GI

Burns: Pediatric Primary Care, 6th Edition

Chapter 33: Gastrointestinal Disorders

 

Test Bank

 

Multiple Choice

 

 

1. 1. A child is in the clinic after swallowing a metal bead. A radiograph of the GI tract shows a 6 mm cylindrical object in the child’s stomach. The child is able to swallow without difficulty and is not experiencing pain. What is the correct course of treatment? 

1. a. Administer ipecac to induce vomiting.
2. b. Have the parents watch for the object in the child’s stool.
3. c. Insert a nasogastric tube to flush out the object.
4. d. Refer the child for endoscopic removal of the object.

 

ANS: B

A small foreign body that is not corrosive or sharp and that has reached the stomach is most likely to continue to pass through the GI tract and no intervention is necessary. Inducing vomiting increases the risk of aspiration of the FB. NG tube removal and endoscopy are not indicated unless the object has the potential to damage the GI tract; most objects that are not sharp or corrosive that have reached the abdomen will pass through without causing damage.

 

 

1. 2. A toddler who was born prematurely refuses most solid foods and has poor weight gain. A barium swallow study reveals a normal esophagus. What will the primary care pediatric nurse practitioner consider next to manage this child’s nutritional needs?

1. a. Consultation with a dietician
2. b. Fiberoptic endoscopy evaluation
3. c. Magnetic resonance imaging
4. d. Videofluoroscopy swallowing study

 

ANS: D

A videofluoroscopy swallowing study will evaluate other structural defects that may interfere with swallowing and is relatively non-invasive. A dietician consult may be a part of the overall plan, but the toddler first needs a thorough evaluation of potential problems. Fiberoptic endoscopy is invasive. MRI may be performed if videofluoroscopy is inconclusive, but this is an expensive test.

 

 

1. 3. A school-age child has a 3-month history of dull, aching epigastric pain that worsens with eating and awakens the child from sleep. A complete blood count shows a hemoglobin of 8 mg/dL. What is the next step in management?

1. a. Administration of H2RA or PPI medications
2. b. Empiric therapy for H. pylori (HP)
3. c. Ordering an upper GI series
4. d. Referral for esophagogastroduodenoscopy (EGD)

 

ANS: D

EGD is the procedure of choice in children for detecting PUD because it allows direct visualization of mucosa, localization of the source of bleeding, and collection of tissue specimens. Empiric therapy for HP is not recommended due to increased antibiotic resistance. An upper GI series may have false negative findings. Once peptic ulcer disease is diagnosed, H2RA or PPI medications are first-line drugs.

 

 

1. 4. A 2-year-old child has an acute diarrheal illness. The child is afebrile and, with oral rehydration measures, has remained well hydrated. The parent asks what can be done to help shorten the course of this illness. What will the primary care pediatric nurse practitioner recommend?

1. a. Clear liquids only
2. b. Lactobacillus
3. c. Loperamide
4. d. Peppermint oil

 

ANS: B

Lactobacillus, given early in a viral diarrheal illness, can decrease the duration of diarrhea by about 25 hours and is safe to use in children. Parents should begin refeeding early to stimulate enterocyte growth and help facilitate mucosal repair. Loperamide may be given to children over the age of 3 years. Peppermint oil may help reduce cramping, but its efficacy is not certain.

 

 

1. 5. A school-age child has recurrent diarrhea with foul-smelling stools, excessive flatus, abdominal distension, and failure-to-thrive. A 2-week lactose-free trial failed to reduce symptoms. What is the next step in diagnosing this condition?

1. a. Lactose hydrogen breath test
2. b. Serologic testing for celiac disease
3. c. Stool for ova and parasites
4. d. Sweat chloride test for cystic fibrosis

 

ANS: B

This child has symptoms consistent with celiac disease, especially FTT and foul-smelling stools. Since the lactose-free trial did not reduce symptoms, the likelihood of lactose intolerance is less and thus testing is not likely to be helpful. The symptoms are recurrent, so giardiasis is less likely. CF is still possible, but most children with CF are diagnosed as infants and have accompanying respiratory symptoms of some type.

 

 

1. 6. A 12-month-old infant exhibits poor weight gain after previously normal growth patterns. There is no history of vomiting, diarrhea, or irregular bowel movements, and the physical exam is normal. What is the next step in evaluating these findings?

