CHAPTER 08- Gastrointestinal System

Question 1

One pharmacological intervention for a patient with diabetes or pre-diabetes with NASH is:

1. Tenofovir.
2. Acetylsalicylic Acid.
3. Gabapentin.
4. Metformin.

Answer 1

4. Metformin.

While you the FNP could encourage the patient to lose weight,make lifestyle changes to decrease risk of cardiovascular risk factors, and avoid alcohol, a pharmacological intervention for a patient with diabetes or pre-diabetes with NASH is Metformin.

Question 2

Of the following options, which two are factors that may lead to faster progression of hepatitis C (HCV) disease?

1. Female gender, comorbid cardiovascular disease
2. Male gender, comorbid HIV infection
3. Male gender, comorbid pulmonary disease
4. Female gender, comorbid irritable bowel syndrome

Answer 2

2. Male gender, comorbid HIV infection

Factors associated with increased progression and severity are age of 40+, HIV co-infection, chronic HBV co-infection, increased alcohol intake, and being a male.

Question 3

A 33-year-old male patient is new to the FNP’s practice. During the health history, he mentions he was told he had hepatitis. He is unsure which type of hepatitis and asks what it is. The FNP tells him that hepatitis is:

1. Fibrosis of the liver.
2. Infection of the liver.
3. Cirrhosis of the liver.
4. Inflammation of the liver.

Answer 3

4. Inflammation of the liver.

Hepatitis is liver inflammation arising from an autoimmune disorder or viral infection.

Question 4

A 33-year-old male patient is new to the FNP’s practice. During the health history, he mentions he was told he had hepatitis. He is unsure which type of hepatitis and asks what it is. The FNP is ordering bloodwork for this new patient. To evaluate which hepatitis the patient was previously diagnosed with, the initial laboratory testing will include:

1. HAV viral load, HDV IgG.
2. HCV Ag, HBV eAg, HAV viral load.
3. HAV total Ab, HCV Ab, HBV sAg and HBsAb.
4. HCV IgG, HAV IgG, HBV viral load.

Answer 4

3. HAV total Ab, HCV Ab, HBV sAg and HBsAb.

The FNP is ordering bloodwork for this new patient. To evaluate which hepatitis the patient was previously diagnosed with the initial laboratory testing will include: HAV total Ab, HCV Ab, HBV sAg and HBsAb.

Question 5

A 33-year-old male patient is new to the FNP’s practice. During the health history, he mentions he was told he had hepatitis. He is unsure which type of hepatitis and asks what it is. The patient’s labs return. What do these results indicate?: HBsAg = positive; HBsAb = negative; IgM HbcAB = negative; HAV Ab total = positive; HCV Ab = nonreactive

1. Acute hepatitis C infection, past hepatitis A infection
2. Chronic hepatitis B infection, acute hepatitis A infection
3. Past hepatitis A infection, chronic hepatitis B infection
4. Past hepatitis B infection, past hepatitis A infection

Answer 5

3. Past hepatitis A infection, chronic hepatitis B infection

For hepatitis A, the causative agent is RNA Picornavirus–a single serotype worldwide. The virus is transmitted via fecal or oral routes and has an incubation period of 15-20 days. There is a vaccination.

Question 6

Which type of hepatitis is most commonly caused by contaminated foods?

1. HBV
2. HCV
3. HDV
4. HAV

Answer 6

4. HAV

The type of hepatitis most commonly caused by contaminated foods is HAV.

Question 7

A 50-year-old female patient thinks she may have gotten hepatitis C from a previous sexual partner. She asks what the signs and symptoms of acute infection are. The FNP responds by listing which options?

1. Nausea, vomiting, bloody diarrhea
2. Fever, fatigue, body aches
3. Sweating, dyspepsia, tachycardia
4. Vomiting, headache, diarrhea

Answer 7

2. Fever, fatigue, body aches

Fever, fatigue, body aches are all symptoms of Hepatitus C. This is transmitted through blood products and can occur in sexual transmission.

Question 8

Peter is a 50-year-old African American male who is HCV+ from IVDU (intravenous drug users) many years ago. He has not used street drugs for over 15 years and works long hours as a train conductor. He is asking about his routine health maintenance in regard to HCV. Which of the following yearly exams are recommended by the FNP?

1. CT scan, liver biopsy, HCV viral load, and liver enzymes
2. Liver ultrasound, liver enzymes, AFP, HCV viral load
3. Liver biopsy, liver ultrasound, liver enzymes, CBC
4. HCV viral load, genotype, and CT scan

Answer 8

2. Liver ultrasound, liver enzymes, AFP, HCV viral load

Yearly exams recommended: Liver ultrasound, liver enzymes, AFP, HCV viral load.

