Answer A is incorrect: 6.35% chose this answer, “No changes are needed because kidney function is within normal range.” A is incorrect. Although eGFR indicates stage 2 kidney disease, the elevated UACR, ≥30 mg/g, confirms moderately increased risk and recommendation to treat. Additionally, PJ’s blood pressure is also above the target. Intervention is needed to protect kidney and cardiovascular health.

Answer B is correct: 83% chose this answer, “Initiate an ACE inhibitor or ARB to reduce progression the of diabetic kidney disease.” PJ has a mildly decreased eGFR, but UACR is elevated above 30 mg/g, indicating a recommendation to treat. Additionally, intervention is needed to optimize blood pressure. According to the ADA Standards of Care in Diabetes, individuals with diabetes, hypertension, and moderately increased albuminuria should be treated with an ACE inhibitor or angiotensin receptor blocker. The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 agonists (GLP1-RA), with demonstrated benefits, could also be considered to reduce CKD progression.

Answer C is incorrect: 5.25% chose this answer, “Discontinue metformin due to the risk of kidney injury with reduced eGFR.” Metformin is safe to continue unless eGFR falls below 30 30 mL/min/1.73m². PJ’s kidney function is adequate for continued use. However, consideration to add a change to SGLT2 or GLP1 with kidney benefit could also promote additional A1c reduction.

Answer D is incorrect: 5.52% chose this answer, “Increase statin therapy to target albuminuria reduction.” Statins are recommended for ASCVD prevention, but they do not reduce albuminuria. Lipids are within normal range, and albuminuria should be addressed with an ACE inhibitor/ARB or potentially a SGLT2 inhibitor or GLP-1 RA.

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Answer A is incorrect: 1% chose this answer, “Stress with R.S. the importance of never missing his meal time lispro to prevent diabetes-related complications.” R.S. is aware that his glycemic control is important, and he is already aware of the risk of diabetes-related complications. Counseling him on this would not help him be successful with his insulin management.  

Answer B is correct: 96% chose this answer, “Using open-ended questions, explore R.S.’s routine, stressors, and support systems to understand the barriers to his insulin use.” R.S. is struggling with barriers to successful insulin management.  A holistic approach would be to ask open-ended questions about his current routine, stressors, and support systems to gain a better understanding of these barriers. This information can lead to a personalized plan of care to help improve glycemic control. 

Answer C is incorrect: 2% chose this answer, “Recommend R.S. switch to another non-insulin medication to make his regimen easier for him to manage.” He has already attempted other non-insulin therapies, and these were either ineffective or not tolerated. Changing his regimen would not be successful at improving his glycemic control and quality of life.

Answer D is incorrect: 1% chose this answer, “Since it appears R.S. did not understand how to take his insulin lispro, write out step-by-step instructions on how to take the insulin.” R.S. appears to understand how to take his insulin lispro at meals. Writing out the instructions would not improve his situation. It is not a lack of knowledge, but the multiple barriers in his life that are keeping him from being able to implement this new medication regimen.  

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Answer A is incorrect: % chose this answer, “Turn on her CGM alarms but increase the high alarm so she doesn’t get as many
hyperglycemia related alerts.” Helping Katie turn on and increasing her high alarm will not help improve her glycemic control.

Answer B is correct: % chose this answer, “Show her step-by-step how to use the app and how to troubleshoot the alerts and alarms.” Guiding Katie through the CGM app and its functions helps her ask questions, resolve issues, and better monitor her glycemic control.

Answer C is incorrect: % chose this answer, “Have the school nurse monitor her CGM trends when Katie is at school, since her mom
monitors the CGM trends when she is at home.” Asking the school nurse to monitor CGM data while Katie is at school is not helping to improve Katie’s self-management skills.

Answer D is incorrect: % chose this answer, “Email Katie’s mother once a week for updates to make sure she is monitoring CGM
trends.” Emailing Katie’s mother does not help improve Katie’s CGM self-monitoring skills or her confidence level with the CGM app.

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Answer A is incorrect: % chose this answer, “Partner with CS to reduce missed boluses and reassess in 3 months.” Answer A is incorrect as it is not the best answer. While reducing missed boluses and optimizing insulin therapy are essential to support A1c reduction, this intervention alone does not address the likely underlying psychological barriers to self-management.

Answer B is incorrect: % chose this answer, “Simplify regimen to support current state of diabetes distress.” Answer B is incorrect; it is not the best answer. While simplifying insulin dosing may be supportive in some cases, without addressing the underlying diabetes distress it is unlikely to achieve sustained improvement.

Answer C is correct: % chose this answer, “Refer to a qualified behavioral health professional for evaluation and treatment.” Answer C is correct. The 2026 ADA Standards of Care recommends a referral to a qualified behavioral health professional for evaluation and treatment when diabetes distress, burnout, reduced engagement in diabetes management or other psychosocial factors are impacting self-care and glycemic targets. ¹

Answer D is incorrect: % chose this answer, “Recommend referral to MNT for a structured weight-loss program.” Answer D is incorrect. Focusing solely on weight loss does not address the primary psychosocial barriers and weight gain may be a symptom of underlying behavioral health needs. Evaluation and treatment from a behavioral health provider would be the most appropriate next step.

