Hypoglycemia Practice Exam: Diabetes Chapter 14

Hypoglycemia remains the most frequent and potentially dangerous complication for many individuals treated with insulin or insulin secretagogues. The 2023 Guidelines emphasize a shift from simply treating low blood glucose to actively preventing it through risk stratification, education, and the use of technology.

This practice exam tests your ability to apply the latest recommendations regarding the prevention, recognition, and management of hypoglycemia, including protocols for severe events and impaired awareness.

Key Concepts Covered in This Exam:

Prevention First: Understanding that preventing hypoglycemia is safer and more effective than treating it, and knowing how to reassess medication doses at every visit.
Impaired Awareness of Hypoglycemia (IAH): Screening all individuals with Type 1 diabetes (and those with Type 2 on insulin/secretagogues) for IAH and implementing structured education or technology solutions.
Treatment Protocols: Applying the correct treatment steps—administering fast-acting carbohydrates (e.g., glucose tablets) to achieve the fastest rise in blood glucose, followed by a snack or meal to prevent recurrence.
Severe Hypoglycemia: Mastering the management of severe events, including the prescription of glucagon and the critical role of counseling support persons on its administration.
Role of Technology: Identifying when Continuous Glucose Monitoring (CGM) should be used to detect and prevent hypoglycemia in high-risk individuals.

1. Case: A patient with type 1 diabetes is found unconscious by a family member at home. The family member has been trained to use glucagon. What is the recommended dose of subcutaneous or intramuscular glucagon?

1 mg
3 mg
2 mg
0.5 mg

2. What is the time interval recommended for retesting blood glucose after initial hypoglycemia treatment?

15 minutes
30 minutes
5 minutes
10 minutes

3. Case: A 62-year-old patient with type 2 diabetes and chronic kidney disease (CKD stage 3) is on insulin therapy. According to the guidelines, which insulin formulation may be beneficial?

NPH insulin due to its short duration
Regular insulin only
Basal insulin analogues
Premixed insulin 70/30

4. Case: A patient with type 1 diabetes is planning to engage in 45 minutes of cardio exercise. According to the guidelines, what pre-exercise strategy should be considered?

Exercise without any adjustments
Skip the meal before exercise
Reduce pre-exercise boluses or implement short-term basal reduction
Increase pre-exercise bolus insulin

5. A diabetes healthcare team is debating the use of rtCGM versus isCGM for a patient with type 1 diabetes and frequent exercise-related hypoglycemia. Based on the guidelines, which statement is most accurate?

isCGM is always preferred for active individuals
rtCGM may be superior to isCGM in reducing hypoglycemia during exercise due to alarms
CGM should not be used during exercise
Both types of CGM are equally effective for exercise-related hypoglycemia

6. Case: A 55-year-old patient with type 2 diabetes has a history of cardiovascular disease and experiences symptomatic hypoglycemia. Based on the evidence regarding hypoglycemia and cardiovascular outcomes, what is the most appropriate clinical consideration?

There is a clear association between severe hypoglycemia and increased mortality in patients with CVD
Symptomatic hypoglycemia improves cardiovascular outcomes
Only asymptomatic hypoglycemia affects cardiovascular risk
Hypoglycemia has no relationship with cardiovascular outcomes

7. Case: An 80-year-old patient with type 2 diabetes, cognitive impairment, and recurrent hypoglycemia is being reviewed. According to the guidelines, what should be the priority in this patient’s management?

Focus only on hyperglycemia management
Maintain A1C target of <7.0%
Intensify glycemic control to prevent long-term complications
Prevention of hypoglycemia should be prioritized given frailty and cognitive decline

8. What is the recommended approach for individuals at high risk of severe hypoglycemia regarding glucagon?

Glucagon should be prescribed with counselling on administration for support persons
Glucagon should only be kept at healthcare facilities
Glucagon should only be given by healthcare professionals
Glucagon is not necessary if the patient has CGM

9. What is the prevalence of fear of hypoglycemia (FoH) among individuals with type 1 and type 2 diabetes treated with insulin and/or insulin secretagogues?

