T3

A patient has a history of colon polyps. The family nurse practitioner knows: 1. A history of polyps increases the risk of colon cancer, and more frequent screening is required. 2. Hyperplastic polyps are a concern for malignancy. 3. Small polyps <1 cm are not a concern. 4. A colonoscopy is 99% accurate for finding colon polyps and cancer.

1. A history of polyps increases the risk of colon cancer, and more frequent screening is required. Rationale: A history of polyps does increase the risk of colon cancer and on average patients will need a repeat colonoscopy in 3-5 years rather than the recommended 10 years if there are no polyps and no family history. Hyperplastic polyps, in general, are not a concern and do not turn into cancer. Adenomatous polyps can turn into cancer. Small polyps may or may not be cancerous. A colonoscopy is sensitive and specific for polyps and cancer, but there is a miss rate that can vary with the endoscopist. It is not as high as 99%.

Which patient would be at lowest risk for developing diverticular disease? 1. A vegetarian on a high-fiber diet. 2. A patient with chronic constipation for 10 years. 3. An older adult on a small-meal diet. 4. A fad dieter on a fiber diet.

1. A vegetarian on a high-fiber diet. Rationale: A high-fiber diet is the treatment for diverticular disease, and vegetarians who eat increased amounts of fruits, vegetables, grains, and cereals are in the lowest risk category. Chronic constipation causes chronic increased pressure in the sigmoid colon, which increases the likelihood of bowel wall weakening and diverticula (outpouches) developing. Small meals and low-fiber diets would also increase the risk of constipation.

An exam of the male genitalia that consists of inserting a finger into the lower scrotum and into the inguinal canal and asking the patient to cough that causes the family nurse practitioner to feel a sudden presence of a viscus that lies within the inguinal canal and comes through the external canal passing into the scrotum is most likely called: 1. An indirect inguinal hernia. 2. A direct inguinal hernia. 3. A strangulated inguinal hernia. 4. A femoral hernia.

1. An indirect inguinal hernia. Rationale: When there is a defect in the abdominal wall, a hernia can develop. The hernia is a protrusion of a peritoneal-lined sac (i.e., bowel or omentum) through the weakness in the abdominal wall. An indirect hernia protrusion occurs directly through the floor of the inguinal canal and exits through the external inguinal ring. A direct hernia is less common and occurs more in those over 40 years of age. It may be felt medial to the external canal and rarely passes into the scrotum. A femoral hernia is noted when the femoral artery exits the abdomen and is the least common of pelvic hernias. It occurs more in females. A strangulated hernia is nonreducible and can be a surgical emergency.

Which drug would be most useful for the family nurse practitioner to prescribe for an adult patient's arthritis pain to reduce the risk of ulcers? 1. Celecoxib (Celebrex). 2. Cimetidine (Tagamet). 3. Misoprostol (Cytotec). 4. Omeprazole (Prilosec).

1. Celecoxib (Celebrex). Rationale: Treating a patient who has arthritis pain with a nonsteroidal anti-inflammatory drug (NSAID) that is a cyclooxygenase (COX-2) selective agent (celecoxib, rofecoxib) is recommended for the majority of patients at high risk of NSAID-induced complications. Prostaglandins help protect the gastrointestinal (GI) mucosa and are blocked by COX-1 agents, such as ibuprofen and other NSAIDs that make the class of drugs risky. Misoprostol is used to prevent stomach ulcers when patients take NSAIDs by protecting the stomach lining by decreasing the amount of acid that comes in contact with it. Additionally, there are risks because it is a prostaglandin analog and should not be taken by pregnant women. Cimetidine would not be suggested because it is an H2-blocker and carries side effects. Omeprazole can help protect the mucosa if the patient is taking an NSAID, but, ideally, not using a COX-1 inhibitor may be the best solution.

Successful treatment for an adult patient with Helicobacter pylori (H. pylori)-induced peptic ulcer disease requires therapy with which regimen? 1. Clarithromycin, amoxicillin, and omeprazole (Prilosec). 2. Bismuth (Pepto-Bismol), cephalexin (Keflex), and metronidazole (Flagyl). 3. Amoxicillin, bismuth (Pepto-Bismol), metronidazole (Flagyl), and cimetidine (Tagamet). 4. Clarithromycin, cephalexin (Keflex), and lansoprazole.

1. Clarithromycin, amoxicillin, and omeprazole (Prilosec). Rationale: Patients with gastric or duodenal ulcers due to Helicobacter pylori (H. pylori) are successfully treated with the triple-drug therapy of omeprazole, amoxicillin, and clarithromycin. Other FDA-approved regimens include proton pump inhibitor (PPI), clarithromycin, and metronidazole or bismuth, metronidazole, tetracycline, and ranitidine. Treatment should be given for 10-14 days. After completion of H. pylori eradication therapy, treatment should continue with a proton pump inhibitor for 4-8 weeks to promote healing of the ulcer. Cephalosporins are not recommended.

The family nurse practitioner knows that in patients with ulcerative colitis that involve the entire colon, careful surveillance of the colon is required because of an increased risk of: 1. Colon cancer. 2. Diverticulosis. 3. Ischemic colitis. 4. Irritable bowel syndrome.

1. Colon cancer. Rationale: Colon cancer risk in patients with universal ulcerative colitis increases by 0.5%-1% per year after the 10th year of diagnosis. Ulcerative colitis limited to the left colon carries less of a risk. Colonoscopy with random biopsies every 1-2 years is recommended 8-10 years after diagnosis. Diverticulosis is common in the general population but is less common in ulcerative colitis. Ischemic colitis occurs when a mesenteric artery is temporarily blocked and the colon at the splenic flexure develops ischemia from lack of blood flow, which is usually temporary. There is not a higher risk for patients with ulcerative colitis. Irritable bowel syndrome is common in patients with ulcerative colitis, but it is a functional disorder and does not require surveillance.

For a patient exposed to household or sexual contacts with hepatitis A, the family nurse practitioner would: 1. Give immunoglobulin 0.02 mL/kg as soon as possible but no later than 2 weeks after exposure. 2. Give one dose of HBIG and immunoglobulin 0.02 mL/kg as soon as possible. 3. Give immunoglobulin 0.02 mL/kg and two doses of HBIG. 4. Understand that no injections are needed.

1. Give immunoglobulin 0.02 mL/kg as soon as possible but no later than 2 weeks after exposure. Rationale: To minimize the risk of a contact developing hepatitis A, immunoglobulin 0.02 mL/kg should be given as soon as possible after exposure. It has not been shown to be effective if administered more than 2 weeks after exposure. Hepatitis B immune globulin (HBIG) is for hepatitis B.

Which two forms of viral hepatitis are transmitted by the fecal-oral route? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D. 5. Hepatitis E.

1. Hepatitis A. 5. Hepatitis E. Rationale: Hepatitis A and E are transmitted by the fecal-oral route. Hepatitis A spreads rapidly in households and daycare centers for children. Risk is higher in daycare centers with young children who wear diapers. Outbreaks can also occur from contaminated food and water infected with human sewage. Hepatitis C and hepatitis D are transmittedby blood transfusion, needle sharing, sexual contact, and vertical (perinatal) transmission. Hepatitis D occurs as a coinfection with hepatitis B.

All of the following are common causes of cirrhosis in the United States except: 1. Hepatitis A. 2. Nonalcoholic fatty liver disease. 3. Chronic hepatitis C. 4. Alcohol ingestion.

1. Hepatitis A. Rationale: Hepatitis A never becomes chronic and is not a cause of cirrhosis. Nonalcoholic fatty liver disease (NAFLD) is common, affects 20% of the general population, and is related to metabolic syndrome. There are excess fat deposits in the liver in persons who drink little or no alcohol, which can cause inflammation and scarring (cirrhosis). NAFLD has become a common cause of cirrhosis. Chronic hepatitis C is a major cause of cirrhosis and need for liver transplantation. It is estimated that 3 million people in the United States are infected. Alcohol is the most common cause of cirrhosis worldwide. Daily drinking and recent alcohol consumption have an increased risk of liver disease and cirrhosis

A middle-aged male patient with elevated liver enzymes and no other symptoms has a history of type 2 diabetes and hypercholesterolemia. The family nurse practitioner would first consider: 1. Nonalcoholic fatty liver disease (NAFLD). 2. Autoimmune hepatitis. 3. Celiac sprue. 4. Drug-induced liver disease.

1. Nonalcoholic fatty liver disease (NAFLD). Rationale: Nonalcoholic fatty liver disease (NAFLD) is associated with diabetes, hyperlipidemia, and obesity. The liver is storing excessive amounts of fat, which can, over time, cause inflammation of the liver. If the inflammation continues, the liver can become scarred, which can lead to cirrhosis. Autoimmune hepatitis is not common and affects women more than men. Celiac sprue is not associated with obesity or diabetes. Drug-induced liver disease is related to certain medications that can cause acute injury to the liver. Depending on the medications he is taking and the elevation of the enzymes, this diagnosis would be considered.

To test for a positive obturator sign in a patient with abdominal pain, the family nurse practitioner: 1. Passively flexes, and laterally and medially rotates the right leg from the 90-degree hip/knee flexion position. 2. Asks the patient to take a deep breath while palpating in the abdominal right upper quadrant. 3. Passively extends and elevates the right leg. 4. Palpates the right abdomen one third the distance from the anterior superior iliac spine to the umbilicus.

1. Passively flexes, and laterally and medially rotates the right leg from the 90-degree hip/knee flexion position. Rationale: If abdominal pain results from passive flexion to 90 degrees and lateral and medial rotation of the right leg causes right hypogastric pain, then inflammation of the obturator internus muscle, a positive obturator sign, suggests a ruptured appendix or pelvic abscess. A positive Murphy's sign, severe pain, and a brief inspiratory arrest result when a patient takes a deep breath while the examiner applies pressure over the right upper quadrant suggestive of cholecystitis. McBurney's point and sign, eliciting pain in the right lower quadrant, is associated with acute appendicitis. The psoas sign, extension and elevation of the right leg that causes pain, is a sign of inflammation of the psoas muscle, which is a sign of appendicitis.

When discussing diet with a patient with irritable bowel syndrome (IBS), the family nurse practitioner tells the patient to avoid: 1. Simple sugars. 2. Dairy products. 3. Red meat. 4. Vegetables.

