Comprehensive CDCES Examination Practice Bank: Advanced
Pharmacotherapy, Behavioral Change Theories, Pattern Management,
Technology, Acute/Chronic Complications, Pregnancy, and Culturally Tailored
DSMES Strategies
Questions 1–150
1. A 58-year-old with type 2 diabetes (T2D) on basal-bolus insulin reports recurrent early morning hyperglycemia
(200–250 mg/dL) with no nocturnal hypoglycemia. His 3 AM glucose is 110 mg/dL. What is the most likely diagnosis?
A) Somogyi effect
B) Dawn phenomenon
C) Insulin stacking
D) Waning insulin action
Correct Answer: B
Rationale: Dawn phenomenon = rise in fasting glucose due to nocturnal growth
hormone surge without preceding hypoglycemia. Somogyi = rebound from nocturnal
hypoglycemia.
2. Which medication is preferred as first-line injectable therapy for T2D with established atherosclerotic
cardiovascular disease (ASCVD) and an eGFR 35 mL/min?
A) Liraglutide
B) Dulaglutide
C) Semaglutide (oral)
D) Insulin glargine
Correct Answer: A
*Rationale: Liraglutide (LEADER trial) showed CV benefit; dulaglutide also CV-protective but liraglutide has more real-
world evidence in CKD G3b; FDA approves liraglutide for CV risk reduction.*
3. A patient with type 1 diabetes (T1D) using insulin pump reports frequent infusion set occlusions. Which
intervention is most appropriate?
A) Switch to steel cannula sets
B) Decrease basal rate by 20%
C) Increase insulin concentration to U-500
D) Change set every 5 days
Correct Answer: A
Rationale: Steel (straight) cannulas reduce occlusion risk in patients prone to kinking or
inflammatory reactions. Changing every 3 days is standard.
4. According to the AADE7 (now ADCES7) Self-Care Behaviors, which domain addresses medication-taking
consistency?
A) Healthy eating
B) Taking medication
C) Reducing risks
D) Problem solving
,Correct Answer: B
Rationale: The "Taking Medication" behavior includes adherence, timing, dose
adjustment, and understanding action/side effects.
5. A 45-year-old with T1D has HbA1c 8.9%, frequent hypoglycemia unawareness, and wide glucose variability (SD 85
mg/dL). Which technology is most likely to improve outcomes?
A) Intermittent scanning CGM (isCGM)
B) Real-time CGM (rtCGM) with alert thresholds
C) Blood glucose monitoring (BGM) 6x/day
D) Insulin patch pump without CGM
Correct Answer: B
Rationale: rtCGM with predictive alerts reduces hypoglycemia and improves time-in-
range (TIR) in hypoglycemia unawareness per studies like DIAMOND and GOLD.
6. In gestational diabetes (GDM), which fasting glucose target is recommended by the ADA?
A) 60–80 mg/dL
B) 70–95 mg/dL
C) 90–110 mg/dL
D) <120 mg/dL
Correct Answer: B
*Rationale: ADA recommends fasting ≤95 mg/dL (5.3 mmol/L) for GDM; postprandial ≤140 mg/dL (1-hour) or ≤120
mg/dL (2-hour).*
7. Which lab finding indicates possible Maternally Inherited Diabetes and Deafness (MIDD)?
A) Elevated C-peptide with severe insulin resistance
B) Islet autoantibodies positive
C) Macular pattern dystrophy on eye exam
D) Very low HDL (<20 mg/dL)
Correct Answer: C
Rationale: MIDD (mitochondrial DNA m.3243A>G) presents with diabetes, sensorineural
hearing loss, and macular pattern dystrophy.
8. A patient with T2D on metformin 2000 mg/day and empagliflozin 25 mg/day presents with euglycemic diabetic
ketoacidosis (DKA) after bariatric surgery. Which lab is most helpful in diagnosis?
A) Serum ketones (beta-hydroxybutyrate)
B) Anion gap
C) Venous pH
D) Serum bicarbonate
Correct Answer: A
*Rationale: Euglycemic DKA (glucose <200) requires direct ketone measurement; beta-hydroxybutyrate >3 mmol/L is
diagnostic. Urine ketones may be falsely low.*
9. What is the minimum recommended time-in-range (TIR) for a frail elderly patient with T2D on low-dose insulin?
A) >70%
B) >50%
C) >40%
,D) Individualized, often <50%
Correct Answer: D
Rationale: For frail elderly, ADA recommends less stringent targets: TIR as low as 50%,
avoiding hypoglycemia.
