diabetes quiz 1

What is the onset time for Ultralente? 1. 30 minutes to 60 minutes 2. 1 hour to 2.5 hours 3. 4 hours to 6 hours 4. 15 minutes to 30 minutes

3. 4 hours to 6 hours Rationale: Ultralente is a long acting insulin, which has an onset of 4 hours to 6 hours.

Which characteristic is related to the anion gap? 1. Anion gap is used as a way of monitoring response to therapy. 2. Anion gap is useful for determining metabolic alkalosis. 3. Serum sodium represents the majority of the cations. 4. Chloride represents approximately the majority of the anions.

. Anion gap is used as a way of monitoring response to therapy. Rationale: Anion gap is essentially used as a way of monitoring response to therapy.

Which is a modifiable risk factor related to type 2 diabetes mellitus? Select all that apply. 1. Body mass index above 26 2. Polycystic ovary syndrome in a female client 3. Physical inactivity of the client 4. HDL cholesterol level below 35 mg/dL 5. Hypertension above 140/90 mm Hg

1 & 3 Rationale: 1. Body mass index above 26 falls under the category of modifiable risk factors. 3. Physical inactivity of the client is a modifiable risk factor related to type 2 diabetes mellitus in a client.

The RN is teaching a diabetic client about proper foot care. Which statement made by the client indicates the need of further teaching? Select all that apply. 1. "I should wash my feet weekly." 2. "I should always ask the primary health-care provider before soaking my feet." 3. "I should use moisturizers, creams and lotions in between the toes." 4. "I should not walk barefoot." 5. "I should be very careful of hot water."

1 &3 Rationale: 1. The client should be advised to wash the feet on a daily basis. The washing should be followed by extensive drying of the feet. 3. The client should use moisturizers, creams and lotions to moisten the feet, but not in between the toes.

The RN is teaching a client about physical activities recommended for glycemic control. Which statement made by the client indicates a need for further teaching? Select all that apply. 1. "I will take up anaerobic exercise to control diabetes." 2. "I should adjust my medication dose and carbohydrate intake when I am keeping an exercise regimen." 3. "I should work out at least 120 minutes every week. " 4. "I should adapt myself to moderate intensity exercise along with strength training. " 5. "I should ingest carbohydrates if my pre-exercise blood sugar level is less than 100 mg/dL."

1&3 Rationale: 1. The client should take up aerobic exercise and resistance training to control diabetes. 3. It is imperative for the client to work out for 150 minutes every week, not 120 minutes.

The presence of which traits indicate that a client is at risk for metabolic syndrome? Select all that apply. 1. Body mass index (BMI) of 34 2. Serum triglycerides are 180 mg/dL 3. Blood pressure is 120/80 mm Hg 4. Fasting blood glucose is 90 mg/dL 5. High-density lipoprotein (HDL) is 30 mg/dL

1&5 Rationale: 1. A BMI of more than 30 indicates obesity. Obesity is the risk factor for developing metabolic syndrome. 5. HDL level of less than 40 mg/dL indicates possible metabolic syndrome.

Which clinical manifestations are most likely to be seen in a client with diabetes mellitus? Select all that apply. 1. Fatigue 2. Weight gain 3. Excessive thirst 4. Decreased appetite 5. Increased urine output

1,3,5 Rationale: 1 Fatigue is seen with diabetes mellitus. This is caused by the continual breakdown of fats and proteins leading to weight loss and fatigue. 3.Excessive thirst caused by increased urine output may occur with diabetes mellitus. 5. Urine output increases because of an increase in the thirst mechanism.

A client with a long-standing history of diabetes mellitus reports to the emergency room with fruity smelling breath. The laboratory reports show that the postprandial blood glucose level of the client is 280 mg/dL, the arterial pH is 7, and there is presence of ketone bodies in the urine. In order of occurrence, what is the pathophysiology involved in the development of the condition in this client? 1. insulin deficiency 2. metabolic acidosis 3. diabetic ketoacidosis 4. formation of ketone bodies 5. Release of fatty acids from adipose tissues

1,5,4,2,3 Rationale: Inadequate insulin production in pancreas will result in rapid breakdown of the fat stores releasing fatty acids from the adipose reserves. In the liver fatty acids are converted to ketone bodies. Because of low pH of the ketone bodies, the condition of metabolic acidosis arises, which further results in diabetic ketoacidosis.

