Patho Test Review NCLEX Q's GI GU

12. Untreated acute cholecystitis may lead to ________ of the gallbladder wall. a. gangrene b. infection c. distention d. inflammation

ANS: A If left untreated, the inflammatory process often escalates, and gangrene of the gallbladder wall with rupture may occur. Acute cholecystitis is defined as acute inflammation of the gallbladder wall. Distention of the gallbladder wall is not a risk factor related to untreated cholecystitis. Acute cholecystitis is defined as acute inflammation of the gallbladder wall.

Match the grades of hepatic encephalopathy to the assessment findings. a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4

19. Stuporous, able to follow commands, marked confusion, slurred speech, liver flap present 20. Confusion, subtle behavioral changes, no liver flap 21. Coma, no liver flap 22. Drowsy, clear behavioral changes, liver flap present ---------------------------------------------------------------------------------- 19. ANS: C 20. ANS: A 21. ANS: D 22. ANS: B

1. Which symptom suggests the presence of a hiatal hernia? a. Nausea b. Heartburn c. Diarrhea d. Abdominal cramps

ANS: B Individuals with hiatal hernia are predisposed to GERD and may experience symptoms such as heartburn, chest pain, and dysphagia. Nausea and abdominal cramps are not symptoms that suggest hiatal hernia. Hiatal hernia is not manifested by diarrhea.

8. Chronic pancreatitis may lead to a. diabetes mellitus. b. Crohn disease. c. gallstones. d. celiac sprue.

ANS: A About 10% to 15% of patients will present not with pain, but rather with the sequelae of chronic pancreatitis, including diabetes mellitus, malabsorption, and weight loss. Chronic pancreatitis does not lead to Crohn disease. Increased incidence of gallstones is not the result of chronic pancreatitis. Celiac sprue is not related to chronic pancreatitis.

18. Steatohepatitis is caused by an accumulation of ________ in the liver cells. a. fat b. bile c. acetaminophen d. ferritin

ANS: A Alcoholic fatty liver (alcoholic steatohepatitis) is an accumulation of fat in the liver cells. It is caused by more fat being delivered to the hepatocyte than it can normally metabolize or by a defect in fat metabolism within the cell. An accumulation of bile does not contribute to steatohepatitis. Steatohepatitis is not related to an accumulation of acetaminophen levels. Serum ferritin levels are elevated in patients with hereditary hemochromatosis.

10. Celiac sprue is a malabsorptive disorder associated with a. inflammatory reaction to gluten-containing foods. b. megacolon at regions of autonomic denervation. c. ulceration of the distal colon and rectum. d. deficient production of pancreatic enzymes.

ANS: A Celiac disease (also called celiac sprue) is characterized by intolerance of gluten, a protein in wheat and wheat products. Current research suggests that celiac sprue is an immune disorder. The main pathologic finding is villus atrophy, with a decrease in the activity and amount of surface epithelial enzymes. Celiac sprue is not associated with ulceration of the distal colon and rectum. Celiac disease is an intolerance of gluten.

20. A patient with chronic gastritis would likely be tested for a. Helicobacter pylori. b. occult blood. c. lymphocytes. d. herpes simplex.

ANS: A It is now known that H. pylori causes chronic, superficial gastritis in virtually all infected persons. Once established in the gastric mucosa, H. pylori sets up a destructive pattern of persistent inflammation. The presence of bloody stools is not generally seen in chronic gastritis. Lymphocytes are not tested in the presence of chronic gastritis. Herpes simplex is not a manifestation of chronic gastritis.

22. Premature infants are at greater risk for developing a. necrotizing enterocolitis. b. pseudomembranous colitis. c. appendicitis. d. diverticular disease.

ANS: A Necrotizing enterocolitis (NEC) is a disorder occurring most often in premature infants (less than 34 weeks' gestation) and infants with low birth weight (less than 5 lbs. or 2.25 kg). This disorder is characterized by diffuse or patchy intestinal necrosis accompanied by sepsis. Pseudomembranous colitis is an acute inflammation and necrosis of the large intestine caused by Clostridium difficile, usually affecting the mucosa but sometimes extending to other layers. The most common cause of emergency surgery on the abdomen, appendicitis is an inflammation of the vermiform appendix. The prevalence of diverticular disease increases with age.

1. Normal bile is composed of a. water, electrolytes, and organic solutes. b. proteins. c. bile acids. d. phospholipids.

ANS: A Normal bile is composed primarily of water, electrolytes, and organic solutes. Bile has a low protein content. The low amount of protein in bile contains bile acids, pigment, cholesterol, and phospholipids. Phospholipids are part of the low protein content in bile.

