Question #1 by Elizabeth Diaz

During the school day, a 12-year-old male student comes to the nurse’s office complaining of severe pain in his scrotum. He reports that he was tackled while playing football at recess yesterday, and while the pain started then, it has gotten worse overnight. He is now walking hunched over, appears pale and distressed, and is cupping his genital area. He denies nausea but says the pain is “really bad” and not going away.

• 1. What serious condition should be suspected based on this student’s symptoms, and why is urgent medical evaluation important?

• 2. What immediate steps should the school nurse take to assess and respond to this situation, considering the potential for the condition?

• 3. What key health education points should be shared with the student and family to prevent delayed reporting and promote future awareness of testicular health?

Model Answer:

1. The nurse should suspect testicular torsion. It’s considered an emergent condition that requires intervention right away. The spermatic cord twists, cutting off blood supply to the testicle. Since the pain is still present and has gotten worse, it indicates ischemic damage. Irreversible damage can happen within 6 hours of injury. Delays in treatment can lead to testicular loss, infertility, or future complications related to hormonal and psychological health

2. The school nurse’s office is busy, and the student should be provided privacy. An assessment should include, asking: the onset of pain, is there swelling, is there discoloration, referral to a provider, contact family. If family not available, follow the district policy. 

3. The nurse should let family know that prolonged testicular pain is not typical, and it should be addressed right away. Educate about testicular torsion and its implications if not treated within a timely manner such as loss of fertility and/or testicular removal. Encourage use of sports appropriate protective equipment while playing sport. 

The Intention of the Question: 

The intent of the question is to recognize critical symptoms and prioritize urgent care while educating family about probable condition. 

References

American Academy of Pediatrics. (2022). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.

American Urological Association. (2023). Testicular torsion. Testicular Torsion: Symptoms, Diagnosis & Treatment - Urology Care Foundation 

KidsHealth from Nemours. (2023). Testicular torsion. https://kidshealth.org/en/parents/torsion.html 

Ringdahl, E., & Teague, L. (2006). Testicular torsion. American Family Physician, 74(10), 1739–1743. https://www.aafp.org/pubs/afp/issues/2006/1115/p1739.html 

Model Answer:

1. Several strategies can be employed to promote an environment of inclusivity, respect, and dignity for Kiry including:

• Using only surnames in the waiting room

• Including my pronouns when introducing myself

• Confirming the patient’s name and pronouns and doing this in a private and confidential manner

• Communicate the patient’s name and pronouns to everyone providing care

• Respectfully correct anyone who dead names or misgenders the patient

• Conducting an organ survey with sensitivity (acknowledging certain body parts can be distressing for non-binary or gender-queer people)

• Have a patient-centered conversation regarding the steps of the exam and how the team can maintain the patient's safety and comfort, physically and mentally

• Ask the patient if they want a support person present during the exam

• Ensure all steps of the exam are explained as to why and how

• Ensure permission is asked before the patient is touched

• Do a thorough medication reconciliation with the patient to ensure selected treatment is appropriate (Jardine et al., 2024).

2. Candida vulvovaginitis – yeast infection (Sobel & Mitchell, 2024)

3. While miconazole is cheap and available over the counter, Kiry may struggle with applying the cream inside their vagina if they experience distress with this aspect of their body. Oral antifungals like fluconazole could be considered as an alternative (Sobel, 2024). Kiry’s insurance status, their ability to pay for this medication, and their comfort with accessing a pharmacy can be discussed to determine the best option. 

The Intention of the Question: 

The primary goal of the question is to learn about non-binary and gender-queer people, the health inequities they experience, and what providers can do to mitigate these inequities during clinical visits. The student nurse must consider their knowledge of clinical manifestations of a disease process while primarily keeping the patient’s mental health at the forefront of the clinical exchange. 

References

Jardine, L., Edwards, C., Janeway, H., Krempasky, C., Macias-Konstantopoulos, W., Whiteman, P., & Hsu, A. (2024). A guide to caring for patients who identify as transgender and gender diverse in the emergency department. Journal of the American College of Emergency Physicians open, 5(3), e13217. https://doi.org/10.1002/emp2.13217 

Sobel, J.D. (2024, December 16). Candida vulvovaginitis in adults: Treatment of acute infection. UpToDate. Retrieved May 26, 2025, from https://www-uptodate-com/contents/candida-vulvovaginitis-in-adults-treatment-of-acute-infection 

Sobel, J.D., & Mitchell, C. (2024, April 10). Candida vulvovaginitis: Clinical manifestations and diagnosis. UpToDate. Retrieved May 25, 2025, from https://www-uptodate-com/contents/candida-vulvovaginitis-clinical-manifestations-and-diagnosis 

Taylor, D. (2021, July 16). As doctors, we must do better to provide healthcare for trans and nonbinary patients. Rewire News Group. https://rewirenewsgroup.com/2021/07/16/as-doctors-we-must-do-better-to-provide-health-care-for-trans-and-nonbinary-patients/ 

Question #3 by Suman Roy

A Pregnant patient in her first trimester presents with severe lower abdominal pain and vaginal bleeding that began two days ago and has progressively worsened. She reports the pain is now at a level of 10/10. In the ER, the attending physician orders a vaginal ultrasound to assess the viability of the pregnancy and B-hCG test. However, while awaiting the results, the patient’s condition worsens. Her pain becomes increasingly unbearable, and she starts to vomit profusely. Ultrasound results come in and patient was taken to the OR for an emergency procedure. 

Hx: endometriosis, Hypothyroidism , current smoker

Please provide general overviews of the questions as this topic is quite broad. Based on the scenario: 

• 1. What likely led to the emergency procedure? Briefly explain the findings of the vaginal ultrasound. 

• 2. What is the role of beta-human chorionic gonadotropin in confirming pregnancy and how might abnormal levels relate to the ultrasound findings in this scenario? 

• 3. What would you monitor and assess after the patient returns from the procedure?

Model Answer:   

The patient was experiencing symptoms related to ectopic  pregnancy, mainly ruptured ectopic pregnancy, most likely in the fallopian tube. Ectopic pregnancy occurs when the implantation of the fertilized ovum outside of the uterine cavity. The most common location is the ampulla of the fallopian tube. The current diagnosis of ectopic pregnancy is vaginal ultrasound and B-hCG ( Beta-human chorionic gonadotropin. a hormone produced by the placenta shortly after the embryo attaches to the uterine lining. Abnormal level can indicate complications such as a miscarriage or an ectopic pregnancy. Normal level of B-hCG range from 5 mIU/ML to over 100,000 mIU/ml in early pregnancy. The vaginal ultrasound  showed: no intrauterine pregnancy, despite a positive pregnancy test. possibly a mass or gestational sac outside the uterus, free fluid in the abd or pelvis which indicate internal bleeding from a ruptured tube. these findings prompt emergency surgical intervention like laparoscopic salpingectomy to control bleeding and remove the ectopic tissue. 

B-hCG is a hormone produced by the placenta shortly after the embryo attaches to the uterine lining. Abnormal level can indicate complications such as a miscarriage or an ectopic pregnancy. Normal level of B-hCG range from 5 mIU/ML to over 100,000 mIU/ml in early pregnancy. in a normal intrauterine pregnancy, B-hCG level typically double every 48-72 hrs. 

In ectopic pregnancy, the levels may not rise as expected or they may rise slowly. This abnormal rise or plateau in B-hCG along with the symptoms , can help guide clinicians toward a diagnosis of an ectopic pregnancy. 

Post Op management of the patient includes monitoring vital sign: Hemodynamically instability not common in laparoscopic procedure but hypovolemia or shock can occur.  monitor bleeding and initiate measures to prevent shock. Pain management is the most appropriate assessment and intervention. Pain can be the sign of surgery going wrong as well. If the pain is not relieved by the pain medication, immediately call the Obgyn for further evaluation. Hemoglobin/Hematocrit for blood loss, surgical site for infection. most importantly emotional support as this can be a traumatic experience and follow up B-hCG levels to ensure that all pregnancy tissue was removed.  