1. Simple sugars. Rationale: People with irritable bowel syndrome (IBS) can have many food triggers. The challenge is to identify the foods without having them avoid entire food groups. Simple sugars, specifically fermentable oligodi-, and monosaccharides and polyols (FODMAPS), can cause symptoms of cramping, gas, bloating, and diarrhea. Rather than avoiding all fruits and vegetables, patients need to be aware of the most offending foods and carefully avoid those that cause a problem. Dairy products have lactose, which is not able to be broken down when someone is lacking some or all lactase, the enzyme needed for digestion of lactose. Although people have IBS and lactose intolerance, it should not be assumed the patient has both. Red meat and saturated fat can cause some problems but are not the prime offenders.

The family nurse practitioner reviews laboratory results for a patient that reveal a positive Helicobacter pylori stool antigen test. The family nurse practitioner would want to treat this if the patient complained of: 1. Upper abdominal pain. 2. Altered bowel habits. 3. Dysphagia. 4. Nausea.

1. Upper abdominal pain. Rationale: Helicobacter pylori is a bacteria that is responsible for most duodenal and gastric ulcers. The most accurate noninvasive test for active infection is the stool antigen test. Serum IgG and IgM antibody testing may not indicate a current infection. The bacteria cause ulcers and gastric inflammation, which can present as upper abdominal pain. Altered bowel habits may be indicative of irritable bowel syndrome, which has no relation to the bacteria. Nausea is a nonspecific symptom with no strong correlation to the bacteria.

Nonpharmacologic management of GERD includes which of the following? 1. Weight reduction and sleep with head of bed elevated 4-6 inches with blocks. 2. Lying down and resting after meals and weight reduction. 3. Drinking large amounts of fluids with meals and avoiding alcohol. 4. Avoiding mint, orange juice, and milk.

1. Weight reduction and sleep with head of bed elevated 4-6 inches with blocks. Rationale: An important nonpharmacologic intervention for gastroesophageal reflux disease (GERD) is to advise the patient not to lie down within 2-3 hours after meals to allow the stomach to empty. Patients with GERD also should reduce weight, avoid large meals and exercise after meals, and elevate the head of the bed. Certain drinks (alcohol, mint, and orange juice) should be avoided because they can increase acid production and can relax the lower esophageal sphincter (LES). Acidic foods (tomato products; spicy foods) may worsen symptoms of reflux and should be avoided. The patient should be taught to avoid bending after meals. Drinking large amounts of fluid with meals may affect GERD, depending on the volume of the fluids.

A patient with a history of cholelithiasis presents to the office complaining of increased right upper quadrant abdominal pain. The family nurse practitioner would arrange immediate hospital admission for possible prompt intervention if the history also showed that the patient is: 1. HIV positive. 2. 75 years old and diabetic. 3. 5 weeks pregnant. 4. Vomiting with a slight fever

2. 75 years old and diabetic. Rationale: Although most patients need eventual intervention, those who are older adults and diabetic are at increased risk and should be hospitalized for prompt diagnosis, which could include a right upper quadrant (RUQ) abdominal ultrasound, and/or a magnetic resonance cholangiopancreatography (MRCP). The MRCP is very sensitive at documenting a gallstone lodged in the bile duct. Abnormally elevated transaminases and possibly pancreatic enzymes would be present with bile duct blockage, and the patient may have secondary pancreatitis. Intravenous fluids, pain control, and surgical consultation would also be warranted.

A young adult patient presents with a complaint of intermittent diarrhea and cramping for the past 2 years. Screening blood tests reveal iron-deficiency anemia and elevated liver transaminases. The family nurse practitioner suspects: 1. Hepatitis B. 2. Celiac sprue. 3. Salmonella infection. 4. Bleeding peptic ulcer.

2. Celiac sprue. Rationale: Celiac sprue is a genetic disease of the small bowel that is caused by gluten intolerance. The diarrhea and cramping are related to the gluten effects. Because of malabsorption, many patients have iron-deficiency anemia and can have elevated liver enzymes. Hepatitis B would produce elevated liver enzymes but not the other symptoms. Salmonella infection could produce diarrhea and cramping. A bleeding ulcer could produce anemia but not the other symptoms.

An older adult patient presents with fever, leukocytosis, and a sudden onset of lower left quadrant pain for the past 12 hours. She has not had a bowel movement since the pain began. The family nurse practitioner's top differential diagnosis would be: 1. Appendicitis. 2. Diverticulitis. 3. Irritable bowel syndrome. 4. Ruptured ovarian cyst.

2. Diverticulitis. Rationale: Diverticulitis usually presents with a sudden onset of abdominal pain in the left lower quadrant. The patient may have a lowgrade fever and leukocytosis. Patients with diverticulitis have a range of mild to severe disease. Severe pain may be accompanied by nausea and vomiting. Appendicitis may present with pain in the periumbilicus that eventually travels to the right lower quadrant and may not be severe for several hours after onset. Other signs, including nausea and vomiting, leukocytosis, and fever, may or may not be present. Irritable bowel syndrome (IBS) may present with aching or cramping periumbilical or lower abdominal pain, often precipitated by meals and relieved by defecation. The pain can be severe occasionally, and there is an altered frequency and consistency of the stools. Fever, leukocytosis, and awakening at night are not indicative of IBS. A ruptured ovarian cyst would not be a differential in an older adult woman because the ovaries shrink and stop functioning with menopause.

Prolapse of the anal cushion, made up of vascular, connective and muscular tissue, through the anal canal below the dentate line describes: 1. Rectal prolapse. 2. External hemorrhoid. 3. Rectocele. 4. Internal hemorrhoid.

2. External hemorrhoid. Rationale: A hemorrhoid is a vascular anal cushion and can be internal (above the dentate line) or external (below the dentate line), which can enlarge and bleed. Everyone has internal hemorrhoids even without any symptoms. In a rectal mucosa prolapse, the wall of the rectum prolapses through the anal canal on straining. A rectocele is a herniation into the vaginal wall and can cause constipation

An organism associated with etiology of peptic ulcer disease (PUD) is: 1. Streptococcus pneumoniae. 2. Helicobacter pylori. 3. Moraxella catarrhalis. 4. Staphylococcus aureus.

2. Helicobacter pylori. Rationale: Helicobacter pylori has been shown to be responsible for most duodenal and gastric ulcers. The other common cause of ulcers is from use of nonsteroidal anti-inflammatory drugs (NSAIDs) at regular and/or high doses. The other organisms listed are implicated in other types of infections (e.g., acute otitis media; skin infections). Streptococcus pneumoniae and Moraxella catarrhalis have been implicated as causative agents in pneumonia.

An acute illness with jaundice, anorexia, malaise, arthralgias, an incubation period of 2-6 months, a chronic and acute form, and that is transmitted by parenteral, sexual, and perinatal routes describes: 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis E.

2. Hepatitis B Rationale: These characteristics describe hepatitis B, which affects less than 1% of the U.S. population and is a much less common cause of cirrhosis. Hepatitis A has common causes of fever and up to 50% jaundice. Transmission is by the fecal-oral route or sexual contact and has an incubation period of 15-50 days (average 30 days) and no chronic form. Hepatitis C infection causes jaundice up to 25% of the time and can cause arthralgias, but there is no fever. It is transmitted parenterally, sexually, and perinatally and has an incubation period of 14-18 days (average 42-49 days). Up to 75% of those infected with hepatitis C will develop chronic infection. Hepatitis E is characterized by oral-fecal transmission that is associated with contaminated food and water and has an incubation period of 14-60 days and no chronic disease state

A patient comes to the emergency department concerned about pain and swelling in his groin. He tells the family nurse practitioner that his doctor said he has an incarcerated hernia. Which assessment finding correlates with an incarcerated hernia? 1. Hernia that easily moves back and forth across the abdominal wall. 2. Hernia that protrudes from the groin area and cannot be reduced into the abdomen. 3. Hernia that is very painful to palpation with significant abdominal swelling. 4. Hernia that decreases in size when the patient increases intraabdominal pressure.

2. Hernia that protrudes from the groin area and cannot be reduced into the abdomen. The most common hernia is an inguinal hernia, protruding at the inguinal canal. Incarcerated means the hernia cannot be reduced or returned to the abdominal cavity. A reducible hernia easily moves across the abdominal wall. There should be no abdominal swelling, and if the hernia is particularly painful and associated with nausea and vomiting, strangulation/incarceration should be considered as a surgical emergency.

After percutaneous or permucosal exposure to a hepatitis B source, what is the appropriate treatment for the patient? 1. In an unvaccinated patient, begin the hepatitis B series. 2. In a person with a positive hepatitis B surface antibody, no treatment is necessary. 3. In a vaccinated person with a negative antihepatitis B surface antigen, give hepatitis B immune globulin (HBIG), and initiate a new hepatitis B vaccine series. 4. In a patient with a positive antihepatitis B surface antibody who completed the entire hepatitis B vaccine series, give a hepatitis B booster.

2. In a person with a positive hepatitis B surface antibody, no treatment is necessary. Rationale: If a person exposed to a patient known to be positive for hepatitis B has sufficient immunity to hepatitis B, no treatment is necessary. If this same person had not been vaccinated, in addition to initiation of the hepatitis B vaccine series, HBIG 0.06 mL/kg IM is also administered. If an exposed person has had an inadequate immune response to the hepatitis B vaccine series (negative anti-hepatitis surface antibody), a hepatitis B booster should be given.

A primary therapy for patients with mild ulcerative colitis is: 1. Metronidazole (Flagyl). 2. Mesalamine (Pentasa). 3. Ciprofloxacin (Cipro). 4. Prednisone (Deltasone).

2. Mesalamine (Pentasa). Rationale: Mesalamine (5-aminosalicylic acid) therapy for patients with mild ulcerative colitis has been shown to improve symptoms and induce and maintain remission. There are several mesalamine products available, including rectal suspension and suppositories that can be very helpful for left-sided colitis. If no response is seen after 2-4 weeks, the addition of corticosteroids (prednisone) can be helpful, but they are not first-line therapy. Ciprofloxacin and metronidazole are typically used for gastrointestinal infections.

A young adult female presents to the family nurse practitioner for evaluation of 2 days of increasing crampy abdominal pain. She states that she also has some mild nausea, anorexia, and a low-grade fever. The patient states that the pain is periumbilical. Her STAT complete CBC reveals a slightly elevated WBC but is otherwise normal. What is the family nurse practitioner's next step in the care of this patient? 1. Refer to a gynecologist for evaluation of possible ectopic pregnancy. 2. Order a CT of the abdomen and refer to surgeon for evaluation of possible appendicitis. 3. Observe overnight and reassess the next day. 4. Place on a clear liquid diet and have patient watch for increasing symptoms.