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Answer A is incorrect: 14.85% chose this answer, “BMI and activity level.” This answer is incorrect but tempting. BMI level is used as a a screening tool for prediabetes and diabetes risk, but is not included as a factor contributing to secretory defects. According to the ADA, there are four factors related to insulin secretory defects in type 2 diabetes. They include; genetics, epigenetics, metabolic stress and inflammation.

Answer B is incorrect: 16.92% chose this answer, “Lifestyle and inflammation.” This juicy answer is incorrect.  Lifestyle is not a direct factor related to insulin secretory defects, but inflammation is a contributor. According to the ADA, there are four factors related to insulin secretory defects in type 2 diabetes. They include; genetics, epigenetics, metabolic stress and inflammation.

Answer C is incorrect: 25.75% chose this answer, “Genetics and visceral adipose distribution.” This answer is incorrect. Visceral adiposity is associated with an increased risk for diabetes, but does not contribute to insulin secretory defects. According to the ADA, there are four factors related to insulin secretory defects in type 2 diabetes. They include; genetics, epigenetics, metabolic stress and inflammation.

Answer D is correct: 42.48% chose this answer, “Epigenetics and metabolic stress.” This answer is correct, GREAT JOB! According to the ADA, there are four factors related to insulin secretory defects in type 2 diabetes. They include; genetics, epigenetics, metabolic stress and inflammation.

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Answer A is incorrect: % chose this answer, “Discuss the insulin pump options that connect with the Dexcom G7 CGM. This will help simplify her transition to pump therapy by minimizing the learning curve when starting an AID system.” Although some insulin pumps are compatible with the Dexcom CGM, switching to a different CGM supplier should not restrict clients from selecting the insulin pump that best suits their needs.

Answer B is incorrect: % chose this answer, “Acknowledge Grace’s interest in insulin pump technology and recommend that she wait until more advanced insulin pump algorithms are available that are easier to use.” Automated insulin delivery systems offer advanced automation. Waiting for future technology will not help Grace improve glycemic control now.

Answer C is incorrect: % chose this answer, “Recommend that Grace use a tubeless pump as it will suit her better due to her work as a nurse and active lifestyle. This will help to avoid tubing issues or the insertion site becoming dislodged.” The type of pump, with or without tubing, is a personal decision and is not based solely on occupation.

Answer D is correct: % chose this answer, “Review with Grace the details of all the available insulin pumps, algorithms, and compatible CGMs so she can make a personalized decision based on her preferences and lifestyle.” Choosing the right insulin pump is a highly personalized decision. Each insulin pump has different variables and CGM connectivity that must be considered. Grace will need to be educated on the available options so she can determine which insulin pump will work best for her.

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Answer A is incorrect: % chose this answer, “Drink sugar-free cranberry juice a few times a week.” Scientific studies have yielded mixed and inconsistent results regarding the effectiveness of cranberry juice for prevention. MS needs an intervention that will provide ongoing relief.

Answer B is correct: % chose this answer, “Apply topical vaginal estrogen cream.” Vaginal estrogen cream can help prevent recurrent urinary tract infections (UTIs) in postmenopausal women by restoring the health of vaginal and urinary tissues. Estrogen helps restore a healthy vaginal pH, increases beneficial bacteria, and improves circulation, creating an environment that is less hospitable to uropathogens. It is a non-antibiotic option recommended by medical societies and is associated with a significant reduction in rUTIs.

Answer C is incorrect: % chose this answer, “Get A1C below 7% by adding basal insulin.” Getting A1C to target can reduce risk of infections, but MS A1C is already close to target. They need an effective treatment for their frequent UTI’s.

Answer D is incorrect: % chose this answer, “Evaluate MS for autoimmune conditions.” Frequent UTIs are not usually associated with autoimmune conditions. MS needs an effective treatment for their frequent UTI’s.

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Learn more about HRT and UTIs in our blog “Hormone Replacement Therapy (HRT) – What You Need to Know”

Answer 1 is incorrect. 25.14% chose this answer, “It decreases cortisol synthesis in the adrenal cortex, lowering circulating cortisol levels.” As tempting as this answer is, mifepristone does not inhibit cortisol synthesis.

Answer 2 is incorrect. 15.21% of you chose this answer, “It reduces ACTH release from the pituitary, leading to decreased adrenal stimulation.” This medication does not directly reduce ACTH release from the pituatary.

Answer 3 is correct. About 48.73% of respondents chose this, “It blocks glucocorticoid receptors, preventing cortisol from exerting metabolic effects.” Mifepristone is a glucocorticoid receptor antagonist. By competitively binding to glucocorticoid receptors, it prevents cortisol from exerting downstream effects, including increased hepatic gluconeogenesis, peripheral insulin resistance, and lipolysis. This mechanism is particularly useful in people with hypercortisolism and concurrent type 2 diabetes, as it improves insulin sensitivity and lowers blood glucose without lowering circulating cortisol levels.

Finally, Answer 4 is incorrect. 10.99% chose this answer, “It directly enhances insulin secretion and sensitivity, independent of cortisol pathways.” This medication does not act directly on pancreatic β-cells or insulin receptors.

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