The Intention of the Question: “Ectopic pregnancies are the leading causes of mortality in the first trimester, with an incidence of  5% to 10% of all pregnancy-related deaths ( Mullany et al., 2023).” Diagnosing an ectopic pregnancy can be challenging because its symptoms, like abdominal pain and vaginal bleeding, can be similar to other conditions. The standard way to diagnose it is through transvaginal ultrasound imaging and monitoring levels of B-human chorionic gonadotropin. Most importantly psychological support which is often forgotten. 

References

Mullany, K., Minneci, M., Monjazeb, R., & C Coiado, O. (2023). Overview of ectopic pregnancy diagnosis, management, and innovation. Women's Health (London, England), 19, 17455057231160349. https://doi-org./10.1177/17455057231160349 

Farquhar C. M. (2005). Ectopic pregnancy. Lancet (London, England), 366(9485), 583–591. https://doi-org./10.1016/S0140-6736(05)67103-6 

Question #4 by Teighler Gella

Quinn, a 30-year-old female, presents to a clinic with complaints of chronic lower abdominal and pelvic pain, especially during her menstrual periods. She reports that the pain radiates to her lower back and has progressively worsened over the past two years. She also experiences pain during intercourse and has been unsuccessfully trying to conceive for over a year. During your nursing assessment, she rates her pain as 8/10 during menstruation and appears visibly uncomfortable when discussing her symptoms. She states she takes Tylenol for the pain, but it doesn’t help, and it interferes with daily activities. 

• 1. What is the most likely diagnosis? Why? (hint: include risk factors and symptoms)

• 2. What is one of the diagnostic approaches that would help support suspicion or confirm the diagnosis? (State one method and a sentence on what it looks for)

• 3. What two pieces of education could you provide the patient regarding management? (Answers can include pharmacological interventions, surgical interventions, or supportive resources. Give 1-2 sentences on when and why each intervention is used)

Model Answer:

• 1. Quinn most likely has endometriosis. Endometriosis occurs predominantly in females 25 to 35 years of age and commonly presents as chronic abdominal/pelvic pain, severe dysmenorrhea, painful intercourse, heavy menstrual bleeding, and infertility. Other symptoms can include bowel and bladder dysfunction, low back pain, and chronic fatigue.

• 2. Diagnostic approaches include:

  • a. Vaginal examination – findings of tender nodules along the uterosacral ligaments, adnexal

  • b. Transvaginal ultrasound – ovarian endometriomas

  • c. Abdominal ultrasound – deep endometriosis

  • d. Laparoscopy – visualize endometrial lesions

  • e. MRI – bowel endometriosis, thoracic endometriosis

  • f. Tissue biopsy – usually from laparoscopy

  • g. Presumption using symptoms, signs, and imaging

• 3. Treatments include:

  • a. Pharmacological treatment

    • i. NSAIDs + continuous hormone contraceptives – NSAIDs manage pain, while contraceptives prevent excess growth of endometrial tissue

    • ii. GnRH agonist or antagonists – added on if NSAIDs + hormone therapy doesn’t improve symptoms

  • b. Supplemental treatment

    • i. Pelvic Floor Therapy – complementary therapy, reduces pain from pelvic muscle spasm

    • ii. Acupuncture – treats dysmenorrhea

  • c. Surgical intervention

    • i. Ablation, lysis, or excision of superficial lesions – reduce heavy bleeding

    • ii. Excision of ovarian endometrioma – removes cysts, relieves pain, addresses fertility issues

    • iii. Hysterectomy – eliminates the source of the menstrual cycle and associated pain

  • d. Referral to a fertility specialist

  • e. Suggest support groups

The Intention of the Question: 

Endometriosis is often misdiagnosed or underdiagnosed due to a lack of awareness, even among healthcare providers. Although I don’t have personal or professional experience with endometriosis, I think it’s important to recognize the symptoms, advocate for patients, and challenge the stigma surrounding menstruation and pelvic pain.

References

Ball, J. E., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier.

Lebovic, D. (2024). Endometriosis: surgical management of pelvic pain. UpToDate. Retrieved from https://www-uptodate-com/contents/endometriosis-surgical-management-of-pelvic-pain 

Schenken, R. (2025) Endometriosis in adults: clinical features, evaluation, and diagnosis. UpToDate. Retrieved from https://www-uptodate-com/contents/endometriosis-in-adults-clinical-features-evaluation-and-diagnosis 

Warren, M., Greathouse, E., Fedorowicz, Z., & DeGeorge, K. (2025) Endometriosis. DynaMedex. Retrieved from https://www-dynamedex-com/condition/endometriosis 

Question #5 by Norma De Leon 

You are a nurse in an OB/GYN office. The patient is a 32 year old female here for a new problem visit. She is coming out of concern that she has been trying to conceive with her male partner for the past nine months without success. She is tracking her irregular cycles and the couple is having timed intercourse when her cervical fluid is egg-white consistency. She does report very painful periods since menarche at age 13. This past cycle she has had some intermittent LLQ pain bloating. Her in-office pregnancy test is negative. 

• 1. Is she experiencing infertility?

• 2. When considering possible causes of her symptoms and presentation, list at least two disorders your patient might be facing. Describe them and include additional assessments or questions that would help support your differential. 

• 3. What diagnostics evaluations do you anticipate today or in the future?

Model Answer:

1. No, not yet. Infertility is defined after 1 year of timed intercourse. 

2. She could be experiencing PCOS – Polycystic ovarian syndrome, which causes delay and infrequent ovulation, and is a result of hormone imbalance. It is the most common endocrine pathology in females of reproductive age, affecting 5-26% of females (Shukla et al., 2025) I would want to know more about her cycle length, regularity, her weight, vitals, and previous medical history including medications. I would prepare her for lab draw today and an outpatient pelvic ultrasound. PCOS has a string of pearls appearance on ultrasound (Shukla et al., 2025)

Additionally, her dysmenorrhea suggests endometriosis. The intermenstrual pain is a clue and I would ask if she has pain with intercourse of bowel movements. I would ask about menstrual cycle length again, and how heavy her flow is. I would ask about intermenstrual bleeding. Endometriosis is a common cause of infertility, affecting about 10 to 15% women, defined by endometrial cells in anatomical positions and organs outside the uterus (Tsamantioti & Mahdy, 2023). Chronic pelvic pain is a symtpom. Laparoscopy is the definitive diagnostic tool, but blood filled ovarian cysts are visible on pelvic ultrasound. 

3. We anticipate labs for hormone levels, likely a pelvic ultrasound to start, and if her assessment and or ultrasound suggest endometriosis, she might need a laparoscopy. 

The Intention of the Question: 

I asked these questions to bring awareness to infertility and reproductive disorders. A diagnosis of endometriosis often comes after several years of suffering and medical gaslighting. I was told by my own OB/gyn that the ultrasound she was ordering was unlikely to find anything, and it did in fact find endometriosis. Lets listen to our patients and help them find answers to improve their quality of life and reach their goals. 

References

Shukla, A., Rasquin, L.I., & Anastasopoulou, C. (2025, May 4). Polycystic Ovarian Syndrome. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK459251/ 

Tsamantioti, E.S., & Mahdy, H. (2023, January 23). Endometriosis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK567777/ 

Model Answer:

1. TPE stands for total pelvic exenteration. This procedure can often be a curative option for reproductive-based cancer because the cancer can be resected entirely with adequate margins to prevent the disease from spreading in the lymph, blood, or peritoneal pathways (Mann, 2023). As long as the patient’s cancer is confined to the pelvic cavity and they are a candidate, this can be a curative option, but it does come with major lifestyle changes. 

2. cervix, vagina, uterus, fallopian tubes, ovaries, parametrium, bladder, rectum, anus, colon, urethra (Mann, 2023)

3. There are many postoperative and patient care considerations related to this surgery. Some of the options include the following. 