2. Order a CT of the abdomen and refer to surgeon for evaluation of possible appendicitis Rationale: Increasing crampy abdominal pain that starts as periumbilical pain, anorexia, and fever are classic symptoms of appendicitis. A surgeon should evaluate the patient to decrease the risk of rupture. An abdominal CT scan has a high sensitivity to document appendicitis. Although ectopic pregnancy should always be a consideration in young females with abdominal pain, the characteristics of the pain and other symptoms are not typical of an ectopic pregnancy. However, a good gynecologic history would be needed. The patient should not be sent home unless the CT scan is negative, and then followup within 24 hours would be warranted.

A young female adult reports she had the flu and recovered 2 weeks ago. She reports resolution of her symptoms, except she continues to have nausea, decreased appetite, and early satiety. The family nurse practitioner suspects: 1. A relapse of the influenza infection. 2. Post-viral gastroparesis. 3. Vertigo, causing nausea related to a possible ear infection. 4. Peptic ulcer from taking ibuprofen.

2. Post-viral gastroparesis. Rationale: A common sequela of a viral infection is gastroparesis. The virus can affect the gastric pacer, causing it to malfunction and result in slow gastric emptying. Typical symptoms of nausea, decreased appetite, and early satiety occur because of the lingering of solid food in the stomach, which can be more than 4 hours. Accumulation throughout the day can result in a full stomach that does not empty. These are not typical symptoms of an influenza infection. Vertigo causes nausea, but not the other symptoms. Although the patient may have taken ibuprofen for several days, it is less likely that an ulcer would have developed with a short course, but it should be in the differential.

A 78-year-old patient is diagnosed with Clostridium difficile infection, and the physician prescribes vancomycin (Vancocin) 125 mg PO qid. In following the patient's progress, the family nurse practitioner would monitor which of the following in regard to medication tolerance? 1. CBC, platelet count, clotting studies. 2. Serum creatinine, BUN, hearing changes. 3. Serum electrolytes, urinalysis, ataxia. 4. Changes in bowel habits, diarrhea, ECG changes.

2. Serum creatinine, BUN, hearing changes. Rationale: Vancomycin causes problems with nephrotoxicity and ototoxicity (eighth cranial nerve). Renal function should be monitored regularly with laboratory tests (serum creatinine and BUN) and the patient evaluated frequently for hearing loss. The geriatric patient is particularly susceptible.

Which finding most likely indicates a need for an endoscopy in patients with heartburn? 1. All new cases of heartburn. 2. Symptoms persisting after 8-12 weeks of empiric therapy. 3. Negative Helicobacter pylori (H. pylori) test. 4. Good response to empiric treatment after 7-10 days.

2. Symptoms persisting after 8-12 weeks of empiric therapy. Rationale: An endoscopy is needed for patients with no/minimal response to therapy, indicated by persistent symptoms after 8-12 weeks of therapy. Heartburn may be characterized by burning substernal chest pain and may have gastroesophageal reflux. The factors that would raise a red flag would be long-term history of reflux, dysphagia, or weight loss.

The family nurse practitioner knows that the following principle is most important in understanding the pathophysiology of gastroesophageal reflux disease (GERD): 1. A hiatal hernia is always a coexisting and major contributing factor. 2. The lower esophageal sphincter (LES) has become a poor antireflux barrier. 3. The amount of acid reflux depends on a familial tendency for GERD. 4. Overeating and use of caffeine and alcohol cause GERD.

2. The lower esophageal sphincter (LES) has become a poor antireflux barrier. Rationale: The factor contributing most to reflux is an incompetent lower esophageal sphincter (LES), the antireflux barrier. A hiatal hernia is frequently present with reflux but is not a significant factor in the pathophysiology, unless it is large, but may be associated with greater reflux and delayed esophageal acid clearance in patients with reflux. Gastroesophageal reflux disease (GERD) can be familial but is not always a factor. Overeating, alcohol, and caffeine all affect the LES pressure and increase stomach acid production, affecting symptoms, but are not the main cause.

Which is true about enterobiasis (pinworm infection)? 1. The parasite is in the soil and enters the body through the feet. It can cause anemia. 2. The parasite causes pruritus around the anus because the gravid females exit through the anus at night and lay eggs on the skin. The human is the only host of this parasite. 3. The eggs of this parasite enter the body by ingestion of dirt (pica) or dirt on unwashed vegetables that contain the eggs, or through water containing the eggs. 4. This parasite is a protozoan. The source is usually contaminated water, but it is spread from person to person by fecal-oral contamination.

2. The parasite causes pruritus around the anus because the gravid females exit through the anus at night and lay eggs on the skin. The human is the only host of this parasite.

An adult patient has early alcoholic cirrhosis diagnosed by a liver biopsy. While teaching the patient to manage her symptoms, the family nurse practitioner instructs that it is most important that the patient: 1. Take a daily vitamin E supplement. 2. Decrease her alcohol intake to less than 2 drinks a day. 3. Abstain from alcohol. 4. Maintain a nutritious diet.

3. Abstain from alcohol. Rationale: Abstinence from alcohol, the most important treatment for cirrhosis, can halt progression of cirrhosis and reverse the damage, if the liver is minimally scarred. Continuing to drink even occasionally can be detrimental and rapidly increase the disease process. It is known that 1-2 drinks a day for a woman raises her risk of cirrhosis up to 4 times the risk of the general population. Recent research shows that current drinking may be more of a factor than a lifetime amount. The patient's diet should be nutritious, and she should avoid herbal and other supplements because some have been known to cause liver toxicity. Vitamin E supplementation is controversial and may be recommended by the patient's hepatologist. It is not a routine part of care.

The family nurse practitioner knows that colon cancer screening with colonoscopy is definitely warranted in a patient with: 1. Anemia. 2. Diarrhea. 3. Bright-red rectal bleeding. 4. Change in bowel habits.

3. Bright-red rectal bleeding. Rationale: The risk of colorectal cancer increases in patients over age 50 years. The most frequent ages that colon cancer is found are in the 6th and 7th decades of life. Almost all colon cancers begin as polyps, which can be slow growing, taking 8-15 years to begin to grow and eventually turn into cancer. Therefore, colon screening is recommended beginning at age 50 to find and remove polyps before cancer can develop. Frequently, there are no symptoms, even with left-sided colon cancers, and because of the bright red rectal bleeding always should be explored. Although hemorrhoidal bleeding would be most common, without a colonoscopy one cannot be sure. Anyone over the age of 45 years, if African American, or 50 years, for all other races, needs regular screening. Colonoscopy is the most accurate and the only test where polyps can be removed at the time of testing. Symptoms such as weight loss, pain, and change in bowel habits are usually a late sign and do not frequently occur. Anemia can be present, but it may not necessarily indicate a need for a colonoscopy, although blood loss would be in the differential. Diarrhea is not typically a sign of cancer.

Which is true of early cancer of the esophagus in the older adult patient? 1. Alcoholism and smoking increase the risk for adenocarcinoma of the esophagus. 2. It is associated with high caffeine use. 3. Dysphagia for solids and cough may be the first symptoms. 4. Boring-type midchest pain indicates mediastinal involvement and requires immediate surgery.

3. Dysphagia for solids and cough may be the first symptoms. Rationale: Dysphagia and cough with solid and liquid intake may be the first indication that the patient has cancer, but this is usually late in development. Alcoholism and smoking are the primary risk factors for squamous cell esophageal cancer, which is not as common as adenocarcinoma. Midchest pain indicates late disease, which does not usually respond to treatment, including surgery.

An older adult male presents to the family nurse practitioner for evaluation of years of "heartburn" and recent significant weight loss (30 lb in 1 month). He has been taking antacids and an oral histamine (H2 ) blocker for "years off and on" and has not had relief of his symptoms. He has a 60-pack-year history of cigarette smoking and drinks alcohol daily. What differential diagnosis must the family nurse practitioner consider first? 1. Gastric ulcer. 2. Gastroesophageal reflux disease (GERD). 3. Esophageal cancer. 4. Lung cancer.

3. Esophageal cancer. Rationale: Long-term GERD ("heartburn for years") without effective treatment carries a risk of Barrett's esophagus, a precursor to esophageal adenocarcinoma, especially in a nonHispanic white male smokers over the age of 50 years. Rapid weight loss is a concerning clinical finding that may indicate esophageal cancer or other cancer. Squamous cell carcinoma of the esophagus is associated with cigarette smoking and alcohol use and is less common than adenocarcinoma (ratio 1:2). Adenocarcinoma of the esophagus most commonly develops in men (men/women ratio 6:1) age 65 years and older. The symptoms of heartburn caused by either gastric ulcer or long-term GERD will not likely be controlled with an H2 blocker/antacid and would require a proton pump inhibitor daily. A patient with a gastric ulcer would be tested for Helicobacter pylori and would be questioned about a history of nonsteroidal anti-inflammatory drug (NSAID) use and then treated appropriately. Clinical manifestations of lung cancer include cough, hemoptysis, dyspnea, chest pain, and weight loss, and the substantial pack-year history does place the patient at risk.

Patient education for a patient with nonalcoholic fatty liver disease (NAFLD) should include: 1. Lowering cholesterol intake. 2. To not take a statin medication. 3. Exercise and weight loss. 4. To take vitamin A.

3. Exercise and weight loss. Rationale: One of the ways patients can decrease the fat in the liver is to lose weight with exercise. It is important to treat hyperlipidemia because this is associated with fatty liver, and statins should not be discontinued. Lowering cholesterol is not as effective as lowering saturated fats in the diet. Excessive doses over 10,000 mg of vitamin A daily can cause liver damage.

An adult male presents with midsternal chest pain with radiation to the neck and left arm. He denies other symptoms. He was seen in the emergency room and had a negative cardiac workup. What might be the diagnosis? 1. Pneumonia. 2. Costochondritis. 3. Gastroesophageal reflux. 4. Esophageal spasm.

3. Gastroesophageal reflux. Rationale: A negative workup for cardiac disease leads to other considerations for chest pain. Gastroesophageal reflux can cause chest pain, and patients do not always have classic symptoms of reflux. This would be the most likely diagnosis to consider. Pneumonia is very unlikely without any respiratory symptoms. Costochondritis is a common musculoskeletal symptom that is noted on palpation of the rib cage. Esophageal spasm can cause pain but is usually accompanied by dysphagia.