An RN is teaching a nursing student about a glycosylated hemoglobin test. Which statement made by the nursing student indicates the need for further teaching? 1. "A glycosylated hemoglobin test should be done after 8 hours of fasting." 2. "Physical activity and stress do not alter the results of a glycosylated hemoglobin test." 3. "A glycosylated hemoglobin test does not yield accurate results in clients with diabetic renal disease." 4. "A glycosylated hemoglobin test measures the plasma glucose concentration over a period of 120 days."

1. "A glycosylated hemoglobin test should be done after 8 hours of fasting." Rationale: A glycosylated hemoglobin test can be done in clients at any time in the day and does not require fasting.

The RN is teaching a group of LPNs about the use of insulin pumps. Which statement made by an LPN indicates the need for further teaching? 1. "The insulin pump can deliver only bolus insulin." 2. "The insulin is provided by computer driven device." 3. "More precise doses can be delivered through the insulin pump. " 4. "The insulin pump can be very expensive."

1. "The insulin pump can deliver only bolus insulin." Rationale: Insulin pumps can be used to deliver both bolus and basal insulin with the help of the multiple injection technique.

A nurse asks the client to drink a beverage containing 75 grams of glucose after an 8-hour fast. Which diagnostic test is the client having? 1. A 2-hour plasma glucose test 2. Fasting plasma glucose test 3. Random plasma glucose test 4. Glycosylated hemoglobin test

1. A 2-hour plasma glucose test Rationale: A client scheduled for a 2-hour plasma glucose test should consume a carbohydrate beverage containing 75 grams of glucose 8 to 12 hours before the test. Then the blood glucose levels are assessed after 1 and 2 consecutive hours, to evaluate the glucose tolerance by the client.

Which class of drug is contraindicated in the client with kidney failure who is diagnosed with type 2 diabetes mellitus? 1. Biguanides 2. Meglitinides 3. Sulfonylureas 4. Thiazolidinediones

1. Biguanides Rationale: Biguanides such as metformin are the drug of choice in type 2 diabetes mellitus. They decrease the production of glucose in the liver and increase the insulin sensitivity in skeletal muscle. They are contraindicated in clients with renal impairment.

A client presents with early satiety, bloating, nausea, and vomiting. On assessment, the primary health-care provider identifies that there is erratic emptying of contents of the stomach into the intestine. Which condition does the client most likely have? 1. Diabetic gastroparesis 2. Prolonged hyperglycemia 3. Diabetic peripheral neuropathy 4. Hyperosmolar hyperglycemic state (HHS)

1. Diabetic gastroparesis Rationale: Diabetic gastroparesis occurs when the nerves that innervate the stomach are damaged, which leads to erratic emptying of stomach into the intestine. The clinical manifestations include bloating, nausea, and vomiting.

A client is being treated with medication for diabetes mellitus. On a follow-up visit, the nurse finds that the client has developed nasopharyngeal inflammation. Which class of antidiabetic drug may be responsible for the client's condition? 1. Gliptins 2. Meglitinides 3. Thiazolidinedione 4. Alpha-glucosidase inhibitors

1. Gliptins Nasopharyngitis is the condition in which there is inflammation of the nasopharynx. It is an adverse effect associated with gliptins, which are used in the treatment of diabetes mellitus.

A 10-year-old client has an autoimmune disease resulting in the destruction of beta cells of the pancreas. Which antidiabetic drug is most likely to be prescribed to the client? 1. Insulin therapy 2. Biguanide therapy 3. Sulfonylureas therapy 4. Alpha-glucosidase inhibitors

1. Insulin therapy Rationale: Destruction of pancreatic beta cells in a 10-year-old client indicates type 1 diabetes mellitus, for which insulin therapy is the only efficient treatment option available.

Which is true regarding the administration of alpha-glucosidase inhibitor to a diabetic client? 1. It should be taken with the first bite of every meal. 2. It should be taken three times before meal. 3. It should be taken once daily. 4. It should be taken twice daily.

1. It should be taken with the first bite of every meal. Rationale: Alpha-glucosidase inhibitors should be taken with the first bite of every meal.

