Test Bank for Alexanders Surgical Procedures, 1st Edition, Rothrock

Test Bank for Alexanders Surgical Procedures, 1st Edition

By Jane C. Rothrock , Sherri Alexander CST

Rothrock: Alexander's Surgical Procedures Chapter 01: Importance of the Surgical Technologist on the Surgical Team Test Bank MULTIPLE CHOICE 1. The Association of Surgical Technologists (AST) was formed in ________________________. a. 1965 b. 1970 c. 1969 d. 1980 ANS: C The association was formed in 1969.

REF: 2 2. Entry level surgical technologists can fill which of the following roles: a. Scrub surgical technologist b. Circulating surgical technologist c. Second assisting surgical technologist d. All of the above ANS: D The entry level surgical technologist can serve in any of the listed roles. It is always important for surgical technologists to be familiar with their institutional job description and comply with it. Knowing federal and state rules and regulations is also important.

REF: 2 3. The scrub surgical technologist is defined as the: a. The non sterile member of the surgical team. b. The assisting member of the team. c. The sterile member of the team d. None of the above ANS: C The term ‘scrub’ in this instance refers to the surgical technologist who has donned a sterile gown and gloves, making them a sterile member of the surgical team.

REF: 2 4. Professional settings for the surgical technologist can include:

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Hospital suites and ambulatory surgery centers.

Ambulatory surgery centers and PACU Labor and delivery units and for a physician as a private scrub All of the above

ANS: D Surgical technologists can work in both hospital surgical suites and ambulatory surgery centers. They can also work in labor and delivery suites within the hospital setting.

REF: 2 5. Which role of the surgical technologist would likely include making hospital rounds, first-assisting, and expanded patient interaction? a. scrub surgical technologist b. circulating surgical technologist c. labor and delivery technologist d. private scrub technologist ANS: D A surgical technologist who is practicing as a private scrub for a surgeon or group of surgeons can take on expanded duties under their direct supervision. Activities such as making hospital rounds often require additional credentialing to obtain privileges to assume an expanded role. The surgical technologist who acts as an assistant during surgery needs both additional educational preparation for the role and credentialing if they are a private employee of the surgeon.

REF: 2 6. What is the minimum number of Continuing Education (CE) credits required for a 4-year CST recertification cycle? a. 30 b. 40 c. 50 d. 60 ANS: D In order to maintain current certification, a surgical technologist must acquire 60 Continuing Education credits in a four year certification cycle or sit for re-examination through the National Board of Surgical Technologists and Surgical Assistants (NBSTSA).

REF: 4 7. How many phases of patient care constitute surgical case management? a. 2 b. 3

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c. 4 d. 5 ANS: B This three-phase involvement – preoperative, intraoperative and postoperative - is called surgical case management.

REF: 4 8. Prevention of which of the following is the MAIN reason for performing surgical sponge, sharps, and instrument counts? a. stock/supply depletion b. accidental disposal in trash or linen c. retained foreign objects in patient d. revenue loss from non-charged items ANS: C Performing sponge, sharps, and instrument counts with the circulating nurse helps to ensure that all items have been retrieved from the patient.

REF: 6 9. Which of the following personal character traits pertains to one’s pledge to recognize and admit mistakes so that corrective action can be taken immediately? a. Surgical conscience b. Respect for the team c. Good manual dexterity d. Organizational skills ANS: A Beside education in critical technical skills, the surgical technologists needs to have good communication with and respect for the entire surgical team. This produces the necessary environment to safely admit one's own mistakes and provides the ability for corrective action.

REF: 5 10. Which of the following describes “An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”? a. Guideline initiative b. Sentinel event c. Time out d. Paradigm shift ANS: B

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A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury; or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation of which a recurrence would carry a significant chance of serious adverse outcomes. Such events are called "sentinel" because they signal the need for immediate investigation and response.

(The Joint Commission, 2010) REF: 6 11. Which of the following groups created a patient safety campaign titled “Safe Surgery Saves Lives” which utilized a surgical safety checklist to aid in the time-out process? a. American College of Surgeons (ACS) b. Council on Surgical and Perioperative Safety (CSPS) c. Agency for Healthcare Research & Quality (AHRQ) d. World Health Organization (WHO) ANS: D WHO designed a campaign titled” Safe Surgery Saves Lives”, which includes a Surgical Safety Checklist to be used by all operating room teams to aid in the time-out process.

REF: 6 12. A set of guidelines for professional advancement and recognition within an institution or department through the use of an AST-established set of performance-based evaluation and advancement criteria is also known as: a. clinical ladder b. continuum of care c. core curriculum d. crew management model ANS: A A clinical ladder is a tool for encouraging surgical technologists to pursue continuing education and competency in their field.

REF: 7 13. Which of the following involves establishment of high standards, professional conduct, legal rights, and protection of the profession’s integrity? a. Recommended Standards of Practice b. Position Statements c. Code of Ethics d. Guidelines ANS: C The code of ethics focuses on protecting the patient but expands to protect professional standards and the profession’s integrity.

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Rothrock: Alexander's Surgical Procedures Chapter 02: Gastrointestinal Surgery Test Bank MULTIPLE CHOICE 1. Select the statement that best reflects the functional components of the gastrointestinal (GI) tract. a. The GI tract is a continuous pathway from mouth to rectum. b. Peristaltic waveforms produce agitation, which digests large food particles. c. The alimentary canal extends from the mouth to the anus. d. The microscopic ecosystem of the GI tract is an unbalanced colony of germs.

ANS: C The GI tract, or alimentary canal, is a continuous tubelike structure that extends the entire length of the trunk. The tract includes the mouth; pharynx; esophagus; stomach; small intestine, consisting of the duodenum, jejunum, and ileum; and large intestine, which consists of the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus.

REF: 12 2. A patient whose neck has been slashed and has a severed lower trachea may also have injury to the: a. aorta. b. esophagus. c. duodenum. d. bronchial merge.

ANS: B The esophagus begins at C6 and passes through the neck posterior to the trachea.

REF: 12 3. Exposure of intra-abdominal anatomy is crucial to safe surgery and employs varied instruments, applications of highly technical energy sources, patient manipulations, light, and imaging. What is unique to the laparoscopic approach that promotes exposure? a. Self-retaining retractors b. Automatic rod-lens fiberscope c. Carbon dioxide pneumoperitoneum d. Endoscopic fan blades ANS: C

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Abdominal insufflation with carbon dioxide expands the abdominal compartment, permitting better visualization and room to manipulate instruments.

REF: 20 4. Select the statement that most correctly matches a risk factor for adhesions with an appropriate preventive strategy. a. Multiple surgeries may be managed with the use of sequential compression devices. b. Glove powder adhesions can be prevented with cellulose mist. c. Patients with endometriosis may be best served with a laparoscopic approach. d. Fibrous bands within the peritoneum can be treated with sterile talcum powder.

ANS: C Adhesions may also develop as a result of radiation-induced endarteritis, endometriosis, pelvic inflammatory disease (PID), or Crohn’s disease. Preventive measures include the following: minimizing tissue trauma and inflammation with meticulous surgical technique and using the laparoscopic approach when indicated.

REF: 32 5. The general risks associated with gastrointestinal surgery parallel those risks associated with most abdominal procedures. Select a complication that is the most typical risk associated with surgery of the large bowel. a. Colitis b. Peritonitis c. Paralytic ileostomy d. Intestinal obstruction ANS: B The risks for injury or failure to achieve the intended outcome are equally present in GI surgery as in any surgical or invasive procedure. The surgical and anesthesia experience challenges the immune system and poses many risks of introducing endogenous and exogenous microorganisms.

REF: 71 6. As the surgeon prepared to clamp and transect the bowel during a small bowel resection for tumor, the scrub person transferred instruments from the Mayo stand to the back table and prepared the sterile field for bowel isolation technique. The rationale for this application involves a. Risk for Infection b. Risk for Metastasis c. Risk for Tissue injury d. Risk for Infection

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ANS: A Bowel technique, also referred to as contamination or isolation technique, prevents crosscontamination of the wound or abdomen with bowel organisms. Initiate practices required for creating and maintaining a sterile field. Protect the patient from crosscontamination—employ bowel/GI technique as appropriate.

REF: 27 7. During a laparoscopic colectomy, the scrub person carefully placed the endoscopic electrosurgery instruments on the Mayo stand after inspecting the integrity of the insulation along the shaft. This practice is designed to meet the expectation for the following outcome: The patient will be free from: a. fluid and electrolyte imbalance. b. thermal burns and adhesions. c. impaired tissue integrity. d. thermal burns and adhesions, and impaired tissue integrity.

ANS: C The patient is at risk for impaired tissue integrity from thermal burns that may be caused by defects in the surface of the insulation coating on laparoscopic electrosurgery instruments.

REF: 58 8. Which statement about the McBurney incision is most correct? a. It is an oblique inguinal incision in the left lower quadrant. b. It is the incision of choice to repair a direct inguinal hernia. c. It is an oblique inguinal incision in the right lower quadrant. d. The direction is more transverse than oblique.

ANS: C The McBurney incision is an open appendectomy approach and the appendix is typically in the right lower quadrant of the abdomen.

REF: 28 9. Triangulation is a term used to describe the method used to provide instrument access to the anatomy during abdominal surgery. It is uniquely associated with which surgical incision? a. Mid-epigastric transverse incision b. Left paramedian incision c. Thoracoabdominal incision d. Laparoscopic port incisions ANS: D

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Traditional laparoscopic port placement, via triangulation, is the fundamental concept of laparoscopic surgery. It places the instruments on planes where they meet to effectively support dissection with adequate visualization and identification of anatomy and pathology. Incorrectly placed ports can cause “sword-fighting” instruments and indirect access to the operative anatomy.

REF: 34 10. When setting up for a gastrectomy, the scrub person will ensure that appropriate instruments are available to clamp and ligate the: a. branches of the peritoneal artery. b. splenic vessels. c. popliteal artery. d. Treitz arterial stump.

ANS: B Gastrectomy requires clamping and ligating the splenic vessels.

REF: 51 11. Two patients are scheduled to have a gastrojejunostomy for obstruction. How will perioperative planning differ for a patient weighing 280 lb as compared to that for a 150lb patient? a. The ligament of Treitz will not need to be identified in a lighter person. b. Forced air–warming devices are more important for a lighter patient. c. The anastomosis will require sutures rather than staples for the heavier patient. d. Deaver retractors will replace Richardson retractors with the heavier patient.

ANS: D The larger patient will require longer instruments and deeper retractors.

REF: 22 12. Edward Lewis is scheduled for a transthoracic esophagectomy with lymph node dissection for cancer of the esophagus. Which incisional approach is indicated for this procedure? a. Left thoracoabdominal incision b. Right posterior lateral thoracotomy and midline abdominal incision c. Three-incision (three-hole) approach with cervical, right thoracotomy, and midline laparotomy incisions d. Any of the three above incisions may be used per surgeon preference or tumor location.

ANS: D

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Transthoracic esophagectomy is indicated for disease of the middle third of the esophagus and high-grade dysplasia in Barrett’s esophagus, permitting complete lymph node dissection under direct vision and combines a left-sided thoracoabdominal incision or separate right posterior lateral thoracotomy and midline abdominal incision. The latter describes the traditional Ivor Lewis approach. Another variation, sometimes called the “three-hole esophagectomy,” combines an approach for proximal tumors. The singleincision thoracoabdominal incision provides the best exposure for low gastroesophageal junction tumors and is indicated for patients with cardiac and pulmonary disease.

REF: 39 13. Sharon Close has been diagnosed with severe gastroesophageal reflux disease (GERD) without the dysplastic changes of Barrett’s esophagus. Her GERD is unresponsive to proton pump inhibitors and histamine blockers. She also has a history of endometriosis with multiple surgeries for ablation of endometrial implants on her small bowel and adhesiolysis. Her surgeon is hesitant to pursue an open or a laparoscopic Nissen surgical approach. What procedure might her surgeon consider in lieu of a Nissen? a. Thoracoabdominal partial esophagectomy b. Endoscopic mucosal resection c. Endoluminal plication of the lower esophageal segment d. Heller’s myotomy ANS: C Endoluminal plication is an antireflux procedure that can be performed endoscopically in an endoscopy procedure room using moderate sedation or a general anesthetic. One example is the EndoCinch (Bard Medical) technique that dilates the lumen of the esophagus before passing the EndoCinch device through an EGD scope. The device is a sewing capsule that pinches or pleats mucosal folds and anchors them in place with suture. Several plications are placed in a circumferential or staggered vertical pattern.

Another device is the Wilson-Cook sewing system (Wilson-Cook Medical). It is a submucosal plication device that suctions a small fold of tissue into the lumen of the scope accessory, and then plicates, sutures, and knots the tissue pleat.

REF: 40 14. An abdominal perineal resection, or APR, for a patient at high risk for colon cancer without anal/rectal involvement (e.g., familial adenopolyposis [FAP]) can be accomplished through an open laparotomy or laparoscopic-assisted ileoanal pull-through approach, per surgeon preference and appropriate patient selection. Which of these statements about approaches for APR is correct? a. Both open and laparoscopic approaches require an abdominal skin incision(s) and perineal incision(s). b. Neither approach requires two or more skin incisions. c. Both procedures require only an abdominal skin incision(s) as the rectal segment is removed and anastomosed intraluminally. d. The laparoscopic-assisted approach only has an abdominal skin incision(s).

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ANS: D The laparoscopic-assisted ileoanal pull-through procedure for total colectomy creates a rectal anastomosis in which the distal ileal segment is anastomosed to the rectal segment.

Intraluminal staples are inserted through the rectum to connect the rectum to the created J pouch. The only skin incisions are the trocar port sites.

REF: 66 15. Select the diagnosis/procedure option that pairs the correct surgical diagnosis with the surgical/endoscopic procedure for diseases of the esophagus: a. Barrett’s dysplasia of the distal esophagus/endoscopic mucosal resection (EMR) b. Gastroesophageal reflux disease (GERD)/photodynamic therapy (PDT) c. Zenker’s diverticulum/Ivor Lewis esophagectomy d. Esophageal varices/Heller myotomy ANS: A Endoscopic mucosal resection (EMR) is an interventional technique to remove submucosal flat or depressed lesions of Barrett’s esophageal dysplasia.

REF: 38 16. Review the list below and select the answer that reflects the correct match between the procedure and the disease. a. Duodenoscopy for gastric reflux disease and hiatal hernia b. Bariatric surgery for Roux-en-Y for gastritis c. Esophagogastroduodenoscopy (EGD) for gastric ulcer disease d. Small bowel enteroscopy for ulcerative colitis ANS: C Common GI endoscopy procedures used to establish a diagnosis or monitor gastric disease include esophagogastroduodenoscopy (EGD) (also referred to as gastroscopy or upper endoscopy).

REF: 36 17. Carly Shelmire is a 5-year-old girl with a history of weight loss and stomach upset and pain after eating; she is also small for her age. Her pediatrician suspects celiac disease.

Carly has arrived at the pediatric endoscopy unit for a procedure that is less invasive and will also have the benefit of spending the next few hours in the mall across from the hospital with her mom until the procedure is over. What is Carly’s scheduled procedure? a. GI manometry b. Small bowel enteroscopy c. Capsule endoscopy d. Stretta procedure

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ANS: C Capsule endoscopy is an emerging technology and noninvasive diagnostic test that uses a small wireless camera in the shape of a capsule about the size of a large vitamin. This device is suitable for imaging the mucosal surface of the esophagus, stomach, and small intestine.

REF: 20 18. Select the option that pairs the correct surgical diagnosis with the surgical/endoscopic procedure for diseases of the abdomen. a. Peritoneal cancer/hyperthermic intraperitoneal chemotherapy b. Ascites/hyperthermic intraperitoneal antibiotic therapy c. Adhesions/lysis of adhesions d. Peritoneal cancer/hyperthermic intraperitoneal chemotherapy and adhesions/lysis of adhesions ANS: D Cancer of the peritoneum can be treated with topical application of selected chemotherapeutic agents instilled into the abdomen after induction of anesthesia. Lysis of adhesions is a surgical procedure that employs sharp tissue dissection to cut and release adhesions.