A patient with PUD is treated with a regimen that includes bismuth subsalicylate (Pepto-Bismol), tetracycline, and metronidazole (Flagyl). The patient calls the family nurse practitioner to report that his stools are unusually dark. He is not experiencing any gastric discomfort, orthostatic hypotension, or increased lethargy. How would the family nurse practitioner interpret the information? 1. He is probably bleeding and should come in immediately. 2. He ate something to affect the color of his stool. 3. His stools are dark, secondary to Pepto-Bismol. 4. The stool discoloration is caused by metronidazole.

3. His stools are dark, secondary to Pepto-Bismol. Rationale: This is a common observation for a patient taking Pepto-Bismol. The patient may also experience a problem with discoloration of his tongue. The stool discoloration is not related to bleeding or metronidazole. Certain foods can affect the stool color, but bismuth is more likely the cause.

An overweight, middle-aged woman has right upper quadrant pain that radiates to her right subscapular area and is severe and persistent. She is also experiencing anorexia, nausea, and a fever. Her most recent meal was a double quarter-pound hamburger with cheese, french fries, and a vanilla shake. Based on this information, the family nurse practitioner examines the abdomen and percusses for costovertebral angle tenderness. The abdomen is tender in the right upper quadrant. Which of the following signs, if positive, corresponds to the correct diagnosis? 1. Obturator sign; patient has appendicitis. 2. Costovertebral angle tenderness; patient has a urinary tract infection. 3. Murphy's sign; patient has cholecystitis. 4. McBurney's sign; patient has acute appendicitis.

3. Murphy's sign; patient has cholecystitis Rationale: The history, right upper quadrant pain that radiates to the right subscapular area, especially after a fatty meal, and positive Murphy's sign are all associated with cholecystitis. A positive Murphy's sign is noted with severe pain with inspiratory arrest on palpation of the right upper quadrant.

Which of the following would be prescribed as initial treatment for uncomplicated peptic ulcer disease (PUD) with negative Helicobacter pylori? 1. Clarithromycin 500 mg bid. 2. Famotidine (Pepcid) 25 mg daily. 3. Omeprazole (Prilosec) 20 mg qd. 4. Bismuth (Pepto-Bismol) 2 tablets twice a day.

3. Omeprazole (Prilosec) 20 mg qd. Rationale: Goals of peptic ulcer disease (PUD) treatment include relief of pain, healing of ulcer, and cost-effectiveness. Proton pump inhibitors (PPIs) heal 90% of duodenal ulcers after 4 weeks and 90% of gastric ulcers after 8 weeks, if Helicobacter pylori (H. pylori) is negative. PPIs, such as omeprazole, are recommended for ulcers because these drugs provide faster pain relief and more rapid healing than H2 antagonists, because of their ability to decrease acid production. Clarithromycin and bismuth (Pepto-Bismol) are some of the accepted treatment therapies against active H. pylori-associated ulcers, but not as single agents. Eradication of H. pylori requires a combination regimen.

The diagnosis of early acute pancreatitis would be considered by the family nurse practitioner based on history of severe acute upper abdominal pain and which of the following laboratory results? 1. White blood cell (WBC) count of 10,300/mm3. 2. Serum albumin of 6.2 g/dL. 3. Serum amylase of 350 U/L. 4. Serum lipase of 75 U/L.

3. Serum amylase of 350 U/L. Rationale: In acute pancreatitis, the serum amylase increases within 3-6 hours of onset. A level 3 times normal is more diagnostic. The serum lipase elevates after the increase in amylase. In adults, the normal level for serum amylase is 30-110 IU/L and for serum lipase 13-141 IU/L. An elevated serum albumin occurs with dehydration and high-protein diets.

What condition is a contraindication for the administration of the hepatitis B vaccine? 1. Pregnancy. 2. Lactation. 3. Severe hypersensitivity. 4. Age >60 years.

3. Severe hypersensitivity. Rationale: The only contraindication to the hepatitis B vaccine is prior anaphylaxis or severe hypersensitivity to the vaccine or components of the vaccine.

In patients suspected of having celiac sprue with elevated antibodies, but negative biopsy, the family nurse practitioner knows: 1. The patient may have a negative biopsy because she has been gluten free for 3 weeks. 2. The positive antibodies are likely a laboratory error. 3. The patient may have a gluten sensitivity. 4. The biopsy may be a false negative result.

3. The patient may have a gluten sensitivity. Rationale: Abnormal villi found on the small bowel biopsy are the gold standard for diagnosis. A negative biopsy is sufficient for diagnosis. The antibody panel is a blood test and the tissue transglutaminase (TTG) antibody is the most sensitive test for celiac sprue. The patient likely has gluten sensitivity, meaning the genetic abnormality of celiac sprue is not present, but removing gluten may improve the patient's symptoms. A gluten-free diet will reverse the abnormal findings on biopsy and convert the antibodies to negative, but both tests would be affected and it could 2-3 months or longer to have normal results.

Which patient presentation would most likely suggest dysphagia caused by esophageal spasm? 1. They usually have more difficulty swallowing solids than liquids. 2. There is a long history of gastroesophageal reflux. 3. They have difficulty swallowing both solids and liquids. 4. They have marked weight loss.

3. They have difficulty swallowing both solids and liquids. Rationale: Patients with dysphagia due to an esophageal spasm may report difficulty with both liquids and solids, as the spasm has closed the esophagus temporarily. Relaxation of the esophagus usually occurs within a minute, and the food will pass down. This can cause choking with liquids as well. Spasm can occur for many reasons, one of which can be acid reflux. It is episodic, nonprogressive, and unpredictable. Difficulty swallowing solids and feeling that food is sticking is most likely because of an esophageal stricture or obstruction. Marked weight loss is not usually a symptom of dysphagia, unless is it related to esophageal cancer.

Irritable bowel syndrome (IBS) affects: 1. Men more than women. 2. Children more than young adults. 3. Women more than men. 4. Older adults more than young adults

3. Women more than men. Rationale: The female/male ratio for irritable bowel syndrome (IBS) is thought to be 3:1. It is a functional disorder, not a disease that can affect any age, children to older adults, but IBS frequently has an onset in young adults.

A young woman presents with a history of recent unprotected sexual activity (in the past 2 weeks) with a partner now diagnosed with hepatitis B. She is currently asymptomatic and does not recall having a vaccine in the past. What is the best action for the family nurse practitioner? 1. Obtain a hepatitis B e antibody test (anti-HBe). 2. Administer one dose of HBIG. 3. Obtain a viral load for hepatitis B. 4. Administer one dose of HBIG and initiate vaccination.

4. Administer one dose of HBIG and initiate vaccination. Rationale: For unvaccinated patients with exposure to hepatitis B, one dose of hepatitis B immune globulin (HBIG) is administered and the HBV series initiated. HBIG may be protective or may attenuate the severity of the illness if given within 7 days of exposure (adult dose of 0.06 mL/kg). If the patient thinks the individual may have been vaccinated, but does not know whether there was a response, the family nurse practitioner can test antihepatitis B surface antibody. Neither the HBe antibody nor the viral load would be a first-line test. Because of the timing of appearance of the antibodies to hepatitis B, testing would need to be delayed.

An older adult woman is noted to have iron-deficiency anemia. She has no pain. What history would raise the suspicion of a gastric ulcer? 1. Symptoms of acid reflux for the past 2 years, occurring at least 3 times a week. 2. Postmenopausal with no recent history of vaginal bleeding. 3. Weight loss of 10 lbs in the past 2 months. 4. An ankle sprain requiring 800 mg of ibuprofen three times a day for the past 6 weeks.

4. An ankle sprain requiring 800 mg of ibuprofen three times a day for the past 6 weeks. Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, cause a high risk of gastrointestinal erosion and ulcers. There may be no symptoms until anemia is noted. Gastroesophageal reflux does not contribute to anemia, unless there is gastritis with erosions or other signs of bleeding. Postmenopausal history is significant because it rules out a cause of anemia but not a concern for ulcer development. Weight loss of 5 lb a month is a nonspecific symptom that needs further exploration.

An adult patient presents to the family nurse practitioner complaining of weakness and vomiting. He gives a history of "several" drinks per day for the past 22 years and cirrhosis, diagnosed 6 months ago. The family nurse practitioner questions the patient about excessive bleeding. The patient reports 2 episodes of hematemesis. What emergent condition is the family nurse practitioner most concerned about? 1. Bleeding peptic ulcer (PUD). 2. Excessive nosebleed. 3. Hemoptysis. 4. Esophageal varices.

4. Esophageal varices. Rationale: Esophageal varices are dilated submucosal veins that are a late sign and complication of cirrhosis because of scarring of the liver and portal hypertension. The cirrhosis would likely be advanced for varices to develop, usually in the esophagus, but can also occur in the stomach. As these varices are under high pressure, the patient can have anything from a slow leak of blood to a major, life-threatening bleed. The patient is diagnosed by endoscopy and treated with beta blockers to lower the blood pressure. Of patients with cirrhosis, approximately 50% will develop gastroesophageal varices and will have a yearly rate of bleeding from 5- 15%. A history of heavy alcohol intake may be the cause of this patient's cirrhosis. These patients can present clinically with bleeding, spontaneous "coffee ground" or bright-red blood, hypotension, and eventual shock. The other choices could all be associated with this patient. A bleeding peptic ulcer is possible but is not the first concern. An excessive nosebleed is possible because of thrombocytopenia from cirrhosis and would need to be explored. Hemoptysis implies lung disease.

When obtaining a history from a young female adult patient with abdominal pain, which of the following should initially be assessed? 1. Food effects on the pain. 2. Location and onset of the pain. 3. Change of pain with bowel movements. 4. First day of last menstrual period.

4. First day of last menstrual period. Rationale: Although all the information is important in determining the cause of abdominal pain, for a young female patient of childbearing age, ascertaining whether the patient is pregnant is a priority. A possibility of pregnancy would alter the testing that might need to be ordered, so a pregnancy test should be ordered. Additionally, abdominal pain may be from pelvic inflammatory disease or related gynecologic disorders. The family nurse practitioner should obtain a gynecologic, pregnancy, and recent sexual history, including dates of last two normal menstrual periods, condom use and other birth control use, and timing of last sexual intercourse. Food effects are important to ascertain because it may lead to a diagnosis of dietary intolerances. Location and associated symptoms are valuable to narrow down the differential diagnoses of the pain. Abrupt onset of pain has differential diagnoses that are different from pain that is recurrent or has occurred for weeks or longer (chronic). Acute pain can be visceral (internal), somatic (superficial), or referred, which arises from the viscera and terminates in the spinal cord where there are fibers in the skin. These sensations produce the perception of pain at the referred site. Change in bowel habits may indicate an intestinal origin if there is relief, even if only temporary. Pain not affected by a bowel movement or passing gas is not likely intestinal/colonic pain and may be related to other sources, such as kidney/bladder or the musculoskeletal system.