Question 9

A 62-year-old female patient comes to the FNP’s office with complaints of constipation for the past few months. She has tried to increase her intake of water and fiber without much success. A yearly physical exam and colonoscopy were negative for any significant findings 6 months prior to this visit. Which of the following options would be most appropriate for the next step?

1. Recommend daily Dulcolax use as an addition to the fiber and water.
2. Recommend an increase in exercise, such as walking, and daily Miralax use for 2 weeks, then have her return for evaluation in one month.
3. Recommend daily Fleet enema use upon arising in addition to current approach. Refer to GI specialist if no improvement.
4. Recommend CT scan of abdomen to rule out malignancy.

Answer 9

2. Recommend an increase in exercise, such as walking, and daily Miralax use for 2 weeks, then have her return for evaluation in one month.

Being fiber isn’t working, Miralax is the best choice. It is a Osmotic laxative and it works with lactulose to pull water into the intestine.

Question 10

A 50-year-old male with a BMI of 29 comes in for an annual physical exam. Upon review of systems, he mentions he has a lot of heartburn and is taking over-the-counter omeprazole twice a day. He also takes Tums throughout the day. When deciding whether to refer this patient to a gastroenterologist as the next step, what should the FNP take into consideration?

1. How long the patient has had this problem
2. How often he is taking the medications
3. The severity of his symptoms
4. His age

Answer 10

1. How long the patient has had this problem

The FNP should find out how long the patient has been having this problem and how long they have been taking the medications.

Question 11

The FNP is treating a patient for an H. pylori infection. The patient has a penicillin allergy. Which regimen would be the best choice for this patient?

1. Omeprazole 20 mg bid, clarithromycin 500 mg bid, and metronidazole 500 mg bid
2. Lansoprazole 30 mg bid, amoxicillin 1 gm bid, and metronidazole 500 mg bid
3. Omeprazole 20 mg daily, metronidazole 1 gm bid, and clarithromycin 1 gm bid
4. Lansoprazole 30 mg bid, metronidazole 500 mg daily, tetracycline 500 mg daily

Answer 11

1. Omeprazole 20 mg bid, clarithromycin 500 mg bid, and metronidazole 500 mg bid

This is the best choice for a patient with a penicillin allergy.

Question 12

An 80-year-old male patient comes to the clinic with complaints of diarrhea for 2 days. The FNP notes that the patient had been hospitalized 2 weeks ago for pneumonia. What is the most appropriate next question to ask the patient?

1. What type of antibiotic were you given in the hospital?
2. How many days were you hospitalized?
3. How many times per day are you passing stool?
4. What over-the-counter medications are you taking for the diarrhea?

Answer 12

3. How many times per day are you passing stool?

Individual perception of constipation or diarrhea can vary greatly.

Question 13

A patient with generalized lower abdominal pain and nausea is being evaluated. The patient has a low-grade fever (100.4 degrees F). Which of the following signs if found upon physical examination would suggest appendicitis?

1. Mittleschmerz
2. Psoas
3. Murphy’s
4. Kernig

Answer 13

2. Psoas

Have the patient lift his or her leg while your hand is placed on the thigh, creating resistance. In appendicitis, the psoas contraction produces pain.

Question 14

The correct sequence for physical examination of the abdomen is:

1. Inspection, auscultation, percussion, palpation
2. Inspection, percussion, auscultation, palpation
3. Auscultation, inspection, percussion, palpation
4. Auscultation, inspection, palpation, percussion

Answer 14

1. Inspection, auscultation, percussion, palpation

This is the proper order:

Inspection- Examine the abdomen and report scars, rashes, striae, symmetry, contour, masses, pulastions, peristalsis, hernias, and skin discoloration.

Auscultation- Listen over all four quadrants for bowel sounds and for bruits over the aorta, iliac, renal, and femoral arteries.

Percussion- Note areas of dullness indicative of solid or fluid-filled masses rather than air. Percuss for the liver span and spleen to assess for organomegaly.

Palpation- Start with light palpation in non-tender areas and then move on to deep palpation to assess for organomegaly or masses.

Question 15

Crohn’s disease differs from ulcerative colitis because:

1. Crohn’s disease causes more severe abdominal cramping.
2. Crohn’s may affect any part of the gastrointestinal GI tract. Ulcerative colitis is limited to the large intestine.
3. Ulcerative colitis symptoms tend to flare up more often around menses.
4. Ulcerative colitis is a chronic condition, whereas Crohn’s disease may occur once and no further flare-ups happen.

