up to 2%, while other agents only lower A1C by 0.5% to 1%, including: GLP-1 receptor agonists like liraglutide (Answer A); SGLT2 inhibitors like canagliflozin (Answer B); DPP-4 inhibitors like saxagliptin (Answer C).

A 52-year-old woman with type 2 diabetes presents for evaluation. Which of the following would be considered the most significant reason to avoid initiation of metformin therapy? History of gastric reflux NYHA Class I heart failure History of iron deficiency anemia Glomerular filtration rate 26 ml/min/1.73m2

D - Glomerular filtration rate 26 ml/min/1.73m2 is correct. Metformin is considered safe to use in patients down to glomerular filtration rate (GFR) of 45 mL/min/1.73m2 or even 30 mL/min/1.73 m2. Although metformin causes gastrointestinal upset, history of reflux (Answer A) is not considered a contraindication. Caution should be used in patients with symptomatic heart failure (NYHA Class III or IV); however, metformin is safe in patients with mild heart failure (Answer B). Metformin may impair B12 absorption resulting in anemia, but is not associated iron deficiency anemia (Answer C).

Which of the following is a NOT associated with endogenous GLP-1 action? Promotes centrally mediated satiety Decreases postprandial glucagon secretion Enhances glucose-dependent insulin secretion Increases gastrointestinal motility

D - Increases gastrointestinal motility is correct. Endogenous GLP-1 effects includes the following: promotes centrally mediated satiety; decreases postprandial glucagon secretion; enhances glucose-dependent insulin secretion; and decreases gastrointestinal motility.

Which of the following drug therapies has been shown to decrease diabetes-related deaths in patients who are overweight? Glipizide Sitagliptin Pramlintide Metformin

D - Metformin is correct. A subgroup analysis of the UK Prospective Diabetes Study (UKPDS) showed that metformin was associated with a decrease in diabetes-related deaths in overweight patients. Sulfonylureas, DPP-4 inhibitors and amylin mimetics (Answers A, B, and C) do not decrease cardiovascular risk.

A 36-year-old pregnant woman with gestational diabetes inadequately controlled with diet and exercise presents for follow-up. She and her husband have tried to become pregnant several times without success, and they are very concerned about the effects of drugs on the fetus. Which of the following would be the most appropriate addition to her regimen? Glyburide Metformin Liraglutide NPH insulin

D - NPH insulin is correct. Recombinant human NPH insulin is preferred during pregnancy due to its amino acid structure and long history. Several meta-analyses suggest that glyburide (Answer A) is inferior to metformin and insulin due to increased risk of neonatal hypoglycemia and macrosomia. About 50% of the metformin dose crosses the placenta but is not associated with adverse effects on the fetus; however, metformin may slightly increase the risk of prematurity (Answer B). The GLP-1 receptor agonists (liraglutide, Answer D) are all FDA Pregnancy Category C.

A 72-year-old patient with irregular eating patterns is concerned about hypoglycemia in between meals. Which of the following would be most appropriate for this patient? Glyburide Sliding scale insulin Chlorpropramide Nateglinide

D - Nateglinide is correct. The 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults advises against the use of long-acting sulfonylureas (glyburide, Answer A; chlorpropamide Answer C) in patients > 65 year of age because of prolonged half-life in older adults and subsequent increased risk of hypoglycemia. Glyburide is metabolized to two active metabolites which exponentially increase the potential for hypoglycemia. Sliding scale insulin (Answer B) refers to administration of short- or rapid-acting insulin as the only insulin product in response to elevated blood glucose levels. Sliding scale insulin is associated with increased risk of hypoglycemia without improvement in glycemic control regardless of the care setting. Nateglinide (Answer D) stimulates insulin release from the beta-cells; however, its short half-life and mealtime administration limits the risk of hypoglycemia.

An active 54-year old patient with type 2 diabetes, hypertension and dyslipidemia returns to follow-up on atorvastatin 40mg daily. He complains of muscle pain in his thighs and calves that occurs during exercise. The decision is made to stop atorvastatin for 2 weeks then begin a new therapy. Which of the following would be the most appropriate for this patient? Niaspan Lovastatin Simvastatin Rosuvastatin

D - Rosuvastatin is correct. Statin myositis is caused by inhibition of cholesterol synthesis within muscle cells. Without sufficient endogenous cholesterol, working muscle cells are unable to repair damage cell walls resulting in lysis and pain. The lipophilic statins (atorvastatin, lovastatin and simvastatin, Answers B and C) are most commonly associated with myositis because they easily penetrate cells and become trapped. Patients who experience statin-myositis may be rechallenged with other statins, especially hydrophilic compounds (rosuvastatin, Answer D; or pravastatin). Monotherapy niaspan would not be an appropriate substitute for statin therapy (Answer A).

Which of the following interventions is most effective prevent peripheral vascular disease in patients with diabetes? Aspirin therapy Pentoxifylline Routine ambulation Smoking cessation

D - Smoking cessation is correct. Smoking cessation is the most effective intervention to prevent peripheral vascular disease. Management of existing peripheral vascular disease includes routine ambulation (Answer C) to promote corollary artery blood flow, pentoxifylline (Answer B) to and reduce pain, and aspirin therapy (Answer A) to decrease associated cardiovascular risk.