14. A patient being treated for hepatic encephalopathy could be expected to receive a(n) ________diet. a. low-protein and high-fiber b. high-protein and high-carbohydrate c. high-sodium d. unrestricted

ANS: A Restriction of protein is indicated for chronic encephalopathy, along with enhanced elimination of toxic nitrogenous substances. High fiber intake may help decrease constipation. As ammonia levels drop, protein is reintroduced into the diet. When protein is restricted, carbohydrate levels should be at least 400 g. Excessive levels of sodium in the diet are contraindicated with renal insufficiency. Dietary restrictions are utilized in patients with hepatic encephalopathy.

5. Acute right lower quadrant pain associated with rebound tenderness and systemic signs of inflammation are indicative of a. appendicitis. b. peritonitis. c. cholecystitis. d. gastritis.

ANS: A The earliest manifestation of appendicitis is generalized periumbilical pain accompanied by nausea and, occasionally, diarrhea. The pain is often described as "migrating" or localizing to the lower right abdomen (McBurney's point) due to distention of the serosa from inflammatory edema, at which time fever usually manifests. Acute localized pain with rebound tenderness is not associated with peritonitis. Cholecystitis is not manifested by lower quadrant pain. Gastritis is not associated with symptoms of right lower quadrant pain and systemic inflammation.

11. The most common causes of prehepatic jaundice are ________ and ineffective erythropoiesis. a. hemolysis b. metabolism c. fibrosis d. canalicular bilirubin transport

ANS: A The most common causes of prehepatic jaundice are hemolysis and ineffective erythropoiesis. The reabsorption of large hematomas in patients with mild liver disease is a frequent and harmless cause of mild jaundice. Dysfunction of each of the hepatic steps in bilirubin metabolism may cause jaundice. Increased resistance from fibrosis may cause jaundice in the cholestatic pathway. At the canalicular posthepatocytic level, jaundice may occur due to conjugated hyperbilirubinemia.

7. Ulcerative colitis is commonly associated with a. bloody diarrhea. b. malabsorption of nutrients. c. fistula formation between loops of bowel. d. inflammation and scarring of the submucosal layer of the bowel.

ANS: A Ulcerative colitis (inflammation and ulceration of the colon and rectal mucosa) is manifested as bloody diarrhea and abdominal pain. Ulcerative colitis is not associated with malabsorption of nutrients. Fistula formation in the bowel is related to Crohn disease. Acute inflammation of the intestinal wall may manifest as pseudomembranous enterocolitis or necrotizing enterocolitis.

18. Chronic cholecystitis can lead to (Select all that apply.) a. biliary sepsis. b. calcified gallbladder. c. porcelain gallbladder. d. cirrhosis. e. diabetes mellitus.

ANS: A, B, C Chronic cholecystitis may lead to biliary sepsis, as well as a specific type of scarring known as a calcified or porcelain gallbladder. Chronic cholecystitis is associated with a higher risk of cancer, not cirrhosis which affects the liver. Diabetes mellitus is a predisposing factor of chronic cholecystitis. Chronic cholecystitis does not cause diabetes mellitus.

24. A disorder of the esophageal smooth muscle function where dysphagia is a symptom is (Select all that apply.) a. esophageal stricture. b. achalasia. c. esophageal tumors. d. Mallory-Weiss syndrome. e. hiatal hernia.

ANS: A, B, C Esophageal stricture, achalasia, and esophageal tumors are all disorders of the esophageal smooth muscle function that cause dysphagia. Manifestations of Mallory-Weiss syndrome include vomiting of blood and passing of large amounts of blood rectally after an episode of forceful vomiting. Hiatal hernia is a defect of the diaphragm, not the esophagus, even though hiatal hernia is associated with dysphagia.

25. Crohn disease is associated with what complications? (Select all that apply.) a. Perianal fissures b. Fistulae c. Green stool d. Abscesses e. Rectal pain

ANS: A, B, D Complications such as perianal fissures, fistulae, and abscesses are common in Crohn disease and may be the symptoms that lead individuals to seek health care. The stool may be bloody, and thus would be red or black, not green. In Crohn disease, abdominal pain is often constant and in the right lower quadrant of the abdomen.

17. Patients who may be at risk for development of cholesterol gallstones include (Select all that apply.) a. high spinal cord injuries. b. patients receiving total parenteral nutrition. c. patients receiving chemotherapy. d. patients with rapid weight loss. e. pregnant women.

