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Could you just read this and comment? Not sure I agree with it.

Discussion in 'Parents of Children with Type 1' started by mmgirls, Dec 3, 2011.

  1. mmgirls

    mmgirls Approved members

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    A 14 year-old female is currently on insulin pump therapy.
    It is noted that her hemoglobin A1C is 14%. She insists that
    she boluses for her insulin based on suggested insulin/
    carbohydrate ratios and insulin sensitivity factors. What is
    the MOST likely reason for her high A1C?
    A. The insulin/carbohydrate ratios for meals need to be
    increased.
    B. The insulin sensitivity factor needs to be decreased.
    C. Her infusion sets need to be changed more frequently.
    D. She forgets to bolus for meals and snacks


    The above question is a sample question from a CDE exam, and it is just rubbing me the wrong way.

    There are just too many variables at work with a 14yr old female, to assume she is fibbing to you is the MOST LIKELY reason. REALLY?
     
  2. StillMamamia

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    Is the D the correct answer per the sample test??

    I agree there are other things to consider, like a big wonking basal increase and a reworking of the I:C given, but there is the possibility of running higher on purpose to lose weight, but no info is given.
     
  3. mmgirls

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    Yes they say D is the correct answer.
     
  4. StillMamamia

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    Yeah, I would not immediately assume it would be D without lots of tweaking beforehand.
     
  5. funnygrl

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    If her a1c were 8-10 or even 11 I'd think a-c reasonable problems, but an a1c of 14% suggests pure insulin deficiency, not just a matter of tweaking. At 14, even if the best of intentions are present, it's easy to forget to bolus. Heck, I forget to bolus sometimes.
     
  6. mmgirls

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    But apply that same reasoning to C, what if she is only changing her site every week, or the type of site simply is not working or if she is not rotating?

    Purely from a Testing perspective, and not knowing statistical infomation in regards to high a1c and females, it just runbbs me the wrong way. I guess that is a good thing, keeps me thinking about the bigger picture.
     
  7. MommaKat

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    You're going to hear this phrase a lot in nursing: MSU or making stuff up, usually as a joke about finally getting time to chart and trying to decipher notes. When it comes to nursing assessments, I have a rule for my NCLEX students. Never, ever, ever, MSU - there is no back story, you only know exactly the information they give in the question in front of you.

    You have only one fact A1c=14%, and a key word insists. A, B, and C are not reasons for the stated value, but possible treatment interventions. D is the only reason listed as an answer choice. Does that make sense? The exam will almost always give both causes and responses in a question like this, so you have to ask what are they looking for? In this case a cause. If it said the insulin carb ratio used is too low, that would be stated as a cause, and you could evaluate whether it's correct or not.

    Now, all of that said, do I agree with the answer choice? Not at all, but this is about understanding how test questions are framed. I hope that helps.
     
  8. Lisa P.

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    AAAAAAAAAAHHHHHHHHHHHHHHH!!!!!!!!!!!!

    I'm telling you, I've been around enough medical to know that even if the assumption that the patient is screwing up is right 90% of the time, the extreme amount of damage you can do when you think "it's all in their head" and variations of that and it's ACTUALLY A REAL, PHYSICAL PROBLEM is dramatic. Like, I've seen friends die because of that kind of thinking.

    Please, check the D if you gotta to pass, get out there into practice and if you can't turn this system around single handedly then at least make sure you're a secret rebel who actually believes people despite their status as adolescent girls!!!

    AAAAAAAAAAHHHHHHHHHHHHHHH!!!!
     
  9. Amy C.

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    My son forgets to bolus and forgets that he forgot, so yes, I would agree with D being the answer. Teenagers loose their brains.
     
  10. mmgirls

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    Thank you for this reponce, I am just starting nursing school, the program I am in does general ed first so I have yet started actual "nursing education".

    Your explanation is what I needed, kind of that teaching to the test, looking at what they are asking for and not MSU.

    I know I want to be in diabetes management so I was looking around online and came across this sample test and I got to this question and went hummmm, well, then.

    I still don't like it.
     