• Mental Health – Having a TPE is a significant procedure that also requires extensive body changes that can have a cosmetic impact on the patient (Mann, 2023). Patients need a strong support system, mental health, and access to continued medical care to have this procedure done (Mann, 2023). Though this procedure has the benefit of curing their cancer, the consequence is now having to change their way of life completely, especially when having 2 ostomies and voiding/defecating is different. 

• Ostomy/Drains – Since the bladder, bowel, rectum, and anus are removed during this surgery, patients will have both a urostomy and a colostomy/ileostomy (Mann, 2023). Having new ostomies requires significant patient teaching regarding how to change the ostomy appliance, how often to empty the bags, knowing the signs of a healthy vs unhealthy stoma, and nutrition. Patients may also have drains, such as a JP, in various areas of their abdomen, which can be removed as healing progresses (Mann, 2023).

• Infection—Due to the number of incision sites required during this surgery, patients have a high chance of developing an infection. Therefore, patients must take prophylactic antibiotics if prescribed and monitor incision sites for signs of infection, such as swelling, redness, irritation, and fever (Cleveland Clinic, 2022). 

• Nutrition—Nutrition is important for healing, but the introduction of food can vary since developing an ileus can be common after surgery. The patient’s diet should be advanced slowly, as the provider recommends. Some patients may also be started on TPN if providers want them to be on bowel rest for a longer period of time (Mann, 2023). 

• Pain – A TPE is an extensive abdominal procedure, and many patients have high amounts of postoperative pain. Patients are often on narcotics and can stay in the hospital for extensive amounts of time for assistance with pain management and other postoperative care/education (Cleveland Clinic, 2022). Pain should be managed and not hinder the patient’s mobility and ability to start participating in daily activities.

The Intention of the Question: 

I wrote this question on TPEs because I work with oncology patients, specifically gyn-onc patients. TPEs are not a common procedure but I remember being a new grad nurse and caring for a patient with a TPE for the first time. It is a procedure that I had never considered existing prior to working in oncology and found it to be very interesting because it’s a curative option if patients meet the surgical criteria. 

References

Cleveland Clinic. (2022). Pelvic Exenteration. Retrieved May 22, 2025, from https://my.clevelandclinic.org/health/treatments/22455-pelvic-exenteration 

Mann, W. J. (2023). Exenteration for gynecologic cancer. UpToDate. Retrieved May 22, 2025, from https://www.uptodate.com/contents/exenteration-for-gynecologic-cancer 

Question #7 by Jack Jorgensen

A 14-year-old girl named Stella presents to the emergency department with acute onset right lower quadrant abdominal pain, nausea, and vomiting. Her pain began approximately 6 hours ago and has progressively worsened. On assessment, she has guarding and rebound tenderness in the right lower quadrant. She has not yet started menstruating but reports intermittent lower abdominal cramping over the past week.

Briefly: What are your priority nursing assessments (2 points) and interventions (2 points)? What tests/imaging do you anticipate differentiating between ovarian torsion and appendicitis (2 points). What are two pharmacological interventions you might anticipate (2 points)? How might this case be managed differently between pediatrics and adults? (2 points)

Model Answer:

Assessments: Focused abdominal assessment, detailed pain assessment, menstrual and sexual history

Interventions: Initiate NPO status, PIV access, provider communication

Anticipated Tests/Imaging: Blood tests (CBC, CMP, CRP), pregnancy test, urinalysis, pelvic and abdominal ultrasound

Pharmacology: IV Analgesics (morphine, Tylenol), antibiotics, antiemetics, IV fluids

Pediatrics vs. Adults: transvaginal US is more standard and is the gold standard for diagnosing in adults, pelvic (external) is more appropriate in most pediatric cases – bladder must be full to evaluate the ovaries this way – prompt fluid bolus measures can be used. Communication with patient RE sexual history may be sensitive and should be had separately from parents/caregivers; developmentally appropriate assessments (including pain); weight based dosing of medications

The Intention of the Question: 

This is a common occurrence in the pediatric ED. Urgent intervention is needed to differentiate between appendicitis and ovarian torsion as the patient is at risk for worsening condition (burst appendix), sepsis, and infertility. It is important for ED nurses to anticipate the interventions and appreciate the urgency behind them to initiate the treatment/test process and advocate for prompt imaging. 

References

Brandt, M. L., & Lopez, M. E. (2024). Acute appendicitis in children: Clinical manifestations and diagnosis. UpToDate. Retrieved May 24, 2025, from https://www.uptodate.com/contents/acute-appendicitis-in-children-clinical-manifestations-and-diagnosis 

Berek, J. S. (2024). Ovarian and fallopian tube torsion. UpToDate. Retrieved May 24, 2025, from https://www.uptodate.com/contents/ovarian-and-fallopian-tube-torsion

Question #8 by Muskan Priya

A 14-year-old client with cerebral palsy and a right-sided shunt is experiencing persistent vomiting and has not had a bowel movement in over 36 hours. Client has vomited multiple times in an hour period and is requiring constant suctioning. He is showing signs of discomfort, including intermittent crying, swinging his hands, and he is unable to verbally communicate his needs. He is severely malnourished and receives continuous 24-hour GJ tube feeds, with only short pauses for medication administration. Despite receiving Miralax, an enema and Tylenol, client is still showing signs of discomfort and no bowel movement. 

Client is taken to the ED for a workup. You are giving report to the ED nurse on client’s medications. Here is a list of his medications: metoclopramide, docusate, levetiracetam, miralax, and erythromycin.

Given his symptoms and risk factors, could this be an indication of acute pancreatitis? What labs and assessments are necessary to confirm that the client has pancreatitis? 

Model Answer:

Yes, this could be a potential sign of acute pancreatitis due to his persistent vomiting, severe constipation and maybe abdominal pain because client received Tylenol for his pain. Also, client is receiving medication for his gut motility which isn’t effective at this time. His severe malnutrition can be affecting his pancreatic involvement. 

The labs that are necessary at this time are serum amylase and lipase, CBC, electrolyte balances, elevated liver enzymes (ALT/AST, ALP), lactic acid for risk for infection.

It is important to monitor client’s bowel sounds, any tenderness in his abdomen, monitor his vomiting, urine output, bowel activity, his skin turgor for hydration and monitor for any pain. 

The Intention of the Question: 

This is one of the clients that came to my facility out of the blue. We didn’t know anything about him besides the fact that he is extremely malnourished. Client has been in and out of the SCH ED due to his persistent vomiting. He had many days where he would continuously be throwing up for hours at time. He had no breakthrough medications that helped stop his vomiting. Client had been on TPN at the hospital when they had found out he had acute pancreatitis. 

References

Gapp, J., & Chandra, S. (2023). Acute pancreatitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482468/PMC+1PMC+1 

Johns Hopkins Medicine. (n.d.). Pancreatitis in children. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pancreatitis-in-children 

Model Answer:

The development of acute appendicitis is thought to be due to processes that increase intraluminal pressure and compromise venous outflow, resulting in mucosal necrosis and acute inflammation. As the disease progresses, the inflammatory process spreads through all layers of the appendiceal wall. The necrosis and inflammation may lead to gangrene of the appendix and ultimately perforation, which is often associated with abscess formation. In most cases of appendicitis, pain is first referred to the epigastric or umbilical region because the enlargement of the appendix leads to the stimulation of afferent visceral nerve fibers at the T8 to T10 spinal cord level.10 Since this pain is visceral rather than somatic in origin, it is referred pain that is poorly localized. Other symptoms that occur in the early stages of acute appendicitis include vomiting, nausea, and anorexia. Local tenderness over the appendix is often elicited after general abdominal pain has subsided. Tenderness is most often detected on deep palpation two-thirds of the distance from the umbilicus to the right anterior superior iliac spine, which corresponds to the base of the appendix (McBurney point). Tenderness that is elicited on palpation of the right lower quadrant indicates irritation of the parietal peritoneum, which stimulates somatic nerves causing pain at the site of irritation (Breeding & Conran, 2020)

Rovsing sign, initially described Niels Thorkild Rovsing (1862-1927), involves deep palpation at the left lower quadrant with a sliding motion directed proximally at the descending colon towards the splenic flexure. As described by Rovsing in 1907: “I wondered whether I could elicit the typical pain in the right iliac fossa by applying pressure at the left iliac fossa. This involves compressing the descending colon by pushing the fingers of my right hand onto the fingers of the left hand placed flat against the abdomen in the left iliac fossa. Using this method, the hands slide upward toward the left colonic flexure”. Thus, the maneuver involves more than simple palpation of the left iliac fossa as stated by the authors — it causes air within the colon to flow retrograde in response to compression, resulting in distension of the inflamed appendix and activation of a viscerosensory segmental reflex (Yale et al., 2022).