ANS: A, B, D, E A significant factor that promotes the continued growth of stones is hypomotility or stasis of bile within the gallbladder. Patients with high spinal cord injuries, patients receiving total parenteral nutrition, and persons who undergo prolonged fasting or rapid weight loss have impaired emptying and are at particular risk for development of cholesterol gallstones. Other risk factors for cholelithiasis include pregnancy, oral contraceptives, obesity, and diabetes mellitus. Patients receiving chemotherapy are not at greater risk for developing gallstones.

26. What is a pathophysiologic mechanism involved in the development of diarrhea? (Select all that apply.) a. Osmotic diarrhea b. Excessive flatus c. Secretory diarrhea d. Exudative diarrhea e. Motility disturbances

ANS: A, C, D, E Osmotic diarrhea is due to increased amounts of poorly absorbed solutes in the intestine. Secretory diarrhea is usually due to toxins that stimulate intestinal fluid secretion and impair absorption. Exudative diarrhea (mucus, blood, protein) results from inflammatory processes. A decreased transit time in the small intestine results in diarrhea because the absorptive capacity of the large intestine is exceeded. Excessive gas in the intestine is not a mechanism for developing diarrhea.

6. Liver transaminase elevations in which aspartate aminotransferase (AST) is markedly greater than alanine aminotransferase (ALT) is characteristic of a. viral hepatitis. b. alcohol-induced injury. c. cirrhosis. d. acetaminophen toxicity.

ANS: B Alcoholic and other toxic hepatitides virtually always show the aspartate aminotransferase (AST) markedly elevated in comparison with the alanine aminotransferase (ALT). In viral hepatitis, the alanine aminotransferase (ALT) is markedly higher than the aspartate aminotransferase (AST). Jaundice in patients with cirrhosis often shows elevations in all parameters, reflecting the widespread liver dysfunction and obstruction of the bile canals and small vessels due to scarring. Acetaminophen toxicity will cause signs of hepatic injury within 24 to 48 hours, including abnormal liver enzyme levels.

16. Hepatitis with the presence of autoantibodies and positive antinuclear antibodies (ANA) is a. hepatitis D. b. autoimmune hepatitis. c. hepatitis A. d. hepatitis B.

ANS: B Autoimmune hepatitis is characterized by the presence of several autoantibodies as well as a polyclonal hypergammaglobulinemia. Antinuclear antibody (ANA) is generally positive at a high level. The diagnosis of hepatitis D is by anti-HDV IgM and IgG enzyme-linked immunosorbent assays. HAV infection is diagnosed through serologic testing. Presence of anti-HAV immune globulin G (IgG) indicates previous infection, and presence of immune globulin M (IgM) indicates acute infection. The serologic diagnosis for hepatitis B is complicated.

19. Esophageal varices represent a complication of ________ hypertension. a. primary b. pregnancy-induced c. portal d. secondary

ANS: C Esophageal varices represent a complication of portal hypertension, which in Western society is generally the result of cirrhosis due to alcoholism or viral hepatitis. Primary hypertension is not manifested by esophageal varices. Pregnancy-induced hypertension is unrelated to esophageal varices. Esophageal varices is not a complication of secondary hypertension.

12. Barrett esophagus is a a. gastrin secreting lesion. b. preneoplastic lesion. c. benign condition. d. gastrin-secreting tumor.

ANS: B Barrett esophagus is a complication of chronic GERD and represents columnar tissue replacing the normal squamous epithelium of the distal esophagus. It carries a significant risk for esophageal cancer. Patients with Barrett esophagus should undergo regular endoscopic screening for cancer, along with pharmacologic control of their reflux. Barrett esophagus carries a significant risk for esophageal cancer and does not secrete gastrin.

2. Patients with acute pancreatitis are generally made NPO and may require continuous gastric suctioning in order to a. prevent abdominal distention. b. remove the usual stimuli for pancreatic secretion. c. prevent hyperglycemia associated with loss of insulin secretion. d. prevent mechanical obstruction of the intestine.

ANS: B Conservative management is indicated for mild to moderate cases of acute pancreatitis. In general, withholding oral feedings, providing nasogastric suction, and providing careful volume replacement with IV fluids are indicated. Gastric suctioning is not indicated for preventing abdominal distention. Hyperglycemia is not influenced by the presence of gastric suctioning. Continuous gastric suctioning may be used in the presence of a significant ileus.

14. Fecal leukocyte screening would be indicated in a patient with suspected a. lactose intolerance. b. enterocolitis. c. laxative abuse. d. giardiasis.

