NURS660 Exam 2- Updated- 308
Questions with Correct
Solutions
What is the most common site for referred gallbladder pain? - -right
shoulder
What radiological tests are preferred when working up abdominal pain?
- -Ultrasound, CT scan
Abdominal x-ray not recommended
The patient is screaming in pain and saying their abdominal pain is
10/10 but their exam shows a soft abdomen with no guarding. Is this
concerning? - -VERY concerning
pain disproportionate to exam is an emergency, hallmark finding of
acute abdominal mesenteric ischemia
Describe the 3 anatomical causes of GERD - -1. Increased intra-
abdominal pressure
2. Decreased sphincter tone
3. Inappropriate lower esophageal sphincter relaxation
What is Barrett's esophagus? - -When normal squamous epithelium is
replaced with metaplastic columnar epithelium
This is a mechanism of protection the body does when exposed to
gastric acid for too long, but puts patient at risk for cancer due to
cellular changes (40x risk)
Describe some subjective complaints a patient with GERD may have. - -
Heartburn, regurgitation, reflex salivation, sour taste in the morning,
belching, coughing, hoarseness
Could be silent reflux, for example may not have heartburn but have
unexplained hoarseness
What subjective complaint is NOT a common finding with GERD and is
concerning? - -Dysphagia
Name some risk factors or aggravating factors for GERD. - -Reclining
after eating, large meals, alcohol, chocolate, caffeine, decaf coffee, fatty
or spicy foods, constrictive clothing, heavy lifting/straining/working in a
bent over position, peppermint, tomato products
also pregnancy, obesity, hiatal hernia
How is GERD diagnosed? - -Typically, history is sufficient but you could
do ambulatory pH monitoring (not routine)
, Which patients require an EGD to further evaluate their GERD? - -those
with red flags that you want to evaluate for Barrett's esophagus
Dysphagia, anemia, weight loss, bleeding, recurrent vomiting, or non-
responsive to treatment/meds
What life-threatening condition must be ruled out when you suspect
GERD? - -Angina/MI
What is the first step in GERD treatment? Describe it. - -Lifestyle
modifications always first
Lose weight, small frequent meals, avoid high-fat meals, avoid
heartburn triggers, quit smoking, avoid tight garments around the waist,
sleep with head of bed elevated, no drinking/eating 2-3 hours before
bed
Don't need to cut out foods they enjoy, but reduce or eat earlier
Why is smoking bad for GERD? - -decreases saliva production which
increases acid
nicotine is an aggravating drug as well
If your patient with GERD is not seeing improvement with lifestyle
modifications, what is the next step in treatment? - -1. PPIs. Typically
start with once a day and can increase to BID as needed (can be hard to
get insurance approval though)
Caution w/ C Diff (can trigger), okay for osteoporosis/Plavix (used to
think otherwise)
You start your patient on a PPI for GERD. When do you wanna follow
up? If they are still having symptoms, what's your next step? - -f/u in 8
weeks
add a H2 blocker, these are better for breakthrough use though as body
can adjust and not respond as well
Your patient is maxed out on PPIs for GERD and has also tried adding
H2 blockers and prn antacids. What's the next step? - -They require
endoscopic evaluation
Your patient has tried everything for their GERD and you are wondering
if they are a candidate for surgery. What is required first? - -pH probe
may want to order and refer to GI
Your patient did not have GERD prior to gaining weight. They are now in
the obese category. Nothing has helped their GERD and they want
surgery. What surgery might you recommended? - -bariatric surgery
if obese, this is more appropriate than the GI surgeries like Nissens,
endocinch, strettas, etc because the cause is likely the weight
, You thought your patient had GERD but you've maxed them on PPIs
and you're realizing that their symptoms are a little atypical for what
you usually see with GERD. What is the next step? - -Refer out
ENT, pulmonary, allergy, etc
not likely GERD but something along these lines
What populations are you automatically concerned about with
gastroenteritis? - -older adults, children
Name some objective findings that would concern you for dehydration
in your gastroenteritis patient. - -Tachycardia, dry mucus membranes,
hypotension, dizziness
Name some tests you could run on someone's stool if they are having
severe symptoms that are persisting beyond the usual 1-3 days. - -Fecal
leukocytes (positive in most bacterial infections like E Coli, Shigella,
Salmonella, C diff)
Stool Culture (encouraged if positive fecal leukocytes, 103 degree fever,
severe diarrhea, bloody diarrhea, etc)
Stool for ova or parasites (esp if in daycare or travel to Russia/Nepal)
Which patients with diarrhea should not use antimotility drugs? - -those
with fevers, bloody diarrhea, or positive fecal leukocytes
Pepto bismol is a good choice when having gastroenteritis because - -it
is both antimicrobial and antimotility
Who are some populations that will require antibiotics with
gastroenteritis? - -Daycare worker or child
Fever, chills, weight loss, night sweats
>6/dayof diarrhea, salmonella, shigella, campylobacter confirmed
What is the antibiotic of choice for gastroenteritis (if required)? How do
you start it/adjust it? - -Cipro
Start immediately if positive fecal leukocytes
Send stool for culture, adjust as needed
Your patient has had gastroenteritis symptoms for >2 weeks and has
been unresponsive to any treatments. What do you suspect and what do
you prescribe? - -likely a protozoa (giarrdia?)
