The nurse practitioner is reviewing the laboratory values of a 28-year-old male patient who presents to the office to establish care with a primary care provider. The lab results from the previous week indicate an A1C of 7.2. The nurse practitioner obtains a fasting blood sugar in the office of 142. The patient denies any significant past medical history and states that he "feels fine." The nurse practitioner recognizes that:
- The patient has developed type 1 diabetes.
- The patient has developed type 2 diabetes.
- The patient has diabetes and further testing is required.
- The patient has pre-diabetes.
3. The patient has diabetes and further testing is required.
The patient meets the criteria to be diagnosed with diabetes. The clinician would be unable to determine what type of diabetes the patient has without further testing.
The nurse practitioner has been working with a 40-year-old diabetic, single mother of two teenage children. The patient has an A1C of 8.0%. The patient and provider agree upon a plan that is designed to achieve glycemic control and set a target date of 6 months. When the patient returns six months later, her A1C is 7.8%. The NP would then:
- Encourage the patient to take a greater responsibility for her health, reinforcing the concept that she is a role model for her children.
- Reassess the plan and consider barriers such as income, health literacy, and family dynamics.
- Encourage the patient to design a plan that will meet the needs of both herself and her family.
- Explain to the patient that as long as there was improvement in her A1C, the plan is a success.
2. Reassess the plan and consider barriers such as income, health literacy, and family dynamics.
The clinician needs to reassess the plan and work with the patient to identify barriers that are preventing the patient from achieving the goal.
The nurse practitioner is reviewing the laboratory values of a patient during a follow-up office visit. The NP observes the following results in the chart: September: A1C = 6.6 Fasting glucose = 118; December: A1C = 6.8 Fasting glucose = 122. The nurse practitioner is correct in noting:
- The patient does not meet the criteria to establish a diagnosis of diabetes mellitus.
- The patient partially meets the criteria to establish a diagnosis of diabetes mellitus, but further confirmatory testing is required.
- The patient has diabetes mellitus.
- The A1C and fasting tests should be repeated in 3 months to confirm a diagnosis of diabetes mellitus.
3. The patient has diabetes mellitus.
The patient has diabetes mellitus and meets the criteria to establish diagnosis with an A1C3 6.5% and confirmatory testing.
The American Diabetes Association (ADA) recommends the use of laboratory testing to screen for pre-diabetes in asymptomatic people. The recommendation is to perform this screening on:
- All children who are overweight or obese.
- All adults with a BMI > 25 with one or more risk factors for diabetes mellitus.
- All adults and children as part of their complete routine physical exams.
- All children who were born to mothers that have had gestational diabetes.
2. All adults with a BMI > 25 with one or more risk factors for diabetes mellitus.
The ADA recommends screening for pre-diabetes and diabetes in all adults with a BMI > than 25 and at least one other risk factor.
Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are both markers for pre-diabetes. Both IFG and IGT are closely associated with:
- Autoimmune disorders such as hypothyroidism, rheumatoid arthritis, and Sjögren’s syndrome.
- Elevations in liver enzymes and inflammatory markers such as C-reactive protein.
- Obesity, coronary artery disease, and peripheral vascular disease.
- Central obesity, high triglycerides, low HDLs, and hypertension.
4. Central obesity, high triglycerides, low HDLs, and hypertension.
Central obesity, high triglycerides, and low HDLs are consistent with metabolic syndrome and are closely associated with pre-diabetes and diabetes.
Which of the following laboratory results would be a strong indicator that the patient has pre-diabetes?
- An A1C between 5.5 and 5.7
- A 2-hour post-prandial glucose between 110 and 140, after a 75 gm oral glucose tolerance test.
- A fasting glucose between 100 and 125 after an 8-hour fasting interval.
- AnA1C of greater than or equal to 6.5%.
3. A fasting glucose between 100 and 125 after an 8-hour fasting interval.
An individual may be diagnosed with pre-diabetes if the fasting glucose (8-hour fast) is 100–125. If the fasting glucose is > 125 on two or more occasions, the patient would be diagnosed with diabetes mellitus.
Immune mediated diabetes accounts for 5–10% of all diabetes mellitus and is caused by autoimmune destruction of the pancreatic beta cells. Which of the following statements is true regarding immune-mediated diabetes?
- It will develop during early childhood or adolescence.
- Patients with immune-mediated diabetes have a BMI less than 25.
- The rate of beta cell destruction is more rapid in some individuals and slower in others.
- Initial treatment with oral hypoglycemic agents is appropriate until there is a complete loss of beta cell function.
4. Initial treatment with oral hypoglycemic agents is appropriate until there is a complete loss of beta cell function.
The rate of beta cell destruction with immune-mediated diabetes mellitus is highly individualized.