ANS: B Enterocolitis is manifested by diarrhea (often bloody), abdominal pain, fever, leukocytosis, and rarely, colonic perforation. Lactose intolerance would not be a cause of leukocytosis. Leukocyte screening would not be a factor in laxative use or abuse. Suspected giardiasis would not be a reason to screen fecal leukocytes.

11. It is true that gallstones are a. a minimal risk for Native Americans. b. more common in women. c. more common in men. d. at highest risk among Asians.

ANS: B Gallstones are twice as common in women as in men. Native Americans, particularly the Pima Indians of North America, are markedly susceptible to gallstones. Gallstones are twice as common in women than men. European Caucasians are intermediate in prevalence, and persons of Asian descent are at the lowest risk.

9. A patient who should be routinely evaluated for peptic ulcer disease is one who is a. taking 6 to 8 tablets of acetaminophen per day. b. being treated with high-dose oral glucocorticoids. c. experiencing chronic diarrhea. d. routinely drinking alcoholic beverages.

ANS: B Glucocorticoids released in response to stress may have a role in the promotion of excess acid production or the destruction of gastric mucosal defenses. Therefore, a patient taking high-dose glucocorticoids would be at higher risk of developing peptic ulcer disease. Acetaminophen is not a risk factor for development of peptic ulcer disease. Chronic diarrhea is not a symptom of peptic ulcer disease. There is little evidence of a pathogenic role for alcohol, spicy foods, and caffeine in the development of peptic ulcer disease.

9. What form of viral hepatitis is likely to be transmitted sexually? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis E

ANS: B Hepatitis B is spread by parenteral contact with infected blood or blood products, including contaminated needles, and by sexual contact. Hepatitis A virus (HAV) is usually spread by the fecal-oral route. The mode of transmission of hepatitis C closely resembles that of HBV, although sexual and perinatal transmission is much less likely. The majority of infections were acquired through IV drug abuse. Hepatitis E is an RNA virus spread via the fecal-oral route, especially through contaminated water.

10. The finding of hypotension, rigid abdomen, and absent bowel sounds in a patient with pancreatitis a. is an expected finding and requires no specific intervention. b. indicates peritonitis with substantial risk for sepsis and shock. c. requires immediate surgical intervention. d. is an unusual finding in pancreatitis and indicates misdiagnosis.

ANS: B In acute pancreatitis, fever is common but is usually low-grade initially. In more severe pancreatitis, hypotension, rigid abdomen, and absent bowel sounds are present. Hypotension, rigid abdomen and absent bowel sounds are unexpected findings. Pancreatic surgery is technically challenging and risky, and generally is only considered as a last resort. Findings indicative of peritonitis do occur and should be treated promptly.

13. A patient admitted with bleeding related to esophageal varices could be expected to receive a continuous intravenous infusion of a. glucose. b. octreotide acetate. c. anticoagulants. d. proton pump inhibitors.

ANS: B Pharmacologic management is used to lower portal pressure by dilating collateral pathways and reducing splanchnic blood flow. Controlling bleeding is often accomplished using vasopressin, but side effects limit its use. Recently, octreotide acetate, a synthetic analog of the naturally occurring hormone somatostatin, has been effectively used as a replacement for vasopressin. Fluid resuscitation is carried out using normal saline. Anticoagulants are contraindicated in a patient with active bleeding. Intravenous proton pump inhibitors may be used, but not as a continuous infusion.

8. What laboratory data would support a diagnosis of hemochromatosis? a. Deficient protease inhibitor b. Elevated ferritin c. Elevated urine copper d. Positive antinuclear antibody

ANS: B Serum iron and ferritin studies are performed to diagnose hemochromatosis. Protease inhibitor is not used to diagnose hemochromatosis. Copper in the urine is not indicative of hemochromatosis. Antinuclear antibody is not diagnostic of hemochromatosis.

18. A patient receiving chemotherapy may be at greater risk for development of a. gastroesophageal reflux. b. stomatitis. c. esophageal varices. d. Mallory-Weiss syndrome.

ANS: B Stomatitis is defined as an ulcerative inflammation of the oral mucosa that may extend to the buccal mucosa, lips, and palate. Among its many causes are pathogenic organisms, including bacteria and viruses; mechanical trauma; exposure to such irritants as alcohol, tobacco, and other chemical substances; certain medications, particularly chemotherapeutic agents. Gastroesophageal reflux disease is not related to chemotherapy. Patients taking chemotherapy are not at greater risk for developing esophageal varices. Chemotherapy is not a risk factor for Mallory-Weiss syndrome.

