GI
A 45-year-old man is admitted with acute epigastric pain that radiates to his back. He says that he has been vomiting continuously for 12 hours and that the pain has been worsening. His social history includes the information that he drinks about two six-packs of beer each night. He has dry, cracked lips and poor skin turgor. His abdomen is distended and tender. He is restless and agitated. Vital signs are blood pressure of 90/60 mm Hg, heart rate of 135 beats/min, and respiratory rate of 28 breaths/min. Acute pancreatitis is suspected. Which of the following diagnostic study results are consistent with a diagnosis of acute pancreatitis? A. Elevated serum amylase, elevated serum lipase, decreased serum albumin B. Decreased serum amylase, decreased serum lipase, elevated serum calcium C. Elevated serum bilirubin, decreased serum albumin, elevated serum calcium D. Elevated serum amylase, elevated serum lipase, elevated serum calcium
ANSWER: A. Acute pancreatitis causes elevations in serum amylase, serum lipase, and possibly bilirubin, whereas calcium and albumin are decreased. Go with what you know: You are probably very aware that amylase and lipase are increased in acute pancreatitis. Options a and d have amylase and lipase elevated. The effect of acute pancreatitis on albumin and calcium is more difficult. Serum calcium is decreased so eliminate option d. Serum albumin is decreased so choose option a.
A 55-year-old man is admitted to the critical care unit with upper gastrointestinal bleeding. Endoscopy identifies esophageal varices, but bleeding continues despite sclerosing. The physician inserts a Sengstaken-Blakemore tube. The family tells you that the patient has a long history of alcohol use, drinking about one half of a fifth of Jack Daniels every day. Which of the following are early indications of alcohol withdrawal syndrome for which the nurse should monitor? A. Diaphoresis, pruritus B. Marked tachycardia, marked hypertension C. Hyperthermia, dehydration D. Delirium, hallucinations
ANSWER: A. Diaphoresis, pruritus, mild tachycardia, mild hypertension, nausea, vomiting, visual disturbances, tremors, anxiety, agitation, and sleep disturbances are signs of early alcohol withdrawal syndrome. Options b, c, and d describe late signs. Because the question says "early," look for the mildest symptoms.
A 48-year-old woman is 1 week past gastrectomy. She is experiencing weakness, diaphoresis, tachycardia, headache, and nervousness 1 to 2 hours after eating. Which of the following is the primary physiologic reason for these symptoms? A. Hypoglycemia B. Hypervolemia C. Hypokalemia D. Hyperacidity
ANSWER: A. Early dumping syndrome is related to hypovolemia because of hyperosmolar food being "dumped" into the duodenum. Symptoms occur within 30 minutes of eating. Late dumping syndrome is the result of an increase in insulin secretion stimulated by hyperglycemia after eating. When part or all of the stomach is removed, the food is "dumped" into the duodenum and jejunum instead of the food gradually being released in small amounts. This causes hyperglycemia and a resultant surge of insulin being secreted by the pancreas. This results in hypoglycemia 1 to 2 hours after eating and the symptoms of hypoglycemia. Look at the symptoms: weakness, diaphoresis, tachycardia, and nervousness. Consider these symptoms in any other setting. These are the symptoms of hypoglycemia. Choose option a. Also note that time frame is important in this question. If the given time was 30 minutes after eating, the reason for the symptoms would be intravascular hypovolemia.
A 42-year-old woman is admitted with biliary obstruction and acute pancreatitis. She is severely malnourished. Nutritional deficiencies anticipated in this patient are: A. protein and fat-soluble vitamins. B. vitamin B12 and water-soluble vitamins. C. carbohydrates and fat-soluble vitamins. D. fat and water-soluble vitamins.
ANSWER: A. Exudates from the pancreas are high in protein, which reduces serum albumin and total proteins. The biliary obstruction causes an inability to absorb fat-soluble vitamins. Remember that fat-soluble vitamins are absorbed in the presence of bile in the gastrointestinal tract. Biliary obstruction results in an inability to absorb these vitamins (A, D, E, and K). Options a and c have fat-soluble vitamins included. Remember that serum proteins and calcium are decreased in pancreatitis. Choose option a.
