Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
The NP is seeing a 60-year-old woman with a ten-year history of Type 2 diabetes. Her current medications include oral metformin and an oral SGLT2i. She states she's feeling well without report of blurred vision, without excessive thirst, or polyuria. She's not had any laboratory tests done in the past six months. Which of the following represents the best choice of tests to determine her overall glucose control?
Is it:
A. Fasting plasma glucose.
B. Serum creatinine with estimated GFR or estimated glomerular filtration rate.
C. Hemoglobin. A1c.
D. Random blood glucose.
The correct answer here is C. Hemoglobin A1c.
Where should you start? First, determine what kind of question this is. Given that we're supplied with her diagnosis and her treatment plan and am now asked about laboratory monitoring, this is an evaluation question looking at response to care. First, let's take a look at some background information. Diabetes is a chronic disease where the pancreas is no longer able to produce enough insulin to meet the body's needs and or where the body is unable to appropriately utilize insulin. The net result is a relative or an absolute insulinopenia. Insulin, a pancreatic hormone, plays a variety of roles critical to health in that it regulates the metabolism of dietary carbs that have been converted into glucose, enabling this glucose to enter the body's cells, particularly the muscles and liver cells.
Type 2 diabetes comprises about 95% of all individuals with this condition. In type 2 diabetes, the insulinopenia, especially in earlier disease, is relative in that insulin is produced, but it's not well utilized due to a number of factors, including insulin resistance. Insulin resistance, often abbreviated IR, which is a genetically predetermined and environmentally modified condition. What we see here is a reduced sensitivity in the tissues to insulin's action at a given concentration, which causes a subnormal effect on glucose metabolism. Hyperglycemia results, which stimulates pancreatic insulin production in an effort to reduce the blood glucose level. Euglycemia can occur, albeit in the presence of hyperinsulinemia. And remember what euglycemia is--that is a normal or acceptable blood sugar level. When coupled with acquired or lifestyle characteristics that contribute to insulin resistance such as obesity, physical activity, and a high carb diet where more than 60% of the calories consumed are in carbs, the body has greater difficulty maintaining a blood glucose level. Over time, generally, after a number of years of insulin resistance, the pancreatic beta cell deficiency occurs, resulting in impaired glucose tolerance, hyperglycemia and the role of type 2 diabetes. In a person diagnosed with type two diabetes, ongoing laboratory monitoring is advised, in part to assess glucose control, but as well watching for diabetic target organ dysfunction. With that information in mind, let's take a look at the question and the given answers.
As with all other questions, we need to choose the best, not just the potentially correct response.
The NP is seeing a 60-year-old woman with a ten-year history of Type 2 diabetes. Her current medications include oral metformin and an oral SGLT2i. And she states she's feeling well without reports of blurred vision, without excessive thirst, or polyuria. She's not had any laboratory tests done in the past six months. Which of the following represents the best choice of tests to determine her overall glucose control?
A. Fasting plasma glucose? This is incorrect. This question is asking specifically about overall glucose control. And keep in mind fasting blood glucose provides information about glucose control in a non-caloric state. For it to be considered fasting, the person has to be non-caloric for at least 8 hours. This is a single point in time measure. Now it certainly contributes to the overall glucose control, but it's not a good measure of what we're being asked, which is “overall glucose control.”
B. Serum creatinine and estimated GFR. This is also not correct. A periodic check of serum creatinine and estimated GFR usually done annually is an important part of monitoring for type 2 diabetes target organ dysfunction. And this is obviously looking for evidence of impaired renal function, a common complication of type 2 diabetes. Particularly we see the development of impaired renal function, a.k.a CKD, chronic kidney disease in patients with chronic poor glucose control. However, choosing this answer ignores what the question is.
Option C. Hemoglobin A1c. This is of course the correct answer. When you measure hemoglobin A1c, you're looking at a method evaluating glucose control over time, both the fasting, the post-meal, and the bedtime glucose. The measurement best reflects blood glucose trends over the last 90 days. And being in appropriate range of A1c marks that 50% or greater of the fasting and the post-meal glycemic goals have been met, so far and away the best answer is C. Hemoglobin A1c.
Option D. Random blood glucose. This is also, of course incorrect. Once again, it's a single point-in-time measure that certainly contributes to the A1c. However, the A1c is a better measure of overall glucose control, which is exactly what the question is asking.
Key takeaway: As we see in this question, every word in the stem of the question or the question story contributes to choosing the correct answer.
Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com