ATI LPN
NCLEX Questions on Gastrointestinal System Questions
Question 1 of 5
A 36-year-old woman complains of reflux symptoms and intermittent diarrhea. The diagnosis of gastrinoma is suspected so a fasting serum gastrin is obtained and found to be 280 pg/mL (normal <115 pg/mL). An abdominal CT is negative. What would you do now?
Correct Answer: D
Rationale: Although the fasting serum gastrin is elevated, this finding alone is insufficient for establishing the diagnosis of gastrinoma. The serum gastrin can be elevated in other conditions, most notably recent therapy with proton-pump inhibitors or H2 antagonists and gastric achlorhydria. In fact, the serum gastrin has been reported to be elevated over 1000 pg/mL in patients with pernicious anemia. Thus, a measurement of basal acid output is required. If the gastric pH is less than 2, the diagnosis of gastrinoma is highly suspicious, and a serum secretin test should be performed. Secretin 2 IU/kg is given over 2 minutes and measurements of the serum gastrin are obtained 2.5, 5, 10, 15, and 30 minutes after infusion. A paradoxical increase in the serum gastrin of greater than 200 pg/mL is diagnostic of Z-E syndrome.
Question 2 of 5
An 82-year-old female nursing home resident was admitted with left-sided aspiration pneumonia. She improved quickly on intravenous antibiotics. During her admission, a chest x-ray incidentally revealed a large calcification in the right upper quadrant of the abdomen. Subsequent abdominal ultrasound confirmed the presence of a single large stone in the gallbladder (3 cm in diameter). She denies any abdominal discomfort or pain. What would be the best course of treatment for her gallstone disease?
Correct Answer: C
Rationale: Asymptomatic gallbladder stones do not require treatment. Only $13 \%$ of patients with silent gallstones will become symptomatic in the future. For this reason, open or laparoscopic cholecystectomy is not indicated for this patient with a silent gallbladder stone. Oral dissolution is only beneficial for small gallstones, preferably less than $5 \mathrm{~mm}$ (smaller stones dissolve faster). Stones larger than $2 \mathrm{~cm}$ will rarely be dissolved with this method. Extracorporeal shock wave lithotripsy has limited rate of success and high rate of recurrence and is rarely used in the United States.
Question 3 of 5
A 47-year-old web designer has a 14-year history of ulcerative colitis. He recently moved to your area and presents to your office for continued management of his ulcerative colitis. He has been asymptomatic for the past two years and off all medications for one year with no rectal bleeding, diarrhea, abdominal pain, tenesmus, or fever. Before that he had very active colitis requiring steroids and immunosuppressants. He brings records from his previous physician that include his last three colonoscopy and pathology reports. The reports from 6 and 12 years ago documented active colitis with friable mucosa from the mid-transverse colon to the rectum, superficial ulcerations, crypt abscesses and crypt distortion, and acute and chronic inflammation. The most recent report, from almost three years ago, was fairly unremarkable endoscopically. Numerous random biopsies had been obtained. They showed mucosal changes on histology also consistent with a history of ulcerative colitis, but there was no evidence of active disease. What do you recommend?
Correct Answer: D
Rationale: The patient has not had active disease for several years and remains well despite being off medications for the past year. Steroids are indicated for active disease only, and steroids do not prevent recurrence. Ulcerative colitis is a chronic disease with recurrence expected. An argument can be made for azulfidine or mesalamine; 5-ASA agents have been documented to decrease flares and appear to decrease the risk of dysplasia and eventual colon cancer. Patients with ulcerative colitis for more than eight years should undergo colonoscopy every two years with random biopsies taken every $10 \mathrm{~cm}$ to rule out dysplasia; then more frequently after 20 years of disease. Definitive evidence of dysplasia requires referral for colectomy to avoid the extremely high risk of colon cancer. Presence of occult blood in the stool will not change endoscopic management because this patient needs to be on a regular screening protocol regardless of heme-occult status.
Question 4 of 5
A 50-year-old woman presents with nocturnal pruritus, an elevated alkaline phosphatase of 284 U/L, and normal bilirubin and aminotransferases. She is on no medications and has a normal physical examination. Ultrasound of the liver reveals no ductal abnormalities and no gallstones. What should be the next step?
Correct Answer: D
Rationale: This presentation is typical of primary biliary cirrhosis. Viral hepatitis does not present with only alkaline phosphatase elevation. With a normal ultrasound, no pain, and no jaundice, common bile duct stone is unlikely. A CT scan will not add any more information in this setting. Antimitochondrial antibodies are positive in over $90 \%$ of patients with primary biliary cirrhosis.
Question 5 of 5
A 16-year-old woman with no significant medical history presents with quickly progressing encephalopathy and jaundice. A friend feels she may have taken a bottle of acetaminophen tablets one day prior to admission. Her bilirubin is 2.4 mg/dL, alkaline phosphatase 240 U/L, AST 2400 U/L, ALT 3200 U/L, creatinine 2.7, arterial pH 7.2, INR 6.6, and acetaminophen level 60. Which of the following is false?
Correct Answer: C
Rationale: This young woman has a poor prognosis for recovery using the King's College criteria, and will likely need a liver transplant. She should be intubated immediately for airway protection, given N-acetylcysteine, and transferred to a transplant center. Lactulose has no efficacy in acute liver failure.