Acute appendicitis is more common in teenagers and young adults, although not exclusive to this group. With advancing age, it is important to include other pathologies in the list of differentials, albeit, the clinical signs should direct the clinician to the correct diagnosis (Chand, Moore, & Nash, 2007).

The Intention of the Question: 

We receive many cases of acute abdomen in the emergency department and personally have handled numerous cases of acute appendicitis.

References

Breeding, E., & Conran, R. M. (2020). Educational Case: Acute Appendicitis. Academic pathology, 7, 2374289520926640. https://doi.org/10.1177/2374289520926640 

Chand, M., Moore, P. J., & Nash, G. F. (2007). A simple case of appendicitis? An increasingly recognised pitfall. Annals of the Royal College of Surgeons of England, 89(7), W1–W3. https://doi.org/10.1308/147870807X227818 

Yale, S. H., Tekiner, H., & Yale, E. S. (2022). Signs and syndromes in acute appendicitis: A pathophysiologic approach. World journal of gastrointestinal surgery, 14(7), 727–730. https://doi.org/10.4240/wjgs.v14.i7.727 

Model Answer:

1. What is this patient’s most likely diagnosis? Please include rationale by using this patient’s clinical presentation. 3 points

The most likely diagnosis is peptic ulcer disease. Upper abdominal pain is the most prominent symptom in patients with peptic ulcers (Vakil, 2024). The patient has been experiencing this pain intermittently for the past 3 months, worse at night at 11 PM to 12 AM which is also indicative of duodenal ulcers where the “classic” pain occurs two to five hours after a meal when acid is secreted in the absence of a food buffer, and at night (between approximately 11 PM and 2 AM) when the circadian pattern of acid secretion is maximal (Vakil, 2024). 

Patients may also experience associated symptoms of bloating, abdominal fullness, nausea, and early satiety that may be provoked by eating (Vakil, 2024). Patients with uncomplicated peptic ulcers have a normal complete blood count which the patient had. The positive urea breath test helps in establishing the etiology of the peptic ulcer disease diagnosis which is a noninvasive test for Helicobacter pylori infection.

2. Considering the positive urea breath test, what medication regimen would you expect to be prescribed for this patient? 3 points

Eradication of H. pylori in patients with PUD is associated with higher healing rates in patients with duodenal ulcers (Vakil, 2024). First-line regimen for the initial treatment of H.pylori infection include the following (Any of the following answers will be considered correct):

• “Optimized” bismuth quadruple therapy (BQT): 10- to 14-day treatment course

  • Proton pump inhibitor (PPI) twice daily

  • High doses of bismuth subsalicylate, tetracycline, and metronidazole 500 mg three or four times daily

  • This can be a fixed-dose combination antibiotic capsule (Pylera) as a 10-day course or a 14-day course of the three antimicrobials as individual pills; combined with a twice-daily PPI taken 30 to 60 minutes before meals on an empty stomach to maximize acid suppression (Shah, et al., 2025)

• Low-dose rifabutin triple therapy

  • 14-day course of rifabutin 50 mg, amoxicillin 1 g, and omeprazole 40 mg three times daily (Shah, et al., 2025)

• Vonoprazan dual therapy

  • Voquezna Dual Pak, vonoprazan-amoxicillin (Shah, et al., 2025)

• Vonoprazan triple therapy

  • Voquezna Triple Pak, vonoprazan-amoxicillin-clarithromycin (Shah, et al., 2025)

3. The patient asks when she should schedule a follow-up appointment. What should you tell her? 

“Since your ulcer was most likely due to H. pylori as evidenced by the positive urea breath test, your health care provider will order another test to confirm that the infection is gone. We will make sure that we keep your primary care provider in the loop to schedule a follow-up appointment after a month, but not later than 2 months. A stool antigen or urea breath test will be performed four to eight weeks after the initial course of treatment is completed. The medications that will be prescribed to you can cause a “false-negative” test even if H. pylori is still present.” (Lamont, J. T., 2024) 

The Intention of the Question: 

In reading about conditions of the digestive tract, attention to H. pylori usually does not get attention and I was interested in this specific infection to learn more about it.

References

Ace Specialist Surgery & Endoscopy. (n.d.). Peptic ulcer symptoms, diagnosis, and treatment. Retrieved May 26, 2025, from https://www.acesurgery.sg/24-7-emergency/acute-peptic-ulcer-complications/ 

Lamont, J. T. (2024). Patient education: Peptic ulcer disease (Beyond the basics). UptoDate. Retrieved May 26, 2025, from https://www.uptodate.com/contents/peptic-ulcer-disease-beyond-the-basics 

Shah, S. C., Kao, J. Y., Moss, S. F. (2025). Treatment of Helicobacter pylori infection in adults. UptoDate. Retrieved May 26, 2025, from https://www.uptodate.com/contents/treatment-of-helicobacter-pylori-infection-in-adults    

Vakil, N. B. (2024). Peptic ulcer disease: Clinical manifestations and diagnosis. UptoDate. Retrieved May 26, 2025, from https://www.uptodate.com/contents/peptic-ulcer-disease-clinical-manifestations-and-diagnosis 

Vakil, N. B. (2024). Peptic ulcer disease: Treatment and secondary prevention. UptoDate. Retrieved May 26, 2025, from https://www.uptodate.com/contents/peptic-ulcer-disease-treatment-and-secondary-prevention 

Model Answer:

Part 1: Correct Answer: (C) Ulcerative Colitis

Explanation:

• Ulcerative Colitis: The presence of bloody diarrhea, lower abdominal pain, weight loss, and continuous inflammation extending from the rectum proximally are characteristic of Ulcerative Colitis.

Part 2: 

1. Initial Medical Management:

• Amino salicylates (5-ASAs): These medications (e.g., Mesalamine, Sulfasalazine) are often the first-line treatment for mild to moderate Ulcerative Colitis.

Purpose: Reduce inflammation in the colon lining. They can be administered orally or rectally (enemas, suppositories).

When Considered: Initial diagnosis, mild to moderate flares, and maintenance of remission.

• Corticosteroids: Medications like Prednisone or Budesonide.

Purpose: Potent anti-inflammatory drugs used to quickly control acute flares.

When Considered: Moderate to severe flares that don't respond adequately to 5-ASAs. Not for long-term maintenance due to side effects.

2. Immunomodulators:

• Azathioprine and 6-Mercaptopurine (6-MP):

Purpose: Suppress the immune system to reduce inflammation.

When Considered: For patients who are steroid-dependent or not responding to 5-ASAs. Can take several weeks to months to become effective.

• Cyclosporine:

Purpose: Another immunosuppressant.

When Considered: For severe flares, particularly when a rapid response is needed.

3. Biologic Therapies:

• TNF-alpha inhibitors (e.g., Infliximab, Adalimumab, Golimumab):

Purpose: Block the action of TNF-alpha, a protein that promotes inflammation.

When Considered: For moderate to severe Ulcerative Colitis that is not responding to other treatments.

• Integrin receptor antagonists (e.g., Vedolizumab):

Purpose: Prevent immune cells from migrating to the gut.

When Considered: Similar to TNF-alpha inhibitors, for moderate to severe disease.

• IL-12/23 inhibitors (e.g., Ustekinumab):

Purpose: Inhibits interleukin-12 and interleukin-23

When Considered: Moderate to severe ulcerative colitis.

• Janus kinase (JAK) inhibitors (e.g., Tofacitinib):

Purpose: Inhibit JAK enzymes involved in inflammation.

