# Situation: A 67-year-old woman who has had type 2 diabetes mellitus for 15 years attends the medical clinic. She takes metformin, glipizide, and acarbose for diabetes and metoprolol for hypertension. Monofilament testing shows loss of protective sensation in both feet. One morning she takes her glipizide but skips breakfast, and 2 hours later she feels unwell. Because she takes metoprolol, which finding is MOST likely to still alert the nurse to hypoglycemia?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630401  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 67-year-old woman who has had type 2 diabetes mellitus for 15 years attends the medical clinic. She takes metformin, glipizide, and acarbose for diabetes and metoprolol for hypertension. Monofilament testing shows loss of protective sensation in both feet.

One morning she takes her glipizide but skips breakfast, and 2 hours later she feels unwell. Because she takes metoprolol, which finding is MOST likely to still alert the nurse to hypoglycemia?

## 보기

1. Fine trembling of both hands
2. Sweat that dampens her clothing **✔ 정답**
3. A pounding heartbeat in the chest
4. A pulse rate of 110/min

**정답: 2**

## 해설

Beta blockers such as metoprolol blunt the beta-adrenergic warning signs of hypoglycemia, including tremor, palpitations, and tachycardia. Sweating is mediated mainly by cholinergic sympathetic nerves, so it is still present, along with confusion and other neuroglycopenic signs.

## 심화 해설

The warning sign that remains
She takes glipizide, a sulfonylurea that stimulates insulin release, and skipped breakfast, so hypoglycemia is likely. She also takes metoprolol, a beta blocker. Beta blockers blunt the beta-adrenergic warning signs of hypoglycemia, including tremor, palpitations, and tachycardia, but sweating is mediated mainly by cholinergic sympathetic nerves and is still present. Sweat that dampens her clothing is therefore the finding most likely to alert the nurse.

The mechanism behind the masking
When blood glucose falls, the sympathetic nervous system releases adrenaline (epinephrine) and noradrenaline (norepinephrine). These act on beta receptors to produce a fast heart rate, a pounding heartbeat, and tremor. A beta blocker occupies these receptors, so these signs are reduced or absent. Sweat glands, however, are supplied by sympathetic fibers that release acetylcholine, not noradrenaline, so their response does not depend on beta receptors. Sweating, hunger, and neuroglycopenic signs such as confusion, difficulty concentrating, and behavior change remain useful clues in a client on a beta blocker.

| Symptom | Mediated by | Effect of metoprolol |
| --- | --- | --- |
| Tremor | Beta-adrenergic | Blunted |
| Palpitations | Beta-adrenergic | Blunted |
| Tachycardia | Beta-adrenergic | Blunted |
| Sweating | Cholinergic sympathetic | Still present |
| Confusion, behavior change | Low glucose in the brain | Still present |

Why the other options are less reliable
Fine trembling, a pounding heartbeat, and a pulse of 110/min are all beta-adrenergic responses that metoprolol can mask. Relying on them could delay recognition of a dangerous low blood glucose. Beta blockade also slows the heart, so a tachycardic response is unlikely.

Nursing application
The nurse checks capillary glucose whenever a client on a beta blocker and an insulin secretagogue reports feeling unwell, rather than waiting for classic adrenergic symptoms. Teaching includes not skipping meals after taking glipizide, recognizing sweating and confusion as warning signs, and checking glucose when in doubt.

Exam takeaway
Key point Beta blockers mask tremor, palpitations, and tachycardia in hypoglycemia; sweating is spared. When in doubt, check the blood glucose.

## 임상 시나리오

Hypoglycemia Masked by a Beta BlockerWhich warning sign survives
Metoprolol blocks beta receptors, blunting the tremor, palpitations, and tachycardia of hypoglycemia. These signs may be absent even when glucose is dangerously low.

Sweating is driven by cholinergic sympathetic fibers, so it persists, along with hunger and neuroglycopenic signs such as confusion. Glipizide taken without breakfast makes hypoglycemia likely.

CautionCheck capillary glucose whenever a client on a beta blocker and an insulin secretagogue feels unwell; do not wait for a fast pulse.

## 핵심 개념

- **Hypoglycemia unawareness** — Reduced ability to recognize low blood glucose because warning symptoms are absent or blunted.
- **Glipizide** — A sulfonylurea that stimulates insulin release and can cause hypoglycemia, especially when meals are skipped.
- **Beta blocker** — A drug that blocks beta-adrenergic receptors, slowing heart rate and blunting adrenergic symptoms.
- **Neuroglycopenic symptoms** — Brain-related signs of low glucose, such as confusion, drowsiness, and behavior change.

## 같은 주제 문제

- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630291)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630292)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630293)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630294)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630295)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630296)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630297)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630298)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._