Which of the following is the most common cause of bacterial skin infections for patients with diabetes? Candida albicans Mycobacterium leprae Haemophilus influenza type b Staphylococcus aureus

D - Staphylococcus aureus is correct. The most common cause of bacterial skin infections is Staphylococcus aureus. Infections with Candida albicans represent the most common fungal infection worldwide and occur in patients where the skin is broken or in patients with compromised immune systems. Because hyperglycemia impairs the chemotaxis of white cells, patients with poor glycemic control may be considered immunocompromised. Mycobacterium leprae (Answer B) and Haemophilus influenza type b (Answer C) are not common causes of skin infection.

An 82-year-old patient with diabetes, benign prostatic hypertrophy and hypertension returns to clinic for a 1-month follow-up of his blood pressure. He reports feeling fine and denies orthostasis symptoms. His medications include lisinopril 20mg daily, hydrochlorothiazide 25mg daily, doxazosin 1mg daily, and sitagliptin 100mg daily. His home blood pressure readings average 110/68 mmHg. In clinic today his BP is 114/70 mmHg, heart rate 60 BPM; laboratory results include serum creatinine 0.9 mg/dL, potassium 3.8 mmol/L, and A1C 6.8%. Which of the following would be the most appropriate recommendation for this patient? Continue all medications at the current dose Stop hydrochlorothiazide Stop lisinopril Stop doxazosin

D - Stop doxazosin is correct. Although most adult patients with diabetes may benefit from lower blood pressure goals, treatment to blood pressure <130/70 mmHg has been associated with increased mortality in older adults (Answer A). Doxazosin should be discontinued because it is not associated with mortality benefit (unlike lisinopril, Answer C; and hydrochlorothiazide, Answer B) and other agents may adequately treat his benign prostatic hypertrophy

Which of the following best describes the short-term and long-term effects of improved glycemic control in patients with painful peripheral neuropathy? Rapid relief of symptoms but no long-term benefit Rapid relief of symptoms and improved long-term prognosis Temporary increased discomfort but no long-term benefit Temporary increased discomfort but improved long-term prognosis

D - Temporary increased discomfort but improved long-term prognosis is correct. Peripheral diabetic neuropathy results from vascular damage and impaired blood flow to nerves leading to erratic nerve firing and signal conduction that the patient interprets as pain. Elevated glucose levels contribute to cellular damage by formation of advanced glycosylation end products. Improved glycemic control is essential to restore normal blood flow and mitigate long-term nerve damage; however, it also tends to initially increase pain signals from damaged nerves.

The use of psychopharmacological agents in the treatment of persons with diabetes who experience anxiety: Has limited effectiveness in select patients Is the most promising area of treatment and intervention modalities Is supported by a number of studies in persons with diabetes Has the potential to improve metabolic control

D is the correct answer. The effective pharmacologic treatment of persons with diabetes and anxiety has been shown to improve metabolic control.

Which of the following is most associated with improved glycemic control? Decreases plasma triglycerides Increases plasma fibrinogen levels Decreases HDL-cholesterol levels Increases platelet aggregation

Decreases plasma triglycerides is correct. Hyperglycemia often leads to elevated triglyceride levels and low HDL-cholesterol levels (Answer C). As insulin resistance increases in the peripheral tissues, the glucose from the blood is less able to enter the cells where energy is needed. As a result, the body switches to an alternate energy source (free fatty acids) which are released by the liver in the form of triglycerides. Elevated glucose levels are also associated with increased plasma fibrinogen levels (Answer B) and platelet aggregation (Answer D).

A 25-year-old pregnant woman with gestational diabetes inadequately controlled with diet, exercise and metformin presents for followup. Which of the following would be the most appropriate addition to her regimen? Glulisine Glargine Detemir Degludec

Detemir is correct. All insulin products are FDA Pregnancy Category B except for glulisine, glargine and degludec which are labeled category C

Which of the following is the most compelling reason to avoid very strict glycemic control (A1C <6%) based on data from the ACCORD trial? Increased mortality Increased drug cost Increased retinopathy Increased nephropathy

Increased mortality is correct. Although intensification of therapy often increases drug cost (Answer B), patients in the intensive therapy group (goal A1C <6% compared with an A1C goal of 7% to 7.9% in the control group) of the ACCORD trial experienced a 22% increase in mortality. This increased mortality risk was not associated with A1C, severe hypoglycemia or weight gain. Intensive glycemic control reduces the risk of microvascular complications (Answer C and D); however, these benefits are offset by the increased mortality risk.