Type 2 diabetes mellitus is associated with insulin resistance. Which of the following statements about insulin resistance is true?
- Patients with insulin resistance have decreased insulin production.
- Insulin resistance may improve with weight loss.
- Insulin resistance and type 2 diabetes mellitus are progressive diseases that will eventually lead to absolute insulin deficiency.
- Insulin resistance is a genetic trait and thus cannot be altered or improved.
2. Insulin resistance may improve with weight loss.
Weight loss is one of the only non-pharmacologic interventions that may reduce insulin resistance.
The most common comorbidities that occur with type 2 diabetes mellitus are:
- Depression, cancer, obstructive sleep apnea.
- Obesity, coronary artery disease, sedentary lifestyle.
- Hypertension, hyperlipidemia, obesity.
- Hypothyroidism, hyperlipidemia, chronic kidney disease.
3. Hypertension, hyperlipidemia, obesity.
The most common comorbid conditions associated with type 2 diabetes are hyperlipidemia, hypertension, and obesity. There is a strong correlation between metabolic syndrome and the development of type 2 diabetes.
DSME (diabetes self-management education) encourages the patient to make informed decisions. This approach is most successful when:
- The diabetic is provided with enough education and information that he or she can make an informed decision.
- It is patient-centered and responsive to individual preferences, needs, and values.
- The patient is given written directions that outline a specific medication regimen and goal.
- A consensus model is used which considers multiple disciplines involved in the care of the diabetic individual.
2. It is patient-centered and responsive to individual preferences, needs, and values.
DSME must be patient-centered and responsive to the individual’s needs, otherwise it is unlikely to be successful.
Medical nutritional therapy (MNT) is an integral part of diabetes self-management education. Which of the following aspects of MNT would be most supportive to the patient?
- All patients with type 2 diabetes should be encouraged to lose between 2 and 8 kilograms of their body weight.
- All members of the health care team involved with the diabetic individual should be knowledgeable about MNT and support its implementation.
- All patients with diabetes mellitus need to know how to count carbohydrates and limit the amount of carbohydrates in each meal.
- Provide the patient with menus and recipes that will be easy for the patient to create at home.
2. All members of the health care team involved with the diabetic individual should be knowledgeable about MNT and support its implementation.
All members of the health care team involved in the care of a diabetic individual should be familiar with MNT (medical nutrition therapy) and be consistent with the recommendations of these life-long behavioral modifications.
Patients who are diagnosed as pre-diabetic may begin pharmacologic therapy. The strongest evidence-based pharmacologic therapy to prevent the patient’s progression to diabetes is to initiate therapy with:
- A DPP4 such as saxagliptin.
- A basal insulin such as glargine.
- A GLP-1 receptor agonist such as liraglutide.
- A biguanide such as metformin.
4. A biguanide such as metformin.
Metformin has the strongest evidence-base as a pharmacologic therapy for diabetes prevention.
Patients who are on intensive insulin regimens should monitor their blood glucose multiple times throughout the day. The patient should be instructed that monitoring of blood glucose is essential:
- Before every meal.
- Before engaging in exercise.
- Upon awakening in the morning.
- Before driving a car.
4. Before driving a car.
Although all answers are acceptable, the patient treated with an intensive insulin therapy poses the greatest risk to self and others when driving.
The "Rule of 15" is used when the diabetic experiences hypoglycemia. The "Rule of 15" instructs the patient to:
- Take 15 units of insulin for every 15 grams of carbohydrate ingested.
- The patient should try to have 15 grams of protein, 15 grams of fat, and 15 grams of carbohydrate in equal portions for each meal.
- The patient should ingest 15 grams of carbohydrate, wait 15 minutes, and re-check their blood glucose level. Repeat as necessary until symptoms abate or blood glucose is > 100.
- Immediately inject 15 milligrams of a glucagon hypoglycemic emergency kit into their mid-thigh muscle.
3. The patient should ingest 15 grams of carbohydrate, wait 15 minutes, and re-check their blood glucose level. Repeat as necessary until symptoms abate or blood glucose is > 100.
The "Rule of 15" was created to simplify treatment for the hypoglycemic patient while that person remains capable of assisting themselves to correct their hypoglycemia. When patients are hypoglycemic, they often have impaired judgment. Teaching the patient this simple rule can help prevent a further decline in blood glucose and prevent overcorrection of their low blood sugar.
The patient is started on metformin therapy. The nurse practitioner should explain to the patient that a potentially fatal side effect of metformin is:
- Nausea and diarrhea.
- Lactic acidosis.
2. Lactic acidosis.
All patients that are on metformin therapy must be aware of the potential for lactic acidosis, which can be fatal.