When Considered: For moderate to severe disease when other therapies have failed or are not tolerated.

4. Surgical Intervention:

• Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA or J-pouch):

Purpose: Removal of the entire colon and rectum, with the creation of an internal pouch from the small intestine that is connected to the anus, allowing for near-normal bowel function.

When Considered: Severe disease not responding to medical therapy, toxic megacolon, uncontrolled bleeding, dysplasia or cancer.

• Proctocolectomy with End Ileostomy:

Purpose: Removal of the colon, rectum, and anus, with the end of the small intestine brought to the abdominal surface as a permanent opening (stoma) for stool collection in an external bag.

When Considered: When IPAA is not possible or desired, or in cases of severe perianal disease.

5. Procedures and Monitoring Nataly will need.

• Colonoscopy:

Purpose: Visualize the colon, take biopsies, assess disease activity, screen for dysplasia (precancerous changes), and detect complications.

When Considered: Diagnosis, monitoring disease activity, screening for cancer (regular intervals depending on disease duration and extent).

• Fecal Calprotectin Testing:

Purpose: Measure inflammation in the intestines

When Considered: To monitor disease activity and response to treatment.

6. Supportive Care:

• Dietary Modifications: During flares, a low-fiber, easily digestible diet may be recommended. Nutritional support may be needed if there is significant weight loss or malabsorption.

The Intention of the Question: 

The intention of these questions is to enhance the understanding of Ulcerative Colitis (UC). It affects 5 million people globally and is a chronic and recurring inflammation of the gastrointestinal tract with clinical presentation of abdominal pain, chronic diarrhea, rectal bleeding, and weight loss, characterized by inflammation and ulceration of the colon and rectum. By exploring potential pharmacological and surgical interventions, as well as the necessity for ongoing monitoring, the goal is to illustrate the comprehensive approach to managing this condition. This includes understanding symptom management and the importance of regular monitoring through procedures like colonoscopies. Ultimately, these questions aim to provide a clearer picture of UC management, enabling a better understanding of the condition, treatment options, and long-term management strategies, leading to improved patient care and outcomes.

References

Ardizzone, S., Cassinotti, A., Manes, G., & Porro, G. B. (2010). Immunomodulators for all patients with inflammatory bowel disease? Therapeutic Advances in Gastroenterology, 3(1), 31-42. https://doi.org/10.1177/1756283X09354136 

Crohn's & Colitis Foundation. (n.d.). Overview of ulcerative colitis. Retrieved May 24, 2025, from https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ulcerative-colitis/overview 

Gajendran, M., Loganathan, P., Jimenez, G., Catinella, A. P., Ng, N., Umapathy, C., Ziade, N., & Hashash, J. G. (2019). A comprehensive review and update on ulcerative colitis. Disease-a-Month, 65(12), 100851. https://doi.org/10.1016/j.disamonth.2019.02.004 

Wangchuk, P., Yeshi, K., & Loukas, A. (2024). Ulcerative colitis: clinical biomarkers, therapeutic targets, and emerging treatments. Trends in Pharmacological Sciences, 45(10), 892-903. https://doi.org/10.1016/j.tips.2024.08.003 

Question #12 by Daysi Rodriguez

Barbie is a 25-year-old female with no significant past medical hx. She presents to the ED with complaints of intermittent lower abdominal pain, mild cramping, and bloating over the past several weeks. Denies fever, vomiting, or changes in bowel habits. Her VS are stable, and physical exam reveals mild tenderness in the lower abdomen without rebound or guarding. 

Her pelvic ultrasound and blood tests reveal no acute abnormalities. A colonoscopy was performed due to persistent symptoms and a family hx of colon polyps. Small polyps were found and scheduled for removal via a polypectomy. 

What is Barbies diagnosis and name the planned surgical procedure for this patient? 

Bonus* what is the significance of early detection of polyps for Barbie?

Model Answer:

Diagnosis:

Barbie is diagnosed with benign colorectal polyps. These are noncancerous growths in the lining of the colon which, if left untreated, could potentially progress to colorectal cancer.

Planned Procedure:

Polypectomy – a minimally invasive endoscopic procedure to remove polyps from the colon lining. This is typically performed during a colonoscopy using a wire loop and cautery to excise the polyps.

Bonus question answer: Prevent colon cancer 

The Intention of the Question: 

Barbie’s polypectomy serves as a reminder that early detection and removal of polyps can prevent colorectal cancer. A holistic nursing approach ensures that the patient receives comprehensive care, from assessment to recovery.

References

Erian, M. M., McLaren, G. R., & Erian, A. M. (2014). Advanced hysteroscopic surgery training. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 18(4), e2014.00396.10.4293/JSLS.2014.00396

Zauber, A. G., Winawer, S. J., O'Brien, M. J., Lansdorp-Vogelaar, I., van Ballegooijen, M., Hankey, B. F., Shi, W., Bond, J. H., Schapiro, M., Panish, J. F., Stewart, E. T., & Waye, J. D. (2012). Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. The New England journal of medicine, 366(8), 687–696. 10.1056/NEJMoa1100370

Model Answer:

1. EoE is a chronic response that occurs due to an immunologic reaction to antigens found in food or in the air. The esophagus physiologically lacks eosinophils, and when present, the condition is considered to be pathologic. The immunogenic process starts as an allergic response to various environmental antigens, food, or aeroallergens which leads to the inflammation of the esophageal mucosa (Roussel & Pandit, 2023). It is characterized by a significant presence of esophageal eosinophilia and esophageal dysfunction (Ryu et al., 2020). 

2. Sam’s medical history of seasonal allergies and atopic dermatitis, as well as his family’s history of EoE, as well as his reports of dysphagia and chest discomfort point toward a diagnosis of EoE.

3. Dietary elimination—like eliminating specific foods that are known to cause reaction may help. A six-food elimination diet may be prescribed which involves progressively eliminating foods with a high allergenic potential (cow’s milk, wheat, nuts, egg, soy, and seafood/shellfish). Pharmacologic treatment can include a trial of PPIs, topical (swallowed) steroids, or prednisone. Endoscopic treatment with the use of dilation can also be helpful (Roussel & Pandit, 2023). 

The Intention of the Question: 

This question was intended to help the student understand this diagnosis and how it is diagnosed, risk factors, and treatment options. As this is a relatively newly understood diagnosis, the diagnosis was given to the students rather than having them diagnose based on symptoms. This question helps students to analyze the implications of this new diagnosis. 

References

Roussel, J. M., & Pandit, S. (2025). Eosinophilic Esophagitis. StatPearls. http://www.ncbi.nlm.nih.gov/books/NBK459297/ 

Ryu, S., Lee, K. H., Tizaoui, K., Terrazzino, S., Cargnin, S., Effenberger, M., Shin, J. I., & Kronbichler, A. (2020). Pathogenesis of Eosinophilic Esophagitis: A Comprehensive Review of the Genetic and Molecular Aspects. International Journal of Molecular Sciences, 21(19), 7253. https://doi.org/10.3390/ijms21197253 

Model Answer:

1. What do you suspect that Heather is suffering from? (2 pts) Small bowel obstruction

2. Beyond the CT scan, what additional assessments might you as the nurse perform to confirm your suspicion? Name 2 assessments and what assessment findings you would expect to find with Heather’s diagnosis. (2 pts)

• a. Auscultation of bowel sounds – hypoactive or absent bowel sounds (Bordeianou & Yeh, 2023).

• b. Palpation of abdomen – looking for any masses or hernias which could represent an abscess, volvulus or tumor that is causing the obstruction (Bordeianou & Yeh, 2023).

• c. Inspection of abdomen – Heather’s abdomen would be distended with a SBO (Bordeianou & Yeh, 2023).

• d. Percussion of abdomen – hyperresonance and/or tympany throughout the bowel expect over fluid-filled loops of the obstruction, which would sound dull (Bordeianou & Yeh, 2023).

• e. Labs – CBC, electrolytes, blood urea nitrogen, creatinine, lactate (Bordeianou & Yeh, 2023). Abnormalities may help indicate cause/severity of obstruction.