Which of the following immunizations would be most appropriate for a 42-year-old patient with type 2 diabetes who received the "pneumonia vaccine" 20 years ago? Zostavax (zoster) Prevnar 13 (pneumococcal 13-valent conjugate) Pneumovax 23 (pneumococcal polysaccharide) MenB (meningococcal B)

Pneumovax 23 (pneumococcal polysaccharide) is correct. Patients with diabetes are at increased risk for pneumococcal infection with a mortality rate as high as 50%. All patients with diabetes older than 2 years of age should initially receive Prevnar 13 prior to pneumococcal polysaccharide vaccine 23 (PPSV23). Patients with diabetes older than 19 years and those at high risk of infection should receive follow-up vaccination with PPSV23. Immunocompromised patients (including people over age 65 with a "naturally" declining immune system) mount a better response with Prevnar 13 followed by PPSV23 one year later. Zostavax (Answer A) is indicated for patients over age 50 to prevent herpes zoster (shingles). Vaccination against meningococcal B (Answer D) is indicated for adults less than age 25 as a 2-dose series at least one month apart.

Which of the following is thought to lower serum concentrations of other drugs? St John's wort Nicotinamide Alpha-lipoic acid Vanadium sulfate

St. John's wort induces metabolism of certain drugs metabolized by CYP3A4, thereby decreasing their serum concentrations of certain medications including antihypertensive, some statins, oral contraceptives, cyclosporine, etc. It also induces CYP2C9 thereby decreasing serum concentrations of warfarin.

The physiological changes of aging include all of the following except: Increased GFR lower reaction time Decreased muscle mass and strength Increased vascular resistance

The correct answer is A. GFR (glomerular filtration rates) actually decreases with age

African Americans with type 2 diabetes: Have the highest rates of diabetes in the US Have a higher incidence of diabetes and greater disability from complications than Caucasian Americans Are 3 times more likely to have diabetes than Caucasians Are at less risk statistically for the development of complications of diabete

The correct answer is B. African Americans have a higher incidence of diabetes than Caucasian Americans as well as greater disability from its complications

Legislation that determines that complementary therapies may be sold as dietary supplements is called: The FDA 10-year plan Dietary Supplement Health and Education Act (DSHEA) Complementary and Alternative Medicine ruling There is no official legislation

The correct answer is B. Congress passed the Dietary Supplement Health and Education Act (DSHEA) in 1994. This legislation created a separate category for botanicals and other products that classify them as dietary supplement. Hence supplements are excluded from the same stringent approval process required for drugs

What level of diabetes education is most appropriate for a person taking insulin who wants to learn how to make medication adjustments? Survival skills Self management education Behavior change therapy Lifestyle education

The correct answer is B. Self-management education is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-management the disease (in this case specifically learning to independently adjust insulin therapy) and its related conditions.

Which of the following might diabetes educators expect as a result of using the empowerment approach? To experience feelings of guilt when patients do not follow suggestions To accept that patients may choose to ignore their recommendations To hold themselves accountable for patient decisions To expect to invest significant time and energy to motivate patients

The correct answer is B. The empowerment approach recognizes that patients have the right to make their own decisions regarding their healthcare and as a result may chose to ignore the educator's recommendations

In relationship to Health Beliefs, there are 4 perceptions that influence a person's behavior in diabetes self-care. These include: Self-care benefits, social supports, susceptibility, and cost Susceptibility, severity, self-care activity benefits, and cost Severity, self-care cost and limitations, and susceptibility Social supports, severity, susceptibility and limitations

The correct answer is B. The four factors that influence self-care include: level of personal vulnerability, severity of the illness, efficacy of the behavior in preventing the development or minimizing consequences of the illness. And costs or deterrents associated with performing the behavior.

Which of the following persons with diabetes is most likely to exhibit an increased readiness to learn? An acutely ill patient A patient who thinks he has "a touch of diabetes" A person who exhibits low-to-moderate anxiety about his condition A person dealing with multiple stressors

The correct answer is C. Both an acute illness (A) and multiple stressors (D) would represent significant barriers to learning. A person who believes they "only have a touch of diabetes (B) does not perceive the severity of their illness and therefore is unlikely to exhibit an increased readiness to learn

In the contemplation stage of readiness, the patient is: Seriously considering change in the near future Choo sing among various behaviors to change Contemplating whether or not to change Considering change in the foreseeable future

The correct answer is D. In the contemplation stage the individual is aware o0f the problem and intends to change his/her behavior

Which of the following may not be a concern in the postpartum care of women with previous gestational diabetes? Achieving a normal body mass index (BMI) Remaining lean and fit throughout life Staying on insulin postpartum if insulin was required during pregnancy Having a follow-up oral glucose tolerance test 6 to 12 weeks postpartum

Women with a history of GDM are at increased risk of developing type 2 diabetes later in life. Insulin is not required for the vast majority of women in the post-partum period, as 95% of women will revert to normal glucose tolerance upon delivery. However, women with a history of GDM remain at increased risk for developing type 2 diabetes later in life. Achieving and maintaining normal BMI (choice A and B) and staying active (choice B) are two successful strategies for reducing that risk. It is also recommended and important for women to be retested for diabetes (choice D) in the postpartum period to ensure that their glucose tolerance has reverted to normal.

The advantages of the selective serotonin reuptake inhibitors (SSRIs) include: Less gastrointestinal side effects Less sedation Less agitation Less sexual dysfunction

correct answer is B. An advantage of SSRIs includes less sedation