prescribe Flagyl
What would you want to educate your patient with gastroenteritis on in
regards to when to be concerned/call for help? - -vomiting and fever,
severe abdominal pain, headache, neck pain, lethargy, diminished or
dark UOP, dizziness, lightheadedness, vomiting blood or coffee ground
emesis, bloody diarrhea
3 main causes of peptic ulcer disease - -1. H pylori
2. Nsaids
, 3. Acid hypersecretion
Is a physical exam helpful in diagnosing PUD? - -no
Name some risk factors for PUD. - -smoking, aspirin, NSAIDs, H pylori,
FH, COPD, steroids, trauma, caffeine, alcohol, cirrhosis, physiologic
stress
Describe the symptoms patients with PUD will describe. - -Burning or
gnawing pain
Pain worsened by eating (gastric) or relieved (duodenal)
Episodic pattern, nocturnal pain
What physical exam findings would require you to send someone to the
ED that you may suspect has PUD? - -rigid abdomen or rebound
tenderness --> perf? peritonitis?
What is the gold standard for diagnosis of PUD? - -upper Gi endoscopy
How do you definitively diagnose H pylori? - -tissue biopsy
breath test and blood test do not differentiate between past and present
infection
When might a fasting gastrin level be helpful? - -in trying to figure out
why someone is having recurrent ulcers
indicative of Zollinger-Ellison syndrome (overproduction of gastric acid)
What is the drug of choice in managing PUD? What is next choice? - -
PPIs
heal 90% of ulcers within 4-8 weeks
next choice: h2 antagonists, slightly lower percent healed but less
expensive than PPIs. Be aware that they can affect metabolism of other
cytochrome P-450 drugs (warfarin, SSRIs)
What is the treatment for H pylori and who initiates it? - -PPI +
Clarithromycin + Amox/Flagyl depending on allergies
this is usually managed by GI
You start your patient with suspected PUD on PPIs and they follow up in
2 weeks with no improvement. What is your next step? - -Referral to GI
or endoscopy
Describe who with a peptic ulcer needs to be seen in the ED. - -anemia,
GI bleed s/s, rigid abdomen, weight loss, new onset dyspepsia, older
than 50 years
Which type of ulcer requires an endoscopy? Gastric or duodenal? - -
Gastric
increased incidence of gastric cancer
Questions with Correct
Solutions
What is the most common site for referred gallbladder pain? - -right
shoulder
What radiological tests are preferred when working up abdominal pain?
- -Ultrasound, CT scan
Abdominal x-ray not recommended
The patient is screaming in pain and saying their abdominal pain is
10/10 but their exam shows a soft abdomen with no guarding. Is this
concerning? - -VERY concerning
pain disproportionate to exam is an emergency, hallmark finding of
acute abdominal mesenteric ischemia
Describe the 3 anatomical causes of GERD - -1. Increased intra-
abdominal pressure
2. Decreased sphincter tone
3. Inappropriate lower esophageal sphincter relaxation
What is Barrett's esophagus? - -When normal squamous epithelium is
replaced with metaplastic columnar epithelium
This is a mechanism of protection the body does when exposed to
gastric acid for too long, but puts patient at risk for cancer due to
cellular changes (40x risk)
Describe some subjective complaints a patient with GERD may have. - -
Heartburn, regurgitation, reflex salivation, sour taste in the morning,
belching, coughing, hoarseness
Could be silent reflux, for example may not have heartburn but have
unexplained hoarseness
What subjective complaint is NOT a common finding with GERD and is
concerning? - -Dysphagia
Name some risk factors or aggravating factors for GERD. - -Reclining
after eating, large meals, alcohol, chocolate, caffeine, decaf coffee, fatty
or spicy foods, constrictive clothing, heavy lifting/straining/working in a
bent over position, peppermint, tomato products
also pregnancy, obesity, hiatal hernia
How is GERD diagnosed? - -Typically, history is sufficient but you could
do ambulatory pH monitoring (not routine)
, Which patients require an EGD to further evaluate their GERD? - -those
with red flags that you want to evaluate for Barrett's esophagus
Dysphagia, anemia, weight loss, bleeding, recurrent vomiting, or non-
responsive to treatment/meds
What life-threatening condition must be ruled out when you suspect
GERD? - -Angina/MI
What is the first step in GERD treatment? Describe it. - -Lifestyle
modifications always first
Lose weight, small frequent meals, avoid high-fat meals, avoid
heartburn triggers, quit smoking, avoid tight garments around the waist,
sleep with head of bed elevated, no drinking/eating 2-3 hours before
bed
Don't need to cut out foods they enjoy, but reduce or eat earlier
Why is smoking bad for GERD? - -decreases saliva production which
increases acid
nicotine is an aggravating drug as well
If your patient with GERD is not seeing improvement with lifestyle
modifications, what is the next step in treatment? - -1. PPIs. Typically
start with once a day and can increase to BID as needed (can be hard to
get insurance approval though)