Which premixed insulin has a composition of 70% intermediate acting insulin and 30% rapid acting insulin? 1. Novolog 70/30 2. Humulin 70/30 3. Novolin 70/30 4. Humulin 50/50

1. Novolog 70/30 Rationale: Novolog 70/30 is composed of 70% intermediate acting insulin and 30% rapid acting insulin.

A client is diagnosed with extreme insulin resistance. Which syringe should be used by the primary health-care provider in this client? 1. U-500 syringe 2. U-100 syringe 1 mL 3. U-100 syringe 0.5 mL 4. U-100 syringe 0.3 mL

1. U-500 syringe Rationale: The primary health-care provider should prescribe a U-500 syringe, which is made by the special order for the client with extreme insulin resistance. This syringe can hold 500 unit of insulin.

Which symptom is evident in clients with type I diabetes mellitus? 1. Fatigue 2. Dysuria 3. Dysphagia 4. Weight gain

1. fatigue Rationale: Fatigue is a symptom of diabetes mellitus.

A client diagnosed with pancreatic cancer has undergone a pancreatic resection. Which hypoglycemic drug is most beneficial to this client? 1. Insulin therapy 2. Biguanide therapy 3. Meglitinide therapy 4. Sulfonylurea therapy

1. insulin therapy A client who underwent a pancreatic resection develops type 1 diabetes mellitus, for which insulin therapy is the only efficient treatment option available.

Which is true regarding a continuous glucose monitoring (CGM) system? 1. It uses a tiny sensor inserted under the skin. 2. It measures the average plasma glucose concentration over time. 3. It uses approved CGM devices that are accurate and reliable. 4. It lets the provider determine the effectiveness of treatment and plan adjustments.

1. it uses a tiny sensor inserted under the skin Rationale: A tiny sensor is inserted under the skin to check glucose levels in the interstitial fluid for CGM system.

The nurse suspects a client has developed diabetic ketoacidosis. Which parameters assessed in the client supports the nurse's conclusion? Select all that apply. 1. Hematuria 2. Arterial pH of 6.9 3. Ketonuria 4. Serum glucose level of 200 5. Serum bicarbonate level of 12

2,3,5 Rationale: 2. An arterial pH of less than 7 may be indicative of diabetic ketoacidosis. The increased levels of ketone bodies in the blood may decrease the pH of the blood. 3. Ketones in the urine are a characteristic of diabetic ketoacidosis. 5. A serum bicarbonate level less than 15 is a characteristic of diabetic ketoacidosis.

An RN is teaching a nursing student about type 1 diabetes mellitus. Which statement made by the nursing student indicates a need for further teaching? 1. "Type 1 diabetes mellitus may occur in adulthood." 2. "Alpha cells of the pancreas are destroyed in type 1 diabetes mellitus." 3. "Clients with type 1 diabetes mellitus do not respond to oral hypoglycemic drugs." 4. "Total insulin deficiency occurs within one year of onset of type 1 diabetes mellitus

2. "Alpha cells of the pancreas are destroyed in type 1 diabetes mellitus." Rationale: The ß-cells of the pancreas are destroyed in type 1 diabetes mellitus.

Which occurs when the nerves of the feet and hands are damaged due to diabetes? 1. Depressed immune response 2. Diabetic peripheral neuropathy 3. Autonomic neuropathy 4. Hyperosmolar Hyperglycemic State (HHS)

2. Diabetic peripheral neuropathy Rationale: Diabetic peripheral neuropathy results when the nerves and feet are damaged. The phenomenon is clinically manifested by numbness, tingling, or pain.

Which test measures the amount of glucose that binds to red blood cells in a non-pregnant adult client? 1. Oral glucose tolerance test 2. Hemoglobin A1C test 3. Fasting plasma glucose (FPG) test 4. Random plasma glucose

2. Hemoglobin A1C test Rationale: Hemoglobin A1C measures the amount of glucose that binds to red blood cells in a non-pregnant adult.

Which is true regarding long acting insulin? 1. It is a dose of prandial insulin used prior to eating or used as correction insulin for blood glucose elevations. 2. It is a dose of basal insulin used in combination with rapid acting or short acting. 3. It covers insulin needs for approximately half the day or overnight. 4. It is a dose of prandial insulin used for meals eaten within 30 to 60 minutes after administration.

2. It is a dose of basal insulin used in combination with rapid acting or short acting. Rationale: Long acting insulin is a dose of basal insulin used in combination with rapid acting or short acting.