1. a. Complete blood count and electrolytes
2. b. Feeding and stooling history and 3-day diet history
3. c. Stool cultures for ova and parasites
4. d. Swallow study with videofluoroscopy

 

ANS: B

Vomiting, diarrhea, and bowel irregularities are more predictive of organic causes of FTT, which are not present in this infant. A careful history and physical examination and limited laboratory evaluation are the first steps unless there is reason to think that an organic cause is present. The fact that the infant was previously gaining weight appropriately makes a swallowing disorder less likely.

 

 

1. 7. The parent of an infant asks about using a probiotic medication. What will the primary care pediatric nurse practitioner tell this parent?

1. a. Probiotic medications have demonstrated efficacy in treating colic.
2. b. Probiotics are not safe to use to treat infants who have colic.
3. c. There are no studies showing usefulness of probiotics to manage colic.
4. d. There is no conclusive evidence about using probiotics to treat colic.

 

ANS: D

While small studies have shown promise in treating colic in infants, the research is contradictory and there is no conclusive evidence about effectiveness. There is no evidence that probiotics are not safe.

 

 

1. 8. A child is diagnosed with Crohn disease. What are likely complications for this child?

1. a. Cancer of the colon and possible colectomy
2. b. Intestinal obstruction with scarring and strictures
3. c. Intestinal perforation and hemorrhage
4. d. Liver disease and sepsis

 

ANS: B

Intestinal obstruction with scarring and strictures are the major complications of CD. The other answers describe complications of ulcerative colitis.

 

 

1. 9. A toddler is seen in the clinic after a 2-day history of intermittent vomiting and diarrhea. An assessment reveals an irritable child with dry mucous membranes, 3-second capillary refill, 2- second recoil of skin, mild tachycardia and tachypnea, and cool hands and feet. The child has had two wet diapers in the past 24 hours. What will the primary care pediatric nurse practitioner recommend?

1. a. Anti-diarrheal medication and clear fluids for 24 hours
2. b. Bolus of IV normal saline in the clinic until improvement
3. c. Hospital admission for IV rehydration and oral fluids
4. d. Oral rehydration solution with follow-up in 24 hours

 

ANS: D

This child has mild to moderate dehydration, according to vital signs and symptoms, and may be managed with oral rehydration solution with good follow-up. Anti-diarrheal medications are generally not useful, but antiemetics may be used. It is not necessary to administer IV fluids or to hospitalize unless more severe dehydration occurs.

 

 

1. 10. A 2-month-old infant cries up to 4 hours each day and, according to the parents, is inconsolable during crying episodes with fists and legs noted to be tense and stiff. The infant is breastfeeding frequently but is often fussy during feedings. The physical exam is normal and the infant is gaining weight normally. What will the primary care pediatric nurse practitioner recommend?

1. a. A complete work-up, including laboratory and radiologic tests
2. b. Eliminating certain foods from the mother’s diet
3. c. Empiric treatment with a proton pump inhibitor medication
4. d. Stopping breastfeeding and beginning a hydrolyzed formula

 

ANS: B

A first step in a breastfeeding infant with symptoms of colic should be to try eliminating certain foods such as cow’s milk products, nuts, eggs, and fish from the mother’s diet to see if improvement occurs. It is not necessary to stop breastfeeding; hydrolyzed formulas may be tried in formula-fed infants. An infant with a normal exam and normal weight gain does not need further diagnostic studies. PPIs are not indicated as first-line therapy.

 

 

1. 11. A school-age child has had abdominal pain for 3 months that occurs once or twice weekly and is associated with a headache and occasional difficulty sleeping, often causing the child to stay home from school. The child does not have vomiting or diarrhea and is gaining weight normally. The physical exam is normal. According to Bishop, what is included in the initial diagnostic work-up for this child?

1. a. CBC, ESR, amylase, lipase, UA, and abdominal ultrasound
2. b. CBC, ESR, CRP, and fecal calprotectin
3. c. CBC, ESR, CRP, UA, stool for ova, parasites, and culture
4. d. Stool for H. pylori antigen and serum IgA, IgG, tTg

 

ANS: A

Bishop suggests these labs as an initial approach in children suspected of having functional abdominal pain, along with a 3-day trial of a lactose-free diet. Fecal calprotectin is added if the child has changes in stool habits suggestive of inflammatory changes in the intestinal tract. Answer C is correct according to Rasquin’s recommendations as is stool for H. pylori antigen.