Which of the following laboratory profiles would be expected in a patient with a history of alcoholism and cirrhosis of the liver? A. Prolonged activated partial thromboplastin time (aPTT), decreased albumin, hypokalemia B. Decreased alanine transaminase (ALT), decreased transferrin, hyperkalemia C. Elevated carcinoembryonic antigen (CEA), decreased aspartate transaminase (AST), hyponatremia D. Decreased bilirubin, decreased lactate dehydrogenase (LDH), hypernatremia
ANSWER: A. In liver disease, the prothrombin time and aPTT are prolonged, albumin and transferrin levels are low (liver cannot convert amino acids to plasma proteins), liver enzymes (ALT, AST, LDH) are elevated, bilirubin levels are elevated, and potassium levels are low. CEA is a cancer marker and would not be abnormal is this patient. Always start with what you know. If you remember that patients with liver disease have coagulopathies, choose option a.
A 52-year-old man is admitted with hepatic failure caused by chronic alcoholism. He is nonresponsive to verbal stimuli at this time. Which dietary restrictions would be maintained for a patient with hepatic encephalopathy? A. Protein and sodium B. Fat and potassium C. Potassium and carbohydrates D. Sodium and potassium
ANSWER: A. Protein is restricted because its breakdown causes increased ammonia levels. Sodium is restricted because patients with hepatic disease have increased circulating levels of aldosterone, which causes increased sodium reabsorption in the distal tubule and resultant edema. Adequate caloric intake in the form primarily of carbohydrates with adequate amounts of fats is necessary to prevent the catabolism of body protein stores. Potassium is not restricted and may need to be replaced because the increased circulating aldosterone levels cause the excretion of increased amounts of potassium. Because you know that this patient is likely to be edematous, you should assume that sodium should be restricted. Options a and d have sodium. Because sodium and potassium are opposite in relationship to aldosterone, eliminate option d because it is unlikely to restrict both (though both are restricted in renal failure). Protein is restricted because it contributes to increased ammonia levels, so choose option a.
A 63-year-old woman is admitted with hepatic encephalopathy. She has chronic alcoholism. Assessment reveals an extremely lethargic and confused patient. Asterixis is present. Which of the following should be a primary concern in managing this patient's diet? A. Reduce protein intake. B. Reduce fluid intake. C. Reduce carbohydrate intake. D. Reduce potassium intake.
ANSWER: A. Protein must be restricted in the diet to prevent further increases in ammonia levels. Ammonia is produced by the action of intestinal bacteria on protein from dietary intake and from protein in blood if there is gastrointestinal bleeding. Carbohydrate intake must be maintained so that protein from muscle mass is not catabolized for energy. Potassium intake may need to be increased because of increased circulating aldosterone. Fluid intake is not restricted and may need to be increased because fluid is trapped in third spaces like the peritoneal space (ascites) and interstitial space. Only option a is correct.
Which of the following analgesic prescriptions would be appropriate for a patient with severe pain caused by acute pancreatitis? A. Morphine 2 to 5 mg IV every 1 to 2 hours as required for pain B. Meperidine 25 mg IV every 1 to 2 hours as required for pain C. Hydrocodone/acetaminophen (Lortab) 10/500 PO every 4 hours as required for pain D. Ibuprofen 800 mg PO every 4 hours as required for pain
ANSWER: A. The expectation is that you know current best evidence and that you base clinical decisions on the best evidence. Many of us were taught that meperidine is preferred for acute pancreatitis because morphine causes spasm of the sphincter of Oddi. Current evidence shows that they both cause spasm; neither is worse than the other. However, morphine is preferable because of the adverse effects of normeperidine, the metabolite of meperidine that has a longer half-life than the meperidine. Accumulation of normeperidine causes neuromuscular irritability and potentially seizures. The oral agents are excluded because nothing should be given by mouth and they will increase the secretion of pancreatic enzymes and, therefore, injury to the pancreas. Consideration of the severity of the pain of acute pancreatitis should lead you to eliminate the oral agents. If given the choice of morphine or meperidine, choose morphine.
A 72-year-old woman is receiving parenteral nutritional support. She is difficult to arouse and feels cold and clammy. You note that the total parenteral nutrition (TPN) bottle is empty. What should you do first? A. Hang dextrose 10% IV. B. Administer glucagon intramuscularly. C. Give the patient orange juice. D. Contact the physician.