Which problem would most likely worsen the symptoms of gastroesophageal reflux disease (GERD)? 1. Small sliding hiatal hernia. 2. An empty stomach when lying down. 3. Gaining 30 pounds over a period of months. 4. Gastroparesis.

4. Gastroparesis Rationale: Gastroparesis can be a significant complication for patients with reflux. The lingering contents in the stomach will contain acid and the frequency of reflux will be increased. Persons with a small sliding hiatal hernia are not likely to have a significant change in their symptoms. Reflux is less likely to occur after lying down with an empty stomach.

The family nurse practitioner is preparing to examine the abdomen of a patient. What is the correct sequence in which to conduct the exam? 1. Inspection, palpation, percussion, auscultation. 2. Palpation, percussion, auscultation, inspection. 3. Percussion, palpation, auscultation, inspection. 4. Inspection, auscultation, percussion, palpation

4. Inspection, auscultation, percussion, palpation Rationale: Inspection and auscultation should be conducted first to prevent eliciting pain and undue guarding. The family nurse practitioner should auscultate and listen to the abdomen before percussing and palpating it, because palpation may alter the frequency of bowel sounds. If the exam is painful initially, the patient will be uncomfortable, which will not allow the examiner to continue.

A history of a patient with a chief complaint of diarrhea alternating with constipation, intermittent cramping, and bloating and relieved by a bowel movement is most likely: 1. Drug-induced diarrhea. 2. Inflammatory bowel disease. 3. Gastroenteritis. 4. Irritable bowel syndrome (IBS).

4. Irritable bowel syndrome (IBS). Rationale: Irritable bowel syndrome (IBS) presents with abdominal pain and altered bowel habits that can be erratic and unpredictable. These symptoms can be aggravated by stress and food triggers. Diarrhea does not occur during sleep, but abdominal pain can occur at any time. Druginduced diarrhea occurs in association with certain medications, usually taken within the previous few months. Prime offending medications include antibiotics (may cause Clostridium difficile colitis) and metformin, for example. Bacterial or viral gastroenteritis presents with a sudden onset of diarrhea and does not alternate with constipation. Inflammatory bowel disease presents with more consistent symptoms of diarrhea and pain and possibly rectal bleeding. In fact, the symptoms can be present for months to years before diagnosis. Extraintestinal manifestations, such as arthritis and skin lesions, may be present, and nocturnal diarrhea and fecal incontinence can be present if rectal inflammation is present.

The family nurse practitioner is examining a 30-year-old obese man with a body mass index (BMI) of 35 who complains of almost daily indigestion and heartburn for the past year with a strong acid taste in the mouth about an hour after meals, and frequent belching and awakening at night with choking. The history is negative for chronic illnesses and alarm symptoms. A diagnosis of gastroesophageal reflux disease (GERD) is made. What is the best initial treatment for the patient? 1. Omeprazole (Prilosec) 20 mg after breakfast daily. 2. Hyoscyamine (Levsin) 0.125 mg tid 15 minutes before eating. 3. Ranitidine (Zantac) 150 mg bid. 4. Omeprazole (Prilosec) 20 mg every morning 30 minutes before breakfast.

4. Omeprazole (Prilosec) 20 mg every morning 30 minutes before breakfast. Rationale: Omeprazole is a proton pump inhibitor (PPI) that blocks acid production for up to 24 hours. It is recommended for patients with frequent symptoms, at least several times a week. It is important to take the PPI on an empty stomach, and then eat 20-30 minutes after for maximum efficacy. PPIs need food to work, and, if a second dose is required, it should be taken before the evening dose. Anticholinergics (hyoscyamine) will likely increase his symptoms by lowering the lower esophageal sphincter (LES) pressure. Anticholinergics are effective for the cramping of IBS. Ranitidine is a histamine blocker (H2-Bl). This blocks one pathway for acid secretion, but there are two other pathways that continue to secrete. H2-Bl is effective for occasional symptoms, a few times a week or less, or as a short trial for new onset of symptoms.

The family nurse practitioner understands that hepatitis B can be transmitted through blood and blood products. Another mode of transmission of hepatitis B is: 1. Respiratory contact. 2. Arthropod vectors. 3. Fecal-oral route. 4. Perinatal exposure.

4. Perinatal exposure. Rationale: A means of hepatitis B (HBV) transmission is from mother to baby, perinatally. Before the hepatitis B vaccine, it was estimated that 30- 40% of chronic HBV infections were transmitted perinatally. Since the widespread use of the vaccine and guidelines of vaccinating newborns, this rate has dropped dramatically. The main routes of transmission are percutaneous or mucosal contact with infectious blood or body fluids, such as semen and saliva. The exposure can occur with sexual contact, intravenous drug use with shared needles and other equipment, contact with blood or open sores, needle sticks, and sharing razors or toothbrushes with an infected person. HBV is not spread by food, water, sharing eating utensils, breastfeeding, hugging, kissing, coughing, or sneezing.

Once a positive anti-HCV test is found, the next step for the family nurse practitioner to do is: 1. Call the patient and explain that hepatitis C is active and treatment is needed. 2. Repeat the anti-HCV test to assure it is positive. 3. Test the hepatitis B panel. 4. Test for an HCV RNA viral load.

4. Test for an HCV RNA viral load. Rationale: Hepatitis C exposure will produce a positive anti-HCV. However, it is not necessarily indicative of active infection. Twenty percent of patients exposed to hepatitis C will clear the virus without treatment but will continue to have a positive antibody. The best approach is to confirm that hepatitis C is present is with the viral load test. Repeating the antibody is not useful. Without confirmation, it is not appropriate to inform the patient of an active infection, but it should be explained that it is possible there is infection.

Which is true of peptic ulcer disease (PUD) in older adult patients? 1. Smoking does not increase the risk of PUD. 2. Duodenal ulcers are more common in older adults. 3. Perforation is a common complication. 4. Weight loss and anorexia are often the only symptoms

4. Weight loss and anorexia are often the only symptoms Rationale: Patients with a gastric ulcer may not have any symptoms, especially in the older adult. Weight loss and anorexia may be present. The patient may not realize an ulcer is present until it bleeds and causes significant anemia. Smoking does increase the risk, and perforation can occur. Gastric ulcers are more common in older adult patients.

The metabolism of which drug is not affected in Marsha, age 74? A. Alcohol B. Anticonvulsants C C. Psychotropics D. Oral anticoagulants

A. Alcohol Although drug metabolism by the liver is usually impaired in older adults, the metabolism of alcohol is unchanged.

Treatment for achalasia may include: A. balloon dilation of the lower esophageal sphincter. b. beta blockers. c. fundoplication. d. an esophagogastrectomy.

A. balloon dilation of the lower esophageal sphincter. Achalasia is an absence of peristalsis of the esophagus and a high gastroesophageal sphincter pressure. After initial noninvasive treatments, clients may require a balloon dilation of the lower esophageal sphincter. Calcium channel blockers, not beta blockers, may be used to decrease symptoms of dysphagia. A fundoplication is done for a hiatal hernia. An esophagogastrectomy is performed for esophageal cancer.

Sidney, age 33, has ulcerative colitis and asks you about a Koch pouch. How do you respond? A. "It's a method of bowel training for clients with chronic diarrhea." B. "It's a name for a continent ileostomy." C. "It's a packet of daily pills to take to relieve diarrhea." D. "It's like a sanitary pad, and it's used to contain any rectal leakage."

B. "It's a name for a continent ileostomy." Performed for clients with ulcerative colitis, a Koch pouch (continent ileostomy) is the surgical removal of the rectum and colon and construction of an internal ileal reservoir, nipple valve, and stoma, allowing for intermittent drainage of ileal contents.

While you are obtaining Henry's history, he tells you that he had a portacaval shunt done in the past. What does this imply? A. A history of liver cancer B. A history of alcohol abuse C. A congenital biliary problem D. Heavy tobacco use

B. A history of alcohol abuse A portacaval shunt is the surgery often performed for bleeding esophageal varices. They are associated with alcoholic cirrhosis and portal hypertension, commonly the result of a history of alcohol abuse (other causes include viral hepatitis, excess iron in the liver, and blood clots). Bleeding esophageal varices occur when the small esophageal veins become distended and rupture from increased pressure in the portal system.A portacaval shunt is not done for the other conditions listed.

An 85-year-old adult has chronic constipation. She has a history of hypertension, osteoporosis, osteoarthritis, and overactive bladder. What is the most likely cause of her constipation? Her medication list includes: amlodipine 5mg, oxybutynin 2.5mg, naproxen 375mg, Prevacid 30mg, and calcium and Vitamin D supplements. A. Inadequate fluid intake. B. Age-related changed. C. Mediation-related. D. Inadequate fiber intake.

C. Mediation-related. Amlodipine (CCB) can slow down GI motility. Oxybutynin has anticholinergic properties; which dry up mucus in the gut. Naproxen (NSAID) inhibits prostaglandins in the gut which leads to constipation. PPI's and calcium supplements are associated with constipation.

Sara, age 59, is taking polyethylene glycol (GoLYTELY) in preparation for a barium enema. What do you teach her about the medication? A. Drink the solution at room temperature. B. Take the medication with food so that it will be absorbed better. C. Take the medication in the early evening so as not to interfere with sleep. D. Drink all of the solution in one sitting.

C. Take the medication in the early evening so as not to interfere with sleep. Polyethylene glycol (GoLYTELY) should be taken in the early evening so as not to interfere with sleep because the first bowel movement begins within1 hour and continues until the sigmoid colon is clear. The solution should be chilled to enhance palatability, taken on an empty stomach, and administered in 8-oz servings every 10 minutes until 1 gallon is consumed.

The family nurse practitioner is performing the initial physical exam on a 51-year-old man. The history reveals that the patient's father died of colon cancer, but the patient is asymptomatic and has not had any screening for colon cancer. What is the best test to use to screen the patient? 1. Barium enema and flexible sigmoidoscopy. 2. CT colonography 3. Colonoscopy. 4. Fecal occult blood and stool DNA testing.