Up to 30%
Up to 20%
Up to 50%
Up to 10%

10. How long should hypoglycemia be avoided to potentially reverse impaired awareness of hypoglycemia (IAH)?

1-2 hours
2 days to 3 months
6-12 months
12-24 hours

11. Which classification of hypoglycemia is defined by the presence of neuroglycopenic symptoms requiring external assistance to treat?

Level 3 hypoglycemia
Level 4 hypoglycemia
Level 2 hypoglycemia
Level 1 hypoglycemia

12. Case: A 70-year-old patient with type 2 diabetes has an A1C of 6.5% and experiences recurrent hypoglycemia. Which management strategy is most appropriate?

Maintain current glycemic targets to prevent complications
Consider individualized A1C targets and reduce hypoglycemia risk
Intensify insulin therapy
Add a sulfonylurea to current therapy

13. According to Diabetes Canada, what blood glucose level is used as an alert value to classify hypoglycemia in individuals treated with insulin or insulin secretagogues?

<3.5 mmol/L
<3.9 mmol/L
<2.8 mmol/L
<4.2 mmol/L

14. Case: A patient is found to have Level 3 hypoglycemia and is conscious but unable to swallow. What is the appropriate treatment?

Wait for symptoms to resolve
Orange juice
Glucagon 1 mg SC/IM or 3 mg intranasal
Oral glucose tablets

15. Which validated questionnaire is MOST commonly used to measure fear of hypoglycemia (FoH)?

WHO Quality of Life Scale
Hypoglycemia Fear Survey (HFS-II)
Problem Areas in Diabetes (PAID)
Diabetes Distress Scale (DDS)

16. Case: A diabetes educator is developing a comprehensive hypoglycemia prevention program. According to the guidelines, which combination of strategies has the strongest evidence for reducing hypoglycemia in patients with type 1 diabetes?

Reducing physical activity
Modifying insulin doses
CGM use combined with structured education and appropriate insulin selection
Diet modification alone

17. What is the recommended initial treatment for Level 1 or 2 hypoglycemia according to Diabetes Canada guidelines?

10 g of fast-acting carbohydrate
15 g of fast-acting carbohydrate
20 g of fast-acting carbohydrate
25 g of fast-acting carbohydrate

18. According to the guidelines, how much can 15 g of oral glucose be expected to raise blood glucose within 20 minutes?

Approximately 4.5 mmol/L
Approximately 3.5 mmol/L
Approximately 1.0 mmol/L
Approximately 2.1 mmol/L

19. Case: A patient with type 1 diabetes and recurrent severe hypoglycemia is being considered for advanced interventions. According to the guidelines, which surgical option may be considered?

Islet cell or pancreas transplantation
Gastric bypass
Kidney transplantation
Bariatric surgery

20. Which antihyperglycemic agents are associated with the lowest risk of hypoglycemia according to the guidelines?

Sulfonylureas and meglitinides
Premixed insulins
GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors
NPH insulin and regular insulin

21. Case: A patient with type 2 diabetes has advanced hepatic disease. When using glucagon for hypoglycemia treatment, what should be considered?

Double the dose of glucagon should be given
Glucagon effectiveness may be reduced
Glucagon is more effective in patients with liver disease
Glucagon effectiveness is not affected by liver disease

22. After treating a hypoglycemic episode, when should a patient consume a snack containing 15 g carbohydrate and a protein source?

Only if blood glucose drops again
Immediately after treatment regardless of meal timing
Only at bedtime
If a meal is more than 1 hour away

23. A patient asks about the relationship between recurrent hypoglycemia and cognitive function. Based on the evidence presented in the guidelines, what is the most accurate response?

Recurrent hypoglycemia has no impact on cognitive function
There is evidence of an association between hypoglycemia and cognitive disorders
Hypoglycemia only affects cognition in children
Intensive insulin therapy definitively causes cognitive decline

24. What dose of intranasal glucagon is recommended for treating severe hypoglycemia?

3 mg
1 mg
2 mg
5 mg

25. Which symptoms are classified as adrenergic (autonomic) symptoms of hypoglycemia?

Confusion, weakness, drowsiness
Trembling, sweating, anxiety
Vision changes, difficulty concentrating
Slurred speech, headache, dizziness

26. Which of the following is a risk factor for severe hypoglycemia?

High A1C (>9%)
Prior episode of severe hypoglycemia
Short duration of diabetes
Use of metformin monotherapy

27. A patient treated with a sulfonylurea experiences a hypoglycemic episode. Which statement about glucagon use in this patient is correct?