REF: 35 19. Ramona Guerne has been admitted through the emergency department for severe abdominal pain, distended abdomen, and fever. The surgery service has been consulted and has scheduled her for exploratory surgery. Ramona has undergone two abdominal surgeries in the past for “female problems” and states that she has a tendency to form keloids. A small bowel obstruction is suspected. Postoperative ileus is a common complication of open abdominal surgery. Select the procedure that is least likely to promote postoperative ileus formation in this patient. a. Long (4-hour) laparoscopic procedure, with incidental peritonitis b. Open small bowel resection with postoperative signs of pancreatitis c. Laparoscopic lysis of adhesions with release of bowel torsion d. Laparoscopic-assisted hemicolectomy with mild peritoneal inflammation ANS: C A laparoscopic approach combined with sharp-dissection lysis of adhesions and release of bowel torsion (twisting) does not include a bowel resection and will not cause excessive manipulation of the bowel. This patient may possess risk factors for development of postoperative (paralytic) ileus attributable to two past surgeries, keloid history, and possible bowel obstruction.

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20. Specific positioning considerations for bariatric patients require particular attention to protecting these patients from inherent risks related to their size and weight. Of considerable concern is the risk of injury to staff. Protective measures to protect both patient and staff include those below. Which measure reflects the most safety protection for both patient and staff? a. Review back safety precautions and awareness during preincision briefing. b. Ensure that the OR bed can accommodate the patient’s weight and girth. c. Employ at least three safety straps over the patient’s largest girth. d. Overlap the viscoelastic gel mattress top with three lifting sheets.

ANS: B A special OR bed is required that can accommodate patients who weigh more than 350 lb (159 kg).

REF: 52 21. Ann Contreras has consulted a noted colorectal surgeon after experiencing episodes of rectal bleeding over the last 2 weeks. She had a screening colonoscopy 5 years ago with several adenomatous polyps and mild diverticular disease. She presents to the endoscopy suite after a successful bowel prep and NPO since midnight. The GI endoscopist is confident that she will find tumor growth in the rectum and decides to employ further diagnostic applications to determine potential for metastasis. Which of the following endoscopic procedures best describes Ann’s procedure? a. Endoscopic retrograde cholangiopancreatoscopy (ERCP) b. Rectal manometry with dilatation c. Flexible sigmoidoscopy d. Colonoscopy with endoscopic ultrasound (EUS) ANS: D Colonoscopy is endoscopic examination of the colon from the rectum to the ileocecal valve. The bowel wall is inspected for abnormalities such as bleeding, polyps, inflammation, ulceration, or tumors during both insertion and withdrawal of the colonoscope. EUS combines endoscopy and ultrasound, using sound waves to generate an image of the histologic layers of the esophageal, gastric, and intestinal walls. The frequencies used, higher than those used in traditional ultrasound, provide high-level accuracy of depth of mucosal invasion. EUS is of critical importance in staging GI malignancies and determining surgical options and potential for therapeutic resection.

REF: 17 22. Michael Mason has suffered from subsacral pain and swelling for 2 weeks and finally was referred to a colorectal surgeon for care. He is currently in the ambulatory surgical center OR bed positioned in the jackknife position. The perioperative nurse has gently but firmly taped his buttocks laterally to the rails of the OR bed to promote exposure to the surgical site. What procedure is Michael prepared to undergo, based on his symptoms and the surgical preparation?

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Internal hemorrhoidectomy External hemorrhoidectomy Removal of rectal foreign body Pilonidal cystectomy

ANS: D Excision of a pilonidal cyst and sinus is removal of the cyst with sinus tracts from the intergluteal fold on the posterior surface of the lower sacrum. A pilonidal cyst and sinus, which may be congenital in origin, rarely become symptomatic until the individual reaches adulthood, most commonly in young men. The patient is placed in jackknife position with the buttocks taped open laterally and secured to the sides of the OR bed.

REF: 70 23. Jeannie Donahue is admitted for the fourth time for treatment and management of her pseudomyxoma peritonei, or peritoneal cancer. She is scheduled for open laparotomy for inspection with lymph node surveillance and frozen sections and peritoneal washings for cytologic examination. Her surgical oncologist has recommended a treatment that may slow the growth of the tumor seedings and prolong her life: intraoperative intraperitoneal hyperthermic chemotherapy. Jeannie’s perioperative nurse prepares the OR and instructs the new scrub person on chemotherapy safety precautions. For this procedure, it is imperative that the staff: a. know how to use the chemo spill kit and where it is stored. b. have the chemotherapeutic solution in the room before the patient arrives. c. be able to calculate the formula for body weight in kilograms per meters squared in order to comply with the 7 rights of medication administration. d. wear full personal protective equipment beyond the sterile scrub attire.

ANS: A Have a chemo spill kit available whenever/wherever chemo is prepared, administered, stored, or disposed. PPE is worn whenever preparing, transferring, spiking, changing, priming, and disposing of chemotherapeutic agents (chemo). Sterile attire provides protective barriers.

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Rothrock: Alexander's Surgical Procedures Chapter 03: Surgery of the Liver, Biliary Tract, Pancreas and Spleen Test Bank MULTIPLE CHOICE 1. The liver, pancreas, and spleen share many similarities. Select the statement about these organs that is true. a. All three are solid organs and very vascular. b. All three are metabolic organs. c. All three organs have terminal attachments to the duodenum. d. All of the options are false.

ANS: A All three organs are solid (not hollow or collapsible) organs. A pathologic condition in the liver, biliary tract, pancreas, or spleen often requires surgical intervention. These organs are highly vascular and control many metabolic and immune functions of the body.

REF: 74 2. The functional units of the liver are the lobules. The functional cells of the liver are the ______________ and they manufacture _______________. a. Kupffer cells; phagocytes b. sinusoid cells; lymphocytes c. hepatocytes; bile d. portal triad cells; ductal epithelium ANS: C Lobules are the functional units of the liver. Each lobule contains a portal triad that consists of a hepatic duct, a hepatic portal vein branch, and a branch of the hepatic artery, nerves, and lymphatics. The hepatic cords consist of numerous columns of hepatocytes— the functional cells of the liver. The hepatic sinusoids are the blood channels that communicate among the columns of hepatocytes. The sinusoids have a thin epithelial lining composed primarily of Kupffer cells—phagocytic cells that engulf bacteria and toxins. Bile is manufactured by the hepatocytes.

REF: 77 3. The liver is essential in the metabolism of carbohydrates, proteins, and fats, generating nutrient stores of which substance that supplies energy sources to the brain and body? a. Carbohydrate glucose substrate b. Glycogen c. Serum glucosamine

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d. Bile salts ANS: B The liver is essential in the metabolism of carbohydrates, proteins, and fats. It metabolizes nutrients into stores of glycogen, used for regulation of blood glucose levels and as energy sources for the brain and body functions.

REF: 77 4. The biliary system (also called the biliary tree) drains bile from the gallbladder to the ampulla of Vater. The primary function of the gallbladder is to: a. manufacture bile. b. convert bile salts into bile enzymes. c. store and concentrate bile. d. contract to secrete bile into the hepatic duct.

ANS: C The gallbladder, which lies in a sulcus on the undersurface of the right lobe of the liver, terminates in the cystic duct (Figure 3-3). This ductal system provides a channel for the flow of bile to the gallbladder, where it becomes highly concentrated during storage. The liver produces about 600 to 1000 ml of bile each day. The gallbladder’s average storage capacity is 40 to 70 ml. As the musculature of the gallbladder contracts, bile is forced into the cystic duct and through the common duct. As the sphincter of Oddi in the ampulla of Vater relaxes, bile is released, flowing into the duodenum to aid in digestion by emulsification of fats.

REF: 77 5. The head of the pancreas is fixed to the: a. spleen. b. duodenum. c. stomach. d. biliary tree ANS: B The pancreas (see Figure 3-3) is a fixed structure lying transversely behind the stomach in the upper abdomen. The head of the pancreas is fixed to the curve of the duodenum.

REF: 77 6. While the pancreas’ function is carbohydrate metabolism with the production of insulin and digestive enzymes, the spleen’s function is primarily ___________ with the production of _______________. a. immunologic; leukocytes b. metabolic; granulocytes c. anabolic; plasma cells

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d. as a blood reservoir; phagocytes ANS: A The spleen has many functions. Among them are defense of the body by phagocytosis of microorganisms, formation of nongranular leukocytes and plasma cells, and phagocytosis of damaged red blood cells. It also acts as a blood reservoir. The pancreas contains groups of cells, called islets, or islands, of Langerhans, that secrete hormones into the blood capillaries instead of into the duct. These hormones are insulin and glucagon, and both are involved in carbohydrate metabolism.

REF: 79 7. An example of an indication for liver transplantation would be: a. end-stage liver disease resulting from advanced hepatic cancer with metastasis. b. acute fulminant biliary disease of unknown origin. c. infection caused by untreated cystic anomalies. d. primary hepatic cancer.

ANS: D Liver transplantation is indicated for patients with primary hepatic cancer, chronic hepatocellular disease, chronic cholestatic disease, metabolic liver disease, acute fulminant liver disease, and inborn errors of metabolism. When malignancies are the cause of end-stage liver disease, the right upper quadrant may be radiated intraoperatively—after hepatectomy and before transplantation.

REF: 107 8. Matthew Ryan, a 9-year-old boy, is admitted to the emergency department for a sledding accident, when he lost control of his sled and crashed into a tree. He is pale and in pain; his abdomen is tender and firm to palpation. The CT scan suggests rupture of the spleen with internal bleeding. Matthew’s scheduled surgery will most probably be a(n): a. laparoscopic splenic resection with sutured mesh overlay. b. open splenic lobectomy with vascular ligation. c. open total splenectomy. d. open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.

ANS: C Splenectomy is removal of the spleen. It is performed for multiple reasons, including trauma to the spleen. Contraindications to laparoscopic splenectomy include severe portal hypertension, uncorrectable coagulopathy, severe ascites, extreme splenomegaly, extensive adhesions, and most traumatic injuries to the spleen. For these patients, an open approach is indicated.

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9. The Whipple procedure is the removal of the head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the ____________ as a surgical treatment for____________. a. left lobe of the liver; metastatic hepatocytoma b. distal segment of the spleen; pancreatic metastasis c. inferior margin of the ligament of Treitz; pancreatic cancer d. lower half of the common bile duct; pancreatic cancer ANS: D Pancreaticoduodenectomy (Whipple procedure) is the removal of the head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct, with reestablishment of continuity of the biliary, pancreatic, and GI tract systems.

REF: 102 10. Open common bile duct (CBD) exploration may be indicated in some cases where: a. the patient has undergone prior biliary surgery. b. a positive cholangiogram shows a CBD obstruction during an open cholecystectomy. c. laparoscopy technology is not available. d. All of the options are correct.

ANS: D With the advent of endoscopic, percutaneous, and laparoscopic techniques (Figure 3-21), open exploration of the common bile duct is rarely performed. When these newer methods are not available, when they are not possible because of prior surgery, or when an open procedure is otherwise necessary, open common bile duct exploration is performed.

REF: 95 11. An example of a potential risk associated with pneumoperitoneum would be: a. tachycardia caused by peritoneal irritation from the CO2. b. CO2 absorption into the peritoneal capillaries, causing decreased oxygen saturation. c. bradycardia from CO2 pressure lower than 15 mm Hg. d. gas embolus into an exposed blood vessel during the procedure.

ANS: D CO2 is the gas of choice for pneumoperitoneum. The perioperative nurse should set the insufflation unit to a maximum pressure of 15 mm Hg. Pressure higher than 15 mm Hg may result in bradycardia or a change in blood pressure, or may force a gas embolus into an exposed blood vessel during the operative procedure.

REF: 92

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12. Jan Stuyvesant, a surgical technologist, was the scrub person during a robotic-assisted laparoscopic cholecystectomy. She locked the robotic endoscissor into the adaptor on the robotic arm and positioned the tip end into the trocar port in order for the surgeon to dissect the cystic duct and artery, while the surgical assistant placed the clips on the cystic duct and artery. As she reached across the sterile field to insert the cholangiocatheter through the port, the anesthesia provider accidentally made contact with the distal end of the catheter as he stood up to reach the monitor controls. The contaminated end of the catheter touched the endoscopic clip applier, the endoscissor connector that the surgeon was using, the glove of the assistant, and Jan’s gown sleeve.

The surgeon ordered everyone to change their gown and gloves and covered the port area with a sterile towel. What was the rationale for the surgeon to continue to dissect and not change his attire? a. The tip of the dissector that was in the patient’s abdomen was not contaminated. b. The surgeon planned to remove the dissector after he finished dissecting and then dispose it. c. The surgeon’s gown was not touched, just the dissector connection to the robotic arm. d. The surgeon was not in contact with the sterile field because he worked from the robotic console.

ANS: D The surgeon manages the robotic system from a console away from the operative field.

With current robotic systems, the surgeon sits at an operative console with threedimensional imaging and handheld controls. Movement of the controls follows the movement of the instrument’s tip. Robotic arms function just like a surgeon’s hands.

REF: 93 13. Joanne Grizwald, a 24-year-old woman with type 1 diabetes who is in end-stage kidney failure, is scheduled for a combined kidney-pancreas transplant. She is relatively healthy and at normal weight for her height in spite of her disease process. Her bleeding time and coagulation parameters are within normal limits. The circulating nurse has set up the autotransfusion system, verified Joanne’s blood type, and crossmatched blood availability. The scrub person, while organizing the sterile back table, identified several instruments that she will not need. She organizes those instruments on the most distant part of the back table. What instruments is the scrub person unlikely to need during this procedure? a. Based on Joanne’s coagulation status, excess bleeding is not expected to be an issue. b. Hemostasis will be achieved by the use of microfibrillar collagen agents that do not leave electrosurgical eschar (burned tissue) on the bleeding surfaces, thereby reducing the chance of infection. c. Any excess bleeding will be removed and returned to the patient through the autotransfusion system. d. The transplant procedure is an open approach and laparoscopic instruments (the

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insulated electrosurgical-adapted scissors, graspers, and the endoscopic suction tips) are not needed.

ANS: D Pancreatic transplantation is the implantation of a pancreas from a donor into a recipient for patients with type 1 (formerly known as juvenile-onset) diabetes. Options for pancreatic transplant include a pancreas transplant alone (PTA), an option chosen for patients with functioning kidneys, or a simultaneous pancreas-kidney transplant (SPK).

The whole-organ pancreatic transplantation procedure is performed through an oblique incision opposite the side of the renal transplant in the lower abdominal quadrant.

REF: 102 14. What technologic characteristic of robotic surgery provides a superior indication for robotic-assisted laparoscopic cholecystectomy? a. The surgeon controls two instruments plus a camera while an assistant suctions and retracts. b. Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage. c. The magnified three-dimensional picture may reduce bile duct injuries during dissection. d. Robotic stapler and suture devices promote intracorporeal anastomotic techniques.

ANS: C Robotic surgery enables surgeons to perform more advanced and complex procedures.

The view of the ductal anatomy is subjectively superior with robotic surgery because of the magnified three-dimensional picture, which may reduce bile duct injuries.

REF: 93 15. The donor liver OR is prepared for an open laparotomy procedure with basic laparotomy and vascular instruments and accessories. A second sterile instrument table is set up to receive and prepare the procured liver. Select the additional instruments and accessories needed on the donor organ preparation table. a. vascular instruments, silk sutures and ties, sterile ice, flushing solution, and slush machine. b. flushing solution, ice chest, sterile ice, powered sternal saw, and long Kocher clamps. c. culture tubes, Wisconsin University forceps, Deaver retractors, and slush machine. d. toothed forceps, vessel loops, two sterile plastic draw-string bags, and flushing solution.

ANS: A

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The donor OR is prepared for a major laparotomy procedure. Basic instrumentation and equipment includes a basic laparotomy set, cardiovascular instruments, power sternal saw, and nephrectomy instruments. A sterile, draped, medium-size instrument table is needed for preparation of the liver away from the main sterile field and instrument tables.

The procurement team provides special Collins solution for flushing the organs, sterile plastic containers and ice chests for organs, and in situ flush tubing. The liver is generally placed in two plastic Lahey bags immediately after procurement.