ANSWER: A. The high sugar content of TPN stimulates the pancreatic release of insulin. If the infusion is abruptly stopped, the patient quickly may become hypoglycemic. Dextrose 10% provides glucose until the TPN can be reinitiated. This patient's diminished level of consciousness contraindicates oral fluids because she may aspirate. Glucagon is a hormone that causes the patient to release stored glucose. Many patients have limited glucose stores, and therefore the response is inadequate. It is better to directly give glucose rather than something that indirectly increases glucose. Before choosing "contact the physician," always consider whether there is anything definitive that you can do first. Yes, give dextrose.
Abdominal pain, abdominal distention, diminished bowel sounds, fever, and leukocytosis after gastric or bowel resection is likely an indication of which of the following? A. Anastomosis leak B. Pancreatitis C. Bowel obstruction D. Fistula
ANSWER: A. These are indications of peritonitis, and the most likely cause of peritonitis after a gastric or bowel resection is anastomosis leak. These are indications of an acute abdomen, and pre-op or post-op they most likely indicate that GI contents are leaking into the peritoneal cavity.
A 52-year-old accountant is admitted to the critical care unit with frank gastrointestinal bleeding for more than 18 hours. He has had a blood loss of more than 1000 mL. Which of the following sets of vital signs would be consistent with the patient's blood loss? A. Blood pressure (BP) 100/84 mm Hg, heart rate 124 beats/min B. BP 86/40 mm Hg, heart rate 92 beats/min C. BP 124/66 mm Hg, heart rate 124 beats/min D. BP 112/60 mm Hg, heart rate 92 beats/min
ANSWER: A. With a loss of 750 to 1500 mL of blood, an increase in heart rate greater than 100 beats/min and a narrowing of the pulse pressure is expected. These changes are due to sympathetic nervous system innervation. Option a shows a narrow pulse pressure and tachycardia. Remember that tachycardia is the first indicator of physiologic stress, so eliminate options b and d. Eliminate option c because it shows normal systolic with a decreased diastolic (widened pulse pressure). You expect this patient in early shock to show narrowed pulse pressure. Choose option a.
A 58-year-old woman is admitted with abdominal pain and jaundice. She is diagnosed with a biliary obstruction. Biliary disease is of concern because it is a common cause of which of the following? A. Gastrointestinal bleeding B. Acute pancreatitis C. Bowel perforation D. Renal failure
ANSWER: B. Alcoholism and biliary disease are the two most common causes of acute pancreatitis. Envision the anatomy of the area. The common bile duct enters the gastrointestinal tract at the duodenum, anatomically close to the pancreas.
Your patient has developed abdominal distention 48 hours after abdominal aortic aneurysm repair. His intraabdominal pressure is measured to assess for abdominal hypertension. Which of the following statements is inaccurate regarding intraabdominal pressure monitoring? A. Decompression laparotomy should be considered when the pressure exceeds 20 mm Hg. B. The transducer should be leveled to the phlebostatic axis. C. The bladder pressure closely reflects intraperitoneal pressure. D. Physiologic compromise begins at a pressure of 12 to 15 mm Hg.
ANSWER: B. All of these statements are true except option b. The transducer is leveled to the symphysis pubis.
In patients predisposed to stress ulcer, the goal of therapy is to keep gastric pH: A. Less than 3 B. Between 3.5 and 5 C. Between 5 and 6.5 D. Above 7
ANSWER: B. Hydrochloric acid has a pH of 1.0 to 3.0. Making the gastric secretions less acidic by using histamine2 receptor antagonists (e.g., ranitidine), proton-pump inhibitors (e.g., pantoprazole), and antacids decreases the caustic nature of the secretions and decreases the risk of stress ulcer. True alkalinization (pH greater than 7) is not desirable because it would allow proliferation of bacteria. The desirable gastric pH in prevention of stress ulcer is between 3.5 to 5. Eliminate both extremes because less than 3 is a normal physiologic level and the goal is not to make them alkaline but rather just less acidic. Because the stomach is normally very acidotic, chose option b which is closer to the normal physiologic level.
A 67-year-old man is in the critical care unit after repair of an abdominal aortic aneurysm. His nasogastric tube has been removed, and he is eating a soft diet. He is now 4 days postoperative and is complaining of excruciating abdominal pain. After a meal he urgently asks for the bedpan and has a large, dark reddish stool. The most likely cause of these recent events is: A. stress ulcer. B. mesenteric infarction. C. hemorrhoids. D. bowel perforation.