An overweight diabetic patient verbalizes that he is interested in beginning therapy with a GLP-1 RA to improve his diabetic control and assist with weight loss. The nurse practitioner must first assess the patient for:
- A personal or family history of medullary thyroid cancer.
- A personal or family history of papillary thyroid cancer.
- A personal or family history of familial hereditary polyposis.
- A personal or family history of polycystic kidney disease.
1. A personal or family history of medullary thyroid cancer.
A black box warning exists for all GLP-1 RAs if there is a family or personal history of medullary thyroid cancer or a history of MEN2 (multiple endocrine neoplasia syndrome). During clinical trials conducted on rats, there was an increase in the development of medullary thyroid cancer when given high-dose concentrations of GLP-1 RA.
A patient presents to the primary care office for an initial evaluation. The patient is complaining of polyuria and polydipsia and exhibits symptoms of dehydration. An A1C is obtained that reveals an A1C of 12.7%. The nurse practitioner should initiate therapy with:
- A GLP-1 RA.
- A sulfonylurea.
A patient with an A1C of 12.7% is considered to be "glucose toxic," and insulin is the recommended therapy. Later, when the A1C improves to < 9%, the patient may consider alternative therapies.
The patient is reviewing her labs with the nurse practitioner. She inquires about the significance of the hemoglobin A1C test. The nurse practitioner explains:
- "It represents the serum glucose level."
- "It reflects the post-prandial (after-meal) increase of the serum glucose."
- "It represents the percentage of red blood cells that contain hemoglobin."
- "It correlates with the average serum glucose level of the previous 90 days."
4. "It correlates with the average serum glucose level of the previous 90 days."
The A1C reflects the average percentage of glucose within the red blood cells. RBCs have a life expectancy of approximately 90 days.
A type 2 diabetic patient is started on pharmacologic therapy that is expected to assist with weight loss. Which pharmacologic therapy may assist with weight loss?
- A dipeptidyl peptidase inhibitor (DPP-4 inhibitor)
- A thiazolinedione (TZD)
- A sodium-glucose co-transporter 2 inhibitor (SGLT-2 inhibitor)
- A sulfonylurea
3. A sodium-glucose co-transporter 2 inhibitor (SGLT-2 inhibitor)
Of the pharmacologic therapies listed, only the SGLT-2 inhibitor contributes to weight loss through the loss of glucose (and therefore calories) by increasing glucose filtrate in the urine.
What is the most common side effect of metformin therapy?
- Gastrointestinal upset
- Weight gain
- Fungal infections
3. Weight gain
Metformin commonly causes gastrointestinal side effects.
A type 2 diabetic patient presents for a diabetic follow-up visit. The patient has a history of hypertension and persistent microalbuminuria. The patient verbalizes that he regularly takes lisinopril (20 milligrams daily). The nurse practitioner observes that the patient’s most recent GFR (glomerular filtration rate) is 29 and knows that the recommended management for this patient is to:
- Refer them to a nephrologist.
- Repeat the GFR in 3 months and monitor electrolytes, bicarbonate, and calcium.
- Obtain a 24-hour urine sample for creatinine clearance.
- Obtain a renal ultrasound to assess for renal artery stenosis.
1. Refer them to a nephrologist.
A diabetic patient that has either persistent microalbuminuria or a GFR < 30 should be referred to a nephrologist.
Diabetic retinopathy is the most common cause of new cases of blindness among adults age 20–74 years. It is associated with the duration of the disease, as well as microvascular damage. Which of the following conditions, when present, would alert the nurse practitioner to recommend an immediate ophthalmic evaluation?
- Orthostatic hypotension
- Coronary artery disease
Nephropathy, retinopathy, and DPN (diabetic peripheral neuropathy) are all manifestations of long-term microvascular damage. The presence of one of these is a strong indicator for the presence of another.
A 38-year-old female patient with type 1 diabetes has developed persistent microalbuminuria, as evidenced by two specimens collected over a 6-month period. The patient is normotensive. The nurse practitioner would be correct in recommending that the patient:
- Continue with watchful waiting and repeat urine microalbumin annually.
- Restrict the protein in their diet to no more than 60 kilograms of protein per day.
- Obtain a serum pregnancy test, and if negative, initiate ACE-inhibitor therapy.
- Repeat the test using a first morning urine sample obtained with a clean-catch, midstream collection method.
3. Obtain a serum pregnancy test, and if negative, initiate ACE-inhibitor therapy.
ACE inhibitors have been shown to decrease and sometimes reverse the progression of microalbuminuria and so should be initiated on all non-pregnant females with persistent microalbuminuria. ACE inhibitors are not necessarily recommended for normotensive patients that do not have microalbuminuria present.