REF: 107 16. The recipient liver OR is arranged for a major laparotomy and vascular procedure with customized instruments, supplies, and sutures according to the transplant surgeon’s preference. In addition to the general patient care accessories, equipment, and supplies needed for any large surgery, also included are intraoperative laboratory testing and an autotransfusion system. Describe the boundaries of the surgical skin prep for the patient about to receive a liver transplant. a. From neck to midthigh; midaxillary line to midaxillary line b. From nipple line to pubis; bedline to bedline c. From the neck to midthigh; bedline to bedline d. From nipple line to midthigh; midaxillary line on the patient’s left side, and bedline on the right ANS: C Each transplant surgeon has preferred instruments, supplies, and sutures. The patient is placed supine with knees slightly flexed and padded. An indwelling urinary catheter is inserted after induction of anesthesia. The patient is prepped from the neck to midthigh, bedline to bedline. Prep solution should not pool at the bedline or wet the sheets on the OR bed. Fire safety precautions for prep solutions must be followed.

REF: 107

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Rothrock: Alexander's Surgical Procedures Chapter 04: Repair of Hernias Test Bank MULTIPLE CHOICE 1. Identify the triad of anatomic sites of abdominal wall weakness with a potential for hernias. a. Groin, ventral line, umbilicus b. Inguinal rings, femoral canal, incision c. Inguinal canal, femoral rings, umbilicus d. Ventral line, aponeurosis, inguinal canal ANS: C The weak places or intervals in the abdominal aponeurosis are (1) the inguinal canal, (2) the femoral rings, and (3) the umbilicus.

REF: 115 2. What composes the lining of a herniated abdominal sac? a. Fascia b. Peritoneum c. Muscularis d. Rectus abdominis muscle ANS: B A hernia is a sac lined by peritoneum that protrudes through a defect in the layers of the abdominal wall. Hernias can occur in several places in the abdominal wall, with protrusion of a portion of the parietal peritoneum and often a part of the intestine.

Generally, the hernia mass is composed of covering tissues, a peritoneal sac, and any contained viscera.

REF: 116 3. Select the triad of the boundaries of the Hesselbach triangle. a. Inguinal ligament, rectus abdominis muscle, deep epigastric vessels b. Rectus abdominis muscle, Cooper ligament, aponeurosis c. Scarpa’s fascia, deep epigastric vessels, external oblique muscle d. Inguinal ligament, inguinal canal, Cooper ligament ANS: A The boundaries of the Hesselbach triangle are deep epigastric vessels laterally, inguinal ligament inferiorly, and rectus abdominis muscle medially.

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REF: 118 4. Select the most common hernia that occurs in both males and females and name the side on which it would most likely occur. a. Direct femoral hernia on the left b. Indirect inguinal hernia on the right c. Indirect femoral hernia on the left d. Direct inguinal hernia on the right ANS: B Although hernias occur most often in males, the most common hernia in both males and females is the indirect inguinal hernia. Hernias occur more commonly on the right side than on the left.

REF: 115 5. Contributing factors to hernia formation include age, gender, previous surgery, obesity, nutritional status, and pulmonary and cardiac disease. The formation of the hernia at a site of weakness is due to any number of conditions that cause: a. impaired healing and defective collagen formation. b. thinning and stretching of muscle fibers. c. increased pressure within the abdomen. d. loss of tissue elasticity.

ANS: C Any number of conditions causing increased pressure within the abdomen can contribute to the formation of a hernia. Loss of tissue turgor occurs with aging and from chronic debilitating diseases. Current evidence suggests that adult male inguinal hernias are likely associated with impaired collagen metabolism and weakening of the fibroconnective tissue of the groin. Smoking has also been noted as a contributing factor to hernia formation.

REF: 115 6. Femoral hernias occur more frequently in which group of individuals? a. Postoperative obese patients b. Newborns c. Weight lifters d. Females ANS: D Femoral hernias occur much more frequently in females, and only 2% of females will develop inguinal hernias in their lifetime.

REF: 115

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7. While direct and indirect hernias both protrude into the inguinal canal and represent tears in the transversalis fascia, which one of the two occurs within the Hesselbach triangle? a. Direct inguinal hernia b. Indirect inguinal hernia c. Both options occur within the triangle d. Neither option occurs within Hesselbach’s triangle ANS: A The triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially is referred to as the Hesselbach triangle. Hernias that occur within the Hesselbach triangle are called direct inguinal hernias. Indirect inguinal hernias occur laterally to the deep epigastric vessels. Both direct and indirect hernias represent attenuations or tears in the transversalis fascia. Direct hernias protrude into the inguinal canal but not into the cord, and therefore rarely into the scrotum.

REF: 118 8. Ryan has an indirect hernia that is characterized by a small neck, thin walls, and close attachment to the cord structures. Marc has a hernia with a short, wide neck, and a thickwalled sac. Based on this description, Ryan has a(n) ____________ hernia and Marc has a(n) __________ hernia. a. acquired; congenital b. reducible; nonreducible c. congenital; acquired d. pantaloon; sacular ANS: C Indirect hernias may be either congenital, representing a persistence of the processus vaginalis, or acquired. In a congenital hernia, the hernia sac has a small neck, is thinwalled, and is closely bound to the cord structures. In an acquired indirect hernia, the neck is wide and the sac is both short and thick-walled. When both direct and indirect hernias are present, the defect is called a pantaloon hernia after the French word for “pants,” which this situation suggests.

REF: 119 9. Hernia-entrapped viscera, typically loops of small intestine, will result in intestinal obstruction with resulting pain, vomiting, and distention. What is the appropriate descriptive diagnosis of this condition? a. Nonreducible hernia b. Incarcerated hernia c. Torsion of the hernia sac d. Gangrenous bowel ANS: B

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Patients with incarcerated hernias may have signs of intestinal obstruction, such as vomiting, abdominal pain, and distention. The greatest danger of an incarcerated hernia is that it may become strangulated.

REF: 117 10. Morris Bettelman, an 86-year-old retired plumber, states that he has suffered from a groin hernia all of his adult life; he states, “as far back as I can remember.” Sometimes he has to push the bulge back into his abdominal muscle and then he is fine until he has a coughing spell. This morning the bulge was large and tender when he woke up and he could not reduce it. As the pain increased, he felt weak and nauseous. His daughter took him to the emergency department. Morris was diagnosed with a strangulated incarcerated hernia and scheduled for emergency surgery. If the contents of Morris’ hernia sac become compromised, with strangulation of the bowel, the probable label on his surgical specimen will be: a. compromised bowel. b. strangulated bowel. c. necrotic bowel. d. intestinal obstruction.

ANS: C In a strangulated hernia, the blood supply of the trapped sac contents becomes compromised and eventually the sac contents necrose. When bowel is strangulated in such a hernia, resection of necrotic bowel, in addition to repair of the hernia defect, becomes necessary. This is a surgical emergency.

REF: 117 11. Depending on their location, hernias are classified as direct inguinal, indirect inguinal, femoral, umbilical, incisional, or epigastric. Hernias in any of these groups are either reducible or nonreducible. The characteristic “reducible” hernia can best be described as a hernia: a. that does not require surgical repair. b. that is an emergent diagnosis. c. with visceral contents that can be returned to the abdomen. d. with a narrow sac neck that is closed with adhesions.

ANS: C A reducible hernia is an abdominal hernia whose contents of the hernia sac can be returned to the normal intra-abdominal position and are not trapped in the extraabdominal sac (incarcerated). The conditions preventing the return of the hernia contents to the abdomen (nonreducible) can result from (1) adhesions between the contents of the sac and the inner lining of the sac, (2) adhesions among the contents of the sac, or (3) narrowing of the neck of the sac.

REF: 116

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12. Of the open hernia procedures listed below, which classic hernia procedure is considered, by some surgeons, to not be anatomically correct because the superior transversalis fascia is sutured to the inguinal ligament instead of to the inferior portion of the transversalis fascia or the Cooper ligament? a. Shouldice repair b. Bassini repair c. McVay repair d. Cooper repair ANS: B The Bassini repair procedure was introduced in 1887 and was formerly the standard of repair. In this procedure the conjoined tendon and the shelving edge of the inguinal ligament are sutured together up to the internal ring. The major difference with this repair is that the superior transversalis fascia is sutured to the inguinal ligament with no attempt made to approximate it to the inferior portion of the transversalis fascia or the Cooper ligament. Critics of this procedure claim that it is not anatomically correct because layers that normally are not integrated (transversalis fascia and inguinal ligament) now are approximated.

REF: 125 13. Which two similar hernia repair approaches reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor by sewing the transversalis fascia to the Poupart ligament? a. The Shouldice and the McVay ligament repair b. The Bassini and the Shouldice repair c. The McVay and the Cooper ligament repair d. The Shouldice and the Cooper ligament repair ANS: C Approaches that reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor are favored. A surgical repair in which transversalis fascia is sewn to the Poupart ligament accomplishes this goal. A McVay or Cooper ligament repair approximates transversalis fascia superior to the inferior insertion of the transversalis fascia along the Cooper ligament.

REF: 122 14. The mesh-plug open hernia repair technique is indicated for which type(s) of hernias? a. Femoral hernias b. Indirect inguinal hernias c. Direct inguinal hernias d. All of the options are correct ANS: D

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The mesh-plug technique has been recommended for the treatment of primary and recurrent direct and indirect inguinal hernias. The various hernia types as classified by Gilbert have a corresponding relationship to the use of mesh plugs type I through type VII. Femoral hernias are classified as type VII. Regardless of the hernia type, the meshplug technique is performed on an ambulatory basis, through a small incision, often laparoscopically. In femoral hernias, a small- or medium-size plug is secured in position after the sac has been reduced.

REF: 127 15. The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin. The key landmark of the _____________ designates the roof of the inguinal canal and the key landmark of the __________ designates the floor of the inguinal canal. a. external oblique aponeurosis; transversalis aponeurosis and fascia b. lateral rectus abdominis; transversalis aponeurosis and fascia c. external oblique aponeurosis; Poupart ligament d. transversalis aponeurosis and fascia; Cooper ligament aponeurosis ANS: A The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin (Figure 4-2). The roof of the inguinal canal is formed by the external oblique aponeurosis, and the floor is formed by the transversalis aponeurosis and fascia. Essential to an understanding of inguinal hernia repair is an appreciation of the central role of the transversalis fascia as the major supporting structure of the posterior inguinal floor. The inguinal canal is covered by the aponeurosis of the external abdominal oblique muscle, which forms a roof (Figure 4-3).

REF: 117 16. The transabdominal preperitoneal patch (TAPP) hernia repair and the totally extraperitoneal patch (TEP) repair differ in the manner in which access is gained to the preperitoneal space. Which of the two provides access to the preperitoneal space without entering the peritoneum? a. The TEP technique b. The TAPP technique c. Both techniques require access into the peritoneal compartment d. Neither technique enters the peritoneal compartment ANS: A TEP provides access to the preperitoneal space without entering the peritoneal cavity.

The TAPP uses intraperitoneal trocars and the creation of a peritoneal flap over the posterior inguinal region.

REF: 128

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17. Charles Wilkins had a laparoscopic hernia repair with good results and an uneventful recovery. Weeks later, as he reviewed his hospital bill, he noted that he had been charged for a very expensive preperitoneal distention balloon, polypropylene mesh, an endomechanical stapler, and three endosurgical trocars. What hernia repair technique was probably performed on Charles? a. TAPP repair b. Laparoscopic Bassini repair c. TEP repair d. Mesh-plug insertion repair ANS: C The totally extraperitoneal patch (TEP) laparoscopic hernia repair technique was used on Charles. Access to the posterior rectus sheath is gained by trocar insertion in the periumbilical region. A balloon dissector is placed on the anterior surface of the posterior rectus sheath and inflated, thereby creating an optical cavity. The proximal peritoneal sac is closed with loop ligature to prevent pneumoperitoneum from occurring. A piece of polypropylene mesh is inserted; unfolded to cover the direct, indirect, and femoral spaces and rest over the cord structures; and carefully secured with a tacking stapler.

REF: 129 18. A group of United Kingdom (UK) researchers undertook an analysis of several research studies comparing the outcomes of laparoscopic versus open incisional hernia repair of patients who had prior laparotomies. They examined surgical time, duration of hospital stay, perioperative complications, postoperative surgical site pain, and recurrence rates in 183 patients whose incisional hernias were repaired by the open approach and 183 repaired by the laparoscopic approach. Based on the results of this study, an appropriate risk reduction strategy for patients with incisional hernias would be to repair incisional hernias: a. laparoscopically. b. through an open approach. c. using either open or laparoscopic approaches for equally good patient outcomes. d. with the open approach to decrease surgical time.

ANS: A Open repair was associated with significantly higher complication rates and longer hospital stays, as well as longer surgical times than laparoscopic repair. There was no statistical difference in surgical site pain or recurrence rates. The researchers concluded that laparoscopic repair of incisional hernias is a safe, feasible, and effective alternative to open repair techniques.

REF: 134 19. An example of a common postoperative complication related to inguinal hernia surgery is:

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delayed return to activity. delayed healing. postoperative adhesions. hernia recurrence.

ANS: D A successful herniorrhaphy is measured by the percentage of recurrence, the number of complications, the total costs, and the ability to return to normal activities of daily living.

REF: 115 MULTIPLE RESPONSE 1. A study was conducted that compared laparoscopic and open-mesh methods of inguinal hernia repair and also compared TEP and TAPP techniques for cost and patient outcome effectiveness. Some of the factors measured included patient’s return to prior activities, persisting pain and numbness, infection, length of operation time, and complications. The researchers discovered several compelling findings and many differences between the two approaches. Select two statements that reflect true findings from the study. a. TEP and TAPP techniques were of similar cost to the patient. b. Mesh infection rate was low with both techniques. c. There was no significant difference in complication rates. d. There was no apparent difference in the rate of hernia recurrence. e. Return to work and activity was similar for the two techniques. f. TEPP and open-mesh techniques shared equal costs to the patient.

ANS: B, D Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound infection and hematoma formation. However, operative times were longer, and there appears to be a higher rate of serious complications (e.g., bowel, bladder, and vascular injuries) with laparoscopic methods. Mesh infection is very uncommon, with similar rates noted among the surgical approaches. There is no apparent difference in the rate of hernia recurrence.

The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. Economic savings in the form of fewer days of work missed and reduced workers’ compensation have been reported.

REF: 129

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Rothrock: Alexander's Surgical Procedures Chapter 05: Gynecologic and Obstetric Surgery Test Bank MULTIPLE CHOICE 1. When catheterizing the female patient, the urethra must be located. The correct order of the external organs of the vulva listed anterior to posterior is: a. mons pubis, labia majora, labia minora, urethra, clitoris, vaginal opening. b. labia majora, labia minora, clitoris, urethra, vaginal opening, mons pubis. c. mons pubis, labia majora, labia minora, clitoris, urethra, vaginal opening. d. labia majora, labia minora, urethra, mons pubis, clitoris, vaginal opening.

ANS: C The external organs, referred to collectively as the vulva, include the mons pubis, the labia majora and labia minora, the clitoris, the vestibular glands, the vaginal vestibule, the vaginal opening, and the urethral opening (Figure 5-3).

REF: 141 2. An example of perineal glands that secrete mucus is: a. Skene’s glands. b. Bartholin’s glands. c. perineal glands. d. labial glands.

ANS: B Bartholin’s glands and ducts are located on each side of the lower end of the vagina.

These narrow ducts open into the vaginal orifice on the inner aspects of the labia minora.

The glands secrete mucus and can become infected or inflamed.

REF: 141 3. Ova travel through the fallopian tubes toward the uterus by which type of action? a. Peristalsis b. Gravity c. Brownian motion d. Intra-abdominal pressure ANS: A

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The Greek word salpinx, meaning “trumpet” or “tube,” is used to refer to the fallopian tubes (Figure 5-4). The tubes are paired and consist of a musculomembranous channel approximately 10 to 13 cm long, forming the canals through which the ova are conveyed to the uterus from the ovaries. The peristaltic action of the muscular layer and the ciliary movement propel the ova toward the uterus.