ANSWER: B. Mesenteric ischemia and infarction are not uncommon after abdominal aortic aneurysm repair. They may be due to embolization or cross-clamping of the aorta above the mesenteric arteries. The primary clinical indications of mesenteric ischemia are abdominal pain and bloody diarrhea (i.e., currant-jelly diarrhea). Stress ulcer most likely would be located in the stomach or duodenum, and the stool would appear black. Hemorrhoids cause stool to be streaked with blood and/or toilet paper to be bloody. Bowel perforation causes the signs/symptoms of an acute abdomen: abdominal distention; rigid, boardlike abdomen; decreased bowel sounds; and rebound tenderness. If you are not sure, use common sense. Because this patient has had vascular surgery, look for a vascular problem. Choose option b.
A 42-year-old woman is admitted with a diagnosis of acute pancreatitis as a result of cholelithiasis. She is complaining of severe abdominal pain and states that she has been vomiting for 2 days. Some of her emesis appears like coffee grounds. Her blood pressure is 80/40 mm Hg, and her heart rate is 130 beats/min. Which of the following is indicated at this time? A. Administration of dobutamine at 5 mcg/kg/min B. Fluid replacement with crystalloids and electrolytes C. Transfusion with packed red blood cells D. Administration of dopamine at 10 mcg/kg/min
ANSWER: B. She has been vomiting for 2 days. The hypotension and tachycardia are signs of severe fluid volume deficit, which must be corrected with the fluid lost. If there is blood in the vomitus, it is not an acute hemorrhage considering the coffee-grounds appearance. She has lost fluid (and electrolytes) and blood, but crystalloids should be initiated first. She has no indications of pump failure, so dobutamine is not indicated. Dopamine at 10 mcg/kg/min is a vasopressor, which will increase her blood pressure but decrease perfusion to her vital organs. Fill the vascular bed rather than just making the vascular bed smaller. Appropriate treatment is to replace the fluid deficit. Start with treatment of cause.
A 45-year-old man is admitted with acute epigastric pain that radiates to his back. He says that he has been vomiting continuously for 12 hours and that the pain has been worsening. His social history includes the information that he drinks about two six-packs of beer each night. He has dry, cracked lips and poor skin turgor. His abdomen is distended and tender. He is restless and agitated. Vital signs are blood pressure of 90/60 mm Hg, heart rate of 135 beats/min, and respiratory rate of 28 breaths/min. While assessing the patient's blood pressure, the nurse notes spasm of the patient's hand. Which of the following does this indicate? A. Hyponatremia related to overhydration B. Hypocalcemia related to fat necrosis and precipitation of calcium C. Metabolic acidosis related to hypoperfusion D. Hypoalbuminemia related to protein loss
ANSWER: B. This is a description of Trousseau's sign, an indication of hypocalcemia or hypomagnesemia. Calcium levels become low in acute pancreatitis because of fat necrosis and precipitation of calcium. Associate Chvostek's and Trousseau's signs with hypocalcemia; calcium loss is critical in acute pancreatitis. Choose option b.
Which of the following would not be an important aspect of care for a patient having bariatric surgery? A. Having appropriate bariatric equipment available B. Preventing prejudice based on size and weight C. Ensuring privacy for procedures D. Maintaining confidentiality
ANSWER: B. Unfortunately, prejudice cannot really be prevented but it should be recognized and acknowledged. These prejudices must not affect the quality of the care that the patient receives and assignments may need to be adjusted to ensure that the patient does receive optimal care.
Vasopressin may be used in patients with gastrointestinal bleeding. How does it work? A. Increases mesenteric blood flow to reduce ischemia B. Decreases portal venous blood flow to decrease bleeding C. Causes sodium and water retention to replace volume D. Blocks histamine2 receptors to inhibit hydrochloric acid secretion
ANSWER: B. Vasopressin slows blood loss by constricting the splanchnic arteriolar bed and decreasing portal venous pressure. Vasopressin is another name for antidiuretic hormone, so it causes water (but not sodium) retention and may cause syndrome of inappropriate antidiuretic hormone. Histamine2 receptor antagonists (e.g., cimetidine) inhibit hydrochloric acid secretion, but vasopressin does not. Vasopressin actually decreases mesenteric blood flow and may cause ischemia. Nitroglycerin may be used to combat the vasoconstriction and ischemia. Because the question relates to bleeding, choose the option that says it decreases bleeding. Choose option b.