3. Most gallstones are composed of a. bile. b. cholesterol. c. calcium. d. uric acid salts.

ANS: B The majority of gallstones among patients are cholesterol stones. Cholesterol eventually precipitates from supersaturated bile. Most gallstones are not composed of calcium. Uric acid salts are not the primary composition of gallstones.

16. The pain associated with chronic pancreatitis is generally described as ________ in nature. a. sharp and constant b. steady and boring c. intermittent and burning d. intermittent and stabbing

ANS: B The pain is often accompanied by nausea and is steady and boring in nature. The pain is usually located in the upper abdomen, particularly in the epigastrium, and radiates to the back in more than half of cases. Pain associated with pancreatitis is most often steady in nature. The pain of chronic pancreatitis is often the major form of debility. Nerve fibers from the pancreas pass to the celiac plexus and then to spinal sympathetic ganglia.

17. ________ disease is a rare autosomal recessive disorder in which excessive amounts of copper accumulate in the liver. a. Kayser-Fleischer b. Wilson c. Reye d. Byler

ANS: B Wilson disease, or hepatolenticular degeneration, is a rare autosomal recessive disorder in which excessive amounts of copper accumulate in the liver and other organs. As with hereditary hemochromatosis, it has now been linked to a specific abnormal protein, ATP7B, which results in retention of copper in the liver. Clinical signs and symptoms of Wilson disease include the presence of Kayser-Fleischer rings on the cornea. Reye syndrome is characterized by fatty infiltration of the liver with severe hepatic dysfunction, including encephalopathy, coagulopathy, and elevated levels of hepatocellular enzymes. Byler syndrome, is caused by a single-gene mutation and traces back to an Amish kindred.

19. Which digestive enzyme is secreted from the intestinal mucosa during a meal? (Select all that apply.) a. Amylase b. Cholecystokinin c. Trypsinogen d. Lecithin e. Lipase f. Secretin

ANS: B, F The release of digestive enzymes during a meal is controlled by hormones secreted from the small intestinal mucosa: cholecystokinin (CCK) and secretin. The juices themselves are composed of both active digestive enzymes (e.g., amylase, lipase) and precursor or proenzymes (e.g., trypsinogen). Trypsinogen is a proenzyme. Lecithin is unrelated to hormone release during meals.

15. Narcotic administration should be administered carefully in patients with acute pancreatitis related to potential for a. respiratory depression. b. narcotic dependency. c. sphincter of Oddi dysfunction. d. allergic reaction.

ANS: C All narcotics should be used carefully because of the potential of sphincter of Oddi dysfunction, although recent studies show that no single agent is contraindicated. Respiratory failure related to adult respiratory distress syndrome is a risk factor with severe pancreatitis. Narcotic dependency should not be a concern with acute pancreatitis. While patients should always be assessed for allergies, this is not the primary concern.

7. A patient with pancreatitis may experience muscle cramps secondary to a. alkalosis. b. hyperglycemia. c. hypocalcemia. d. hypermagnesemia.

ANS: C Associated laboratory findings of acute pancreatitis include leukocytosis, hyperlipidemia, and hypocalcemia. Alkalosis is not associated with pancreatitis. Hyperglycemia would not be a cause for muscle cramps. Hypermagnesemia is not generally related to pancreatitis.

16. An urgent surgical consult is indicated for the patient with acute abdominal pain and a. vomiting. b. CVA tenderness. c. absent bowel sounds. d. borborygmi.

ANS: C Functional bowel obstructions are characterized by the absence of bowel sounds. Uncorrected obstruction may lead to intestinal wall edema, ischemia, and necrosis. Vomiting with abdominal pain is not a cause for urgent surgical consult. CVA tenderness in the presence of abdominal pain is not an indicator for urgent surgical consult. Acute abdominal pain with hyperactive bowel sounds does not indicate the need for an urgent surgical consultation.

3. Hepatitis B is usually transmitted by exposure to a. hepatitis vaccine. b. feces. c. blood or semen. d. contaminated food.

ANS: C Hepatitis B virus is highly prevalent worldwide. It is spread by parenteral contact with infected blood or blood products, including contaminated needles. HBV vaccine is a recombinant vaccine that is highly immunogenic. After the full course, the antibody response rate is 95% for normal hosts. Hepatitis A is spread by the fecal-oral route. Hepatitis E is spread through contaminated water.

1. Jaundice is a common manifestation of a. malabsorption syndromes. b. anemia. c. liver disease. d. cholecystitis.

ANS: C Jaundice results from impaired bilirubin metabolism and is one of the most characteristic signs of liver disease. Malabsorption syndromes are not manifested by jaundice. Anemia is not manifested by jaundice. Jaundice is not a common manifestation of cholecystitis.

