ATI LPN
Upper Gastrointestinal System NCLEX Questions Questions
Question 1 of 5
An otherwise healthy 45-year-old man presents with severe hematochezia and moderate abdominal cramping since this morning. A barium enema one year ago was normal. On examination, his blood pressure is 120/78 and pulse is 100 while lying; when standing, the blood pressure is 110/76 and pulse is 136. His hematocrit is 34. What is the most likely cause of bleeding?
Correct Answer: B
Rationale: Acute GI bleeding from a lower GI source does not cause hemodynamic compromise as commonly as GI bleeding from an upper source. Therefore, despite the absence of melena and no appearance of hematemesis, the hemodynamic compromise indicates that an upper GI source should be sought. Ulcers that arise in the duodenal bulb can erode into the gastroduodenal artery, giving rise to brisk blood loss. A negative nasogastric aspirate does not rule out the possibility. Although diverticular bleeds account for most episodes of acute lower GI bleeding and can occasionally be associated with hemodynamic compromise, the normal barium enema one year ago makes it less likely that the bleeding was of diverticular origin. Inflammatory bowel disease is rarely the cause of severe acute GI bleeding unless an ulcer has eroded into a vessel. Watermelon stomach is associated with chronic GI blood loss from vessel ectasias, presents as iron deficiency anemia, and is found primarily in older women. The presentation is not suggestive of a Mallory-Weiss tear because there was no vomiting, and hematochezia was present.
Question 2 of 5
A 46-year-old man presents complaining of heartburn, hoarseness, and a 'sour taste' in his mouth upon awakening. He has a history of reflux disease and has been taking proton-pump inhibitors for the last three years. He recently started taking the medication twice per day. His symptoms have improved somewhat but are still present. He is referred for EGD, which reveals high-grade dysplasia in distal esophagus but no evidence of carcinoma. How should this patient best be managed?
Correct Answer: A
Rationale: This patient presents with severe symptomatic reflux, refractory to twice per day proton-pump inhibitor therapy. His EGD reveals evidence of Barrett's esophagus with high-grade dysplasia. Since the potential for malignant transformation is high with such pathologic findings, esophagectomy is recommended. Management of Barrett's esophagus of lesser severity requires routine surveillance, although the ideal frequency of repeat endoscopy is yet unknown. Depending on the severity of dysplasia, endoscopies may be repeated every six months to two years.
Question 3 of 5
A 56-year-old man with a history of alcohol abuse presents complaining of diarrhea. He complains of frequent, foul-smelling, oily bowel movements that have gone on for about six months. He notes weight loss of 20 pounds over that period of time. He denies any abdominal pain, nausea, or vomiting. He reports that he used to have frequent episodes abdominal pain that were diagnosed as pancreatitis. He therefore stopped drinking about two years ago. His laboratory values are notable for normal AST, ALT, lipase, and amylase. All of the following statements regarding this man's condition are correct except
Correct Answer: B
Rationale: This man presents with evidence of pancreatic insufficiency due to chronic pancreatitis. Diarrhea and malabsorption (steatorrhea) are the hallmarks of this manifestation of chronic pancreatitis. A 72-hour fecal fat should be elevated in such patients. Low fecal levels of chymotrypsin should also be seen. When pancreatic exocrine function declines due to chronic pancreatitis, the output of lipase from the pancreas is about 10 to $15 \%$ of normal, so serum levels will be low or normal instead of high (as seen in acute pancreatitis). Diarrhea is frequently accompanied by diabetes as a result of destruction of islet cells and impaired insulin production. Treatment of steatorrhea from chronic pancreatitis includes pancreatic enzymes and a low-fat diet. A lactose-free diet is not indicated.
Question 4 of 5
A 46-year-old man had profuse diarrhea for two months. He notes that the diarrhea continues throughout the day. Fasting does not decrease the diarrheal episodes. He has tried using loperamide, but the relief is temporary. He notes a 10-pound weight loss over the last two months. He notes that he is not taking any medications except for the loperamide. Upon questioning, he recently quit smoking and has been chewing a lot of sugarless gum. You measure his stool electrolytes. The results are as follows: Na+ 40 mmol/L, K+ 90 mmol/L, Cl- 15 mmol/L, HCO3- 18 mmol/L. What is the most likely diagnosis?
Correct Answer: C
Rationale: This patient has chronic diarrhea that does not improve with fasting. This is a key feature in distinguishing between osmotic and secretory diarrhea. Additionally, his stool electrolytes do not reveal an osmolar gap (as seen with osmotic diarrhea). His osmolar gap is $290-[(40+90) \times 2]=30$, which is normal. An osmolar gap of greater than 50 is suggestive of osmotic diarrhea. Lactase deficiency, sucrase deficiency, and sorbitol ingestion would all cause an osmotic diarrhea. A VIPoma is the only one of the choices that causes a secretory diarrhea.
Question 5 of 5
Patients with autoimmune hepatitis disease may have the following presentations except
Correct Answer: C
Rationale: Autoimmune hepatitis may present with a fulminant or subfulminant course with new onset of hepatic encephalopathy and transaminases greater than 2000. It tends to relapse without maintenance treatment, and responds well to oral prednisone in a vast majority of cases. However, autoimmune hepatitis does not tend to present with a cholestatic picture as described in C, unless associated with overlap syndromes with PBC or cholangiopathy.