A 58-year-old patient with acute pancreatitis develops agitation, fine tremors, and tachycardia about 48 hours after admission. Which of the following is the most likely cause of these signs/symptoms? A. Pancreatic pseudocyst B. Hypoglycemia C. Alcohol withdrawal D. Pancreatic abscess
ANSWER: C. Alcoholism is a common cause of acute pancreatitis, and alcohol withdrawal is a complication that must be closely observed for approximately 24-72 hours after onset of abstinence. Alcohol withdrawal is not necessarily delirium tremens. Withdrawal from any habitual drug (e.g., alcohol) would cause agitation.
A 71-year-old woman reports that she started vomiting large amounts of bright blood 1 hour ago. In the supine position, her blood pressure is 120/82 mm Hg. When sitting on the edge of the bed, she complains of dizziness. Which of the following blood pressure measurements would be expected? A. 140/90 mm Hg B. 120/82 mm Hg C. 100/60 mm Hg D. 60 mm Hg with Doppler ultrasound
ANSWER: C. Based on the history, you would expect postural or orthostatic hypotension, which is defined as a drop of 20 mm Hg in pressure when the patient changes position. This sometimes is called tilt positive. Postural hypotension is an earlier sign of blood volume depletion than frank hypotension. Considering the blood loss, you certainly would not expect the blood pressure to go up without treatment. The dizziness makes you suspect hypoperfusion to the brain in the upright position, so the blood pressure is probably less than normal. She is talking to you and so is certainly cerebrating and perfusing her brain with a blood pressure of greater than 60 mm Hg systolic. Choose option c.
Abdominal auscultation of a patient with an early mechanical bowel obstruction likely would reveal which of the following? A. Normal bowel sounds B. Hyperactive bowel sounds C. Hypoactive bowel sounds D. Absent bowel sounds
ANSWER: C. Early intestinal bowel obstruction causes hyperactive bowel sounds, sometimes called rushes. Late intestinal bowel obstruction causes hypoactive and then absent bowel sounds. Bowel obstruction is abnormal, so do not choose normal bowel sounds (option a). Early obstruction likely would not cause absent bowel sounds, so eliminate option d. Because hypoactive is closer to absent, which indicates late obstruction, choose hyperactive bowel sounds, option b. In addition, using common sense, if a bowel obstruction is present, the bowel initially tries to push the bowel contents through a narrowed lumen. Eventually bowel sounds become hypoactive and then absent.
A 36-year-old man is admitted with a bowel obstruction. He complains of severe, sharp abdominal pain and vomiting. His blood pressure is 85/60 mm Hg, and his heart rate is 150 beats/min. His abdomen is grossly distended and rigid. The patient returns to the unit after a bowel resection. His abdomen remains grossly distended, and the patient complains that he is "smothering." Which of the following interventions would be most helpful for this patient? A. Starting oxygen by nasal cannula at 3 L/min B. Increasing the suction on the nasogastric tube C. Elevating the head of the bed 30 to 45 degrees D. Positioning the patient on his side
ANSWER: C. Elevating the head of the bed on any patient with abdominal distention can ease the work of breathing because the abdominal contents restrict diaphragmatic excursion with the patient flat in the bed. Start with treatment of cause. The diaphragm is elevated because of abdominal distention, and elevating the head of the bed may allow better diaphragmatic excursion.
A 21-year-old man has profuse bloody vomiting. He has a history of alcoholism and cirrhosis of the liver. His mother found him in his apartment. He is lethargic, pale, and jaundiced. The patient receives two units of packed cells. When should hemoglobin and hematocrit levels be drawn to evaluate the effect of the transfusion on these levels? A. Immediately after the transfusion B. 1 hour after transfusion C. 6 hours after transfusion D. 24 hours after transfusion
ANSWER: C. It will take at least 4 to 6 hours to see changes in the hemoglobin/hematocrit level. Often, a hemoglobin/hematocrit sample is drawn immediately after transfusion, but this only indicates whether bleeding is still occurring. Unfortunately, if you think about your own clinical practice, you may be misled. Yes, we often do a hemoglobin/hematocrit sample an hour after the transfusion is completed, but that is to evaluate current status, determine whether the patient is still bleeding, and learn whether more blood is required. The option of 1 hour after blood transfusion will not reflect the blood just given.