Which is true regarding the Somogyi effect? 1. The phenomenon occurs due to a decreased insulin dosage at night. 2. The body releases growth hormone, cortisol, and catecholamines in the client. 3. The phenomenon leads to lower than normal blood glucose levels in the 7am to 8am morning hours. 4. The Somogyi effect can be prevented by injecting basal insulin without having a small bedtime snack.

2. The body releases growth hormone, cortisol, and catecholamines in the client. In case of Dawn phenomenon and Somogyi effect, the body releases growth hormone, cortisol, and catecholamines in the client.

Which is related to hyperosmolar hyperglycemic state (HHS)? 1. Anion gap in case of HHS is positive. 2. The plasma glucose level in cases of HHS is above 600. 3. HHS occurs more commonly in children in response to stress or infection. 4. Serum ketones in case of HHS are positive.

2. The plasma glucose level in cases of HHS is above 600. Rationale: The plasma glucose level in cases of HHS is above 600.

The RN is teaching a client with diabetes mellitus about the diet to be followed for maintenance of the disease. Which statement made by the client indicates the need for further teaching? 1. I should decrease my dietary trans fat intake 2. I should decrease my intake of foods rich in fiber 3. I should decrease my alcohol intake to one glass per day 4. I should include 45 to 60 grams of carbohydrate per meal in diet.

2. I should decrease my intake of foods rich in fiber Rationale: Intake of fiber-rich foods helps to control blood sugar levels by delaying gastric emptying. Therefore, the client should increase the intake of fiber.

Before undergoing a laboratory diagnostic test, the nurse instructs a diabetic client not to have any caloric intake for 8 hours prior. For which diagnostic method is the client most likely preparing 1. hemoglobin A1c 2. Fasting plasma glucose 3. Random Plasma glucose 4. Oral glucose tolerance test.

2. fasting plasma glucose Rationale: Fasting is defined as no calorie intake for 8 hours. Fasting plasma glucose testing is a preferred method in diagnosing diabetes mellitus since it is more reliable, economical, and accurate.

Which true regarding the pathophysiology of type 1 diabetes? 1. The process is very rapid in older adults. 2. It is an autoimmune process where the insulin producing β-cells are destroyed. 3. A condition called prediabetes is a warning sign for the development of Type 1 diabetes. 4. Type 1 diabetes mellitus involves defects at the cell membrane that prevent the normal action of insulin.

2. it is an autoimmune process where the insulin producing B cells are destroyed Rationale: Type 1 diabetes mellitus is an autoimmune process where the insulin producing ß-cells of the pancreas are destroyed.

What symptom is most likely to occur in a client due to cell starvation? 1. Anemia 2. Polyphagia 3. Polydipsia 4. Glucosuria

2. polyphagia Rationale: The lack of insulin required to move glucose into the cells results in the breakdown of proteins and fat as a source of energy. This results in starvation of the cells leading to polyphagia.

The nurse is educating a client with type 2 diabetes on food choices that contain 15 grams of carbohydrates. Which food choices are most appropriate for the client? Select all that apply. 1. 1 cup of oatmeal 2. 1 cup of pasta 3. 4 to 6 crackers 4. 1 English muffin 5. ½ hamburger bun

3 &5 Rationale: 3. The client can consume 4 to 6 crackers as that contains approximately 15 grams of carbohydrates. 5. The client can consume ½ hamburger bun as it contains approximately 15 grams of carbohydrates.

Which types of food contain carbohydrates? Select all that apply. 1. Milk 2. Fish 3. Corn 4. Meat 5. Dried beans

3&5 Rationale: 3. Corn contains carbohydrates. 5. Dried beans contain carbohydrates.

The RN is teaching a client with diabetes mellitus about foot care. Which statement made by the client indicates the need for further teaching? 1. "I will refrain from walking barefoot." 2. "I will refrain from soaking my feet in water." 3. "I will use lotions between my toes." 4. "I will wash my feet daily and dry them thoroughly."

3. "I will use lotions between my toes." A diabetic client should not use lotions between the toes, as this may encourage infection.