3. What is included in typical treatment of this condition? List general management for non-surgical and surgical options. (6 pts)

• a. Non-surgical: IV fluids for resuscitation as Heather is slightly hypotensive and tachycardic (will be dehydrated from the nausea/vomiting) (Bordeianou & Yeh, 2024). Heather will need to be admitted to inpatient and have gastric decompression by way of nasogastric tube to suction to allow the bowel to rest and hopefully resolve the obstruction (Bordeianou & Yeh, 2024). She should remain NPO for bowel rest (Bordeianou & Yeh, 2024). If NPO for too long, will need nutrition by way of total parenteral nutrition (TPN) to be started via IV (will need central line for this) (Bordeianou & Yeh, 2024).  

• b. Surgical: Lysis of adhesions via exploratory laparotomy will be done if patient clinically worsens (Bordeianou & Yeh, 2024). Bowel resection may be needed if obstruction is severe and bowel becomes necrotic (Bordeianou & Yeh, 2024). 

The Intention of the Question: 

The intention of this question is to explore the care and management of a patient that has a small bowel obstruction, which is a common inpatient diagnosis in a hospital setting. The question aims to focus on what assessments a nurse could perform that would help strengthen the diagnostic of small bowel obstruction and what is included in non-surgical and surgical management of a small bowel obstruction, as both are seen in the hospital and require a prolonged hospital stay with thorough nursing care.

References

Bordeianou, L. & Yeh, D.D. (2023). Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults. UpToDate. Retrieved May 26, 2025 from https://www-uptodate-com/contents/etiologies-clinical-manifestations-and-diagnosis-of-mechanical-small-bowel-obstruction-in-adults 

Bordeianou, L. & Yeh, D.D. (2024). Management of small bowel obstruction in adults. UpToDate. Retrieved May 26, 2025 from https://www-uptodate-com/contents/management-of-small-bowel-obstruction-in-adults 

Model Answer:

The symptoms of fatigue, weight loss, confusion, jaundice, distended abdomen, tea colored urine, and elevated ammonia and liver enzymes are all suggestive of cirrhosis likely related to Earl’s alcohol consumption (Ball et al., 2023). To alleviate Earl’s ascites, a paracentesis is the ideal way to remove the fluid buildup and provide Earl with some relief (ClinicalKey, 2024a). To lower the ammonia level, lactulose is given as it is degraded in the colon by the normal bacterial flora of the gut into lactic, formic, and acetic acids (ClinicalKey, 2024b). As a result of the acidic environment, ammonia is ionized into the ammonium ion, preventing ammonia from diffusing across the colon membrane (ClinicalKey, 2024b). This ammonia is then excreted through stool, which is a key education point to bring up with the patient (ClinicalKey, 2024b). Lactulose is a laxative that will cause Earl to have frequent bowel movements, which he should be aware of and plan accordingly around his doses (ClinicalKey, 2024b). It is also important to relay possible side effects such as nausea, flatulence, belching, abdominal discomfort, and cramping (ClinicalKey, 2024b). Additionally, if Earl is having persistent diarrhea, he must speak with his provider about skipping a dose if fluid loss is a concern, as this may also result in hyponatremia and hypokalemia (ClinicalKey, 2024b). Despite the potential for skipping a dose related to side effects, you do want to stress that Earl takes this medication consistently to avoid hepatic encephalopathy related to ammonia buildup (ClinicalKey, 2024b). You may also recommend ways of improving the flavor of the medication to make it more tolerable. 

The Intention of the Question:

At the University of Washington Medical Center-Montlake, there is a large transplant population, including those involving liver transplants. These patients I care for can have a strict regimen for their treatment and have grown accustomed to a lifestyle generally governed by disease management. A lot of patients I have had in the past would initially present like Earl did, as the symptoms slowly begin to pile on top of each other. It has been interesting for me to see the progression of this disease in multiple stages of people’s lives, from initial diagnosis, then organ transplant, and even passing away from it. I try to be as competent as possible with the management of cirrhosis, so when I do a transplant workup for a patient, I can try and make the transition from home life to the hospital as seamless as possible. 

Rubric:

Diagnosis: 2 points

Correct procedure: 2 points

Medication Education: 2 points for each education point

Mechanism of Action: 2 points

References:

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W (2023). Abdomen. In Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. Seidel’s guide to physical examination (10th Ed.). Elsevier.

ClinicalKey. (2024a, December 6) Hepatic Cirrhosis. Elsevier. Retrieved May 6, 2025, from https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/67-s2.0-0dce5b1c-e2f6-4222-8dbd-d8d74c37107d 

ClinicalKey. (2024b, September 27) Lactulose. Elsevier. Retrieved May 6, 2025, from 

https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/drug_monograph/6-s2.0-338#Administration 

Science Photo Library. (n.d.). Ascites [Photograph]. https://www.sciencephoto.com/media/481094/view/ascites 

Mr. Jones was sent to get an abdominal CT, and the resulting image is included.

Which of the following is the most likely causing Mr. Jones’ symptoms? 

• A) Acute appendicitis

• B) GI viral illness

• C) Small bowel perforation

• D) Severe constipation with referred pain

After speaking with the provider, the nurse informed Mr. Jones that they need to start an IV to give him fluids and IV antibiotics and get him prepped for surgery. Mr. Jones says, “Surgery? Why do I need surgery? Also, I really don’t like needles. Getting that blood drawn was all of the needles I can handle for today. I promise I’ll drink as much water as you need me to and take whatever pills I have to, just please no more needles.” How should the nurse respond to this?

At this point, Mr. Jones’ wife arrives and convinces Mr. Jones to allow the nurse to get IV access. Mrs. Jones asks the nurse to explain to her what is going on with her husband, and the nurse does so after getting permission from Mr. Jones. After taking a few minutes to process what the nurse told her, Mrs. Jones asks, “What could have caused this, and how can we make sure it doesn’t happen again?” How should the nurse respond, keeping in mind Mr. Jone’s PMH/home medications?

Model Answer:

C.) Small bowel perforation

Response to Mr. Jones, “Mr. Jones, I know that there’s a lot going on right now which can be really overwhelming. I wouldn’t be asking to start an IV if it wasn’t necessary. The CT scan that you had done showed free air in your abdomen, or stomach, and that, in addition to your symptoms, is making us think that you have a hole in your intestine, also called a perforated intestine (Odom, 2023). When this happens, we want to have people not consume anything by mouth, because when you have a hole in your intestine, anything that you eat, or drink, can end up leaking out of that hole and damaging the surrounding tissue. The reason that the doctor wants me to get your prepped for surgery is so a surgeon close up the hole in your intestine and clean out anything that’s stuck between your intestines and your abdominal wall. Also, when someone has a hole in their intestine, they’re at a high risk of developing sepsis, or an infection in their blood. The labs we got earlier showed us that you’re in the beginning stages of sepsis. To prevent the infection from getting worse, we want to get antibiotics and fluids into your system as quickly as possible, and the fastest way to do that is through an IV. I hear that you don’t like needles, and that’s okay. I will do whatever I can to make you a comfortable as possible, but it is important that we get the antibiotics and fluids started as soon as possible to prevent you from getting even sicker. What questions do you have about all of that?”

Response to Mrs. Jones: “I saw in your husband’s chart that takes clozapine, also known as Clozaril. While this medication can be extremely helpful for patients with treatment resistant schizophrenia, it can also cause some pretty significant GI, or stomach, side effects, including causing your GI tract to not move as quickly as it’s supposed to. This can cause a bowel obstruction which is a blockage in the intestines, which can happen as a result of prolonged constipation. If a bowel obstruction is left untreated for too long, the pressure on the intestines can cause the intestines to tear, or perforate. One way to help prevent this from happening is by having anyone who takes Clozaril also take senna and docusate daily, which are both medications that help prevent constipation (Freudenreich & McEvoy, 2025). Even with these medications, some people who take Clozaril can still experience some intermittent constipation. When this happens, the doctors usually recommend that the person takes polyethylene glycol, or MiraLax. These things are especially important for your husband, as type II diabetes can also slow down the GI tract, which further increases his risk of developing a bowel obstruction and subsequent bowel perforation. Would you like me to ask the doctor to come talk with you about this more and discuss when your husband should seek medical help for constipation to help prevent this from happening again?”