Rationale: A colonoscopy is the most accurate and best test to use to screen for colon cancer. The improved equipment and medication for sedation and colon preparation have made this test safe and effective. Finding and removing colon polyps increase the prevention of colon cancer. A barium enema has poor sensitivity and specificity for locating polyps and cancer. The test requires a bowel preparation and is uncomfortable for the patient. A flexible sigmoidoscopy is a test with a limited exam of the lower portion of the colon. The "virtual colonoscopy" is performed by a CT scan. It requires a bowel preparation and can be uncomfortable. It does not examine the rectum and can miss smaller polyps. Fecal occult blood testing has low sensitivity and specificity and has limited use for screening. Stool DNA is new technology and will likely have an increasing role, but it detects early cancer, not polyps.

A 50-year-old with a consumption of 3-4 alcoholic drinks daily and weekend binges have elevated liver enzymes. Which set of enzymes is most representative of this patient? a. AST=200, ALT = 75 b. AST=100, ALT = 90 c. AST=100, ALT =200 d. AST=30, ALT =300

a. AST=200, ALT = 75 The NORMAL AST/ALT ratio in health subjects is 0.8. In patients with EtOh hepatitis, the usual ratio is 2:1. When the ALT is very elevated infectious hepatitis must be considered. Normally, both AST and ALT are less than 40. The level of elevation DOES NOT correlate with the degree of damage in the liver and HAS NO pragmatic value in patient with non-acute liver disease.

What choice below is most commonly associated with pancreatitis? a. Gallstones and alcohol abuse b. Hypertriglyceridemia and cholecystitis c. Appendicitis and renal stones d. Viral infection and cholecystic.

a. Gallstones and alcohol abuse Pancreatitis in women is more often due to gallstones, in men, due to alcohol abuse. Hypertriglyceridemia can precipitate pancreatitis, but a serum amylase may be normal.

A patient has the following laboratory values. What does this mean? HbsAg - Positive anti-HBc - Positive IGM anti-HBC - Positive anti - HB's - Negative a. He has acute hepatis B b. He has immunity to Hepatis B c. He has no immunity to hepatitis B d. More data is needed

a. He has acute hepatis B. A positive hepatitis B antigen and positive IgM means that this patient has acute hepatitis B. The first serologic marker to be positive is the surface antigen. A positive IgM indicates acute infection.

A 26-year-old female complains of pain at McBurney's point. She feels nauseated and has a low grade fever (100.1F). The most appropriate initial action by the NP is to: a. Order a CBC and pregnancy test. b. Order an abdominal ultrasound. c. Order a KUB. d. Order an abdominal CT.

a. Order a CBC and pregnancy test. Because the child is of child bearing age, a pregnancy must be part of the differential and ruled out initially. If pregnancy is ruled out then the workup for appendicitis can proceed. CT scan has a high sensitivity and so it is the gold standard for DX of appendicitis.

Which oral medication might be used to treat a client with chronic cholelithiasis who is a poor candidate for surgery? a. Ursodiol(Actigall) b. Ibuprofen (Advil) c. Prednisone(Deltasone) d. Surgery is the only answer.

a. Ursodiol(Actigall) Ursodiol (Actigall) is an oral bile acid that dissolves gallstones. For dissolution, 8 to 10 mg/kg per day is given in two to three divided doses; for prevention, 300 mg twice per day is given. The safety of its use after 24 months has not been established. NSAIDs such as ibuprofen (Advil) may be very irritating to the gastrointestinal mucosa. Steroids such as prednisone (Deltasone) may mask an infection as well as irritate the gastric mucosa.

A 24-year-old female presents with pain and tenderness in the right lower abdominal quadrant. Her pelvic exam and urinalysis are within normal limits. her WBC is elevated and her urine pregnancy test is negative. What is part of the differential diagnoses? a. Pelvic inflammatory disease b. Appendicitis c. Ectopic pregnancy d. UTI

b. Appendicitis CBC with mild elevated in WBC indicated infection is likely. This is present in most patients with acute appendicitis. RLQ abdominal pain, anorexia, N/V are all considered classic symptoms of acute appendicitis. PID is characterized by cervical motion and adnexal tenderness on bimanual examination. Acute pelvic pain and a positive pregnancy test may suggest ectopic pregnancy. Patient has a normal urinalysis so UTI can be ruled out.

An older patient presents with left lower quadrant pain. If diverticulitis is suspected, how should the NP proceed? a. Order a chest and abdominal X-ray b. CT scan of abdomen c. Barium enema d. Ultrasound of the abdomen

b. CT scan of abdomen CT scan of the abdomen is the diagnostic test of choice this patient with suspected diverticulitis. The CT scan is able to demonstrate inflammatory changes in the colonic wall, colonic diverticula, thickening of the bowel wall, fistula formation, peritonitis, and other complications associated with diverticulitis.

A patient has the following lab value. What is the clinical interpretation? a. He has hepatitis A. b. He has immunity to hepatitis A. c. He has no immunity to hepatitis A. d. More data are needed to interpret this.

b. He has immunity to hepatitis A. This patient is immune to hepatitis because he has a positive immunoglobin G (IgG).

A 43-year-ofd male patient reports a possible exposure to hepatitis C about months ago. She has the following laboratory values. Which statement is true about this patient? HBsAg - negative anti-HBc - negative anti-HBs - positive anti-HCV - nonreactive HCV RNA - not detectable a. The patient has hepatitis B and hepatitis C. b. The patient does not have hepatitis B, but has immunity to hepatitis B. c. The patient does not have hepatitis B, but could have hepatitis C. d. More tests are needed to determine this patient's hepatitis B status.

b. The patient does not have hepatitis B, but has immunity to hepatitis B.

Which description is more typical of a patient with acute cholecystitis? a. The patient from side to side on the exam table. b. The patient is ill-appearing and febrile. c. An elderly patient is more likely to exhibit Murphy's sign. d. Most are asymptomatic until a stone blocks the bile duct.

b. The patient is ill-appearing and febrile. Patient usually complains about abdominal pain the upper right quadrant or epigastric area. Many patients complain of nausea. The patient lies very still on the exam table because cholecystitis.

The most common symptoms associated with GERD are heartburn and: a. cough. b. regurgitation and dysphagia. c. cough and hoarseness. d. belching and sore throat.

b. regurgitation and dysphagia. Other common symptoms are chest pain, nausea and and odynophagia.

A patient with a suspected inguinal hernia should be examined: a. in the prone position b. standing c. side-lying d. with patient squatting.

b. standing Also, ask the patient bear down, cough, or strain during the exam. Put the second or third finger through the scrotum and into the external ring. When a patient is asked to cough, a "silky" feel will butt up against the examiner's finger, and the hernia can be easily felt.

All of the following medications are used for the control of nausea and vomiting. Which medication works by affecting the chemoreceptor trigger zone, thereby stimulating upper gastrointestinal motility and increasing lower esophageal sphincter pressure? a. Anticholinergics such as scopolamine (Donnatal) b. Antidopaminergic agents such as prochlorperazine (Compazine) c. Antidopaminergic and cholinergic agents such as metoclopramide (Reglan) d.Tetrahydrocannabinolssuchasdronabinol (Marinol)

c. Antidopaminergic and cholinergic agents such as metoclopramide (Reglan) Metoclopramide (Reglan) is used for diabetic gastroparesis and postoperative nausea and vomiting. It works by affecting the chemoreceptor trigger zone, thereby stimulating upper gastrointestinal motility and increasing lower esophageal sphincter pressure. Anticholinergics work at the site of the labyrinth receptors and the chemoreceptor trigger zones—that is, the vomiting center. Antidopaminergic agentswork at the chemoreceptor trigger zone. The site and mechanism of tetrahydrocannabinols are unknown.

Most patients who have acute hepatitis A infection: a. develop fulminant disease b. become acutely ill c. have a self-limited disease d. develop subsequent cirrhosis

c. have a self-limited disease May be mild flu-like symptoms or there may be a more acute and severe clinical manifestation (especially with other complicated illnesses like HIV, Hep B, or Hep C)

Most patients who have acute hepatitis B infection: a. are females b. are acutely ill c. have varied clinical presentations d. develop subsequent cirrhosis

c. have varied clinical presentations Most patients have subclinical hepatitis (70%). When patients are symptomatic, they typically develop nausea, jaundice, and flu-like symptoms with fever, body aches, and fatigue.

A patient is in the clinic with a 36-hour history of diarrhea and moderate dehydration. Interventions should include: a. oral rehydration with tea, cola, or gatorade. b. IV rehydration. c. oral rehydration with an electrolyte replenishment solution. d. resumption of usual fluid intake and solid food intake.

c. oral rehydration with an electrolyte replenishment solution. Oral tract is always preferred for rehydration when it can be used. Resumption of the usual fluid and solid food intake should occur after rehydration has occurred.

A 70-year-old patient states that he had some bright red blood on the toilet tissue this morning after a bowel movement. He denies pain. What is the least LEAST likely cause in this patient? a. Hemorrhoids b. Diverticulitis c. Colon cancer d. Anal fissure

d. Anal fissure 1 in 3 patients in this age group with acute lower gastrointestinal bleeding have bleeding secondary to diverticulitis. Nearly 1 in 5 have colorectal cancer or polyps, though polyps usually do not bleed. Patients who have anal fissures complain of a tearing pain during bowel movements. Regardless, patients needs referral for a colonoscopy to identify the cause of bleeding. He is at high risk for colon cancer because of his age. The appropriate recommendation is referral to GI for colonoscopy.

You auscultate Julie's abdomen and hear a peritoneal friction rub. Which condition do you rule out? a. Peritonitis b. A liver or spleen abscess c. A liver or spleen metastatic tumor d. Irritable bowel syndrome

d. Irritable bowel syndrome A peritoneal friction rub, which sounds like a rough, grating sound, occurs over organs with a large surface area in contact with the peritoneum when there is peritoneal inflammation (peritonitis). When a peritoneal friction rub is heard over the lower right rib cage, it may be caused by an abscess or tumor of the liver. When heard over the lower left rib cage in the left anterior axillary line, it may indicate infection of the spleen or an abscess or tumor of the spleen. Irritable bowel syndrome does not produce a friction rub.

Which symptom is INCONSISTENT with irritable bowel syndrome in older adults? a. Constipation b. Abdominal pain c. Bloating d. Onset after 50 years of age

d. Onset after 50 years of age IBS starts PRIOR to age 50. Symptoms include intermittent constipation, diarrhea, abdominal pain, and bloating. Other symptoms are associated weight loss, blood in the stool, rectal bleeding, and nocturnal diarrhea.