Answer 15

2. Crohn’s may affect any part of the gastrointestinal GI tract. Ulcerative colitis is limited to the large intestine.

Crohn’s disease differs from ulcerative colitis because Crohn’s may affect any part of the gastrointestinal GI tract. Ulcerative colitis is limited to the large intestine.

Question 16

A 52-year-old male patient is in the office for a physical examination. He has not been seen in three years. The FNP discusses three screening options for detecting colon cancer with the patient. These options include:

1. Yearly fecal immunochemical testing (FIT), colonoscopy every 10 years, FIT every year along with flexible sigmoidoscopy every 5 years
2. Colonoscopy every 5 years, FIT annually
3. Annual FIT along with flexible sigmoidoscopy or colonoscopy every 3 years
4. Yearly colonoscopy and FIT for those with genetic predisposition to colon cancer

Answer 16

1. Yearly fecal immunochemical testing (FIT), colonoscopy every 10 years, FIT every year along with flexible sigmoidoscopy every 5 years

To detect colon cancer, a patient should have yearly fecal blood tests, stool DNA tests every three years and if these tests are positive a colonoscopy should be performed. That said, a colonoscopy should be performed every 10 years and a Flexible sigmoidoscopy every 5 years. These time frames alter if the patient has a strong family history of polyposis.

Question 17

A positive Murphy’s sign occurs when:

1. The diaphragm releases the inflamed gallbladder during percussion.
2. The intestines push against the diaphragm.
3. The diaphragm moves the inflamed gallbladder into the palpating hand.
4. The colon moves the diaphragm against the costovertebral column.

Answer 17

3. The diaphragm moves the inflamed gallbladder into the palpating hand.

A positive Murphy’s sign occurs when the diaphragm moves the inflamed gall bladder into the palpating hand.

Question 18

Which of the following is true concerning the hepatitis B vaccine?

1. The vaccine contains live hepatitis B virus.
2. The nurse practitioner should consider post-vaccination HBsAB titers for those at the highest risk of infection.
3. The vaccine is contraindicated in the presence of HIV infection.
4. Post-vaccine arthralgias are often reported.

Answer 18

2. The nurse practitioner should consider post-vaccination HBsAB titers for those at the highest risk of infection.

The nurse practitioner should consider post vaccination HBsAB titers for those at the highest risk of infection.

Question 19

Serologic features of acute hepatitis B are:

1. HBsAg reactive, and high titer of immunoglobulin M(IgM).
2. HBsAg reactive and high titer of immunoglobin G (IgG).
3. HBeAg and HBsAg negative.
4. IgM anti-HBc- (high titer) HBsAg-nonreactive.

Answer 19

1. HBsAg reactive, and high titer of immunoglobulin M(IgM).

Serologic features, or those that are serum relate, of acute hepatitis B are HBsAg reactive and high titer of immunoglobulin M(IgM).

Question 20

Monitoring for hepatocellular carcinoma in a patient with chronic hepatitis B or C often includes the periodic evaluation of which of the following?

1. Erythrocyte sedimentation rate
2. HBsAB
3. Alpha-fetoprotein
4. Serum creatinine level

Answer 20

3. Alpha-fetoprotein

AFP is made by a fetus’ liver and is found in low levels in adults unless they have certain cancers, in particular hepatocellular cancer.

Question 21

An acute febrile illness with jaundice, anorexia, malaise, and an incubation period of 45–150 days; having a chronic and an acute form; and transmitted by parenteral, sexual activity, and perinatal routes best describes which of the following?

1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D

Answer 21

2. Hepatitis B

HDV can co-occur with HBV, hepatitis A is typically food/water borne and is not chronic, HCV is not commonly spread via heterosexual transmission in a monogamous relationship.

Question 22

Which of the following laboratory studies is used to determine whether a client has hepatitis A?

1. Serum protein
2. Protein electrophoresis
3. Antibody testing
4. Immunoglobulin levels

Answer 22

3. Antibody testing

Antibody testing is the study used for Hepatitis A because it is an acute condition and antibodies from the infuction will provide lifelong immunity.

Question 23

What is the most common source for hepatitis A infection?

1. Needle sharing
2. Raw shellfish
3. Contaminated water supplies
4. Intimate person-to-person contact

Answer 23

3. Contaminated water supplies

The most common source for hepatitis A Infection is contaminated water supplies as the virus is transmitted fecally or orally.