REF: 142 4. Matilda Gunderson, a 55-year-old woman with uterine cancer, is scheduled for an open panhysterectomy. She is positioned in low lithotomy with her legs symmetrically arranged in padded cradle stirrups. After the incision is made and primary dissection accomplished, she will be positioned in Trendelenburg position to facilitate exposure of the lower pelvis and displacement of the small bowel from the operative area. Matilda is at risk for compromise and injury related to prolonged Trendelenburg tilt, which promotes: a. decreased pulmonary compliance and functional residual capacity. b. increased popliteal congestion and peripheral vascular collapse. c. shearing force injury from sliding toward the head of the OR bed. d. avascular ischemic changes to the lower leg and feet from gravitational devascularization.

ANS: A Patients placed in Trendelenburg position for prolonged gynecologic procedures are at increased cardiovascular risk because of decreased pulmonary compliance and functional residual capacity (FRC).

REF: 149 5. The surgical team gently abducted Matilda’s arms into position on padded armboards at less than 90 degrees with palms facing up. Extra padding was placed under her elbows and an armboard strap was secured over her forearm. The armboards were locked into place to prevent inadvertent abduction. This important maneuver is designed as a risk reduction strategy to prevent: a. axillary tension. b. brachial plexus injury. c. celiac plexus injury. d. elbow torsion with displacement.

ANS: B Whenever possible the circulator positions the patient’s arms on padded armboards with the palms up and fingers extended. Armboards are maintained at less than a 90-degree angle to prevent stretching of the brachial plexus. Care should be taken to protect all patients from integumentary, musculoskeletal, and nerve injury while ensuring adequate circulatory, renal, and respiratory functions.

REF: 149

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6. From the list below, select the statement that is true about fallopian tube cancer. a. Fallopian tube cancer metastasizes to the ovaries and cervix. b. Fallopian tube cancer is fast-growing in women with genital herpes. c. Fallopian tube cancer is very rare, with an incidence of less than 1%. d. Fallopian tube cancer is seen primarily as a metastasis from the small intestine.

ANS: C Fallopian tube cancer is very rare, with an incidence of less than 1%. It is seen primarily as a metastasis from ovarian and endometrial cancers. Gynecologic cancers commonly occur in the endometrium, the cervix, the ovaries, or the vagina. Less common sites are the vulva and fallopian tubes. Risk factors associated with the development of these cancers are noted in Table 5-2.

REF: 149 7. Margie Donaldson’s examination has revealed a family history of endometrial cancer.

She has never been pregnant and has been taking hormone replacement therapy for 4 years. Her physician has scheduled her for a surgical procedure to obtain visual and pathologic information and provide treatment as indicated. Margie was sure that she would have to have a D&C (dilatation and curettage). Margie’s surgery, on the operative schedule, would most probably be written as: a. D&C with endocervical biopsies. b. hysteroscopy with endometrial ablation. c. D&C with endometrial biopsies, frozen section, possible LAVH. d. D&E with endometrial washings, frozen section, total abdominal hysterectomy.

ANS: C D&C is done either for diagnostic purposes or as a form of therapy for a variety of pelvic conditions, such as abnormal uterine bleeding or primary dysmenorrhea (see Table 5-1).

D&C may also be performed when carcinoma of the endometrium is suspected.

Indications for LAVH may be absence of genital prolapse, required adnexectomy, history of abdominopelvic surgery, salpingitis or endometriosis, lymphadenectomy, and endometrial cancer.

REF: 161 8. Miranda Cox returned to her gynecologist’s office for a second Pap smear when her routine exam showed dysplastic cells in her cervical cytology test. Miranda has a family history of cervical cancer and had laser ablation within the last 2 years for vulvar condylomata. She can expect her gynecologist to perform another Pap smear and: a. colposcopy with endocervical biopsy. b. hysteroscopy with cervical biopsy and frozen section. c. colposcopy with cervical skinning procedure performed using a local anesthetic. d. second-look vaginal exam with cervical Pap smear.

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ANS: A A colposcopy, with colpomicroscopy, is often performed in the physician’s office. This examination is indicated for the patient with an abnormal Papanicolaou (Pap) smear suggestive of dysplasia. It identifies cellular abnormalities that may involve the vulva, vagina, or cervix and helps identify areas of dysplasia and carcinoma in situ.

Endocervical curette samples may be obtained during the colposcopic procedure to rule out invasive carcinoma or to detect early adenocarcinoma.

REF: 147 9. Sally Hargraves is a 72-year-old patient with multicentric carcinoma in situ (CIS) of the vulva, without evidence of leukoplakia and pruritus. She has a history of prior papillomavirus infection. Select the most appropriate surgical option. a. Radical vulvectomy with inguinal lymph node dissection b. Skinning vulvectomy c. CO2 laser surface ablation of the vulvar lesions d. Simple vulvectomy ANS: D Simple vulvectomy is removal of the labia majora and labia minora, possibly (but not preferably) the glans clitoris, and occasionally tissue from the perianal area. A simple vulvectomy is usually performed to treat carcinoma in situ of the vulva when it is multicentric. Occasionally, a vulvectomy is necessary for the treatment of either leukoplakia or intractable pruritus, especially when a skinning procedure is impractical or has failed.

REF: 152 10. Marla Moriarity, a 32-year-old recently unemployed and uninsured college professor, is diagnosed with an early ectopic pregnancy. Her obstetrician has given her the option of surgical or medical therapy. She is well-informed about the details of each medical and surgical option, but her primary concern about her condition is that her decision will be based upon her strong cultural belief system that will not sanction the destruction of the fetus. Marla’s treatment decision will most likely be: a. the medical therapy of IM methotrexate for 5 to 7 days. b. laparoscopic injection of methotrexate to the extrauterine gestational sac. c. emergency laparotomy for a ruptured ectopic pregnancy. d. salpingectomy.

ANS: C

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Ectopic pregnancy, a devastating complication that affects up to 2% of all pregnancies, may be treated medically with methotrexate or surgically through salpingostomy, segmental resection, fimbrial expression, and salpingectomy. Methotrexate destroys rapidly dividing cells and is often administered in conjunction with the surgical procedure to destroy any residual trophoblastic cells that might remain. Laparoscopic and/or ultrasound-guided application of methotrexate to the extrauterine gestational sac may also be used as an alternative therapy. The more cost-effective medical treatment for ectopic pregnancy is considered a front-line therapy in many major medical centers. Ruptured ectopic pregnancy is considered a surgical emergency and is associated with severe abdominal pain, tachycardia, and hypotension.

REF: 171 11. Select the congenital anomaly that best reflects indications for fetal surgery. a. Imperforate anus b. Tracheoesophageal fistula c. Congenital diaphragmatic hernia d. Nonobstructive uropathy ANS: C Conditions treated by fetal surgery include congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, bronchopulmonary sequestration, obstructive uropathy, sacrococcygeal teratomas (Figure 5-63), twin-to-twin transfusion syndrome, thoracic lesions, twin reversed arterial perfusion syndrome, monochorionic twins, discordant twins, and myelomeningocele (Figure 5-64). Fetal surgery may be accomplished by way of laparotomy and hysterotomy or, in some instances, with endoscopic techniques.

REF: 191 12. What classification of drugs are GYN/obstetric-related medications that require monitoring of blood pressure, assessment for continued bleeding, and monitoring of fundal response to the drug? a. Oxytocics b. Tocolytics c. Antimetabolites d. Cytotoxics ANS: A Oxytocics are medications that increase motor activity within the uterus by hormonal stimulation or by direct stimulation on the smooth muscles, usually resulting in uterine contractions. They may be used intraoperatively and postoperatively. The following are some nursing considerations after their administration: monitor blood pressure, assess for continued bleeding, and monitor fundal response to the drug.

REF: 190

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MULTIPLE RESPONSE 1. During the skin preparation for a gynecologic procedure that requires both an abdominal and a vaginal prep, the circulator must ensure that cross-contamination does not occur.

Select two principles of aseptic technique that support cross-contamination prevention. a. Tuck sterile towels under the patient’s buttocks and both sides of the abdomen. b. Insert the urinary catheter to drainage before beginning the prep. c. Prep the abdomen before beginning the vaginal prep. d. Use two separate prep trays (one for the abdomen, one for the vagina).

ANS: C, D Care must be taken not to cross-contaminate when prepping multiple areas, such as for an abdominal hysterectomy. The circulator always preps the abdomen before beginning the vaginal prep, using the principle “clean to dirty.” Two separate prep trays should be used and the prep setups should be kept separate. The circulator should take care when performing vaginal preps on patients who have been experiencing vaginal bleeding and may have clots in the vaginal vault. The clots and any gross blood on the thighs or vulva should be removed before beginning the prep to allow full contact of the prepping solution.

REF: 144

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Rothrock: Alexander's Surgical Procedures Chapter 06: Genitourinary Surgery Test Bank MULTIPLE CHOICE 1. The renal artery and vein enter and exit the kidney on the medial side of the organ through a concave area known as the: a. calyces. b. pedicle. c. hilum. d. renal pelvis.

ANS: C On the medial side of each kidney is a concave area known as the hilum, through which the renal artery and vein enter and exit. The renal pelvis, a funnel-shaped structure that lies within the kidney and posterior to the renal vascular pedicle, divides into several branches called calyces (Figure 6-3). The renal artery and vein with their accompanying nerves and lymphatics are referred to as the pedicle of the kidney.

REF: 200 2. Select the statement about the prostate that best reflects its location, size, and weight. a. The prostate sits adjacent to the urethra, is 2 to 4 cm in depth, and weighs about 25 g. b. The prostate sits below the urethra, is 2 to 3 cm in depth, and weighs 25 to 30 g. c. The prostate sits below the bladder, is 2 cm in depth, and weighs about 25 to 40 g. d. The prostate sits below the base of the bladder, is 4 cm at the base, and weighs 20 to 30 g.

ANS: D The prostate gland is a donut-shaped organ composed of fibromuscular and glandular components. It is located at the base of the bladder neck and completely surrounds the urethra. The gland is about 4 cm at the base, is about 2 cm in depth, and normally weighs 20 to 30 g (see Figures 6-5 and 6-7).

REF: 202 3. The kidneys are highly vascular organs. Approximately how much of the entire circulating blood volume do the kidneys process at any one time? a. One fifth b. 1 ml per kg body weight c. One third d. 30 ml per hour

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ANS: A The kidneys are highly vascular organs that process approximately one fifth of the entire volume of blood at any one time.

REF: 200 4. The adrenal glands lie retroperitoneally beneath the diaphragm, capping the medial aspects of the superior pole of each kidney. The adrenal medulla secretes ______________ while the adrenal cortex secretes ____________ and ____________. a. epinephrine; steroids and hormones b. steroids; adrenaline and hormones c. epinephrine; pituitary-stimulating hormone and adrenaline d. pituitary hormones; cortisol and norepinephrine ANS: A Each adrenal gland has a medulla, which secretes epinephrine (adrenaline), and a cortex, which secretes steroids and hormones. Secretions from the adrenal cortex are influenced by the activity of the pituitary gland.

REF: 200 5. Which action best reflects the movement of urine from the renal pelvis to the bladder? a. Normal intra-abdominal positive pressure promotes renal drainage. b. Slight distention of the renal pelvis initiates a wave of peristaltic contractions. c. Distention of the proximal ureter facilitates gravity drainage through signaling channels. d. Urine is propelled into the bladder when adrenal hormones bind with ureteral receptor sites.

ANS: B As urine accumulates in the renal pelvis, slight distention initiates a wave of muscular contractions. This peristaltic activity continues down the ureter, propelling urine into the bladder.

REF: 200 6. Patients having genitourinary surgery are at risk for impaired urinary elimination. Select the statement that best reflects a desired outcome for an adult patient. a. The patient will be able to urinate before the bladder exceeds 350 ml of fullness. b. The patient will regain his or her normal pattern of urinary elimination. c. The patient will excrete 50 ml of urine per hour. d. All of the options are desired outcomes.

ANS: B

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The patient outcome related to the risk for urinary retention could be stated as follows: The patient will demonstrate or regain a normal pattern of urinary elimination. Normal urinary output for an adult is 0.5 to 1 ml/kg body weight/hour. Full bladder capacity is 350 to 700 ml.

REF: 199 7. During urologic surgery, large quantities of irrigating fluids are infused intraoperatively.

Which of the following is appropriate? a. monitoring and recording the volume of IV and irrigating fluids instilled. b. maintaining a closed urinary drainage system. c. providing the patient with information on preventing recurrent urinary tract infections. d. monitoring blood loss and volume replacement.

ANS: A Large amounts of irrigating fluids are often used during urologic procedures, which may impact the patient’s electrolyte status. Irrigating fluids should be monitored both for fluid infused and for fluid returned. Thorough knowledge of the potential hazards encountered intraoperatively is extremely important and close observation is essential. A sudden change in signs and symptoms may be suggestive of TURP syndrome, a severe hyponatremia caused by systemic absorption of irrigating fluid used during surgery.

Minimum amounts of fluids should be given and urine output carefully monitored.

Irrigation fluid should be under as little pressure as possible and the bladder emptied before it reaches full capacity to prevent intravesical pressure.

REF: 207 8. The PSA test is a serum lab test for prostate-specific antigen. If the test value is elevated, the patient is at risk for carcinoma of the prostate; a PSA value greater than 10 ng/ml is highly suggestive of prostatic carcinoma. Tissue from a transrectal prostate biopsy provides the cellular information to confirm the diagnosis. The American Urological Association (AUA) prostate cancer staging tool essentially provides what important information about the tissue specimen? a. Prostate cancer stages of severity b. Indications for selecting appropriate intervention c. Prognosis and potential for recovery d. All of the options define the AUA score system.

ANS: A

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The American Urological Association (AUA) recommends that starting at age 40 the prostate-specific antigen (PSA) test and digital rectal examination (DRE) be offered to men at average risk. Clinical evaluation and an elevated PSA usually indicate the need for a transrectal ultrasound needle biopsy to confirm the diagnosis. When the results of the biopsy are positive for cancer, the AUA score measures the severity of the cancer: stage A = clinically unsuspected disease; stage B = tumor confined to the prostate gland; stage C = tumor localized to the periprostatic area; stage D = metastatic prostate cancer.

REF: 232 9. An orthotopic neobladder is surgically created as a bladder substitute after a cystectomy, prostatectomy, or hysterectomy is performed for bladder cancer. Bladder substitution relies on meticulous dissection with preservation of the urinary sphincter and neurovascular bundles, as well as a watertight urethral anastomosis. Also termed the “Le Bag continent diversion,” what segments of the bowel and/or small intestine are used in this technique to create the neobladder? a. Segment of sigmoid colon b. Right colon and ileum c. Proximal right colon segment with cecum d. Transverse colon ANS: B The orthotopic ileocolic neobladder, or Le Bag continent diversion technique, uses the right colon and ileum as an orthotopic bladder replacement. Contraindications include previous radiation therapy, bowel disease (e.g., diverticulosis, Crohn’s disease, colitis), and other major medical problems.

REF: 269 10. In transurethral resection of the prostate gland (TURP), the surgeon passes a resectoscope into the bladder through the urethra and resects successive pieces of tissue from around the bladder neck and the lobes of the prostate gland, leaving the capsule intact. TURP is traditionally indicated for patients with benign obstructive disease of the prostate. A TURP would be indicated for a patient with malignant prostatic disease under which of the following conditions? a. For palliative relief of obstruction for end-stage disease b. For symptom relief of obstruction before initiating other treatments c. For specimen retrieval for diagnostic cancer staging d. For men who cannot tolerate, or who are not candidates for, high-intensity focused ultrasound ANS: B

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TURP is one surgical method of treating benign obstructive enlargement of the prostate gland. If the prostate gland is cancerous, a radical retropubic or radical perineal prostatectomy, in conjunction with open or laparoscopic pelvic lymph node dissection, is usually performed. TURP may also be used in men who cannot have a radical prostatectomy, or to relieve symptoms caused by prostate cancer before other treatments are initiated.