A 56-year-old male patient has been diagnosed with an inguinal hernia. What symptom would make the nurse practitioner suspect an incarcerated hernia? a. Dilated scrotal veins b. Change in skin color c. Constipation d. Pain

d. Pain Normally, hernias are not frankly painful, though they may be tender. A painful hernia should be suspected as one that has become incarcerated or strangulated. Incarceration means the hernia is unable to be reduced; it is trapped. Strangulated means that is incarcerated and ischemia is present. Strangulated hernias are a surgical emergency and surgery should be performed within 4-6 hours to prevent the loss of the bowel.

Irritable bowel syndrome (IBS) can produce which of the following symptoms? 1. Abdominal cramping, rectal bleeding, and diarrhea. 2. Diarrhea alternating with constipation but no pain. 3. Abdominal cramping, diarrhea, and fecal incontinence. 4. Abdominal cramping, diarrhea, and bloating.

4. Abdominal cramping, diarrhea, and bloating. Rationale: The symptoms of cramping, diarrhea, and bloating are classic for irritable bowel syndrome (IBS) with diarrhea predominant. Abdominal pain is a hallmark symptom of IBS but is not associated with rectal bleeding or fecal incontinence.

A sudden onset of diarrhea that consists of 5-6 loose stools a day and awakens the patient at night with cramping, but without blood in the stools, would most likely be caused by: 1. Infection. 2. Irritable bowel syndrome. 3. Ischemic colitis. 4. Lactose intolerance.

Infection. Rationale: Diarrhea is a common symptom with a wide differential. Clues include awakening at night and cramping without blood. A sudden onset that awakens a patient suggests pathology, which could be inflammation or infection. Obtaining a travel history, exposure to infection, and medication history will suggest infection. Irritable bowel syndrome is a functional disorder that does not awaken the patient. Ischemic colitis presents with rectal bleeding, as well as pain and diarrhea. Lactose intolerance and other dietary triggers cause functional diarrhea and cramping.

Susan, age 59, has no specific complaints when she comes in for her annual examination. She does, however, have type 2 diabetes, slight hypertension, dyslipidemia, and central obesity. How would you diagnose her? A. As a healthy adult with several problems B. As having a glycemic event C. As having metabolic syndrome D. As having multiple organ dysfunction

Susan has a constellation of symptoms knownas metabolic syndrome. The World Health Organization (WHO), National Cholesterol Education Program Adult Treatment Panel (NCEP- ATP III), and International Diabetes Federation (IDF) have slightly different criteria for this diagnosis. They all, however, include hypertension, dyslipidemia, and central obesity. If her DM is out of control, she would have a "glycemic event." Eventually, she may end up with multiple organ dysfunction. You might consider that she is headed toward that result. While Susan may look fairly healthy, she is not.

A 48-year-old patient has the following lab values. How should they be interpreted? anti-HCV - Reactive HCV RNA - Detectable a. The patient has hepatitis C. b. The patient does not have hepatitis C. c. The patient should consider immunization. d. The results are indeterminate.

The patient has hepatitis C. He has a reactive HCB antibody (anti-HCV) and the HCV RNA is detectable which confirms infection.

You assess for Cullen's sign in Dan, age 62, after surgery. Cullen's sign may indicate a. intra-abdominal bleeding. b. a ventral hernia. c. appendicitis. d. jaundice.

a. intra-abdominal bleeding. Cullen's sign is a bluish periumbilical color that may indicate intra-abdominal bleeding. The other conditions listed do not produce this.

A 35-year-old patient has the following laboratory values. How should they be interpreted? HBsAg - negative anti-HBc - negative anti - HBs - negative a. The patient had hepatitis B. b. The patient has hepatitis B. c. The patient should consider hepatitis B immunization. d. The patient has had hepatitis B immunization.

c. The patient should consider hepatitis B immunization.

What medication may be used to treat GERD if a patient has tried OTC Ranitidine without benefit? a. Calcium carbonate b. Prescription-strength ranitidine c. Cimetidine d. Pantoprazole

d. Pantoprazole Consider a PPI for GERD. Relief after use of a PPO does not indicate a benign condition. This patient could have esophageal erosions, Barrett's esophagus, or esophageal cancer.

Diagnosis of acute hepatitis B includes the following results: 1. Positive HB surface antigen (HBsAg) and HBe antigen (HbeAg). 2. Positive HB surface antigen (HbsAg) and HB surface antibody (antiHBs). 3. Positive HB core antibody (HbcAg) and negative HB surface antigen (HbsAg). 4. HB core antibody (HbcAg) and HB surface antibody (anti-HBs).

1. Positive HB surface antigen (HBsAg) and HBe antigen (HbeAg) Rationale: Hepatitis B surface antigen (HBsAg) indicates active infection. HBe antigen (HbeAg) is present in early and active disease with high infectivity and can predict chronic infection. HB core antibody (HbcAg) can indicate chronic infection or exposure without having acquired infection. HB surface antibody (anti-HBs) indicates the end of acute infection and can also indicate immunity.

The family nurse practitioner suspects peritonitis in a patient. What assessment finding is most indicative of peritonitis? 1. Palpate and watch for a positive Murphy's sign. 2. Perform a rectal exam and test the stool for blood. 3. Auscultate the abdomen for increased bowel sounds. 4. Palpate for rebound tenderness.

4. Palpate for rebound tenderness. Rationale: Rebound tenderness is found with palpation of the abdomen and quickly lifting the hand. Patients will complain of more pain with releasing the pressure on the abdomen. This suggests peritoneal irritation and inflammation. Stool for occult blood is not a test for peritonitis. Increased bowel sounds would not be present with peritonitis. Decreased bowel sounds may be present.

Which type of hepatitis is transmitted by the fecal-oral route, sewage, contaminated water, shellfish, and possibly blood? A. Hepatitis A(HAV) B. Hepatitis B (HBV) C. HepatitisC(HCV) D. HepatitisD(HDV)

A. Hepatitis A(HAV) Hepatitis A (HAV) is transmitted by the fecal-oral route, sewage, contaminated water and shellfish, and possibly by blood. Hepatitis B (HBV) is transmitted by the percutaneous route (permucosal) through infected blood and body fluids and sexual contact. Hepatitis C (HCV) is transmitted by the percutaneous route in the community, and a large percentage of those infected have no known risk factors. Hepatitis D (HDV) is transmitted by the percutaneous route, but most cases have coinfection with HBV. Hepatitis E (HEV) is transmitted by the fecal-oral route.

Which is the most common presenting symptom of gastric cancer? A. Weight loss B. Dysphagia C. Hematemesis D. Gastrointestinal bleeding

A. Weight loss Weight loss is usually the presenting symptom of gastric cancer, followed by dysphagia. Hematemesis occurs in 10% to 15% of all clients with gastric cancer. Gastrointestinal bleeding is uncommon with gastric cancer, although it is common with colorectal cancer.

Rebound tenderness at McBurney's point would alert you to A. appendicitis. B. peritonitis. C. a spleen injury. D. irritable bowels syndrome.

A. appendicitis. Rebound tenderness at McBurney's point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant, would alert you to appendicitis. The other conditions may elicit tenderness on palpation, but not rebound tenderness.

Margie, age 52, has an extremely stressful job and was just given a diagnosis of gastric ulcer. She tells you that she is sure it is going to be malignant. How do you respond? A. "Don't worry. Gastric ulcers are not cancerous." B. "About 95% of gastric ulcers are benign." C. "You have about a 50% chance of having gastric cancer from your ulcer." D. "Even if it is cancer, surgery is 100% successful."

B. "About 95% of gastric ulcers are benign."

Nausea is difficult to discern in a young child. What question might you ask to determine if a child has nausea? A. "Are you sick to your tummy?" B. "Are you hungry?" C. "Are you eating the way you normally eat?" D. "Are you nauseous?"

B. "Are you hungry?" To elicit information concerning nausea in a young child, ask the child about hunger because a young child cannot usually differentiate between hunger and mild nausea. Young children sometimes equate being "sick to their tummy" with vomiting and thus might answer no when questioned about nausea.

How do you respond when Andrea, who is taking her newborn home from the hospital, asks you when her baby's umbilical cord stump will fall off? A. "Within 7 days." B. "In 10 to 14 days." C. "In 14 to 21 days." D. "In 21 to 30days."

B. "In 10 to 14 days." An infant's umbilical cord stump dries within 7 days and then hardens and falls off in 10 to 14 days. It then takes 3 to 4 weeks for skin to cover the area.

Tom has just been diagnosed with celiac disease. Which of the following might you tell him? A. There is a new pharmaceutical cure for celiac disease. B. A strict gluten-free diet is the only treatment for celiac disease. C. Your children will not be at a higher risk for developing this disease. D. The presence of celiac disease is decreasing dramatically in the United States.

B. A strict gluten-free diet is the only treatment for celiac disease. A strict gluten-free diet is the only treatment for celiac disease. There is no pharmaceutical cure. Patients with first- or second-degree relatives affected by celiac disease are at higher risk for developing it. The prevalence of celiac disease in the United States has increased dramatically. Approximately 1% of today's U.S. residents are affected by it.

A 24-year-old male has recently returned from a weekend camping trip with friends. He has ulcerative colitis and a history of migraine headaches. He reports a 2-day history of headache, nausea, and vomiting with weakness. Which of the following is NOT part of the differential diagnoses? A. Migraine headache B. Exacerbation of ulcerative colitis. C. Acute gastroenteritis. D. Norovirus.

B. Exacerbation of ulcerative colitis. Norovirus is a common cause of gastroenteritis. Ulcerative colitis would produce lower GI symptoms: diarrhea, flatulence, bleeding.

Martha has a Cushing's ulcer. What might have precipitated this? A. Her house burned down when she was not at home. B. She was in a bad auto accident in which she sustained a head injury. C. She spent the weekend deep-sea diving. D. She was on an overseas airline flight that lasted more than 24 hours.

B. She was in a bad auto accident in which she sustained a head injury. Cushing's ulcers are stress ulcers that occur aftera head injury or intracranial disease. They are also called von Rokitansky-Cushing syndrome. A Cushing's ulcer may also occur after a severe burn.

You are counseling Lillian, who is lactose intolerant, about foods to avoid. You know she misunderstands the teaching when she tells you she can have A. yogurt. B. foods containing whey. C. prehydrolyzedmilk. D. oranges.