A 71-year-old woman reports that she started vomiting large amounts of bright blood 1 hour ago. In the supine position, her blood pressure is 120/82 mm Hg. When sitting on the edge of the bed, she complains of dizziness. The nurse would expect to administer which of the following? A. Furosemide (Lasix) B. Dobutamine (Dobutrex) C. Fluid bolus of normal saline D. Dopamine (Intropin)
ANSWER: C. The blood loss represents a decrease in preload, and the blood pressure and perfusion drop that occurs with an upright position demonstrates that preload needs to be replaced. A fluid bolus is the best choice. Blood loss represents a preload loss. The preload is too low, so do not decrease it further with furosemide. Eliminate option a. Do not choose dopamine to increase the blood pressure because the problem is not vascular tone, and dopamine actually may decrease flow and perfusion by constricting vessels. Eliminate option d. The problem is not contractility, so eliminate dobutamine because its primary effect is to increase contractility. Eliminate option b. Remember the patient lost volume, so replace volume in the form of normal saline. Choose option c. Blood administration may also be necessary depending on the degree of hypoperfusion.
A 52-year-old man is admitted with hepatic failure caused by chronic alcoholism. He is nonresponsive to verbal stimuli at this time. Which intervention would not specifically decrease serum ammonia levels in patients with hepatic encephalopathy? A. Administration of rifaximin B. Administration of lactulose C. Provision of adequate caloric intake D. Avoidance of all hepatotoxic agents
ANSWER: D. Although avoidance of hepatotoxic agents is important in patients with liver failure, it only prevents further damage to the liver rather than actually reducing ammonia level. Rifaximin decreases the bacteria in the gastrointestinal tract that break down nitrogenous materials (protein) to ammonia. Lactulose increases ammonia excretion and moves nitrogenous materials through the gastrointestinal tract more quickly, allowing less time for the bacteria to convert the nitrogen to ammonia. The restriction of protein in the diet and provision of sufficient calories (primarily in the form of carbohydrates) to prevent endogenous protein catabolism decreases the ammonia. The key phrase in the questions is "decrease serum ammonia levels." Look at the first word of each option. Avoidance (in option d) is not likely to actively decrease something, although it may prevent further increases.
A 21-year-old college student is admitted with severe retrosternal chest pain which worsens with swallowing. She reluctantly reports binging and purging. She does report blood in the vomitus. Which of the following is likely? A. Gastroesophageal reflux B. Stress ulcer C. Esophageal spasm D. Esophageal tear
ANSWER: D. Forceful vomiting can cause an esophageal tear (i.e., Mallory-Weiss tear). The history, severe retrosternal pain, and hematemesis are consistent with option d. The blood in the vomitus would lead you toward a tear or an ulcer. The history cinches the tear.
A patient is complaining of dull, diffuse abdominal pain. Of the following possible causes, which is most likely to be the cause? A. Appendicitis B. Cholecystitis C. Ulcerative colitis D. Large intestinal obstruction
ANSWER: D. Intestinal obstruction causes dull, generalized pain with abdominal distention. Notice that three of the conditions listed are inflammatory (itis), which causes sharp pain. The noninflammatory condition should be chosen as causing dull pain. Choose option d.
A 42-year-old woman is admitted with a diagnosis of acute pancreatitis as a result of cholelithiasis. She is complaining of severe abdominal pain and states that she has been vomiting for 2 days. Some of her emesis appears like coffee grounds. Her blood pressure is 80/40 mm Hg, and her heart rate is 130 beats/min. Which of the following lab values would be expected in this patient? A. Increased albumin B. Increased calcium C. Increased potassium D. Increased lipase
ANSWER: D. Lipase and amylase are elevated in pancreatitis. Alkaline phosphatase and bilirubin would be elevated because of the biliary disease. Potassium would be decreased because of vomiting. Albumin is decreased because of increased capillary permeability and protein leakage. Calcium is decreased because of fat necrosis and precipitation of calcium salts.
Which of the following sign or symptom is most specific to a small-bowel obstruction? A. Abdominal pain B. Change in bowel habits C. Mucus and blood in the stool D. Vomiting of fecal material
ANSWER: D. Mucus and blood in the stool is characteristic of inflammatory bowel disease. Abdominal pain and change in bowel habits could occur in small- or large-bowel obstruction. Small-bowel obstruction causes reverse peristalsis and movement of bowel contents into the stomach and vomiting of fecal material. Note the question asks for the "most specific." This means that you should eliminate the general signs/symptoms.