Question 24

When answering questions about the hepatitis A vaccine, the FNP responds that it:

1. Should be offered to patients with chronic hepatitis C.
2. Should be offered to those who have traveled to western Europe
3. Usually is a required immunization for all health care workers.
4. Is protective after a single vaccine dose.

Answer 24

1. Should be offered to patients with chronic hepatitis C.

Patients with HCV infection need to be protected against other liver damaging infections such as HAV and HBV.

Question 25

Diarrhea is often generally associated with:

1. Infectious gastroenteritis, inflammatory bowel disease, and diverticulitis.
2. Diseases of the colon or rectum.
3. Fever and abdominal pain in sexually transmitted diseases.
4. Dysuria and flank pain in urinary tract infections.

Answer 25

1. Infectious gastroenteritis, inflammatory bowel disease, and diverticulitis.

Diarrhea is often generally associated with: Infectious gastroenteritis, inflammatory bowel disease, diverticulitis.

Question 26

Potential complications of gastroesophageal reflux disease (GERD) include:

1. Esophageal ulcers, Barrett’s esophagitis, and esophageal stricture.
2. Gastric ulcers, esophageal dilatation, and stricture of the lower esophageal sphincter.
3. Peptic ulcers, esophageal ulcers, and gastric distension.
4. Aspiration pneumonia, gastric ulcers, and esophageal bleeding.

Answer 26

1. Esophageal ulcers, Barrett’s esophagitis, and esophageal stricture.

Gastroesophageal reflux disease occurs when the gastric stomach contents ascend to the esophagus and cause symptoms such as burning, discomfort, or pain. Esophageal ulcers, Barrett’s esophagitis, and esophageal stricture are possible complications of this.

Question 27

In terms of (GERD), Patient education issues that need to be addressed with the goal of improved patient outcome include:

1. Reinforce smoking cessation, weight reduction, avoidance of alcohol and caffeine.
2. Eating no later than midnight, portion control or dietary restrictions, cough suppressants at bedtime.
3. Elevate the head of the bed on blocks, prn (pro re nata) antacids, bland high-fat diet.
4. Encourage bland snacks, use H2 blockers, maintain weight restrictions.

Answer 27

1. Reinforce smoking cessation, weight reduction, avoidance of alcohol and caffeine.

These are all good ways to treat GERD and ways to avoid getting triggers of it.

Question 28

Biliary colic may radiate to the:

1. Infrascapular area.
2. Right shoulder.
3. Neck and left arm.
4. Periumbilical area.

Answer 28

1. Infrascapular area.

Biliary colic may radiate to the infrascapular area.

Question 29

A 55-year-old schoolteacher with type 2 diabetes presents to your office with complaints of low-grade fever for 3 days and cramping right upper quadrant pain, radiating to the right scapula. Laboratory diagnostics indicate: WBC—13,000; (NL 4.5–11,000); SGOT (AST)—55; (NL 5–40); SGPT (ALT)—65; (NL 5–55); BUN 25 (NL 6–25); Alk. Phos.—140; (NL 35–110); Amylase—130; (NL 20–90). Physical exam reveals epigastric tenderness, guarding, and a positive Murphy’s sign. The FNP suspects:

1. Acute cholecystitis.
2. Acute appendicitis.
3. Hepatitis.
4. Peptic ulcer disease.

Answer 29

1. Acute cholecystitis.

The FNP suspects Acute cholecystitis. Mild elevation of white blood cells, liver enzymes, and amylase are found in patients with choleycystitis.

Question 30

The most important contributing factor to the development of a peptic ulcer is:

1. Eating spicy/acidic foods.
2. Use of nonsteroidals (NSAIDs).
3. Stress.
4. Drinking alcohol.

Answer 30

2. Use of nonsteroidals (NSAIDs).

The most important contributing factor to the development of peptic ulcer is the use of nonsteroidals (NSAIDs). Overuse of NSAIDS or infection with H. Pylori are risk factors for the development of peptic ulcer disease.

Question 31

A 25-year-old nursing student has just returned from a mission trip to Central America with traveler’s diarrhea. Which antibiotic should the nurse practitioner order if the symptoms do not improve?

1. Ampicillin
2. Tetracycline
3. Ciprofloxacin
4. Zithromax

Answer 31

3. Ciprofloxacin

In otherwise healthy patients with mild diarrhea of short duration, antibiotics are not required.

Question 32

All the following are risk factors associated with long-term use of PPIs EXCEPT:

1. Pneumonia.
2. COPD.
3. Anemia.
4. Clostridium difficile.

Answer 32

2. COPD.

All the following are risk factors associated with long term use of PPIs except COPD.