How much 80-proof distilled spirits can a female adult diabetic client consume in a day? 1. 5 oz 2. 12 oz 3. 1.5 oz 4. 1 oz

3. 1.5 oz Rationale: A female adult diabetic client can consume around 1.5 oz of 80-proof distilled spirits

A client reports numbness and a tingling sensation in the extremities. Upon assessment, the nurse identifies that there is decreased sensation in the client's feet and hands. Which condition is most likely present in the client? 1. Gestational diabetes 2. Diabetic gastroparesis 3. Diabetic peripheral neuropathy 4. Hyperosmolar hyperglycemic state (HHS)

3. Diabetic peripheral neuropathy Rationale: Diabetic peripheral neuropathy occurs when the nerves to the feet and hands are damaged. Clinical manifestations include numbness, pain, and a tingling sensation.

Which is a major cation? 1. Chloride 2. Phosphate 3. Magnesium 4. Albumin

3. Magnesium Rationale: Magnesium is a major cation.

The RN is caring for a female client who presents with central obesity. The serum triglyceride level is over 165 mg/dL and high density lipoprotein (HDL) is 45 mg/dL for the client. Which is most likely responsible for these symptoms? 1. Depressed immune response 2. Hyperosmolar hyperglycemic state 3. Metabolic syndrome 4. Autonomic neuropathy

3. Metabolic syndrome Rationale: Metabolic syndrome is considered to be a cluster of risk factors related to both cardiovascular disease and type 2 diabetes. In this case, the female client is suffering from central obesity. The client is diagnosed with high level of triglyceride and a low level of HDL as well. Three characteristics indicate that the client has metabolic syndrome.

. The RN instructs a client to consume a glucose-containing carbohydrate beverage after 8 hours of fasting. Later, the nurse obtains the client's glucose levels at 1 hour and 2 hours postconsumption. Which diagnostic test is performed on this client? 1. Fasting plasma glucose test 2. Random plasma glucose test 3. Oral glucose intolerance test 4. Glycosylated hemoglobin test

3. Oral glucose intolerance test Rationale: An oral glucose intolerance test is performed by asking the client to consume a glucose-filled beverage, with 75 grams of carbohydrate after fasting 8 to 12 hours. Blood samples were taken before consuming the drink to get a fasting level, 1 hour after consumption and 2 hours after the consumption of glucose are of diagnostic significance.

Which risk is related to peripheral vascular disease (PVD)? 1. PVD increases susceptibility to periodontal bacteria and dental caries. 2. PVD leads to renal failure in the client. 3. PVD increases the risk of non-traumatic amputation of a lower extremity. 4. PVD leads to early age blindness in a client.

3. PVD increases the risk of non-traumatic amputation of a lower extremity. Rationale: PVD increases the risk of non-traumatic amputation of a lower extremity.

A client is receiving insulin therapy for diabetes mellitus. On a follow-up visit, the nurse finds that the client has developed lipohypertrophy. Which is the most likely cause of this condition? 1. The client is allergic to insulin. 2. The client has taken extra doses of insulin. 3. The client is administering insulin in the same site. 4. The client is taking medication at irregular time intervals.

3. The client is administering insulin in the same site. Rationale: Insulin is administered subcutaneously. Lipohypertrophy is a condition in which the fats are deposits in the skin. It can occur because of the administration of insulin on the same site. This can be avoided by rotating the site of insulin administration.

Which insulin is used in combination with short acting insulin? 1. Lispro 2. Aspart 3. Glargine 4. Regular humulin

3. Glargine Rationale: Long-acting insulin is used in combination with rapid-acting or short-acting insulin. Glargine is an example of long-acting insulin.

Which mechanism of action is related to DPP-4 Inhibitors? 1. It stimulates the β-cells to produce more insulin. 2. It slows the breakdown and absorption of sugars and starches. 3. It prevents the breakdown of naturally occurring GLP-1. 4. It increases insulin sensitivity in the skeletal muscle.

3. it prevents the breakdown of naturally occuring GLP-1 Rationale: DPP-4 inhibitors prevent the breakdown of naturally occurring GLP-1, which is a compound that stimulates insulin release from the pancreas.

The RN is teaching a group of LPNs about depressed immune response in a client. Which statement made by an LPN indicates the need for further teaching? Select all that apply. 1. "The hospital stay of the client is prolonged." 2. "Impaired neutrophil and macrophage phagocytosis of bacteria increases the proliferative phase." 3. "Hypoglycemia is associated with the increased rates of pneumonia, influenza and tuberculosis." 4. "The phenomenon is a long-term complication related to hypoglycemia." 5. "The client's risk of sepsis is increased."