B. foods containing whey. Advise clients who are lactose intolerant to avoid foods containing whey. Whey is a lactose-rich ingredient found in some foods, so labels need tobe read on all foods for clients who are lactose intolerant. To control symptoms, dietary lactose should be reduced or restricted by using lactose- reduced and lactose-free dairy products or byeating lactose-rich food in small amounts or in combination with low-lactose or lactose-free foods. Fermented dairy products, such as aged or hard cheeses and cultured yogurt, are easier to digestand contain less lactose than other dairy products. Most stores carry milk that has been pretreated with lactase, making it more than 70% lactose free. This reduced-lactose milk is also known as prehydrolyzed milk. Lillian can eat oranges.

Sally, age 21, is to undergo a tonsillectomy. She has heard about taste changes after a tonsillectomy. What do you tell her? A. "As the tongue is responsible for sweet, sour, salty, and bitter taste abilities, they will all be affected somewhat." B. "You will have some alterations, but we'll have to wait and see how you are affected personally." C. "You may notice a slight difference initially, but there are no lasting changes in taste." D. "About half of the patients have some permanent alterations in the sense of taste."

C. "You may notice a slight difference initially, but there are no lasting changes in taste." Although some clients report a significant subjective drop in taste function following surgery, none have ongoing taste dysfunction. Sweet, sour, salty, and bitter taste abilities may be temporarily affected, but there is no lasting change in taste seen after a tonsillectomy.

Once gastric cancer has been diagnosed, which test should be ordered to accurately deter- mine the correct staging? A. Computed tomography B. Magnetic resonance imaging C. Endoscopic ultrasound D. Ranson's test

C. Endoscopic ultrasound Once gastric cancer has been diagnosed, accurate staging can be determined by an endoscopic ultrasound. Ranson's criteria are a classification system to assess the severity of pancreatitis. A CT or MRI has nothing to do with staging.

Which organ structure produces and secretes bile to emulsify fats? A. Salivary glands B. Pancreas C. Liver D. Gallbladder

C. Liver The liver produces and secretes bile to emulsify fats. The salivary glands moisturize food and release enzymes that initiate the digestion process. The pancreas secretes substances that regulate blood sugar levels, store carbohydrates, and inhibit insulin and glucagon secretion. The gallbladder stores and concentrates bile.

Which laxative is safe for long-term use? A. Mineral oil B. Bisacodyl (Dulcolax) C. Methylcellulose (Citrucel) D. Magnesiumhydroxide (milk of magnesia)

C. Methylcellulose (Citrucel) Bulk-forming agents such as methylcellulose (Citrucel) are the only laxatives that are safe for long-term use. They contain natural vegetable fiber that is not absorbed. This creates bulk and draws water into the intestine, thus softening the stool. Mineral oil reduces the absorption of the fat-soluble vitamins A, D, E, and K and may cause damage to the liver and spleen because of systemic absorption. Irritant or stimulant laxatives, such as bisacodyl (Dulcolax), work by stimulating the motility and secretion of the intestinal mucosa. Osmotic and saline laxatives and cathartics, such as magnesium hydroxide (milk of magnesia), when used over the long term, may suppress normal bowel reflexes.

Which procedure enlarges the opening between the stomach and duodenum to improve gastric emptying? A. BillrothI B. Total gastrectomy C. Pyloroplasty D. Vagotomy

C. Pyloroplasty A pyloroplasty surgically enlarges the opening between the stomach and duodenum toimprove gastric emptying. A Billroth I is a gastroduodenostomy. A total gastrectomy is removal of the entire stomach and is rarely performed. It results in an anastomosis connecting the esophagus to the duodenum or jejunum. A vagotomy severs a portion or all of the vagus nerves to the stomach.

Which laboratory value would you expect to be increased in the presence of significant diarrhea? A. Serum potassium B. Serum sodium C. Serum chloride D. Bicarbonate

C. Serum chloride Serum chloride level is increased with significant diarrhea when the diarrhea causes sodium loss that is greater than chloride loss. However, when there is severe diarrhea and vomiting, serum chloride levels may be decreased. Serum potassium and chloride levels are decreased as a result of loss through stool, and bicarbonate level is decreased in a metabolic acidotic state.

Zena just had a hemorrhoidectomy. You know she has not understood your teaching when she tells you that she will A. take a sitz bath after each bowel movement for 1 to 2 weeks after surgery. B. drink at least 2,000 mL of fluids per day. C. decrease her dietary fiber for 1 month. D. take stool softeners as prescribed.

C. decrease her dietary fiber for 1 month. For the client who has just had a hemorrhoid- ectomy, teaching would include advising the client to maintain an adequate intake of dietary fiber to maintain stool bulk; to take a sitz bath after each bowel movement for 1 to 2 weeks after surgery to promote relaxation and aid with discomfort; to drink at least 2,000 mL of fluids per day; to take stool softeners as prescribed (for short-term relief only); and to exercise regularly to maintain stool bulk, softness, and regularity.

Stacy, a nursing student, is to begin her series of hepatitis B vaccinations. You test her for a serological marker, and the results show hepatitis B surface antibodies (HBsAb). You tell Stacy that she A. needs to begin the hepatitis B series as soon as possible. B. needs to be tested again because one reading is not indicative of immunity. C. is permanently immune to hepatitis B. D. has an acute hepatitis B infection.

C. is permanently immune to hepatitis B. The marker for permanent immunity, hepatitis B surface antibodies in the serum, will be present 4 to 10 months after exposure and immunity to hepatitis B. Hepatitis B surface antigen is the earliest indicator of the presence of an acute infection and is present 4 to 12 weeks after exposure. This marker is also indicative of a chronic infection.

Which of the following would be usual in a patient with biliary colic? A. Presence of gallstones on imaging studies. B. Presence of gallstones and unpredictable abdominal pain. C. Positive Murphy's sign only. D. Pain in the upper abdomen, in response to to eating fatty foods.

D. Pain in the upper abdomen, in response to to eating fatty foods. Biliary colic refers to discomfort produced by CONTRACTION OF THE GALLBLADDER which occurs in response to EATING. Typically, pain occurs in the URQ or chest, peaks an hour after eating, and then remains constant and finally subsides over the next several hours. This usually lasts at least 30 minutes but less than a 6 hours. A positive Murphy's sign is elicited when the gallbladder wall is inflamed.

Jonas, age 34, had a Billroth II (hemigas- trectomy and gastrojejunostomy with vagotomy) per- formed 1 week ago and just started eating a bland diet. What do you suspect when he complains of epigastric fullness, distention, discomfort, abdominal cramping, nausea, and flatus after eating? a. Obstruction b. Dumping syndrome c. Metabolic acidosis d. Infectious colitis

b. Dumping syndrome Dumping syndrome may occur 1 to 3 weeks after gastric surgery when the client starts to consume larger meals. Food enters the intestine faster and in larger quantities than before the surgery, causing the client to experience epigastric fullness, distention, discomfort, abdominal cramping, nausea, and increased flatus 10 to 30 minutes after eating. While any abdominal surgery may result in adhesions that might possibly cause an obstruction, the symptoms that Jonas is experiencing are classic symptoms of "dumping syndrome." All the distractors are extreme possibilities, but the symptoms are classic for dumping syndrome.

An 83-year-old patient is diagnosed with diverticulitis. The most common complaint is: A. rectal bleeding B. bloating and crampiness. C. left lower quadrant pain. D. frequent belching and flautelence.

c. left lower quadrant pain.

Which of the following statements about cirrhosis is true? a. Biliary cirrhosis is the most common type of cirrhosis in the United States. b. Alcoholic cirrhosis occurs only in malnourished alcoholics. c. Cirrhosis is reversible if diagnosed and treated at an early stage. d. Women tend to develop cirrhosis more quickly with less alcohol intake than men.

d. Women tend to develop cirrhosis more quickly with less alcohol intake than men. Women tend to develop cirrhosis more quickly with less alcohol intake than men, which suggests that a smaller, leaner body mass and enhanced absorption are both factors in the development of alcoholic cirrhosis. Alcoholic cirrhosis, also known as Laënnec's, portal, fatty, or micronodular cirrhosis, is the most common type of cirrhosis in the United States. Alcoholic cirrhosis is often associated with nutritional and vitamin deficiencies but occurs in well-nourished individuals as well as alcoholics. Cirrhosis is the irreversible end stage of liver injury and may be caused by a variety of insults.

The most important diagnostic test for celiac disease is a. confirming malabsorption by laboratory tests. b. a barium enema. c. a peroral biopsy of the duodenum. d. a tTG-IgA test followed by a biopsy of the small intestine.

d. a tTG-IgA test followed by a biopsy of the small intestine. There are several serologic tests available that screen for celiac disease antibodies, but the most important diagnostic test is called a tTG-IgA test. If test results suggest celiac disease, it is recommended that a biopsy of the small intestine be done to confirm the diagnosis. Laboratory tests may confirm malabsorption, but they are not diagnostic of celiac disease. A barium enema may show dilation of the small intestine,but in mild celiac disease, the enema results may be normal. A peroral biopsy showing the gross absence of duodenal folds on endoscopy is a clue to the presence of celiac disease, but it is not diagnostic because this symptom may also occur in tropical sprue, intestinal lymphoma, Zollinger-Ellison syndrome, and other diseases.

Which patient has the LEAST worrisome symptoms associated with his diarrhea? One with: a. blood diarrhea b. temperature >101.3F c. duration of illness >48 hours d. moderate amounts of watery diarrhea

d. moderate amounts of watery diarrhea Further W/U is needed in patients with profuse watery diarrhea with signs of hypovolemia, passage of >6 unformed stools per 24 hours or duration of illness >48 hours, recent ABX use or recent hospitalization, and diarrhea in a patient >70 years old

A patient has the following lab results. This means: anti-HCV Reactive a. he has hepatitis C b. he has imunity to hepatitis C. c. he does not have hepatitis C. d. more data is needed.

d. more data is needed. anti-HCV is a SCREENING test. If the screen is reactive, a confirmatory test should be performed. The confirmatory test is HCV RNA.

The relationship between duodenal ulcer disease and H. pylori infection is: a. distant. b. very unlikely. c. possible. d. very likely.

d. very likely. H. pylori is a gram negative organism that is a major factor in development of duodenal ulcer disease, gastric adenocarcinoma and lymphoma of the stomach. Other etiologic factors in duodenal ulcers are NSAID overuse and smoking.