10. Which behavior change model includes the stages Precontemplation, Contemplation, Preparation, Action,
Maintenance?
A) Health Belief Model
B) Social Cognitive Theory
C) Transtheoretical Model (TTM)
D) Theory of Planned Behavior
Correct Answer: C
Rationale: TTM (Prochaska & DiClemente) focuses on readiness to change; core to
DSMES motivational interviewing.
11. A 28-year-old with T1D has recurrent severe hypoglycemia despite CGM use. Which adjunctive medication may
reduce hypoglycemia frequency?
A) Pramlintide
B) Metformin
C) Hydroxychloroquine
D) Dasiglucagon nasal powder
Correct Answer: A
Rationale: Pramlintide (amylin analog) slows gastric emptying and blunts postprandial
glucose spikes, reducing late postprandial hypoglycemia.
12. Which vaccine is specifically recommended for adults with diabetes regardless of age?
A) Zoster recombinant (Shingrix)
B) Pneumococcal conjugate (PCV20)
C) Hepatitis B
D) Tdap
Correct Answer: B
*Rationale: CDC/ACIP recommends PCV20 or PCV15+PCV23 for all adults with diabetes ≥19 years due to higher
pneumonia risk.*
13. A patient on insulin aspart 70/30 reports morning hypoglycemia and evening hyperglycemia. What is the most
likely pharmacokinetic issue?
A) Inadequate basal coverage
B) Excessive NPH component peak at night
C) Too rapid prandial action
D) Injection site lipohypertrophy
Correct Answer: B
*Rationale: Premix 70/30 contains 70% intermediate (NPH) which peaks ~4–8 hours; evening dose peak coincides with
early morning, causing fasting hypoglycemia.*
14. In the Diabetes Prevention Program (DPP), which intervention most reduced progression from prediabetes to T2D?
A) Metformin 850 mg BID
, B) Intensive lifestyle intervention (7% weight loss, 150 min exercise/week)
C) Pioglitazone 30 mg daily
D) Acarbose 100 mg TID
Correct Answer: B
Rationale: Lifestyle reduced risk by 58% vs metformin 31%; number needed to treat 7 for
lifestyle vs 14 for metformin.
15. What is the most common cause of hyperglycemia in a patient using an insulin pump with no alarms?
A) Basal rate too low
B) Infusion set dislodgement
C) Battery failure
D) Insulin degradation from heat
Correct Answer: B
Rationale: Silent dislodgement leads to rapid hyperglycemia without occlusion alarm;
patients must check ketones and replace set.
16. Which CGM metric correlates best with HbA1c for clinical decision-making?
A) Coefficient of variation (CV)
B) Standard deviation (SD)
C) Time above range (TAR) >250 mg/dL
D) Glucose management indicator (GMI)
Correct Answer: D
Rationale: GMI (formerly estimated A1C) is calculated from mean glucose; correlates
with lab A1c but may differ in anemia, CKD, hemoglobinopathies.
17. A 62-year-old with T2D, HFpEF, and CKD G3a (eGFR 55) is on metformin, glimepiride, and sitagliptin. HbA1c 8.2%.
Which medication improves heart failure hospitalization risk?
A) Pioglitazone
B) Saxagliptin
C) Dapagliflozin
D) Linagliptin
Correct Answer: C
Rationale: SGLT2 inhibitors (dapagliflozin, empagliflozin) reduce HF hospitalization
regardless of baseline HbA1c; FDA approved for HFrEF and HFpEF.
18. Which clinical finding is most suggestive of type 1 diabetes in a 35-year-old newly diagnosed?
A) BMI 34 kg/m²
B) Fasting C-peptide 0.4 ng/mL (normal 0.8–3.9)
C) Acanthosis nigricans
D) Hypertension
Correct Answer: B
*Rationale: Low C-peptide with hyperglycemia indicates endogenous insulin deficiency; typically <0.6 ng/mL in T1D;
further confirmed by autoantibodies.*
19. A patient with T1D using automated insulin delivery (AID) has persistent post-breakfast hyperglycemia. Which
adjustment is most appropriate?