REF: 234 11. High-intensity focused ultrasound (HIFU) is a noninvasive technique used in the treatment of prostate cancer. HIFU is a targeted therapy that is highly focused into a small area without causing collateral tissue damage. Aside from primary therapy, HIFU can be used as salvage therapy, primarily after radiation. HIFU can be performed as an outpatient procedure, often with an epidural anesthetic. The HIFU-directed energy modality is best described as: a. high-temperature nonionizing thermal energy. b. cavitation of the prostate cell cytoplasm by the implosion of microscopic bubbles. c. mechanical shearing force of ultrasonic waves. d. radiofrequency coagulation of prostatic cell nuclei.

ANS: A HIFU is highly focused into a small area, creating intense heat of 80° to 100° C, which is lethal to prostate cancer tissue. HIFU destroys tissue by heat, rather than by cavitation or mechanical shearing. Since ultrasound is nonionizing, there is no collateral tissue damage.

For the majority of patients, HIFU is indicated as a curative therapy. The best candidates are clinical/pathologic stages T1c to T3. Because of the limited focal length of HIFU, gland volume cannot be 40 ml or larger. Aside from primary therapy, HIFU can be used as salvage therapy, primarily after radiation. HIFU can also be repeated without any increase in risk or complications.

REF: 233 12. A wide variety of ureteral and urethral drains, stents, and other catheters are designed and used for specific urologic procedures. A commonly used catheter is described by its tip.

What catheter type is described as open-ended tip, whistle tip, cone tip, and olive tip? a. Irrigation catheter b. Urethral catheter c. Ureteral catheter d. Pigtail catheter ANS: C

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The most commonly used ureteral catheters include the open-ended, whistle tip, cone tip, and olive tip. When a retrograde ureterogram is indicated, a cone-tipped ureteral catheter may be helpful in occluding the ureteral orifice to accomplish the x-ray study effectively.

A variety of urethral and ureteral catheters are designed for specific procedures. Ureteral catheters are manufactured of polyurethane material and are graduated so that the urologist may determine the exact distance the catheter has been inserted into the ureter.

REF: 211 13. A kidney transplant entails transplantation of a living-related or cadaveric donor kidney into the recipient’s iliac fossa. It is performed in an effort to restore renal function and maintain life in a patient who has end-stage renal disease. Select the statement that best reflects the ideal living-related donor candidate. a. An identical twin or spouse, young, ABO and Rh factor compatibility b. An identical twin or parent, good health, and large right kidney c. An identical twin or sibling, no family history of diabetes, Rh factor compatibility d. An identical twin or sibling or parent, ABO and HLA compatibility, good health ANS: D The kidney donor must be in good health. ABO (blood typing) and histocompatibility (human leukocyte antigen [HLA] tissue typing) along with a negative white cell (lymphocyte) crossmatch determine donor-recipient compatibility. It is not necessary to match the Rh factor. If there is a family history of diabetes, a 5-hour glucose tolerance test is also performed. The ideal living donor is an identical twin, although any immediate family member (usually a sibling or parent) may be a donor. Usually the right kidney is chosen for removal because of its smaller size, leaving the donor patient with the left and larger kidney.

REF: 279 14. Although each potential kidney transplant recipient is judged individually as a candidate, which condition from the list below would most likely eliminate a patient as a candidate for kidney transplant? a. Systemic disease b. Cardiovascular disease c. Post-treatment cancer in remission d. Active cancer ANS: D Each potential recipient is judged individually in regard to kidney transplantation. Most persons younger than 55 years are acceptable; older patients are less tolerant of postoperative complications. The following are contraindications for renal transplantation: systemic disease that precludes major surgery, oxalosis (a metabolic disorder), a positive HLA cytotoxic antibody screen, untreatable cardiovascular disease, active cancer, and noncompliance.

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REF: 282 15. TURP syndrome is a state of severe hyponatremia, caused by systemic absorption of irrigating fluid during the procedure. Select the sign/symptom that the anesthesia provider would report in a patient experiencing TURP syndrome. a. Hypertension b. Hyperthermia c. Hypernatremia d. Hypokalemia ANS: A Signs and symptoms such as sudden restlessness, apprehension, irritability, confusion, nausea, slow pulse rate, seizures, dysrhythmias, and rising blood pressure may be suggestive of TURP syndrome. This syndrome results in severe hyponatremia caused by systemic absorption of irrigating fluid used during surgery.

REF: 208 MULTIPLE RESPONSE 1. The flexible cystoscope is a delicate and valuable endoscopic instrument indicated for diagnostic bladder evaluation for patients with obstructive symptoms from prostatic hyperplasia and a rigid prostatic urethra. It has valuable benefits because of its small diameter and flexibility. Select all of the benefits from the list below that support the use of flexible endoscopy in the outpatient setting. a. It may be accomplished using a local anesthetic. b. It can be used for patients unable to assume the lithotomy position. c. It can be performed on the patient’s bed on the nursing unit. d. The cystoscope can be processed between patients without manual cleaning and disinfection.

ANS: A, B The flexible cystoscope (Figure 6-25) is used for patients with obstructive symptoms resulting from prostatic hyperplasia and a rigid prostatic urethra. In addition, the flexible cystoscope can be used for patients who cannot assume a lithotomy position, such as those with spinal cord injuries or severe arthritis. Flexible cystoscopy may be accomplished with the use of a local anesthetic. It affords the patient a higher degree of comfort, is less traumatic to the urethra, and can be performed in the patient’s bed on the nursing unit. The flexible cystoscope must be reprocessed with manual cleaning and high-level disinfection or sterilization.

REF: 217

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Rothrock: Alexander's Surgical Procedures Chapter 07: Thyroid and Parathyroid Surgery Test Bank MULTIPLE CHOICE 1. The pyramidal lobe of the thyroid is described as: a. a small lobe often involved in 30% of cases of thyroid dysfunction. b. a protrusion of an immature thyroglossal duct cyst overgrowth. c. a thin upward protrusion of thyroid tissue from the isthmus. d. a vestige of an embryonic thyroid cyst.

ANS: C The pyramidal lobe, a long, thin projection of thyroid tissue protruding cephalad from the isthmus, is found in about 30% of patients at surgery; it is the vestige of the embryonic thyroglossal duct and migrates from the foramen cecum at the base of the tongue. If the migratory tract fails to degenerate, a fistula or cyst may be present.

REF: 287 2. The primary function of the three thyroid hormones is to regulate: a. energy metabolism. b. body growth and development. c. calcium storage in the bones. d. the decrease in blood calcium levels.

ANS: A The thyroid gland produces three hormones: thyroxine (T4) and triiodothyronine (T3) (together known as the thyroid hormones [THs]) and calcitonin. T3 and T4 cannot be synthesized without iodine. Calcitonin increases calcium storage in the bone and decreases blood calcium levels. The primary function of thyroid hormones is to regulate energy metabolism, but they also play an important role in growth and development.

Thyroid-stimulating hormone (TSH) is synthesized by the anterior pituitary, and stimulates the production and release of thyroid hormones and the uptake of iodine.

REF: 288 3. Postoperative hoarseness, obstructed airway, or paralysis of the vocal cords is a serious complication of thyroid surgery. During surgery, care is taken to identify and protect which nerve? a. Superior branch of the vagus nerve b. Intrinsic cricothyroid nerve c. Recurrent tracheoesophageal nerve d. Recurrent laryngeal nerve

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ANS: D The recurrent laryngeal nerve, a branch of the vagus nerve, innervates the intrinsic muscles of the larynx. During surgery, care is taken to identify and protect this nerve.

Immediate hoarseness occurs if the nerve is divided on one side. If the recurrent nerve is injured bilaterally, acute paralysis of both vocal cords may obstruct the airway and require emergency tracheotomy. Injury to the external branch of the superior laryngeal nerve, which innervates the cricothyroid muscle, results in difficulty shouting or singing high notes.

REF: 288 4. What is the mechanism by which the parathyroid glands maintain calcium homeostasis? a. They secrete parathyroid hormone (PTH), which promotes calcium storage in the intestines. b. They produce a hormone that, with calcitonin, takes calcium from the bones and promotes calcium absorption by the intestines. c. They stimulate the pituitary to produce PTH and calcitonin, which elevates serum calcium levels. d. They secrete hormones that stimulate the production of calcium in the bones and small intestines when serum calcium levels fall below 4.5 mg/dl.

ANS: B The parathyroid glands secrete parathyroid hormone (PTH), an antagonist to calcitonin.

Both PTH and calcitonin work together to maintain calcium homeostasis by increasing calcium removal from storage in bone and increasing absorption of calcium by the intestines.

REF: 289 5. Hypothyroidism results from undersecretion of thyroid hormone. The most common cause of primary hypothyroidism is chronic autoimmune thyroiditis (Hashimoto’s disease). Select the set of symptoms that is most commonly associated with hypothyroidism. a. Dry skin, edema, constipation, and depression b. Irritability, mood changes, visual disturbances, and diarrhea c. Heat intolerance, anorexia, hair loss, and menstrual irregularity d. Bradycardia, hypotension, hypoxia, and poor concentration ANS: A Symptoms of hypothyroidism include fatigue, weight gain, cold intolerance, hair dryness or loss, dry skin, depression, hoarse voice, poor concentration, muscle stiffness and pain, edema, bradycardia, constipation, and menstrual irregularity (especially heavy menses; infertility).

REF: 290

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6. Pamela Morris is a 62-year-old woman with a 4-year history of Graves’ disease that has not responded to medical therapy. She is scheduled for a subtotal thyroidectomy. What condition, a complication of Graves’ disease, is her probable indication for a subtotal thyroidectomy? a. Tracheal obstruction b. Diffuse unilateral enlargement of a lobe c. Hyperthyroidism with cricothyroid compression d. Autoimmune hypothyroidism ANS: A Graves’ disease, the most common cause of hyperthyroidism, is associated with diffuse, bilateral enlargement of the thyroid gland. Surgery is not the first response for Graves’ disease, but is reserved for those patients who fail medical therapy (antithyroid drugs and radioactive iodine) or have a contraindication to medical therapy. Surgery is performed to relieve tracheal obstruction.

REF: 296 7. Thyroid storm can occur in patients whose hyperthyroidism is partially controlled or untreated. Thyrotoxic crisis can be precipitated by a stressful event, such as surgery. An example of an action(s) the circulator and surgical technologist can take to reduce the risk of thyroid storm is: a. administer potassium iodide before transfer to the OR. b. provide a quiet, calm atmosphere and help the patient relax. c. provide comfort measures, including a cooling blanket. d. provide a quiet, calm atmosphere and help the patient relax, and provide comfort measures, including a cooling blanket.

ANS: D By planning a quiet, calm atmosphere and helping the patient relax, the circulator and surgical technologist can reduce the risk of thyroid storm. Collaborating with the surgical and anesthesia team, they can plan for appropriate interventions to assist in reducing body temperature and heart rate, provide oxygen and intravenous solutions, and administer medications as prescribed in the event thyrotoxic crisis occurs.

REF: 292 8. Thyroid surgery is considered surgery of the head and neck. There is a high risk for surgical fires because of the proximity of all three components of the fire triangle. Select the statement that best reflects an appropriate nursing action to prevent a surgical fire. a. Include the fire risk score during the time-out briefing. b. Prevent prep solution from pooling under the patient’s head, neck, and shoulders. c. Permit the prep solution to dry before draping. d. All the options are risk reduction considerations.

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ANS: D The entire team should note, discuss, and determine the fire risk score during the preincision time-out briefing. The operative area (chin and anterior neck region, lateral surfaces of the neck from the earlobes down to the outer aspects of the shoulder, and upper anterior chest region to the nipples) is prepped with an antimicrobial solution.

Appropriate precautions must be taken to prevent pooling of solution under the neck or in the axillary area. Alcohol-based prep solutions around the head and neck area present a risk for surgical fire. They must be used with caution, allowing time for the prep to dry and the fumes to dissipate. Bed sheets that become soaked with a flammable prep solution should be removed from the OR. REF: 294 9. A patient having a subtotal thyroidectomy for tracheal or esophageal obstruction is best served by a surgical team that recognizes and is prepared for patients who are at risk for difficult intubation. An example of a postoperative patient care management plan is: a. monitor the patient closely for airway difficulty. b. prevent coughing. c. support the neck during movement. d. prevent postoperative nausea and vomiting.

ANS: A Postoperatively, the patient is monitored closely for airway difficulty. Hypertension is treated and controlled. The incision site is observed for swelling and/or bleeding. Ice packs may be applied to reduce swelling. Coughing should be minimized and neck support during coughing should be demonstrated. Complications of hemorrhage, compromised airway, thyroid storm, and hypocalcemia are recognized and treated immediately.

REF: 293 10. Anatomic exposure is promoted and supported by proper body alignment in collaboration with safe and secure surgical positioning. The optimal presentation of the thyroid and surrounding structures of the neck can be achieved with the patient in supine or beachchair position. Select the positioning considerations that enhance visualization and access to important structures. a. 30-degree Trendelenburg’s tilt of the OR bed, shoulder roll, and arms tucked snuggly at sides b. Hyperflexion of the neck, shoulder roll, and arms tucked loosely at sides with palms facing up c. Hyperextension of the neck, shoulder roll, and 30-degree reverse Trendelenburg’s tilt of the OR bed d. Headrest, arms abducted at 90 degrees on armboards, and axillary roll ANS: C

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Proper patient positioning on the OR bed is crucial for optimal exposure of the thyroid gland. The patient is positioned supine. Some surgeons prefer a beach-chair position or a wedge under the back. Hyperextension of the neck is required for maximal exposure. A headrest provides proper support, keeps the head straight, and prevents aggravation of prior neck problems. Alternatively, a shoulder roll may be used. The arms are tucked at the side, the elbows are padded to protect the ulnar nerve, the palms face inward, and the wrist is maintained in a neutral position. Reduction of venous congestion can be accomplished by a 30-degree reverse Trendelenburg’s tilt of the OR bed.

REF: 293 11. Total thyroidectomy is the removal of both lobes of the thyroid and all thyroid tissue present. Total thyroidectomy is the desired surgical treatment for patients with: a. hyperthyroidism with more than two episodes of thyroid storm. b. thyroid cancer. c. autoimmune inflammatory thyroid dysfunction. d. hypothyroidism unresponsive to antithyroid medications.

ANS: B For patients with cancer of the thyroid, total thyroidectomy is the desired surgical treatment followed by iodine-131 remnant ablation. Preventing thyroid cancer recurrence does not depend on surgical approach, but on complete surgical excision of the tumor.

REF: 295 12. Substernal or intrathoracic thyroidectomy is indicated for extensions of goiters that are encroaching into the substernal or intrathoracic regions, causing tracheal or esophageal obstruction. Access to the substernal compartment is typically facilitated by: a. splitting the sternum. b. using a right mini-thoracotomy approach. c. using long instruments through a regular thyroid incision. d. using a mediastinoscopy approach.

ANS: C Extensions of goiters enlarging into the substernal and intrathoracic regions may occur. If they cause tracheal and esophageal obstruction, they are usually excised surgically.

Longer instruments are sometimes required. Splitting the sternum is rarely necessary because access to the substernal part of the gland is usually satisfactory through the standard thyroid incision.

REF: 299 13. Open parathyroidectomy is currently being replaced with less invasive and more targeted techniques; however, the amount of parathyroid tissue that should be removed remains controversial and relates to whether single or multiple glands are involved. A portion of a gland must remain to:

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prevent hypocalcemia and its complications. serve as a marker for later surgery should the gland fail to produce PTH. regenerate into normal parathyroid tissue. maintain the patient in a state of hypercalcemia to compensate for the lost glands.

ANS: A Although it is quickly being replaced with the focused approach to parathyroidectomy, in the classic open approach, with the thyroid gland visible, bilateral neck exploration of the “normal” locations of the four parathyroid glands is conducted. A portion of a gland must remain to prevent hypocalcemia and its complications. The amount of remaining parathyroid tissue can then be adjusted to regulate PTH to the desired level.

REF: 304 14. Jennifer Peoples is a 41-year-old woman with suspected primary adenocarcinoma of the thyroid; she is scheduled for total thyroidectomy surgery. How can the scrub person, Joni, a new surgical technologist, participate in using risk reduction strategies in the scrub role? a. Pay meticulous attention to sterile technique. b. Provide efficient and expedient hemostatic devices and materials as needed. c. Maintain sterility of the instruments until the patient leaves the room in the case of need for emergency tracheostomy. d. All of the options reflect appropriate scrub role risk reduction techniques.