Question 33

A 19-year-old male comes to the college health center complaining of a “bulge” on the right side of his groin, which is not painful, but is “uncomfortable.” Upon examination, the FNP is unable to reduce the inguinal hernia found in the right groin area. The best next step to manage this problem by the FNP is:

1. Nothing. It will reduce eventually without any intervention.
2. Immediate referral to a local emergency room. Call the patient’s parents with this information.
3. Instruct the patient to avoid any weightlifting and sports, and use supportive undergarments to hold the hernia in place.
4. Instruct the patient to avoid any heavy lifting, and to go to the emergency department with any severe pain. Also let the patient know you are calling in a referral for consultation with a general surgeon today.

Answer 33

4. Instruct the patient to avoid any heavy lifting, and to go to the emergency department with any severe pain. Also let the patient know you are calling in a referral for consultation with a general surgeon today.

It is important for the FNP to Instruct the patient to avoid any heavy lifting, and to go to the emergency department with any severe pain that day to determine how threatening it is and determine if it will worsen.

Question 34

A 78-year-old male patient walks in to the office complaining of feeling lightheaded for a few hours. He appears pale and anxious. Past medical history includes controlled atrial fibrillation, hypertension, and hyperlipidemia. The patient’s vital signs are: Temp. 98.2 degrees F, BP 100/58, heart rate 92, resp. rate 16, O2 sat 94%.Which one of the following findings on physical exam are most concerning?

1. Obturator sign
2. Cohen’s sign
3. Jackob’s sign
4. Cullen’s sign

Answer 34

4. Cullen’s sign

Bluish discoloration in the periumbilical area strongly indicates retroperitoneal bleeding which can occur in patients on warfarin.

Question 35

A recently divorced 59-year-old female patient comes to the clinic with complaints of new onset diarrhea and alternating constipation over the past 3 months, occasional blood in stool, and unintentional 5 pound weight loss over the past 6 weeks. This patient’s BMI is 30, vital signs are all within normal limits. Her social history includes smoking ½ ppd (pack per day) for 20 years, as well as one glass of wine per day, and she works as a receptionist. The physical examination is unremarkable. What are the best choices for the top 3 differential diagnoses?

1. Diverticulitis, colon cancer, intestinal parasites
2. Colon cancer, appendicitis, malaria
3. Duodenal ulcer, peptic ulcer, Crohn’s disease
4. Intestinal parasites, irritable bowel disease, cytomegalovirus

Answer 35

1. Diverticulitis, colon cancer, intestinal parasites

Of these three, colon cancer is the most likely diagnosis and needs immediate diagnostic testing and follow up.

Question 36

For the above 59-year-old female patient, which of the following genetic disorders increases her risk for colon cancer?

1. Murphy’s syndrome
2. BRCA 1 gene mutation
3. FLAP syndrome
4. Lynch syndrome

Answer 36

4. Lynch syndrome

Lynch syndrome testing is for HNPCC or hereditary non-polyposis colon cancer which is usually seen in persons under the age of 50.

Question 37

What is the best initial diagnostic test to find out if a patient actually has colon cancer?

1. Colonoscopy and biopsy
2. PET scan
3. Abdominal ultrasound
4. Fecal occult blood sample

Answer 37

1. Colonoscopy and biopsy

While there are other diagnostic tests that may be a part of evaluating any spread of cancer, a biopsy is required for definitive diagnosis.

Question 38

Pain related to acute appendicitis can cause tenderness where?

1. Curley’s area
2. McDowell’s point
3. Russell’s site
4. McBurney’s point

Answer 38

4. McBurney’s point

This is over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus.

Question 39

A 72-year-old male presents to the office with severe abdominal pain that radiates to the back and genital area. The FNP knows that this may indicate which of the following conditions requiring immediate intervention?

1. Inguinal hernia
2. Lower lobe pneumonia with effusion
3. Acute choleycystitis
4. Dissection or rupture of abdominal aortic aneurysm

Answer 39

4. Dissection or rupture of abdominal aortic aneurysm

This is an emergency and requires immediate transfer to the emergency department.

Question 40

A 19-year-old male football player has suffered an injury during the game. The patient is pale, anxious, and complains of left upper quadrant abdominal pain radiating to the left shoulder. The FNP recognizes that this most likely indicates:

1. A ruptured spleen.
2. Acute pancreatitis.
3. Right-sided pneumothorax.
4. Testicular torsion

Answer 40

1. A ruptured spleen.

This is a true emergency and requires immediate transfer to the emergency department.