Pharmacotherapy, Behavioral Change Theories, Pattern Management,
Technology, Acute/Chronic Complications, Pregnancy, and Culturally Tailored
DSMES Strategies
Questions 1–150
1. A 58-year-old with type 2 diabetes (T2D) on basal-bolus insulin reports recurrent early morning hyperglycemia
(200–250 mg/dL) with no nocturnal hypoglycemia. His 3 AM glucose is 110 mg/dL. What is the most likely diagnosis?
A) Somogyi effect
B) Dawn phenomenon
C) Insulin stacking
D) Waning insulin action
Correct Answer: B
Rationale: Dawn phenomenon = rise in fasting glucose due to nocturnal growth
hormone surge without preceding hypoglycemia. Somogyi = rebound from nocturnal
hypoglycemia.
2. Which medication is preferred as first-line injectable therapy for T2D with established atherosclerotic
cardiovascular disease (ASCVD) and an eGFR 35 mL/min?
A) Liraglutide
B) Dulaglutide
C) Semaglutide (oral)
D) Insulin glargine
Correct Answer: A
*Rationale: Liraglutide (LEADER trial) showed CV benefit; dulaglutide also CV-protective but liraglutide has more real-
world evidence in CKD G3b; FDA approves liraglutide for CV risk reduction.*
3. A patient with type 1 diabetes (T1D) using insulin pump reports frequent infusion set occlusions. Which
intervention is most appropriate?
A) Switch to steel cannula sets
B) Decrease basal rate by 20%
C) Increase insulin concentration to U-500
D) Change set every 5 days
Correct Answer: A
Rationale: Steel (straight) cannulas reduce occlusion risk in patients prone to kinking or
inflammatory reactions. Changing every 3 days is standard.
4. According to the AADE7 (now ADCES7) Self-Care Behaviors, which domain addresses medication-taking
consistency?
A) Healthy eating
B) Taking medication
C) Reducing risks
D) Problem solving
,Correct Answer: B
Rationale: The "Taking Medication" behavior includes adherence, timing, dose
adjustment, and understanding action/side effects.
5. A 45-year-old with T1D has HbA1c 8.9%, frequent hypoglycemia unawareness, and wide glucose variability (SD 85
mg/dL). Which technology is most likely to improve outcomes?
A) Intermittent scanning CGM (isCGM)
B) Real-time CGM (rtCGM) with alert thresholds
C) Blood glucose monitoring (BGM) 6x/day
D) Insulin patch pump without CGM
Correct Answer: B
Rationale: rtCGM with predictive alerts reduces hypoglycemia and improves time-in-
range (TIR) in hypoglycemia unawareness per studies like DIAMOND and GOLD.
6. In gestational diabetes (GDM), which fasting glucose target is recommended by the ADA?
A) 60–80 mg/dL
B) 70–95 mg/dL
C) 90–110 mg/dL
D) <120 mg/dL
Correct Answer: B
*Rationale: ADA recommends fasting ≤95 mg/dL (5.3 mmol/L) for GDM; postprandial ≤140 mg/dL (1-hour) or ≤120
mg/dL (2-hour).*
7. Which lab finding indicates possible Maternally Inherited Diabetes and Deafness (MIDD)?
A) Elevated C-peptide with severe insulin resistance
B) Islet autoantibodies positive
C) Macular pattern dystrophy on eye exam
D) Very low HDL (<20 mg/dL)
Correct Answer: C
Rationale: MIDD (mitochondrial DNA m.3243A>G) presents with diabetes, sensorineural
hearing loss, and macular pattern dystrophy.
8. A patient with T2D on metformin 2000 mg/day and empagliflozin 25 mg/day presents with euglycemic diabetic
ketoacidosis (DKA) after bariatric surgery. Which lab is most helpful in diagnosis?
A) Serum ketones (beta-hydroxybutyrate)
B) Anion gap
C) Venous pH
D) Serum bicarbonate
Correct Answer: A
*Rationale: Euglycemic DKA (glucose <200) requires direct ketone measurement; beta-hydroxybutyrate >3 mmol/L is
diagnostic. Urine ketones may be falsely low.*
9. What is the minimum recommended time-in-range (TIR) for a frail elderly patient with T2D on low-dose insulin?
A) >70%
B) >50%
C) >40%
,D) Individualized, often <50%
Correct Answer: D
Rationale: For frail elderly, ADA recommends less stringent targets: TIR as low as 50%,
avoiding hypoglycemia.