ANS: D Attention to sterile technique is a core team value. Gentle tissue handling reduces the risk of damage to nerves, parathyroid glands, and surrounding structures. Achieving and maintaining hemostasis promotes visibility and reduces postoperative bleeding. The scrub person keeps instruments sterile for those patients who are at risk for postoperative bleeding. This would include patients with large thyroids that necessitated finger dissection and those who were difficult to intubate.

REF: 293 MULTIPLE RESPONSE 1. A minimally invasive video-assisted thyroidectomy (MIVAT) procedure relies on Miccoli instruments added to the standard thyroid or neck dissection setup, a 30-degree endoscope, and an ultrasonic (harmonic) scalpel with scissors to ligate and divide the vessels. An important risk reduction strategy for any minimally invasive procedure would be (select all that apply from the options below): a. note the amount of CO2 volume in connected tank and tanks available. b. consider and plan for the possibility of conversion to open thyroidectomy. c. position and drape the patient as for thyroidectomy. d. use fire-resistant light cords, endoscopes, light sources, and cable connections

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ANS: B, C The possibility of conversion to open thyroidectomy should be included on the operative consent form. Instruments and supplies for a possible open procedure are readied. A set of long Miccoli instruments is added to the standard thyroid or neck dissection setup. A 30-degree endoscope and harmonic scalpel with scissors are used to ligate and divide vessels. Fire safety precautions are implemented for illuminated light cords, endoscopes, light sources, and cable connection. The patient is positioned and draped as for thyroidectomy.

REF: 300

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Rothrock: Alexander's Surgical Procedures Chapter 08: Breast Surgery Test Bank MULTIPLE CHOICE 1. Identify the marginal boundaries of the breasts. a. Second to fifth rib horizontally, lateral edge of sternum to mid-clavicular line b. Second to sixth rib horizontally, mid-sternum to mid-clavicular line c. Second to sixth rib horizontally, lateral edge of sternum to anterior axillary line d. Second to fifth rib horizontally, lateral edge of sternum to mid-axillary line ANS: C The breasts extend from the second to the sixth rib horizontally and from the lateral edge of the sternum to the anterior axillary line.

REF: 308 2. The internal thoracic lymph nodes, which drain the inner half of the breast, can also be a channel for the: a. secretion of estrogen. b. spread of metastasis. c. drainage of the outer half of the breast. d. spread of infections.

ANS: B Lymph drainage generally follows the course of the vessels. Lymphatics drain into two main areas represented by the axillary nodes and the internal thoracic chain of nodes (see Figure 8-3). The internal thoracic nodes are few, but are responsible for most lymph drainage from the inner half of the breast. Thus the lymph system can also be a channel for the spread of malignant disease from the breast to associated areas of the chest wall or to the axilla.

REF: 308 3. The mammary glands are affected by physiologic changes throughout a woman’s life span. Select the option that best reflects the life cycle events that impact the anatomy and physiology of the breasts. a. Growth and development, menstruation, and menopause b. Menstruation, pregnancy, and lactation c. Hormone development, pregnancy, and menopause d. Growth and development, menstruation, and pregnancy and lactation ANS: D

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The mammary glands are affected by three types of physiologic changes: (1) those related to growth and development, (2) those related to the menstrual cycle, and (3) those related to pregnancy and lactation.

REF: 309 4. Fibrocystic changes in the breast describe many different breast changes. These changes affect almost all women at some time in their lives. Nipple discharge is more commonly associated with benign lesions than with cancer; however, discharge is usually significant only if it is spontaneous, persistent, and: a. chronic. b. unilateral. c. bloody. d. All of the options are significant.

ANS: D Discharge is usually significant only if it is spontaneous and persistent. Chronic unilateral nipple discharge, especially if bloody, should prompt an investigation for occult carcinoma.

REF: 309 5. In the past, radical procedures, which involved removal of the affected breast and all axillary and thoracic lymph nodes, were used to treat breast cancer. These procedures did not significantly lower mortality. What factor(s) may have contributed to mortality after these procedures? a. Distant metastases may have already occurred without adjacent lymph node involvement at the time of its palpable detection. b. Early pathology techniques for frozen section and histology microexamination could not define margins. c. Breast cancer was believed to spread by direct extension from its initial site in the breast to adjacent lymph nodes. d. Tumor size was not usually correlated with involvement of lymph nodes and cancer spread.

ANS: A

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Breast cancer may be a systemic condition at the time of diagnosis. Distant metastases may have already occurred without adjacent lymph node involvement at the time of its palpable detection. External physical changes, such as dimpling of the skin, can also indicate the presence of a benign or malignant pathologic process. The older the patient, the more likely it is that a mass is malignant. The most common form of breast cancer is infiltrating ductal carcinoma (see Table 8-2). The cause of breast cancer remains unknown. The belief that breast cancer spreads by direct extension from its initial site in the breast to adjacent lymph nodes may not always be correct. This could explain why radical breast surgery of the past, which involved removal of the affected breast and all axillary and thoracic lymph nodes, did not greatly lower mortality. Tumor size can usually be correlated with involvement of lymph nodes. The larger a tumor is, the more likely it is that lymph nodes are involved.

REF: 310 6. Ductal ectasia is a benign breast disorder that is difficult to distinguish from cancer, primarily because it presents with: a. bilateral tenderness, mottled skin patterns of the breast, and fullness. b. bilateral multicentric nodules and nipple discharge. c. mottled skin patterns of the breast and edema. d. a hard and irregular mass, nipple discharge, and enlarged axillary nodes.

ANS: D Ductal ectasia, generally seen in women approaching menopause, is described by a hard, irregular mass or masses with nipple discharge, enlarged axillary nodes, redness, and edema. It is difficult to distinguish from cancer.

REF: 310 7. Women of high socioeconomic status and higher education also have a high incidence of breast cancer, most likely due to: a. high-fat diet. b. lifestyle-related genetic mutations. c. later age at first birth. d. better compliance with regular screening.

ANS: C Breast cancer incidence is greater in women of higher education and socioeconomic background. This relationship is possibly related to lifestyle differences, such as age at first birth. Other risk factors for breast cancer include alcohol consumption (the equivalent of two drinks per day may increase risk by 21%). Women of Jewish Ashkenazic (eastern European) heritage also have higher incidences of BRCA1 and BRCA2 genetic mutations.

REF: 311

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8. Breast screening guidelines are developed and published by the American Cancer Society (ACS) for asymptomatic women of various age and risk groups. Select the statement that best reflects the ACS guidelines for women at high risk for breast cancer. a. Biannual mammography with two views of each breast and clinical breast exam b. An individualized screening plan c. Biannual clinical breast exam, mammography, and bimonthly breast self-exam d. Annual mammography, ultrasonography, and MRI with CT ANS: B The American Cancer Society Breast Cancer Screening Guidelines for Asymptomatic Women (see Table 8-4) recommends breast self-examination (BSE) monthly and clinical breast examination (CBE) every 3 years for women ages 20 to 39. For women 40 and older, the guidelines recommend BSE monthly, CBE annually, and screening mammography (two views of each breast) annually. Asymptomatic women who are identified to be at higher risk need to have an individualized screening plan that may differ from these guidelines.

REF: 312 9. Select the statement that best describes fine needle aspiration of a suspicious breast mass. a. The aspirate fluid is cytologically examined. b. The aspirate fluid is histologically examined by frozen section. c. The aspirate fluid is microscopically examined immediately by the procedural physician. d. If the aspirate fluid is positive, the excisional biopsy can be done immediately.

ANS: A Once a mass is identified, the physician has multiple techniques to establish a diagnosis.

Cytologic examination of the aspirate can assist in microscopic evaluation of the mass.

During a fine needle aspiration biopsy (FNAB), the physician anesthetizes a small area of the breast with lidocaine. A 22- or 25-gauge needle attached to a 20-ml syringe is inserted into the mass, and a small amount of the contents is aspirated.

REF: 313 10. The goal of breast cancer surgery is removal of the mass with a margin of normal tissue and a good cosmetic result. The choice of procedure depends on the size and site of the mass, the characteristics of the cells, the stage of the disease, and the patient’s choice.

Select the statement that best reflects the difference between minimally invasive excisional breast biopsy with stereotactic image-guided location and removal of tissue. a. The stereotactic biopsy produces a specimen for cytologic study, while the excisional biopsy produces a histologic specimen. b. The excisional biopsy is performed under direct visualization, while the stereotactic approach is image-guided. c. The excisional approach requires drain placement, while stereotactic biopsy rarely requires a drain.

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d. Stereotactic biopsy is recommended for lesions in the areola, high in the axilla, or chest wall while excisional biopsy is not appropriate for these areas.

ANS: B In an excisional biopsy, the entire tumor mass is excised along with a small margin of normal tissue for examination. Digital stereotactic imaging and use of minimally invasive instruments to locate and remove tissue allow for simultaneous biopsy and removal of mammographic densities. Masses located near the patient’s areola, high in the axilla, or near the chest wall are not appropriate for this technique. The benefits to the patient include small incisions for cosmetic results, decreased disfigurement, shortened time between detection and diagnosis, and elimination of the need for more involved surgical intervention.

REF: 319 11. Breast cancer is usually staged to measure the extent of the disease and to design a specific treatment plan, using the TNM (T = tumor; N = node; M = metastasis) classification system. Apply the description of a stage 0 carcinoma in situ to the appropriate disease description listed below. a. Lobular carcinoma in situ (LCIS) has abnormal cells lining the lobule and often becomes invasive. b. Ductal carcinoma in situ (DCIS) is defined as abnormal cells lining the ductal system and is not invasive. c. Lobular carcinoma in situ (LCIS) has abnormal cells infiltrating the lobule and often does not become invasive. d. Ductal carcinoma in situ (DCIS) has abnormal cells lining the ductal system and is often invasive.

ANS: D Stage 0 is carcinoma in situ. Ductal carcinoma in situ (DCIS) is defined as abnormal cells that are in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not invaded the nearby breast tissue. DCIS sometimes becomes invasive cancer if not treated. Lobular carcinoma in situ (LCIS) is defined as abnormal cells that are in the lining of a lobule. LCIS seldom becomes invasive cancer.

REF: 315 12. Sarah Pergines, an 82-year-old woman, was referred to the breast surgery service by her gerontologist because of a large inflammatory mass in her left breast. Sarah stated that the lump has existed for several years and she believed it was just part of old age. The surgeon examined Sarah and found tumor nodules growing into the skin of the breast, with breast swelling and redness. Diagnostic imaging results described a tumor that had grown into the chest wall and may have spread to axillary lymph nodes and to other lymph nodes behind the breastbone and below the collarbone. Based on this description, what is Sarah Pergines’ probable cancer stage? a. Stage IIa

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b. Stage IIIc c. Stage IIIb d. Stage IV ANS: B Stage IIIc is a tumor of any size that has spread either to the lymph nodes behind the breastbone and axillary lymph nodes or to the lymph nodes above or below the collarbone.

REF: 315 13. A breast biopsy, performed after the patient has received a local anesthetic, will require adjunct sedation and monitoring equipment. What relevant considerations should the surgical team member note during the preoperative assessment? a. Skin assessment b. Allergies c. ASA physiologic status d. Risks for injury ANS: B Patient allergies should be reviewed to avoid allergic or toxic reactions to local anesthetics. When adjunct sedation is also scheduled, monitoring equipment (e.g., electrocardiogram [ECG], pulse oximeter, blood pressure apparatus) should also be readied.

REF: 323 14. Talia Mendelson, a 27-year-old patient who had a lumpectomy for early-onset breast cancer, arrived at the ambulatory surgery center for infusion port insertion. She is scheduled to begin adjuvant chemotherapy next week. The catheter component of Talia’s port system is inserted into what structure(s)? a. Left mammary or subclavian vein b. Right atrium by way of the jugular vein c. Subclavian or jugular vein d. Inferior vena cava ANS: C A breast cancer patient who needs further medical treatment may opt to have an implanted venous access port placed under the skin in either the chest, the abdomen, or the upper arm.

The port has a soft, pliable plastic catheter that is threaded into the subclavian vein or right atrium by way of the subclavian or internal jugular vein under x-ray guidance.

REF: 314

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15. Many breast cancer patients subscribe to various complementary and integrative therapies to provide relief from anxiety, depression, pain, and chemotherapy and radiation therapy related complications and side effects. Quality of life issues become important in providing comfort and life balance. In addition to their oncology physicians and other health care providers, patients may also receive therapeutic assistance for their cancer care from which of the following? a. Pharmacists b. Nutritionists and dietitians c. Wound ostomy care nurses d. Genetic counselors ANS: B Breast cancer patients are increasingly seeking and using complementary and alternative medicine (CAM) and integrative therapies to enhance their surgical and medical treatment (see Table 8-5). Besides using products such as green tea, vitamins E and C, and flaxseed, breast cancer patients are incorporating massage therapy and meditation and enlisting the help of dietitians and nutritionists as they battle breast cancer.

REF: 317

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Rothrock: Alexander's Surgical Procedures Chapter 09: Ophthalmic Surgery Test Bank MULTIPLE CHOICE 1. The refractive apparatus of the eye directs (refracts) the light rays to strike the: a. retina. b. optic nerve. c. vitreous body. d. lateral geniculate body.

ANS: A Light rays from an object pass through the system of refractory devices—the cornea, aqueous humor, lens, and vitreous body—and are refracted (bent) so that the rays strike the retina.

REF: 332 2. The extraocular muscles work in yoked pairs, with ocular movements generated by an increase in the tone of one set of muscles and a decrease in the tone of the antagonistic muscles. Of the two muscle types, how many are represented in each eye? a. Two recti muscles and four oblique muscles b. Two superior muscles and one lateral muscle c. Four recti muscles and two oblique muscles d. Two inferior muscles and two medial muscles ANS: C Named according to their relative position on the eyeball, the extraocular muscles of the eyeball include the four recti (the superior rectus, inferior rectus, medial rectus, and lateral rectus) and two oblique muscles (the superior oblique and inferior oblique) (see Figure 9-3).

REF: 331 3. To accommodate near and distant focus, the lens changes shape and focus by relaxation and tightening of the zonular fibers. What physiologic change of the normal aging process is typically corrected with bifocals? a. Cataracts b. Presbyopia c. Glaucoma d. Astigmatism ANS: B

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The lens changes shape and focus (accommodation) by relaxation and tightening of the zonular fibers. Over time (particularly after age 40), the lens and lens zonules become progressively less elastic, resulting in presbyopia. This loss of accommodative power is typically corrected with reading glasses or bifocals.

REF: 332 4. How does the lacrimal gland differ from the lacrimal sac? a. The lacrimal gland produces hormones that stimulate the lacrimal sac to secrete tears. b. The lacrimal sac stores and concentrates the tears secreted by the lacrimal gland. c. The lacrimal gland and lacrimal sac are the same structure. d. The lacrimal gland secretes tears that are drained by the lacrimal sac and duct system.

ANS: D The lacrimal apparatus effectively functions like a sink, with a faucet (main and accessory lacrimal glands) and drain (lacrimal puncta, canaliculi, sac, and nasolacrimal duct). The lacrimal gland produces tears and secretes them through a series of ducts onto the anterior ocular surface, thereby keeping the cornea moist and washing away any debris. The tears then flow inward to the puncta, from which they are conducted by the canaliculi to the lacrimal sac and finally pass into the nasolacrimal duct (see Figure 9-2).

REF: 330 5. A wide range of equipment is used in ophthalmic surgery. The perioperative team’s knowledge of proper operation should be confirmed through inservice education and training specific to new equipment, plus demonstrated competency. To ensure patient safety and appropriate function and application of surgical devices, which statement best reflects recommended practice when using complex biomedical equipment? a. Use the device according to the manufacturer’s directions and test for proper performance before the patient enters the OR. b. Follow the policy and procedure of the facility and/or unit, and request biomedical support. c. Request assistance and technical support from the appropriate vendor representative; encourage the vendor to operate the device or equipment, or request biomedical support. d. Follow the explanation and demonstration as originally provided by the preceptor during orientation.

