ATI LPN
NCLEX Questions on Gastrointestinal System Questions
Question 1 of 5
A 50-year-old man is admitted to A&E with severe, tearing central chest pain radiating into his back. On examination, he has a high BP with variability between both arms. An ECG shows T-wave inversions in the inferior leads. What should be the next step in the management of the patient?
Correct Answer: B
Rationale: Symptoms suggest aortic dissection (tearing pain, BP variability); urgent BP control and CT angiogram are critical, making B the correct answer.
Question 2 of 5
A 65-year-old man frequently regurgitates food several hours after eating, and experiences chest pain and dysphagia to both liquids and solids. He has lost 20 pounds. A CXR shows an air/fluid level in a dilated esophagus and an absent gastric air bubble. No mass in the distal esophagus or proximal stomach is identified at upper endoscopy. The best therapy for this patient is
Correct Answer: B
Rationale: The patient has the classic presentation and radiologic findings of achalasia. The upper endoscopy and CT scan are important for ruling out secondary achalasia which is caused by a malignant growth at the GE junction, producing symptoms and findings that mimic primary achalasia. Patients with achalasia typically do not suffer from GERD since they have a lower esophageal sphincter that fails to relax appropriately. However, achalasia patients can describe heartburn and chest pain due to the accumulation of ingested material in a massively dilated esophagus. Achalasia responds well to endoscopic balloon dilatation and to myotomy. Injection of botulinum toxin at the GE junction has been helpful in nonsurgical candidates. Esophageal resection is not indicated for achalasia unless malignancy has developed.
Question 3 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 4 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 5 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.