10. Which behavior change model includes the stages Precontemplation, Contemplation, Preparation, Action,
Maintenance?
A) Health Belief Model
B) Social Cognitive Theory
C) Transtheoretical Model (TTM)
D) Theory of Planned Behavior
Correct Answer: C
Rationale: TTM (Prochaska & DiClemente) focuses on readiness to change; core to
DSMES motivational interviewing.
11. A 28-year-old with T1D has recurrent severe hypoglycemia despite CGM use. Which adjunctive medication may
reduce hypoglycemia frequency?
A) Pramlintide
B) Metformin
C) Hydroxychloroquine
D) Dasiglucagon nasal powder
Correct Answer: A
Rationale: Pramlintide (amylin analog) slows gastric emptying and blunts postprandial
glucose spikes, reducing late postprandial hypoglycemia.
12. Which vaccine is specifically recommended for adults with diabetes regardless of age?
A) Zoster recombinant (Shingrix)
B) Pneumococcal conjugate (PCV20)
C) Hepatitis B
D) Tdap
Correct Answer: B
*Rationale: CDC/ACIP recommends PCV20 or PCV15+PCV23 for all adults with diabetes ≥19 years due to higher
pneumonia risk.*
13. A patient on insulin aspart 70/30 reports morning hypoglycemia and evening hyperglycemia. What is the most
likely pharmacokinetic issue?
A) Inadequate basal coverage
B) Excessive NPH component peak at night
C) Too rapid prandial action
D) Injection site lipohypertrophy
Correct Answer: B
*Rationale: Premix 70/30 contains 70% intermediate (NPH) which peaks ~4–8 hours; evening dose peak coincides with
early morning, causing fasting hypoglycemia.*
14. In the Diabetes Prevention Program (DPP), which intervention most reduced progression from prediabetes to T2D?
A) Metformin 850 mg BID
, B) Intensive lifestyle intervention (7% weight loss, 150 min exercise/week)
C) Pioglitazone 30 mg daily
D) Acarbose 100 mg TID
Correct Answer: B
Rationale: Lifestyle reduced risk by 58% vs metformin 31%; number needed to treat 7 for
lifestyle vs 14 for metformin.
15. What is the most common cause of hyperglycemia in a patient using an insulin pump with no alarms?
A) Basal rate too low
B) Infusion set dislodgement
C) Battery failure
D) Insulin degradation from heat
Correct Answer: B
Rationale: Silent dislodgement leads to rapid hyperglycemia without occlusion alarm;
patients must check ketones and replace set.
16. Which CGM metric correlates best with HbA1c for clinical decision-making?
A) Coefficient of variation (CV)
B) Standard deviation (SD)
C) Time above range (TAR) >250 mg/dL
D) Glucose management indicator (GMI)
Correct Answer: D
Rationale: GMI (formerly estimated A1C) is calculated from mean glucose; correlates
with lab A1c but may differ in anemia, CKD, hemoglobinopathies.
17. A 62-year-old with T2D, HFpEF, and CKD G3a (eGFR 55) is on metformin, glimepiride, and sitagliptin. HbA1c 8.2%.
Which medication improves heart failure hospitalization risk?
A) Pioglitazone
B) Saxagliptin
C) Dapagliflozin
D) Linagliptin
Correct Answer: C
Rationale: SGLT2 inhibitors (dapagliflozin, empagliflozin) reduce HF hospitalization
regardless of baseline HbA1c; FDA approved for HFrEF and HFpEF.
18. Which clinical finding is most suggestive of type 1 diabetes in a 35-year-old newly diagnosed?
A) BMI 34 kg/m²
B) Fasting C-peptide 0.4 ng/mL (normal 0.8–3.9)
C) Acanthosis nigricans
D) Hypertension
Correct Answer: B
*Rationale: Low C-peptide with hyperglycemia indicates endogenous insulin deficiency; typically <0.6 ng/mL in T1D;
further confirmed by autoantibodies.*
19. A patient with T1D using automated insulin delivery (AID) has persistent post-breakfast hyperglycemia. Which
adjustment is most appropriate?