10. Brain injury secondary to high serum bilirubin is called a. hepatic encephalopathy. b. hepatic meningitis. c. kernicterus. d. encephalitis.

ANS: C Kernicterus refers to brain injury as a result of hyperbilirubinemia. It is a serious complication of the neonatal period, generally occurring in the setting of premature birth, neonatal jaundice, and especially hemolytic disease of the newborn. Hepatic encephalopathy is typically characterized by high ammonia levels in the blood. Meningitis is not associated with high serum bilirubin levels. Encephalitis may accompany viral hepatitis in children, but is not related to high serum bilirubin levels.

3. Epigastric pain that is relieved by food is suggestive of a. pancreatitis. b. cardiac angina. c. gastric ulcer. d. dysphagia.

ANS: C Manifestations of peptic ulcer disease include epigastric burning pain that is usually relieved by the intake of food (especially dairy products) or antacids. Pancreatitis is not manifested by epigastric pain. Epigastric pain is not a symptom of cardiac angina. Dysphagia is not associated with epigastric pain relieved by food.

4. Elevated serum lipase and amylase levels are indicative of a. gallbladder disease. b. appendicitis. c. pancreatitis. d. peritonitis.

ANS: C The laboratory evaluation of acute pancreatitis begins with measurements of serum pancreatic enzymes. Serum lipase and amylase levels rise more or less in tandem. Elevated serum lipase and amylase levels are not indicative of gallbladder disease. Appendicitis is not related to lipase and amylase levels. Peritonitis is not caused by elevated serum lipase or amylase levels.

8. An early indicator of colon cancer is a. rectal pain. b. bloody diarrhea. c. a change in bowel habits. d. jaundice.

ANS: C The manifestations of colon cancer depend on the anatomic location and function of the bowel segment containing the tumor. Early manifestations may include a change in bowel habits. Later in the progression of tumor growth, a sensation of rectal fullness and a dull ache may be felt in the rectum or sacral region. Although no signs of obstruction are present, black, tarry stools, which signify bleeding into the intestinal lumen, are a significant finding. Jaundice is not an early indicator of colon cancer.

4. The most common cause of mechanical bowel obstruction is a. volvulus. b. intussusception. c. adhesions. d. fecal impaction.

ANS: C The most frequent contributing factors for bowel obstructions are previous abdominal surgery with adhesions and congenital abnormalities of the bowel. Intestinal obstruction can be caused by volvulus. Intussusception can be related to bowel obstruction, but the most common cause is surgical adhesions. Mechanical bowel obstructions can be related to fecal impaction, but this is not the most common cause.

11. What clinical finding would suggest an esophageal cause of a client's report of dysphagia? a. Nasal regurgitation b. Airway obstruction with swallowing c. Chest pain during meals d. Coughing when swallowing

ANS: C Two types of pain occur in the esophagus: (1) heartburn (also called pyrosis) and (2) pain located in the middle of the chest, which may mimic the pain of angina pectoris. Heartburn is caused by the reflux of gastric contents into the esophagus and is a substernal burning sensation that may radiate to the neck or throat. A person experiencing pharyngeal contractions may cough and expel the ingested food or fluids through their mouth and nose or aspirate when they attempt to swallow. Airway obstruction with swallowing would be an oropharyngeal cause of dysphagia. A person experiencing pharyngeal contractions may cough and expel the ingested food or fluids through his or her mouth and nose or aspirate when he or she attempts to swallow.

14. More than half of the initial cases of pancreatitis are associated with a. trauma. b. stones. c. alcoholism. d. high cholesterol.

ANS: C Up to 66% of first cases of pancreatitis are associated with alcoholism. Trauma is a possible mechanism for acinar cell injury. A prominent factor in pancreatitis is obstruction of the pancreatic duct by a stone. Hypertriglyceridemia is a predisposing factor for pancreatitis in the United States.

23. Dumping syndrome is commonly seen after __________ procedures. a. appendectomy b. intestinal biopsy c. colonoscopy d. gastric bypass

ANS: D Dumping syndrome is a term used to describe the literal dumping of stomach contents into the proximal portion of the small intestine because of impaired gastric emptying. Interestingly, dumping seems to occur only with Roux-en-Y gastric bypass procedures. Dumping syndrome is not related to procedures involving appendectomy. Intestinal biopsies do not produce a dumping effect. Colonoscopies are not related to dumping syndrome.

13. It is true that biliary cancer a. is most often cured by surgery. b. respond well to chemotherapy. c. are identifiable and treatable when diagnosed early. d. tend to be asymptomatic and progress insidiously.