 

 

1. 12. An 18-month-old child has a 1-day history of intermittent, cramping abdominal pain with non-bilious vomiting. The child is observed to scream and draw up his legs during pain episodes and becomes lethargic in between. The primary care pediatric nurse practitioner notes a small amount of bloody, mucous stool in the diaper. What is the most likely diagnosis?

1. a. Appendicitis
2. b. Gastroenteritis
3. c. Intussusception
4. d. Testicular torsion

 

ANS: C

Intussusception is characterized by intermittent pain associated with drawing up the legs, “currant jelly” stools, and lethargy in between episodes. Appendicitis is characterized by pain localizing to the RLQ and is not intermittent. Gastroenteritis is likely when vomiting precedes symptoms of pain or discomfort. Testicular torsion involves the testicles and thus has different physical findings and would not be accompanied with bloody stools.

 

 

1. 13. A 9-year-old girl has a history of frequent vomiting and her mother has frequent migraine headaches. The child has recently begun having more frequent and prolonged episodes accompanied by headaches. An exam reveals abnormal eye movements and mild ataxia. What is the correct action? 

1. a. Begin using an anti-migraine medication to prevent headaches.
2. b. Prescribe ondansetron and lorazepam to help manage symptoms.
3. c. Reassure the parent that this is expected with cyclic vomiting syndrome.
4. d. Refer to a pediatric gastroenterologist for further workup.

 

ANS: D

This child has an abnormal neurologic examination, which is a red flag warranting referral for further workup for children with cyclic vomiting syndrome. Anti-migraine medications are used in children over age 12 years and therefore should not be used for this patient. Ondansetron and lorazepam may be useful for unrelenting nausea and poor sleep, but this child needs to be referred to evaluate neurologic symptoms. These signs are not expected.

 

 

1. 14. A 10-year-old child has had abdominal pain for 2 days, which began in the periumbilical area and then localized to the right lower quadrant. The child vomited once today and then experienced relief from pain followed by an increased fever. What is the likely diagnosis?

1. a. Appendicitis with perforation
2. b. Gastroenteritis
3. c. Pelvic inflammatory disease (PID)
4. d. Urinary tract infection (UTI)

 

ANS: A

The child has the progression of symptoms typical of appendicitis with perforation – pain before vomiting that localizes to the RLQ and then relief of pain with onset of fever upon perforation. With gastroenteritis, vomiting precedes pain. PID symptomology includes increasing pain over time. The symptoms of an UTI include fever, chills, and urinary symptoms.

 

 

1. 15. The parent of a 3-month-old reports that the infant arches and gags while feeding and spits up undigested formula frequently. The infant’s weight gain has dropped to the 5th percentile from the 12th percentile. What is the best course of treatment for this infant?

1. a. Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks.
2. b. Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI).
3. c. Perform esophageal pH monitoring to determine the degree of reflux.
4. d. Reassure the parent that these symptoms will likely resolve by 12 to 24 months.

 

ANS: A

Formula-fed infants may be given a trial of a hydrolyzed protein formula to see if improvement occurs. An empiric trial of a PPI may be used in children and adolescents but is not recommended in infants. Esophageal pH monitoring may be performed in consultation with a specialist but not as first-line evaluation. The infant has warning signs of GERD that require further investigation and not just reassurance.

 

 

1. 16. An adolescent is diagnosed with functional abdominal pain (FAP). The child’s symptoms worsen during stressful events, especially with school anxiety. What will be an important part of treatment for this child?

1. a. Informing the parents that the pain is most likely not real
2. b. Instituting a lactose-free diet along with lactobacillus supplements
3. c. Teaching about the brain-gut interaction causing symptoms
4. d. Using histamine2-blockers to help alleviate symptoms

 

ANS: C

This child has symptoms associated with stress, and treatment should be aimed at biobehavioral methods, beginning with teaching about the brain-gut interaction. Even though the pain is functional, it is real. Lactose-free diets and lactobacillus supplements may be used with documented lactose intolerance, although there is a lack of high-quality evidence of their effectiveness. H2-blockers should not be used unless dyspepsia is present.