  11. MommaKat

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    I know - the assessment exam questions like this are ridiculous when it comes to stuff like this!!! It is the one time I will 'teach to a test' b/c it's not real life
     
  12. bnmom

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    I read it and went hmmmm, but...well...or....:p

    In hindsight knowing D is the correct answer, I'd maybe watch for "clues" in the questions. Like this question they specified she's a teenager...so maybe they are trying to lead toward the desired answer by the details provided in the questions (teenagers are notoriously forgetful).

    Theory goes out the window if wording on other questions doesn't hold to that, but that's my best guess on how I'd look at the rest of the questions knowing D is what they wanted on this one.

    They sure don't make it easy! Good luck!
     
  13. emm142

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    I think that it's right, and that probably is the most likely reason.
     
  14. joshualevy

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    Well, just to play devil's advocate, while I'm sure D is the "full credit" answer, I don't think it is the most likely truth. I think the most likely truth is
    E - lying about bolusing, and rarely does it.
    I view D as the polite answer.

    I don't see how A-C could possibly lead to an A1C of 14; not even all of them put together. I see the same problem with D, although not as bad. Even a type-1 who forgets 1-2 boluses a week is not likely to get to 14. Which is why I think this patient is simply not bolusing for lunch and snack at all, or bolusing rarely.

    I also think it is important to teach medical people that not everything they hear will be the truth. And that they need to be able to properly diagnose people who are lying to them (or shading the truth a little, if you prefer). It's part of the real world they will operate in.

    Joshua
     
  15. DRANMA

    DRANMA New Member

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    Teaching to the test for this KIND of test is great---IF the test TAKER then remembers to FORGET the BS answers and gets some "Real World" info from the kids them selves or the parents who have observed them.

    My son had a friend as a teen who was on a pump and would "lie" to the coach if he didn't want to run track---"Oh my BG is off; can't do it today!"

    And when they went overseas he managed to drink himself practically comatose--in the 900's!!!!----with a combo of beer, wine and sugared soda---ALL perfectly LEGAL for that age BTW. (My son was his "kid caretaker" for the trip with trained adults too---NON school trip for those who worry about this sort of thing)

    Did he ever tell his parents??/ Dunno! But when I was Dx'd my sons experience "caretaking" this kid was priceless.

    So---as other posters have said--Fix it and FORGET IT :D
     
  16. MHoskins2179

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    While you don't want your CDE or Endo or whomever to assume FIRST that someone is lying or doing something intentionally wrong, the 14% pretty much tells the answer.

    I'm sorry, you don't get that high of an A1c by innocently dosing incorrectly or having basal rates that are off. Even when in the teenage years where everything is crazy. Even at that age, it takes real effort for a teen to get that high of a number.

    It's not a stat-necessary piece of knowledge. It's simply real-world living with diabetes information.

    Like a previous commenter mentioned, I think "forgetting to bolus" is sugar-coating or being polite and not addressing the real problems of denial and not-testing/insulin-taking.
     
  17. Darryl

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    That is the reason why (d) is the most likely answer.
     
  18. Jeff

    Jeff Founder, CWD

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    I recall Marissa sharing similar, poorly worded exam questions from her nursing years. The good news for you is you know that the real world is often not so simple.

    An A1c of 14, as others have noted, usually means a significant insulin deficit, whether by missing all or almost all meals, woefully inadequate basal rates, or both (probably both). This is often because of fear of lows from a previous frightening (or embarassing) incident.

    But, there are other possibilities, such as rare abnormalities in hemoglobin, which can be verified by other tests such as fructosamine.

    I also recall a story from a good friend who is a peds endo. She told of a teenage girl on injections who was frequently admitted for DKA. Turns out that the girls mom was a heroin addict and was stealing her syringes. The solution -- provide the girl with twice the needed number of syringes so she could hide hers and let her mom take what the mom needed. This solved the problem.
     
  19. Seans Mom

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    This is just so unbelievably sad in so many ways. :(
     
  20. mmgirls

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    Thank you guys.

    I really did not even think about the other answers, just had a knee jerk reaction to the last answer before going back and rereading for what they where asking for.

    I still dont like it, but understand that in the real world people allot of the time do know what they should be doing but choose to not do the right things to keep them healthy and then choose to fib about it knowing the right answers.
     

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