The Intention of the Question: 

I’ve cared for a decent number of patients who take the medication, and we end up having way more conversations about their bowel movements than they would probably like to have. I also regularly have to have conversations with these patients during med passes about why they’re prescribed laxatives and stool softeners if they aren’t currently constipated. While constipation definitely isn’t the worst thing that Clozaril can cause (I once had a patient need to be transferred to a liquid oncology unit for about a week while his ANC recovered from severe, Clozaril induced neutropenia), I always worry that something like this will happen to one of my patients due to embarrassment around talking about bowel movements.

References

Bell, D. (2025, January 10). Bowel Perforation. Radiopedia. https://radiopaedia.org/articles/bowel-perforation-1 

Freudenreich, O. & McEvoy, J. (2025). Schizophrenia in adults: Guidelines for prescribing clozapine. UpToDate. Retrieved May 24, 2025, from https://www.uptodate.com/contents/schizophrenia-in-adults-guidelines-for-prescribing-clozapine?search=clozapine%20induced%20gastrointestinal%20gastroparesis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H2889684357 

Odom, S. (2023). Overview of gastrointestinal tract perforation. UpToDate. Retrieved May 24, 2025, from https://www.uptodate.com/contents/overview-of-gastrointestinal-tract-perforation?search=small%20bowel%20perforation&source=search_result&selectedTitle=1~88&usage_type=default&display_rank=1#H12750238 

Question #17 by Mariah Wilson

Ruth is a 48-year-old female with a past medical history of obesity, type 2 diabetes, hypertension, and gallstones. She arrived to the ED with fever, irretractable nausea, emesis (X3), and severe RUQ abdominal pain that she is rating as 10/10. You are taking her history and ask her to confirm the medications listed in the chart. She tells you, “I just started taking that fat shot that starts with a Z about 2 months ago. I buy it from this pharmacy in Canada”. After helping the patient look up her medication, you determine that she has been taking 5mg of Tirzepatide (Zepbound) SubQ weekly (last dose 48 hours ago). 

Describe the physiology/pharmacokinetics behind Tirzepatide and how it might be influencing Ruth’s digestive symptoms (please use in-text citations) – 6 pts.

A CT scan is ordered, and she is diagnosed with acute calculous cholecystitis and is scheduled for surgery. She is admitted to your unit for supportive care and will return to your unit post-op. The anesthesiologist comes to evaluate Ruth 2 hours before surgery and says they are going to ultrasound her gastric area prior to surgery. Briefly describe why the anesthesiologist might do this and what post-op precautions you need to initiate when she returns from surgery. (Hint: this question is related to Tirzepatide, and you may find the ASA guidelines helpful. Please use in-text citations). – 4 pts.   

Model Answer:

Describe the physiology behind Tirzepatide and how it might influence Ruth’s digestive symptoms. – 6 pts.

• Physiology: Tirzepatide is a GLP-1/GIP receptor agonist. GLP-1 peptides act on multiple areas of the body including the brain, stomach, vagus nerve, heart, pancreas, and fat cells. GLP-1 and GIP peptides stimulate the beta cells in the pancreas causing the release of insulin, which lowers blood glucose. GLP-1 peptides also inhibit glucagon secretion which can raise blood sugar and delay gastric emptying which slows digestion and the release of blood glucose. These actions together improve glycemic homeostasis. In addition, Tirzepatide acts on the peripheral vagus nerve which sends signals to the brain indicating fullness. GLP-1 and GIP also increase lipolysis and mediate lipogenesis causing the break down of fat cells resulting in weight loss (Sokary & Bawadi, 2025).

• Digestive symptoms: Most symptoms are a result of delayed gastric emptying and slowed digestion, which is the desired effect of Tirzepatide. GI side effects include constipation, diarrhea, nausea, vomiting, abdominal pain, dyspepsia, and decreased appetite. There is some evidence that it can contribute to GERD, cholecystitis, and acute pancreatitis, and rarely bowel obstruction. Additionally, these side effects may cause dehydration and worsen symptoms. For Ruth who has a previous history of gallstones, Tirzepatide may have contributed to acute cholecystitis, but it likely not the cause. However, the drug is likely exacerbating these symptoms (Perreault, L. & Reid, T. J., 2025; UpToDate, n.d.) 

Briefly describe why the anesthesiologist might do this and what post-op precautions you need to initiate when she returns from surgery. – 4 pts.

• Rationale for ultrasound: GLP-1 agonists delay gastric emptying, and SubQ formulations have a long half-life. The ASA recommends holding a dose the week prior to surgery, but in an urgent situation where surgery should not be delayed the patient should be treated on “full stomach” precautions. A gastric ultrasound can help assess gastric contents and aspiration risk. Aspiration risk should be discussed with the patient and the surgeon (Joshi, et al., 2024). 

• Post-op precautions: the patient should be placed on aspiration precautions post-op and carefully evaluated for signs of dysphagia (UpToDate, n.d.).

Grading Criteria

• Full points will be given for answers that include a well-thought-out answer with most of the elements listed above. Points will be deducted for answers that do not include major themes listed above. 

• 1 point will be deducted from each answer if proper APA in-text citations are not present.

The Intention of the Question: 

I was at NTI this past week and attended a lecture on GLP-1 agonists in the acute care setting. It was really interesting, and I learned a lot, and since these drugs are becoming more popular, I think it is important to know how they work and what effects they may have for patient care in the acute care setting. I hope that this question will give the class a chance to learn more about these medications and the promise they hold for patients struggling with obesity. One thing I wanted to touch on was the information I learned about compounding pharmacies, which are generally cheaper. The FDA put out a warning about these pharmacies, however the risks they listed are known side effects of the drug! Most compounding pharmacies are safe, and they are required to source ingredients from FDA approved manufacturers, so generally the drugs are safe. To get around patents these pharmacies may be prescribing different doses (2.1 mg vs. 2.5 mg) or they may also add extra ingredients such as B-12. The makers of these drugs continue to update the patents meaning it will be a long time before these are affordable for most patients, which may make compounding pharmacies appealing to those who need the medication but cannot afford it. 

References

Joshi, G. P., Abdelmalak, B. B. Weigel, W. A., Soriano, S. G., Harbell, M. W., Kuo, C. I., Stricker, P. A., & Domino, K. B. (2024, October). American society of anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. American Society of Anesthesiologists. Retrieved May 26, 2025, from https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative 

Perreault, L., & Reid, T. J. (2025, February 18). Obesity in adults: Drug therapy. UpToDate. Retrieved May 26, 2025, from https://www.uptodate.com/contents/obesity-in-adults-drug-therapy 

Sokary, S. & Bawadi, H. (2025). The promise of Tirzepatide: A narrative review of metabolic benefits. Primary Care Diabetes, 19(3), 229-237. https://doi.org/10.1016/j.pcd.2025.03.008 

UpToDate. (n.d.). Tirzepatide: Drug information. UpToDate Lexidrug. Retrieved May 26, 2025, from https://www.uptodate.com/contents/tirzepatide-drug-information 

Model Answer:

1) Marco is most likely experiencing hepatic encephalopathy (HE), a complication of advanced cirrhosis. The damaged liver is unable to detoxify ammonia and other nitrogenous wastes properly. These toxins accumulate in the bloodstream and cross the blood-brain barrier, leading to altered mental status, neuromuscular signs (like asterixis), and cognitive decline (DynaMedex, 2025). 

2) Pharmacologic treatment priority: Continue and potentially titrate lactulose to achieve 2–3 soft stools daily. Lactulose helps trap ammonia in the gut and facilitates its excretion, lowering serum levels (Ridola & Riggio, 2024).