ANS: D Biliary cancers tend to be asymptomatic and progress insidiously until well advanced. Surgery for cure is a treatment option in fewer than 10% of cases. Chemotherapy and radiation therapy are indicted for palliation, and certain patients may benefit from stenting and other procedures to alleviate biliary obstruction. Cancers of the biliary system are relatively rare, accounting for only 1 to 2 cases per 100,000 per year. Unfortunately, they tend to be asymptomatic and progress insidiously until well advanced.

15. What finding would rule out a diagnosis of irritable bowel syndrome in a patient with chronic diarrhea? a. Negative stool leukocytes b. Intermittent constipation c. Abdominal pain and distention d. Bloody stools

ANS: D Bloody stools are not a symptom of irritable bowel syndrome. A person with irritable bowel syndrome would have negative stool leukocytes. The manifestations of IBS may vary greatly, with some persons experiencing only diarrhea or constipation and others experiencing an alternating pattern of both. In addition to cramping abdominal pain, manifestations such as nausea and mucus in the stool may also be present.

13. What finding should prompt further diagnostic testing in a child presenting with diarrhea? a. Periumbilical discomfort b. Greenish, watery diarrhea c. Frequent, large-volume diarrhea d. Blood and mucus in the stools

ANS: D Both ulcerative colitis and Crohn disease have their onset most commonly in childhood and young adulthood, with obviously profound implications. Stools may contain blood or mucus. Periumbilical discomfort, watery diarrhea, and frequent, large volume diarrhea are not causes for further diagnostic testing.

15. An infusion of mannitol would be prescribed to treat a. varices. b. encephalopathy. c. peritonitis. d. cerebral edema.

ANS: D Cerebral edema is managed primarily by the intravenous infusion of mannitol, which by increasing serum osmolarity draws water from the brain and thus reduces the swelling. Octreotide acetate is used in the management of varices. Hepatic encephalopathy would be treated with lactulose. Peritonitis is managed with the use of antimicrobial agents.

12. A patient with a history of alcoholism presents with hematemesis and profound anemia. The expected diagnosis is a. ascites. b. cerebral edema. c. hepatic encephalopathy. d. gastroesophageal varices.

ANS: D Esophageal varices primarily results from portal hypertension due to chronic alcoholism or hepatitis. Initial symptoms are bleeding, anemia, and shock. Ascites is an accumulation of fluid in the abdominal cavity. Cerebral edema is swelling of the brain related to hepatic encephalopathy. Hepatic encephalopathy does not cause symptoms related to bleeding.

2. Pathophysiologically, esophageal varices can be attributed to a. elevated bilirubin. b. diminished protein metabolism. c. fluid accumulation. d. portal hypertension.

ANS: D Esophageal varices result mainly from portal hypertension, which in Western society is generally the result of cirrhosis due to the chronic effects of alcoholism or viral hepatitis. Elevated bilirubin is not attributed to esophageal varices. Diminished protein metabolism does not contribute to esophageal varices. Increased vascular resistance in the liver plays a prominent role in the formation of variceal esophageal veins.

6. A silent abdomen 3 hours after bowel surgery most likely indicates a. peritonitis. b. mechanical bowel obstruction. c. perforated bowel. d. functional bowel obstruction.

ANS: D Functional obstruction or ileus refers to the loss of propulsive ability by the bowel and may occur after abdominal surgery or in association with hypokalemia, peritonitis, severe trauma, spinal fractures, ureteral distention, and the administration of medications such as narcotics. Peritonitis may be associated with functional obstruction. Mechanical obstructions are due to adhesions, hernia, tumors, impacted feces, volvulus (twisting), or intussusception (telescoping). Perforated bowel is a rare condition sometimes associated with Crohn disease.

4. Hepatic encephalopathy is associated with a. hyperbilirubinemia. b. hyperuricemia. c. toxic effects of alcohol on brain cells. d. increased blood ammonia levels.

ANS: D Hepatic encephalopathy is associated with liver failure or liver disease. It is positively correlated with elevated arterial ammonia levels. Hyperbilirubinemia is not related to hepatic encephalopathy but is associated with hypokalemia, hyponatremia, alkalosis, hypoxia, and hypercarbia. Hyperuricemia is not associated with hepatic encephalopathy. Hepatic encephalopathy is a complex neuropsychiatric syndrome characterized by symptoms ranging from mild confusion and lethargy to stupor and coma.

5. An increased urine bilirubin is associated with a. an increased indirect serum bilirubin. b. hemolytic reactions. c. Gilbert syndrome. d. hepatitis.