ANS: A For safety, all items must be used according to the manufacturer’s directions and tested for proper performance before the patient enters the OR. REF: 343

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6. Sutures used in ophthalmic surgery are very fine and range in size from 4-0 to 10-0.

Handling and arming these sutures can be a challenge for the surgical technologist with uncorrected presbyopia. Eye sutures should be handled as little as possible to avoid: a. weakening and fraying. b. causing the formation of needle burrs. c. losing sutures among the drapes or on the floor. d. reaction and discomfort for the patient.

ANS: A Fine eye sutures produce minimum reaction and discomfort for the patient. They should be handled as little as possible to avoid weakening and fraying. Ophthalmic needles also are very delicate and must be handled with extreme care and inspected for evidence of burrs before use.

REF: 345 7. Select the true statement about dacryocystorhinostomy (DCR). a. A DCR is performed for chronic or recurrent dacryocystitis, which is also called epiphora. b. A dacrolithotripsy is attempted if the DCR is unsuccessful. c. DCR establishes a new passageway for tear drainage into the nasal cavity. d. The passageway is usually restored with the use of ultrasonic lacrimal probes.

ANS: C Dacryocystorhinostomy (DCR) is the establishment of a new tear passageway for drainage directly into the nasal cavity. Dacryocystitis (see Figure 9-27) is an infection in the lacrimal sac, which may result in a localized cellulitis. Chronic or recurrent dacryocystitis in adults may necessitate probing or DCR because of resistant obstruction of the nasolacrimal duct related to infection-associated scarring, dacryolith (calculus in the duct), or trauma. Another indication for DCR surgery may be intolerable epiphora (tearing) resulting from tear duct laceration following medial orbital wall fracture.

REF: 348 8. The surgical technologist prepares a sterile treatment set-up for the surgeon to use before the DCR operative procedure is started. Select the statement that describes the justification for this sterile treatment set-up. a. The surgeon will cut and mold the nasal splint to size before the nose becomes edematous. b. The silastic tubing needs to be cut to size and soaked during the procedure. c. The skin markings, with methylene blue, are done on clean skin before the skin prep. d. The nasal cavity is anesthetized with cocaine and a local anesthetic is administered.

ANS: D

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The nasal cavity is anesthetized topically with cocaine just before the DCR. The surgery (see Figure 9-28) is performed after the patient has been administered a local or general anesthetic.

REF: 348 9. Select the appropriate procedure performed for a patient with Fuchs’ dystrophy, edema after cataract surgery, or keratoconus (abnormal steepening) of the cornea. a. Keratoplasty b. Keratorefraction c. Laser epithelial keratomileusis d. Laser-assisted in-situ keratomileusis ANS: A A corneal transplantation (keratoplasty) is performed when the patient’s cornea is thickened or opacified by disease and degeneration. Corneal transparency may be impaired as a result of scars, infection (bacterial, fungal, or viral), thermal or chemical burns, Fuchs’ dystrophy, edema after cataract surgery, or keratoconus (abnormal steepening).

REF: 353 10. A cataract is defined as any opacification of the lens. Cataracts may be congenital, posttraumatic, or induced by medications, but are most commonly the result of agerelated changes. Which of the following statements about cataracts best describes its presentation or etiology (cause)? a. A cataract can be compared to a window that is frosted or yellowed. b. Cataracts can be classified as brittle or pliable, based on collagen matrix fibers in the capsule. c. Cataracts are an early sign of type 1 diabetes. d. The cloudiness is caused by clumping of lipoproteins in the lens capsule.

ANS: A When the lens becomes cloudy through the aging process, vision becomes blurred. A cataract can be compared to a window that is frosted or yellowed. The lens is made mostly of water and protein; over time, some of the protein may clump together, leading to clouding of the lens (cataract). Cataract removal is warranted when there is interference with everyday activities such as driving, reading, and watching television.

REF: 356

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11. When preparing for pars plana vitrectomy in the posterior segment, the perioperative nurse must be aware that a combined scleral buckling procedure may be necessary. Other important information the perioperative team should know before preparing the OR for the procedure includes the location of the ocular problem, the surgeon’s plan to address the problem, and the instrumentation and biomedical equipment and devices to be used.

Technologic advances in ophthalmic surgery require that perioperative teams be familiar with complex biomedical equipment. A best practice, stated below, relevant to the safe use of complex equipment would be: a. determine the presence and appropriate date (not expired) of the biomedical monitoring label. b. demonstrate competence with equipment and check each piece carefully before the patient arrives in the OR. c. schedule the manufacturer's representative to be present to provide technical support. d. schedule the biomedical clinical engineer to check all equipment before each procedure.

ANS: B Technologic advances in ophthalmic surgery require that perioperative nurses be competent to prepare and check each piece carefully before the patient arrives in the OR. REF: 367 12. Local anesthesia, or monitored anesthesia care (MAC), is used for most ophthalmic surgery. The local anesthetic regimen, administered by the operative surgeon, is typically a combination of anesthesia delivery methods, or routes. Select the anesthetic plan that is administered by the surgeon before the start of surgery. a. Subconjunctival block and topical anesthetic eye ointment b. Topical anesthetic eye drops, subconjunctival infiltration, and retrobulbar block c. Ganglionic infiltration and periorbital block of the anterior chamber d. Peribulbar infusion into Tenon’s capsule and periorbital skin infiltration ANS: B The topical method of local anesthesia has gained popularity for cataract extraction procedures. A combination of anesthetic eye drops is instilled into the eye and may be supplemented with infiltration of preservative-free anesthetic into the anterior chamber.

Selection of patients for the topical method requires that they can cooperate and follow verbal commands to keep their eyes open and look up or down. The infiltration method involves the surgeon injecting the anesthetic solution beneath the skin, beneath the conjunctiva (subconjunctival), or into Tenon’s capsule, depending on the type of surgery.

The most common technique for regional anesthesia in eye surgery is a peribulbar block.

The anesthetic is injected around the soft tissue of the globe after the needle is directed to the floor (inferior) or roof (superior) of the orbit (see Figure 17-9). Retrobulbar block is injection of anesthetic solution into the base of the eyelids at the level of the orbital margins or behind the eyeball to block the ciliary ganglion and nerves (see Figure 17-10).

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REF: 335 13. Oculocardiac reflex (OCR) is an intraoperative emergency that can occur during eye surgery. It is characterized by bradycardia that can lead to asystole, hypotension, and a wide range of other dysrhythmias attributable to negative inotropic and conduction effects. Select the definition of the response and contributing factor(s). a. Trigeminal-vagal response caused by pressure on the globe or retrobulbar block b. Increased intracranial pressure response to traction on extraocular muscles c. Adrenergic response to effect of retrobulbar block on the pituitary d. Lidocaine toxicity caused by intravascular uptake of retrobulbar anesthetic ANS: A The most common symptom of OCR is sinus bradycardia, which can lead to asystole.

The patient may become hypotensive and may experience a trigeminal-vagal response caused by pressure on the globe, traction on extraocular muscles, or retrobulbar block.

The incidence of reported OCR ranges from 32% to 90%; in as many as 1 in 2200 strabismus surgeries, transient cardiac arrest may ensue.

REF: 340 14. Miotics and mydriatics produce opposite effects on the pupil of the eye. Select the most appropriate statement about miotic and mydriatic drugs. a. Miotic drugs are anticholinergic drugs useful in lowering intraocular pressure. b. Mydriatic drugs, such as phenylephrine, dilate the pupil. c. Miotic drugs dilate the pupil for posterior chamber access after lens removal. d. Mydriatic drugs are often referred to as cycloplegics.

ANS: B Mydriatics: Phenylephrine 2.5%, and 10% (Neo-Synephrine, Mydfrin) promotes mydriasis (dilates pupil but permits focusing); used for objective examination of the retina, testing of refraction, easier removal of lens; and used alone or with a cycloplegic.

Miotics: (1) Carbachol 0.01% (Miostat) is a potent cholinergic (constricts pupil); used intraocularly during anterior segment surgery; (2) Carbachol 0.75%, 1.5%, 2.25%, and 3% (Isopto Carbachol) is a potent cholinergic (constricts pupil); used topically for lowering intraocular pressure in glaucoma; (3) Acetylcholine chloride 1% (Miochol-E) is a cholinergic that rapidly constricts the pupil; used intraocularly during anterior segment surgery; reconstitute immediately before using; (4) Pilocarpine hydrochloride 1%, and 4%, which is a cholinergic (constricts pupil) used topically for lowering intraocular pressure in glaucoma.

REF: 337 15. Cycloplegic drugs produce a similar effect on the pupil as mydriatic drugs, with one difference. From the options below, select the most appropriate statement about the effects of cycloplegics. a. Anticholinergics dilate the pupil and inhibit focusing.

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b. Epinephrine is added to balanced salt solution (BSS) to constrict sclera vessels and the pupil. c. Homatropine hydrobromide (Isopto Homatropine) sustains the longest and most potent duration of dilation. d. Cycloplegics and mydriatics have similar effects on the pupil; however, cycloplegics preserve the patient’s ability to refract light and focus.

ANS: A Cycloplegics are anticholinergics that dilate the pupil and inhibit focusing. Examples include the following: Tropicamide 0.5%, 1% (Mydriacyl): cycloplegic (paralysis of accommodation, inhibits focusing), dilates the pupil, anticholinergic, used for examination of fundus or refraction; Atropine 1%, anticholinergic, dilates the pupil, inhibits focusing, potent and long duration (7-14 days); Cyclopentolate 0.5%, 1%, and 2% (Cyclogyl), anticholinergic, dilates the pupil, inhibits focusing; Scopolamine hydrobromide 0.25% (Isopto Hyoscine), anticholinergic, dilates the pupil, inhibits focusing; Homatropine hydrobromide 2%, and 5% (Isopto Homatropine), anticholinergic, dilates the pupil, inhibits focusing; Epinephrine (1:1000) preservative free (PF), dilates the pupil, added to bottles of balanced salt solution for irrigation to maintain pupil dilation during cataract or vitrectomy procedure.

REF: 337 16. Select the true statement about antimetabolite drugs and their indications for use. a. These cytotoxic/antineoplastic drugs are also useful as thrombolytic agents. b. Antimetabolites are regulated by TPA and facility policies. c. 5-Fluorouracil and mitomycin can both be administered topically to dissolve scars and pterygia. d. Denuded corneal epithelium responds positively to topical applications of mitomycin.

ANS: C 5-Fluorouracil (5-FU) is an antimetabolite used topically to inhibit scar formation in glaucoma filtering procedures. Mitomycin (Mutamycin) is an antimetabolite used topically to inhibit scar formation in glaucoma-filtering procedures and pterygium excision. Handle and discard these antimetabolites in compliance with OSHA and facility policies for safe use of antineoplastics.

REF: 338 MATCHING Match the three descriptive statements with their appropriate globe and orbital surgical procedures. a. Removal of the eye contents with sclera and muscles left intact b. Removal of the entire orbital contents, including the periosteum c. Removal of the entire globe, severing muscular attachments and optic nerve

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1. Exenteration 2. Enucleation 3. Evisceration 1. ANS: B 2. ANS: C 3. ANS: A

REF: 345

OTHER 1. The procedure for cataract extraction with implantation of an intraocular lens (IOL) exposes the patient to risks of infection of the anterior chamber and corruption of the implanted device. Appropriate measures for the circulating nurse and scrub person include managing patient safety needs. Efforts are directed at preventing foreign substances from being introduced intraocularly. Select all of the following actions that may ensure this outcome . a. The sterile field should be created with lint-free drapes. b. Powder-free gloves should be worn. c. Instruments should be cleaned with gauze sponges. d. Gloved hands should not touch the intraocular tip of the instrument. e. Instruments should be soaked in sterile water when not in use. f. The procedure room should be warm, quiet, and peaceful.

ANS: A, B, D Both the scrub person and the perioperative nurse must also manage additional patient safety needs. Foreign substances must not be introduced intraocularly. Lint-free drapes should be used to create the sterile field. If powder-free gloves are not used, gloved hands must be wiped with moistened gauze sponges to remove starch powder particles before the procedure begins. Gloved hands should not touch the portion of an instrument used in an intraocular wound, and debris should be cleansed from instruments with cellulose sponges.

REF: 343 2. Vitrectomy is narrowly defined as removal of all or part of the vitreous gel (body).

Vitrectomy can also vacuum any pooled blood to enhance visual clarity. Select all indications and complications that apply to vitrectomy. a. Excision of fibrotic membranes b. Electrocoagulation of bleeding vessels c. Extraction of floaters

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d. Removal of retained foreign bodies e. Infection f. Retinal tears and detachment g. Total vision loss. h. Cataract ANS: A, B, D, E, F, G, H In the broader clinical sense of the term, vitrectomy surgery can also include the excision and removal of fibrotic membranes; the removal of epiretinal membranes; the electrocoagulation of bleeding vessels; the treatment of long-standing vitreous opacities, advanced diabetic eye disease, or severe intraocular trauma; the removal of retained foreign bodies; and the treatment of proliferative vitreoretinopathy, retinal detachment from giant tears, endophthalmitis, and diagnostic vitreous biopsy. Complications of vitrectomy include retinal detachment, retinal tears, cataract, and infection. Alternatively, the risk of no treatment can be total loss of vision.

REF: 365 3. Toxic anterior segment syndrome (TASS), also known as sterile endophthalmitis, is a sterile noninfectious form of acute inflammation that occurs after eye surgery (typically cataract surgery). It frequently begins within 24 hours after surgery and is characterized by decreased vision, significant corneal edema, and moderate to severe inflammation in the anterior chamber of the eye. Select all of the possible causes and risk reduction strategy statements. a. Introduction of an infectious, toxic substance into the anterior chamber during surgery b. Introduction of a noninfectious, toxic substance into the anterior chamber during surgery c. Introduction of sterile lint or debris into the anterior chamber during surgery d. Introduction of sterile mineral deposits into the anterior chamber during surgery e. Educate patient/family about signs and symptoms of TASS before discharge. f. Practice vigilant compliance with cleaning, disinfection, and sterilization of equipment and instrumentation. g. Replace balanced salt solution (BSS) with sterile water on the sterile field. h. Irrigate the anterior chamber with gentamicin solution before closure.

ANS: B, E and F TASS can be a very serious and sight-threatening condition. TASS is thought to be a response to the introduction of a noninfectious, toxic substance into the anterior segment of the eye during surgery. Substances that have been implicated include irrigating solutions and other agents such as anesthetics and antibiotics. TASS may also be related to the improper cleaning or sterilization of instruments. The perioperative nurse plays a key role in implementing risk reduction strategies for TASS, not only in prevention through the vigilant implementation of recommended practices for the use, cleaning, disinfection, and sterilization of equipment and instrumentation, but also in the provision of effective patient education.

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REF: 343

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Rothrock: Alexander's Surgical Procedures Chapter 10: Otorhinolaryngologic Surgery Test Bank MULTIPLE CHOICE 1. The external ear, which includes the auricle (or pinna) and external auditory canal, is composed of cartilage covered with skin. The primary function of the auricle is to: a. gather and direct sound waves toward the inner ear. b. concentrate and conduct incoming sound waves into the external auditory canal. c. collect and amplify incoming sound waves by facilitating tympanic membrane vibration. d. facilitate air conduction of sound waves.

ANS: B The auricles are fixed in position and lie close to the head; they concentrate incoming sound waves and conduct them into the external auditory canal.

REF: 376 2. Both ears provide stereophonic hearing that gives us very specific hearing capabilities.

Binaural hearing makes it possible for: a. determination of the source location of sounds. b. enhanced voice recognition. c. amplification and resolution of sound properties. d. recognition of more than one sound at a time.

ANS: A Both ears provide stereophonic hearing that gives us very specific sound localization capabilities. Without binaural hearing, determining where sounds emanate can be difficult; this is a common problem for patients with unilateral or asymmetric hearing loss.

REF: 376 3. The external ear canal lining is protected and lubricated with cerumen (earwax), which traps foreign material and: a. liquefies foreign matter in the ear canal. b. lubricates the external ear. c. maintains the acidic pH in the ear canal. d. reduces bacterial levels in the outer ear.