A 75-year-old patient with a 20-year history of type 2 diabetes presents to the office for a follow-up evaluation. She brings her most recent 3 months of blood glucose logs, which reveal a morning fasting glucose of 58–75. Her A1C is 6.0%. The nurse practitioner reviews her medication regimen, which is: Metformin 1000 mg po BID; Sitagliptin 100 mg po once daily; Glargine insulin 10 units SQ at HS. The nurse practitioner discusses with the patient her concerns regarding persistent hypoglycemia and recommends that the patient:
- Discontinue the metformin.
- Discontinue the sitagliptin.
- Discontinue the glargine insulin.
- Reduce the metformin dose to 1000 mg daily in the a.m.
3. Discontinue the glargine insulin.
The patient is demonstrating significant hypoglycemia, which is particularly dangerous in the elderly diabetic patient. Metformin and sitagliptin are unlikely to cause any hypoglycemia. The insulin should be discontinued.
A 10-year-old male patient is seen in his PCP’s office. The patient has a negative PMH and a glucose reading of 626. The patient has been complaining of abdominal pain and nausea. The NP notes that the patient is breathing with deep, labored, and rapid respirations, and is lethargic. What is the most likely cause of the patient’s condition?
- HHS caused by type II DM
- DKA caused by type I DM
- Uncontrolled hyperglycemia with dehydration
- Diabetes exacerbation related to pneumonia
2. DKA caused by type I DM
The patient is exhibiting Kussmaul’s respirations and clinically presents as diabetic ketoacidosis.
The NP is working in the ED when a patient with known DM 1 is brought in by ambulance. The patient states that she has been sick with the flu and has not been able to control her blood sugar despite taking her usual doses of short-acting insulin. The patient’s BS is 522 upon admission to the ED. Serum and urine Ketones are +. Blood gas reveals a PH of 7.25. The NP is aware that the first step in treatment is:
- Initiate hydration with IV NS.
- Initiate a regular insulin IV.
- Initiate IV bicarbonate therapy.
- Initiate treatment of the underlying causes of elevated BS.
1. Initiate hydration with IV NS.
Initial treatment for DKA is hydration with an IV of normal saline until euvolemia is established.
A female patient with type II DM on oral hypoglycemic therapy is seen in the office for a follow-up evaluation. The patient states that she was recently diagnosed with a UTI over the weekend and went to a walk-in treatment center. She started on antibiotic therapy 24 hours ago. She continues to complain of UTI symptoms. Additionally, her BS has been consistently elevated in the 250–300 range. The NP would be correct in considering:
- Sending the patient to the ED for evaluation of HHS.
- Initiating treatment with insulin in the office and adding an insulin regimen at home to cover the patient’s "sick days."
- Intensifying the oral hypoglycemic therapy.
- Obtaining stat ABGs to assess for acidosis.
2. Initiating treatment with insulin in the office and adding an insulin regimen at home to cover the patient’s "sick days."
All patients with diabetes mellitus should have a "sick days" plan in place in order to prevent more severe consequences of hyperglycemia. It is reasonable to have this patient use short-term insulin therapy while recovering from her UTI. The patient does not exhibit any signs or symptoms of HHS or DKA.
Both DKA and HHS can be seen in the diabetic patient. The NP should be aware that the most common reason for development of these two conditions are:
- Non-adherence to the diabetic medication regimen.
- Non-adherence to the diet and exercise regimen.
- An underlying medical condition causing physiologic stress.
- A lack of understanding by the patient about these two conditions.
3. An underlying medical condition causing physiologic stress.
Both DKA and HHS are often associated with underlying physiologic stress. 40% of the time it is associated with an illness that is either medical or surgical in origin.
A patient with type 2 DM is being evaluated in the NP’s office. The patient states that she has lost a lot of weight lately "without even trying" and expects that the NP will be pleased. The patient’s BS in the office is 524. She has lost 20 pounds since her last visit one month ago. The patient verbalizes profound fatigue. The NP is aware that the patient is most likely experiencing:
- Fatigue related to her rapid weight loss and malnutrition.
- Fatigue related to severe dehydration, which is likely caused by HHS.
- Fatigue related to an underlying infection.
- Fatigue related to severe hyperglycemia.
2. Fatigue related to severe dehydration, which is likely caused by HHS.
The 20-pound weight loss in a 30-day period is most likely caused by severe dehydration. This is consistent with the very high blood sugar and profound fatigue. The patient is exhibiting signs of HHS and should be hospitalized for treatment.
The most sensitive laboratory indicator of overall thyroid function is to evaluate the level of circulating:
- Free T4.
- Free T3.
- TPO (thyroid peroxidase antibody).
TSH is both sensitive and specific for determining circulating T4 and T3 and is used for evaluating both hyperthyroidism and hypothyroidism.