Glucagon is more effective in sulfonylurea-treated patients
Glucagon is equally effective in all diabetes patients
Glucagon is less useful as it stimulates insulin secretion through glycogenolysis
Glucagon should never be given to patients on sulfonylureas

28. Case: A diabetes educator is counselling the spouse of a patient with type 1 diabetes about nocturnal hypoglycemia. What should the educator explain about the sympathoadrenal response during sleep?

The sympathoadrenal response to hypoglycemia is reduced during sleep
Nocturnal hypoglycemia only occurs in type 2 diabetes
Sleep has no effect on hypoglycemia responses
The sympathoadrenal response is enhanced during sleep

29. Case: A 45-year-old woman with type 1 diabetes reports no longer experiencing warning symptoms before hypoglycemic episodes. She has had 3 episodes of severe hypoglycemia in the past year. What intervention is most appropriate according to the guidelines?

Implement CGM with structured educational program
Increase insulin dose to achieve tighter control
Discontinue all or cut the dose in half the diabetes medications
Switch insulin glargine U-100 as this has been shown to reduce the risk of hypoglycemic unawareness

30. Case: A 58-year-old patient with type 2 diabetes on insulin glargine-U-100 experiences frequent nocturnal hypoglycemia. According to the guidelines, which insulin should be considered to reduce this risk?

Insulin lispro
NPH insulin
Regular insulin
Insulin degludec or glargine-U-300

31. What percentage of individuals with type 1 or type 2 diabetes (treated with insulin or insulin secretagogues) self-report at least one episode of hypoglycemia in a given year?

Up to 65%
Up to 45%
Up to 25%
Up to 85%

32. What glucose level defines Level 2 hypoglycemia according to the International Hypoglycemia Study Group classification?

<3.0 mmol/L
<3.5 mmol/L
<2.0 mmol/L
<3.9 mmol/L

33. Case: A 35-year-old patient with type 1 diabetes asks about continuous glucose monitoring (CGM). According to the guidelines, what is a key benefit of CGM for hypoglycemia prevention?

CGM is only useful for hyperglycemia detection
CGM eliminates the need for any glucose testing
CGM replaces the need for glucagon
CGM can help identify episodes of unrecognized hypoglycemia

34. Case: A diabetes educator is developing materials for patients about hypoglycemia treatment. Which of the following is NOT considered an appropriate treatment option for Level 1-2 hypoglycemia?

A chocolate bar
4 glucose tablets (4 g each)
150 mL of juice
15 mL of honey

35. Case: A patient on a low-carbohydrate diet experiences Level 3 hypoglycemia and receives glucagon. What should be considered about the treatment effect?

Glucagon will be more effective
Diet has no impact on glucagon effectiveness
The treatment effect of glucagon may be reduced
A higher dose of glucagon should be administered

36. When comparing intranasal glucagon to injectable glucagon for treating severe hypoglycemia, what advantage does intranasal administration provide according to the evidence?

Higher glucose elevation
Longer duration of action
Lower cost
More complete dosing and faster administration by trained caregivers

37. Case: A patient with type 1 diabetes who consumes more than 2 alcoholic drinks experiences severe hypoglycemia. After glucagon administration, recovery is slower than expected. What explains this?

Alcohol increases glucagon sensitivity
A higher dose of glucagon is needed routinely after alcohol
The effectiveness of glucagon is reduced after alcohol consumption
Alcohol has no effect on glucagon response

38. Which psychoeducational program has been shown to reduce the prevalence of IAH and frequency of hypoglycemia?

Standard nutrition counselling
Smoking cessation program
Cardiac rehabilitation program
Blood Glucose Awareness Training (BGAT)

39. A diabetes educator is counselling a patient who has experienced impaired awareness of hypoglycemia (IAH). Which validated tool can be used to screen for IAH?

Gold or Clarke scores
PHQ-9 questionnaire
GAD-7 questionnaire
PAID questionnaire

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