4. "The phenomenon is a long-term complication related to hypoglycemia." Rationale: The phenomenon is a long-term complication related to hyperglycemia, not hypoglycemia.

Which insulin is used as a sliding scale to compensate for blood glucose elevations is most effective in maintaining tight glycemic control? 1. Basal insulin 2. Prandial insulin 3. Nutritional insulin 4. Correctional insulin

4. Correctional insulin Rationale: Correctional insulin is used as a sliding scale to compensate for blood glucose elevations is most effective in maintaining tight glycemic control.

The laboratory reports of a client reveal a serum sodium level of 130 mEq/L. The client also has a heart rate of 110 bpm. Which is the client most likely to have developed? 1. Hypoglycemia 2. Somogyi effect 3. Dawn phenomenon 4. Diabetic ketoacidosis

4. Diabetic ketoacidosis The normal serum sodium level is 135 to 145 mEq/L. Hyponatremia is defined as a serum level of less than 135 mEq/L. The normal heart rate of a healthy human being is 60 to 100 bpm. An abnormally rapid heart rate is known as tachycardia; the heart rate of 110 bpm indicates tachycardia. The clinical manifestations of diabetic ketoacidosis are hyponatremia and tachycardia.

Which insulin is known for its intermediate action? 1. Humalog 2. Novolin 3. Lantus 4. Lente

4. Lente Rationale: Lente is a type of insulin which is used for intermediate action.

Which environmental trigger plays a part in developing type 1 diabetes in genetically-sensitive individuals? 1. Celiac disease 2. Autoimmune thyroid disease 3. Addison's disease 4. Mumps

4. Mumps Rationale: Mumps is a virus and an environmental trigger that play a part in developing type 1 diabetes in genetically sensitive individuals. Rationale: The RN is teaching a diabetic client about proper foot care. Which statement made by the client indicates the need of further teaching? Select all that apply.

Which is true regarding the epidemiology of type 2 diabetes mellitus? 1. Type 2 diabetes is rarer when compared to Type 1 in the United States. 2. Type 2 Diabetes is more common in juveniles than in adults. 3. In children, the onset of diabetes is typically between 5 to 15 years old. 4. Obesity and inactivity has been the main cause of type 2 diabetes in young people.

4. Obesity and inactivity has been the main cause of type 2 diabetes in young people. Rationale: The increase in obesity and inactivity is the main reason for type 2 diabetes in young adults.

Which is true regarding dietary fat that a diabetic client should include in his or her diet? 1. Total dietary fat should comprise more than 30% of the daily food intake. 2. Dietary saturated fat should be limited to less than 10% of the daily food intake. 3. Food containing trans fat should be substituted for food containing carbohydrates. 4. The client should eliminate the intake of trans fat.

4. The client should eliminate the intake of trans fat Rationale: The client should reduce or eliminate the intake of trans fat.

A client with long-term diabetes mellitus has fruity smelling breath. Further investigation reveals that the client has a postprandial blood glucose level of 300 mg/dL, an arterial pH of 6.8, and ketonuria. Which diabetic complication is most likely occurring in the client? 1. Hypoglycemia 2. Somogyi effect 3. Dawn phenomenon 4. Diabetic ketoacidosis

4. diabetic ketoacidosis Rationale: Diabetic ketoacidosis is diagnosed by the presence of hyperglycemia (greater 250 mg/dL), a decreased arterial blood pH, and the presence of ketone bodies in urine. This complication of uncontrolled diabetes mellitus is associated with fruity breath.

Which client is most at risk for developing type 2 diabetes mellitus? 1. A client with a body mass index (BMI) of less than 25 2. The client with a high-density lipoprotein (HDL) cholesterol level of 30 mg/dL 3. The client with a triglyceride level of 200 mg/dL 4. The client with A1c less than 5.7% mg/dL on previous testing

The normal HDL cholesterol is greater than or equal to 35 mg/dL. A client with an HDL level of 30 mg/dL is at increased risk of developing diabetes mellitus. Rationale: The normal HDL cholesterol is greater than or equal to 35 mg/dL. A client with an HDL level of 30 mg/dL is at increased risk of developing diabetes mellitus.