ANS: D In the presence of liver disease, the hepatic fraction of bilirubin decreases and the urinary fraction increases, thus accounting for a rise in urinary urobilinogen seen with liver dysfunction and hepatitis. An increase in indirect serum bilirubin is a sign of liver disease. Hemolytic reactions do not cause an increase in urine bilirubin. Disorders of the bile acid transport will cause an increase in serum bilirubin.

6. A biliary cause of acute pancreatitis is suggested by an elevation in which serum laboratory results? a. Lipase b. Amylase c. Glucose d. Alkaline phosphatase

ANS: D Marked elevation of the alkaline phosphatase and bilirubin levels suggest the possibility of biliary disease or obstruction, particularly by gallstones. Elevated serum lipase levels and elevated glucose levels do not suggest a biliary cause of pancreatitis. Acute pancreatitis is evidenced by elevated serum amylase and lipase levels, but does not indicate biliary disease.

2. Proton pump inhibitors may be used in the management of peptic ulcer disease to a. increase gastric motility. b. inhibit secretion of pepsinogen. c. neutralize gastric acid. d. decrease hydrochloric acid (HCl) secretion.

ANS: D Proton pump inhibitors are generally given to block acid secretion in individuals with peptic ulcer disease. The major treatment objectives for PUD are to encourage healing of the injured mucosa by reducing gastric acidity and to prevent recurrence. Proton pump inhibitors are not used to inhibit secretion of pepsinogen. Gastric acid is not neutralized by the use of proton pump inhibitors.

21. Rupture of esophageal varices is a complication of cirrhosis with portal hypertension and carries a high ________ rate. a. cure b. morbidity c. insurance d. mortality

ANS: D Rupture of esophageal varices is a dreaded complication of cirrhosis with portal hypertension and carries a high mortality rate. Rupture of esophageal varices does not carry a high cure rate. Varices will affect more than half of cirrhotic patients, and approximately 30% of them experience an episode of variceal hemorrhage within 2 years of the diagnosis of varices. Insurance is not a factor in the rupture of esophageal varices.

5. The definitive treatment for cholecystitis is a. lithotripsy of stones. b. chemical dissolution of stones. c. antibiotics and anti-inflammatories. d. cholecystectomy.

ANS: D Surgical removal of the gallbladder is the definitive treatment for cholecystitis. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstones. Extracorporeal shock wave lithotripsy (ESWL), which involves the breaking up of gallstones using shock waves, is a nonsurgical approach which could lead to recurrence of stones. Chemodissolution of stones has a low overall efficacy. Antibiotics are generally used with acute cholecystitis if infection is involved.

17. Constipation in an elderly patient can be best treated by a. maintaining a low-fiber diet. b. maintaining the current level of activity. c. fecal disimpaction. d. increasing fiber in the diet.

ANS: D The presence of cellulose, the carbohydrate component of dietary fiber that is indigestible in the human intestine, may be effective in promoting regular peristaltic movement in the GI tract by forming bulk within the intestinal lumen to stimulate propulsion. Dietary factors, particularly a diet low in fiber, have been shown to contribute to constipation. In elderly persons the slowed rate of peristalsis that occurs with the aging process, coupled with a decreased level of physical activity, may promote chronic constipation. These factors may eventually contribute to the development of fecal impaction, a condition in which a firm, immovable mass of stool becomes stationary in the lower GI tract.

9. The most challenging aspect of treatment for chronic pancreatitis is a. pancreatectomy. b. strict dietary avoidance of fats. c. abstinence from alcohol. d. pain control.

ANS: D The treatment for chronic pancreatitis is directed toward pain control, exocrine and endocrine insufficiency, and management of complications. By far the most challenging is the management of pain. If endoscopic management fails or is not appropriate in a given patient, surgery may be indicated. Management of exocrine insufficiency can usually be accomplished with low-fat diets. Absolute abstention from alcohol is paramount to prevent worsening of symptoms.

7. A viral hepatitis screen with positive hepatitis B surface antigen (HBsAg) should be interpreted as ________ hepatitis B. a. recovered from b. immunity to c. chronic active d. acute

ANS: D With acute infection HBV core antigen (HBcAg) appears first, followed by seroconversion to core antibody (HBcAb). Presence of HBV surface antigen (HBsAg) indicates active infection. Conversion from surface antigen to surface antibody positivity can take as long as 1 year after acute infection. Development of surface antibody (HBsAb) points to resolution and immunity. In chronic infection, hepatitis B e antigen (HBeAg) is associated with viral replication and infectivity.