Other acceptable answers:

• Rifaximin: A non-absorbable antibiotic that reduces ammonia-producing gut bacteria. Often used in combination with lactulose, especially in recurrent or refractory HE. It helps decrease intestinal ammonia production with fewer side effects than lactulose alone.

• Avoidance or adjustment of sedating medications (e.g., benzodiazepines, opioids). These drugs can worsen mental status in patients with hepatic encephalopathy. Learners may suggest reviewing current meds for CNS depressants.

• Electrolyte management (e.g., correcting hyponatremia or hyperkalemia). Electrolyte imbalances can exacerbate encephalopathy and should be corrected as part of supportive treatment.

• Hold or reduce diuretics (if renal function is worsening). Dehydration and worsening renal function (as seen in this case with elevated creatinine) can trigger or worsen HE.

Non-pharmacologic treatment priority: Temporarily reduce dietary protein intake, especially in recent high-protein supplementation, which can worsen ammonia buildup. A dietitian should guide long-term protein adjustments to avoid malnutrition while controlling encephalopathy symptoms (Ridola & Riggio, 2024).

Other acceptable answers:

• Assess for and treat precipitating factors like GI bleeding, infection, constipation, and dehydration. Identifying and addressing triggers is essential to resolving an HE episode.

• Frequent neuro checks and safety measures. Patients with altered mental status are at risk for falls, aspiration, and injury. Fall precautions and close observation should be implemented.

• Patient and family education. Teaching about early signs of HE, medication compliance (especially with lactulose), and diet can help prevent recurrence.

• Collaborate with a dietitian for long-term nutrition planning. While temporary protein restriction may help in acute HE, malnutrition is common in cirrhosis. A tailored nutrition plan supports recovery and prevents recurrence.

The Intention of the Question: 

This question aims to help learners apply what they’ve learned about cirrhosis to a real-world scenario. It’s not just about naming the condition but showing they understand what’s going on in the body to cause those symptoms. It also pushes them to think through how they’d respond as a nurse- which treatments matter most, both meds and nursing actions, and why. 

References

DynaMedex. (2025). Hepatic encephalopathy. Retrieved May 24, 2025, https://www-dynamedex-com/condition/hepatic-encephalopathy 

Ridola, L., & Riggio, O. (2024). Hepatic encephalopathy in adults: Treatment. UpToDate. Retrieved May 24, 2025, from https://www-uptodate-com/contents/hepatic-encephalopathy-in-adults-treatment 

Model Answer:

1. Upper Gastrointestinal (UGI) Bleeding

Upper gastrointestinal (UGI) bleeding refers to blood loss originating from the esophagus, stomach, or duodenum. Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarry stools), though patients with large-volume upper GI bleeding may also present with hematochezia (red or maroon blood with stool) (Saltzman, 2025). A common cause is peptic ulcer disease, and the patient’s use of apixaban, an anticoagulant, significantly heightens the risk of bleeding, even in the absence of hematemesis. Clinical symptoms such as dizziness and weakness suggest chronic blood loss, which may result in anemia or hypovolemia. UGI bleeding remains one of the most frequent GI-related reasons for hospitalization in the U.S. Early triage, aggressive resuscitation, and timely endoscopic assessment are essential to improve patient outcomes (Antunes et al., 2024).

2. Immediate management for this patient should focus on stabilization and prevention of further hemorrhage. The first step is to withhold apixaban to minimize ongoing bleeding risk. Establishing at least two large-bore (18-gauge or larger) IV lines and starting fluid resuscitation with isotonic saline are vital to maintain perfusion and prevent hypovolemic shock. A key element in the initial management of UGIB is initiation of a proton pump inhibitor. The patient should also receive an intravenous proton pump inhibitor (PPI) such as pantoprazole, which suppresses gastric acid secretion, aiding clot formation and mucosal healing. For significant bleeding, a regimen of 80 mg bolus followed by continuous infusion at 8 mg/hr or intermittent doses of 40 mg several times daily is recommended. If the patient exhibits ongoing severe hematemesis or is at risk of airway compromise, elective endotracheal intubation may be necessary. Initial labs should include a complete blood count (CBC) to assess hemoglobin, hematocrit, and platelets, as well as BUN/creatinine levels to gauge blood loss severity and renal function. Preparation for potential blood transfusion or esophagogastroduodenoscopy (EGD) is also essential, as EGD remains the gold standard for both diagnosis and treatment of UGI bleeding. Vasopressor therapy may be required to maintain adequate end-organ perfusion if a patient remains hypotensive despite aggressive fluid resuscitation. Endotracheal intubation should be considered for patients who develop signs of volume overload, have persistent hemodynamic instability, or are at increased risk of aspiration (eg, those with altered mental status or massive hematemesis). For patients with UGIB, transfusion of blood products can help replace ongoing blood loss and increase delivery of oxygen to tissues (Kumar et al., 2016).

3. Patient education plays a critical role in both managing and preventing recurrence of UGI bleeding. Nurses should begin by teaching patients to recognize early warning signs, such as melena, fatigue, dizziness, or hematemesis, and stress the importance of seeking immediate medical attention if these symptoms arise. Emphasis should also be placed on safe medication practices, advising patients to avoid NSAIDs and alcohol while taking anticoagulants or PPIs, as these substances can worsen mucosal damage and increase bleeding risk. Nurses should also explain the importance of follow-up endoscopy, which helps identify the bleeding source and monitor healing. In addition, patients should be guided on dietary modifications to avoid irritants such as caffeine, alcohol, and spicy foods, which can exacerbate GI irritation and hinder recovery (Antunes et al., 2024).

The Intention of the Question: 

Upper gastrointestinal (UGI) bleeding is a serious and potentially life-threatening condition that requires timely recognition and intervention. As one of the most frequent gastrointestinal emergencies, it commonly results in hospitalization and, if not treated quickly, can lead to severe complications or even death. Timely diagnosis and management are essential to improving patient outcomes. Delays in care, such as fluid resuscitation, medication administration (e.g., proton pump inhibitors), or diagnostic procedures like endoscopy, can significantly increase the risk of rebleeding, hypovolemic shock, and multi-organ failure.

References

Antunes, C., Tian, C. & Copelin II, E. L. (2024). Upper gastrointestinal bleeding. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470300/ 

Kumar, N. L., Travis, A. C., & Saltzman, J. R. (2016). Initial management and timing of endoscopy in nonvariceal upper GI bleeding. Gastrointestinal Endoscopy, 84(1), 10–17. https://doi.org/10.1016/j.gie.2016.02.031 

Saltzman, J. R. (2025). Approach to acute upper gastrointestinal bleeding in adults. UpToDate. Retrieved May 15, 2025, from https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults?search=upper%20gi%20bleed&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 

Question #20 by Erin Woods

Model Answer:

Sarah is likely in fulminant liver failure, caused by Tylenol toxicity. She is at risk for acute hepatic encephalopathy due to rising ammonia levels (among other risk factors) and for critical coagulopathies as the liver is responsible for the clearance of ammonia and for the production of clotting factors (Fuhrman & Zimmerman, 2006).  A thorough assessment would include a detailed neurological examination.  The highest risk to Sarah at this time would be her encephalopathy and the danger of bleeding. Based on the labs and physical assessment, having blood products available to rapidly transfuse is likely necessary.

Necessary labs: liver function tests, ammonia and coags (Bhat & Rao, 2018). 

Necessary medication: Mucomyst (acetylcysteine) for Tylenol toxicity (Fuhrman & Zimmerman, 2006). 

The Intention of the Question: 

Fulminant liver failure is one of the most high-acuity admissions we receive in the PICU. Often these patients require a liver transplant, if they survive their encephalopathy and coagulopathies (among other risk factors). There are ingestion admissions to the PICU with regularity and Tylenol is particularly scary because of the risk of high acuity, mortality and morbidity. 

References

Bhatt, H., & Rao, G. S. (2018). Management of acute liver failure: A pediatric perspective. Current Pediatrics Reports, 6(3), 246–257. https://doi.org/10.1007/s40124-018-0174-7 

Fuhrman, B.A. & Zimmerman, J. (2006). Pediatric critical care: Third edition. Mosby.