Caution w/ C Diff (can trigger), okay for osteoporosis/Plavix (used to
think otherwise)
You start your patient on a PPI for GERD. When do you wanna follow
up? If they are still having symptoms, what's your next step? - -f/u in 8
weeks
add a H2 blocker, these are better for breakthrough use though as body
can adjust and not respond as well
Your patient is maxed out on PPIs for GERD and has also tried adding
H2 blockers and prn antacids. What's the next step? - -They require
endoscopic evaluation
Your patient has tried everything for their GERD and you are wondering
if they are a candidate for surgery. What is required first? - -pH probe
may want to order and refer to GI
Your patient did not have GERD prior to gaining weight. They are now in
the obese category. Nothing has helped their GERD and they want
surgery. What surgery might you recommended? - -bariatric surgery
if obese, this is more appropriate than the GI surgeries like Nissens,
endocinch, strettas, etc because the cause is likely the weight
, You thought your patient had GERD but you've maxed them on PPIs
and you're realizing that their symptoms are a little atypical for what
you usually see with GERD. What is the next step? - -Refer out
ENT, pulmonary, allergy, etc
not likely GERD but something along these lines
What populations are you automatically concerned about with
gastroenteritis? - -older adults, children
Name some objective findings that would concern you for dehydration
in your gastroenteritis patient. - -Tachycardia, dry mucus membranes,
hypotension, dizziness
Name some tests you could run on someone's stool if they are having
severe symptoms that are persisting beyond the usual 1-3 days. - -Fecal
leukocytes (positive in most bacterial infections like E Coli, Shigella,
Salmonella, C diff)
Stool Culture (encouraged if positive fecal leukocytes, 103 degree fever,
severe diarrhea, bloody diarrhea, etc)
Stool for ova or parasites (esp if in daycare or travel to Russia/Nepal)
Which patients with diarrhea should not use antimotility drugs? - -those
with fevers, bloody diarrhea, or positive fecal leukocytes
Pepto bismol is a good choice when having gastroenteritis because - -it
is both antimicrobial and antimotility
Who are some populations that will require antibiotics with
gastroenteritis? - -Daycare worker or child
Fever, chills, weight loss, night sweats
>6/dayof diarrhea, salmonella, shigella, campylobacter confirmed
What is the antibiotic of choice for gastroenteritis (if required)? How do
you start it/adjust it? - -Cipro
Start immediately if positive fecal leukocytes
Send stool for culture, adjust as needed
Your patient has had gastroenteritis symptoms for >2 weeks and has
been unresponsive to any treatments. What do you suspect and what do
you prescribe? - -likely a protozoa (giarrdia?)
prescribe Flagyl
What would you want to educate your patient with gastroenteritis on in
regards to when to be concerned/call for help? - -vomiting and fever,
severe abdominal pain, headache, neck pain, lethargy, diminished or
dark UOP, dizziness, lightheadedness, vomiting blood or coffee ground
emesis, bloody diarrhea
3 main causes of peptic ulcer disease - -1. H pylori
2. Nsaids
, 3. Acid hypersecretion
Is a physical exam helpful in diagnosing PUD? - -no
Name some risk factors for PUD. - -smoking, aspirin, NSAIDs, H pylori,
FH, COPD, steroids, trauma, caffeine, alcohol, cirrhosis, physiologic
stress
Describe the symptoms patients with PUD will describe. - -Burning or
gnawing pain
Pain worsened by eating (gastric) or relieved (duodenal)
Episodic pattern, nocturnal pain
What physical exam findings would require you to send someone to the
ED that you may suspect has PUD? - -rigid abdomen or rebound
tenderness --> perf? peritonitis?
What is the gold standard for diagnosis of PUD? - -upper Gi endoscopy
How do you definitively diagnose H pylori? - -tissue biopsy
breath test and blood test do not differentiate between past and present
infection
When might a fasting gastrin level be helpful? - -in trying to figure out
why someone is having recurrent ulcers
indicative of Zollinger-Ellison syndrome (overproduction of gastric acid)
What is the drug of choice in managing PUD? What is next choice? - -
PPIs
heal 90% of ulcers within 4-8 weeks
next choice: h2 antagonists, slightly lower percent healed but less
expensive than PPIs. Be aware that they can affect metabolism of other
cytochrome P-450 drugs (warfarin, SSRIs)
What is the treatment for H pylori and who initiates it? - -PPI +
Clarithromycin + Amox/Flagyl depending on allergies
this is usually managed by GI
You start your patient with suspected PUD on PPIs and they follow up in
2 weeks with no improvement. What is your next step? - -Referral to GI
or endoscopy
Describe who with a peptic ulcer needs to be seen in the ED. - -anemia,
GI bleed s/s, rigid abdomen, weight loss, new onset dyspepsia, older
than 50 years
Which type of ulcer requires an endoscopy? Gastric or duodenal? - -
Gastric
increased incidence of gastric cancer