ANS: D

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The canal lining is protected and lubricated with cerumen, a waxy substance secreted by sebaceous glands in the distal third of the canal. Cerumen helps to trap foreign material, and has a mildly acidic pH that reduces bacterial levels in the outer ear.

REF: 376 4. A chain of three small articulated bones extends across the middle ear cavity and conducts vibrations from the tympanic membrane across the middle ear into the oval window and the fluid-filled inner ear. What are the names of those three small articulating bones? a. Ossicles, incus, and crura b. Stapes, capitulum, and stirrup c. Malleus, incus, and stapes d. Anvil, head, and hammer ANS: C The malleus (hammer) consists of a head, neck, handle, and short process. The handle and short process are attached to the undersurface of the eardrum, and the head articulates with the body of the incus in the upper segment of the middle ear called the epitympanum or “attic.” The incus (anvil) consists of a body and long and short processes (see Figure10-2). The distal end of the long process of the incus is called the lenticular process and articulates with the capitulum (head) of the stapes, which is the third, innermost bone. The stapes (stirrup) consists of a head, neck, anterior and posterior crura, and a mobile footplate that is secured to the oval window by an annular ligament. The movable joints between these ossicles contribute to a lever system that amplifies the received sound and transmits and converts vibrations from ambient air to the fluid of the inner ear.

REF: 376 5. The nose is divided into the prominent external portion and the internal portion known as the nasal cavity. The primary purpose of the nose is to: a. facilitate the sense of smell. b. warm inspired air. c. moisturize inspired air. d. prepare inspired air for the lungs.

ANS: D The chief purpose of the nose is to prepare air for use in the lungs.

REF: 377 6. The nasal septum is lined with blood vessels and mucus-secreting cells. The proper name of this lining is the: a. Mucoperichondrium b. Septochondrium c. Nasoseptal mucosa

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d. Cartilaginous vascular bed ANS: A The nasal septum is composed of three structures: the nasal cartilage, the perpendicular plate of the ethmoid bone, and the vomer bone. The septum is covered by mucoperichondrium on either side that contains blood vessels and mucus-secreting cells.

The rich blood supply warms and moistens the air while the sticky mucus traps dust, pollen, and other small particles.

REF: 377 7. The nasal cavity is associated with the ear by way of the ____________, and communicates with the conjunctiva through the __________________. Select the options that are appropriate to complete the sentence. a. torus tubarius; canaliculi b. eustachian tube; nasolacrimal duct c. nasopharynx; medial caruncle d. middle ear; lacrimal sac ANS: B The nasal cavity is also associated with each ear, sharing the torus tubarius (opening of the eustachian tube in the nasopharynx) with the paranasal sinuses (frontal, maxillary, ethmoidal, sphenoidal) through their respective orifices (meatus). The nasal cavity also communicates with the conjunctivae through the nasolacrimal duct.

REF: 377 8. The nasal turbinates increase the turbulence of the airflow through the nose to humidify the air. The turbinates also serve another function to the accessory sinuses by: a. filtering inspired air and preventing sinusitis. b. acting as drainage passageways. c. giving resonance to the voice. d. trapping particle matter before it reaches the nasopharynx.

ANS: B The turbinates act as drainage passages of the accessory sinuses and also increase the turbulence of airflow to humidify the air that is nasally inspired. This area is commonly referred to as the sphenoethmoidal recess and contains the bony shelves known as the superior, middle, and inferior meatus or turbinates (Figure10-6).

REF: 377 9. What mouth structure is considered the boundary between the buccal cavity and the lingual cavity? a. Hard palate b. Soft palate

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c. Teeth d. Floor of the mouth ANS: C The portion of the mouth outside the teeth is the buccal cavity, and that on the inner side of the teeth is the lingual cavity. The hard palate forms the upper boundary of the oral cavity. The hard palate is formed by the maxilla and palatine bones. The mandible and floor of the mouth form the lower boundary of the oral cavity.

REF: 378 10. The salivary glands produce saliva, which serves to moisten the mouth and initiate: a. antibacterial activity in the mouth. b. carbohydrate digestion. c. enzymatic activity on all ingested food. d. alimentary (GI) tract peristalsis.

ANS: B The three paired salivary glands communicate with the mouth and produce saliva, which serves to moisten the mouth and initiate digestion of carbohydrates. The minor salivary glands exist in the submucosa of the cheeks, tongue, palates, and floor of the mouth and in the pharynx, lips, and paranasal sinuses.

REF: 378 11. Of the three salivary glands, which one is the largest? a. Sublingual b. Submandibular c. Zygomatic d. Parotid ANS: D The salivary glands consist of three paired glands: the sublingual, the submandibular, and the parotid. The parotid gland, the largest of the salivary glands, lies below the zygomatic arch in front of the mastoid process and behind the ramus of the mandible; it is divided into a superficial portion and a deep portion. The parotid duct (Stensen’s duct) pierces the buccal pad of fat and the buccinator muscle, finally opening into the oral cavity opposite the crown of the upper second molar tooth.

REF: 378 12. The supraglottis, glottis, and the subglottis represent three portions of which structure of the throat? a. Epiglottis b. Tongue c. Larynx

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d. Pharynx ANS: C The larynx can be divided into three portions: supraglottis (or upper portion above the true vocal cords), glottis (level of the true vocal cords), and subglottis (below the true vocal cords). The upper portion of the larynx is continuous with the pharynx above and includes the epiglottis, vallecula, and the laryngeal cartilages.

REF: 380 13. The palatine and lingual tonsils are situated in the oropharynx, while the adenoids are located in the nasopharynx. Both adenoids and tonsils consist of: a. lymphoid tissue. b. glandular tissue. c. vascular tissue. d. mucosal tissue.

ANS: A The adenoids, or pharyngeal tonsils, are suspended from the roof of the nasopharynx and consist of an accumulation of lymphoid tissue. The tonsils are situated on each side of the oropharynx, lodged in a tonsillar fossa that is attached to folds of membrane-containing muscle. The palatine tonsils (a pair of oval structures) are the only lymphatic organs covered with stratified squamous epithelium. The anterior and posterior tonsillar pillars join to form a triangular fossa, with the posterior lateral aspects of the tongue at its base.

The lingual tonsils are lodged in each fossa.

REF: 380 14. The cricoid cartilage is a complete cartilaginous ring that resembles a signet ring; it rests beneath the thyroid cartilage and supports the airway. What membrane, attached to the midline of the upper thyroid cartilage, protects the larynx during swallowing? a. False vocal cords b. True vocal cords c. Arytenoids d. Epiglottis ANS: D The epiglottis is a slightly curled, leaf-shaped, elastic, fibrous membrane that is attached in the midline to the upper border of the thyroid cartilage. The epiglottis helps to protect the larynx during swallowing. Contraction of the cricothyroid muscle pulls the thyroid cartilage and the cricoid cartilage to tighten the vocal cords and close the glottis. The arytenoid cartilages, which rest above the signet-ring portion of the cricoid cartilage, support the posterior portion of the true vocal cords.

REF: 380

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Test Bank

10-6

15. Select the structure of the trachea that is a landmark during bronchoscopy. a. Cartilaginous ring b. Cricoid cartilage c. Carina d. Right main bronchus ANS: C The posterior surface of the trachea is flattened rather than round because the cartilaginous rings are incomplete. The carina is a ridge on the inside of the bifurcation of the trachea. It is a landmark during bronchoscopy and separates the upper end of the right main branches from the upper end of the left main branches of the bronchi.

REF: 382 16. Several types of diagnostic imaging studies visualize structures by producing serial sections through different anatomic planes, highlighting specific structures or tissue densities. Examples of these imaging diagnostics would be: a. complementary CT scan with MRI. b. MRI scan. c. CT scan. d. All of the options ANS: D CT scans are radiographic studies that visualize structures by producing serial sections, many times clinically referred to as “cuts,” through planes of the head and neck.

Magnetic resonance imaging (MRI) is an imaging modality using powerful magnetic and radiofrequency waves to reproduce cross-sectional images of the human body without exposing the patient to ionizing radiation. CT imaging provides visualization of bone, soft tissue, and adjacent intracranial and extracranial pathologic conditions. CT is the study of choice to assess intratemporal bone pathologic conditions and to evaluate the paranasal sinuses and adjacent structures. It is also used in the assessment of the oral cavity and neck. On an MRI scan, fat and fluid produce high-intensity signals, which appear as bright areas, whereas bone and air emit weak signals and appear as darkened areas on the scan. MRI is often used with CT imaging in a complementary fashion when evaluating lesions in and around bone for a variety of head and neck conditions including tumors in the oral cavity, external auditory canal, middle ear, and mastoid.

REF: 383 17. Which of the diagnostic modalities listed below does not employ the use of ionizing radiation? a. Audiogram b. Magnetic resonance imaging (MRI) c. Computed tomography (CT) d. Both audiogram and magnetic resonance imaging (MRI)

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Test Bank

10-7

ANS: D Magnetic resonance imaging (MRI) is an imaging modality using powerful magnetic and radiofrequency waves to reproduce cross-sectional images of the human body without exposing the patient to ionizing radiation. CT scans are radiographic studies that visualize structures by producing serial sections, many times clinically referred to as “cuts,” through planes of the head and neck. Two types of audiometric testing, pure tone and speech audiometry, are performed on patients with suspected hearing loss.

REF: 385 18. What is the purpose of using an intravenous injection of a radiopaque contrast dye during select imaging diagnostic studies? a. There is enhanced uptake of radiation in areas of suspicion. b. It provides visual enhancement of anatomic structures. c. It minimizes ionizing radiation scatter to noninvolved anatomic structures. d. Contrast dye leaves a locator marker for impending surgery.

ANS: B Intravenous (IV) injection of iodine contrast agents produces visual enhancement of some anatomic structures and pathologic tissues, including highly vascularized tumors.

REF: 383 19. Audible facial nerve monitors (nerve integrity monitor systems) are used intraoperatively during procedures in which the facial nerve is at risk for injury. The purpose of this monitoring technique is to assist in the early identification of the nerve, to increase the possibility of its preservation by minimizing trauma, and to assess its integrity after dissection. Communication with the anesthesia provider is essential because: a. the electrodes are often in proximity to the anesthetic airway. b. manipulation of the anesthetic airway during the procedure can misplace the electrodes. c. muscle relaxants, paralyzing agents, and some local anesthetics must be avoided. d. the anesthesia provider is responsible for the facial nerve monitoring.

ANS: C Electrodes are placed into the facial muscles before the patient is draped. Consultation and communication with the anesthesia provider are essential because the use of muscle relaxants and long-term paralyzing agents must be avoided. In the setting of a tympanic membrane perforation, lidocaine should not be allowed to spill into the middle ear space when injecting the ear canal, as temporary facial paralysis can ensue from topical anesthesia of a dehiscent facial nerve in the tympanic segment. Facial nerve monitoring is commonly used during acoustic neuroma and mastoid surgery (Figure 10-13).

REF: 391

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Test Bank

10-8

20. The surgical microscope is often used to provide illumination and magnification for complex procedures to the ear, laryngeal surgery, or reconstructive free flap procedures following neck surgery. A common eyepiece magnification for an otologic microscope is 12.5, and the usual objective (lens) is ______- mm focal length (f). A _______- mm lens is used for laryngeal surgery. a. 250 or 300; 400 b. 400; 150 c. 150; 400 d. 400; 250 or 300 ANS: A Several kinds of surgical microscopes with different attachments are available for otologic and laryngologic surgery. A common eyepiece magnification for an otologic microscope is 12.5, and the usual objective (lens) is 250- or 300-mm focal length (f). A 400-mm lens is used for laryngeal surgery. The total magnification is determined by multiplying the magnification of the eyepiece times that of the microscope body times that of the objective. The type of head and objective selected is based on the surgeon’s preference. Microscopes equipped with a variable distance feature allow the surgeon to adjust the focal length from 200 to 400 mm without changing the lens objective.

REF: 392 21. Lasers assist in vaporization of scar tissue, granulomas, and cholesteatomas without damaging surrounding tissue and may be used for select otolaryngologic procedures.

Lasers can be secured to the operating microscope and laser energy delivered to the tissue by means of a: a. fiberoptic probe. b. beam separator. c. micromanipulator. d. flexible micro laser fiber.

ANS: C Lasers can be secured to the operating microscope and laser energy delivered to the tissue by means of a micromanipulator. Lasers used in this specialty include the carbon dioxide (CO2), potassium titanyl phosphate (KTP), erbium:yttrium-aluminum-garnet (Er:YAG), and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers. Laser energy is delivered directly to tissue by fiberoptic probes, which can be navigated around obstructing structures.

REF: 392 22. A power drill and assorted rotating burrs are essential for middle ear surgery and some sinus procedures. A selection of burrs including assorted sizes of round cutting burrs and diamond polishing burrs should be available. During drill and power saw use, the scrub person keeps irrigation solution on the sterile field to: a. keep the drill bit or burr cool and prevent breaking.

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10-9

b. prevent clogging of the burr and contamination of the area with bone dust. c. prevent aerosolized bone dust particles, because they are an occupational hazard. d. avoid using a wire brush.

ANS: B Bone dust must be prevented from settling in areas such as those in stapedectomy, tympanoplasty, or endolymphatic sac or fenestration surgery. A sterile field continuously flooded with irrigation solution helps to lessen clogging of the burr and washes bone dust from the field. A diamond burr cuts slowly and grinds the bone away rather then tearing into it; it is commonly used around vital structures. Cutting burrs assist in quickly removing bone from areas not close to vital structures. The grooves or teeth of burrs must be clean of bone dust. Bone-cutting burrs tend to clog more easily than coarse-toothed burrs. A sterile wire brush may be used to keep burrs clean intraoperatively.

REF: 393 23. Myringotomy is often accompanied by the aspiration of fluid under pressure in the tympanum, and the subsequent placement of small, hollow, pressure equalization tubes. It is indicated for acute otitis media (AOM) in the presence of an exudate that has not responded to antibiotic therapy. If left untreated, what is the main concern for a child with chronic otitis media? a. Impaired language development b. Encephalitis c. Hearing loss d. Impaired language development and hearing loss ANS: D The majority of children with AOM have spontaneous resolution. Hearing loss is the main concern when fluid is present in the middle ear. If left untreated, hearing loss can affect language development. If the fluid persists more than 8 to 12 weeks and is accompanied by hearing loss, removal of the fluid and placement of ventilating tubes in the eardrum are necessary.

REF: 395 24. Tympanoplasty is the surgical repair of the tympanic membrane and the tympanum and the reconstruction of the ossicular chain. Conductive hearing loss is caused by an obstruction in the external canal or middle ear, which impedes the passage of sound waves to the inner ear. A common cause of conductive hearing loss would be: a. acute otitis media. b. fluid invasion of the ear canal. c. perforation of the tympanic membrane. d. a healed myringotomy.

ANS: C

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Test Bank

10-10

Tympanoplasty is indicated for conductive hearing losses caused by perforation of the tympanic membrane as a result of trauma or infection; for ossicular discontinuity; for chronic or recurrent otitis media; for progressive hearing loss; and for the inability to safely bathe or participate in water activities as a result of perforation of the tympanic membrane with or without hearing loss. Perforation of the tympanic membrane is the most common ear injury necessitating surgical intervention. It may be attributable to disease of the middle ear or tympanic membrane. Occasionally the tympanic membrane does not heal after myringotomy.

REF: 396 25. A stapedotomy is removal of the stapes superstructure and creation of a fenestra (opening) in the fixed stapes footplate for treatment of abnormal bone growth around the footplate that results in its immobility. A prosthesis is placed to restore ossicular continuity and alleviate conductive hearing loss. The patient scheduled for a stapedotomy will probably have a surgical diagnosis of: a. otosclerosis. b. ossicular immobility. c. indeterminate hearing loss. d. All of the options apply.

ANS: A Otosclerosis is the formation of abnormal bone around the stapes footplate, resulting in immobility of the footplate. Sound waves cannot be transmitted adequately through the oval window and round window to be changed into electrochemical impulses in the cochlea.

REF: 398 26. Acoustic neuromas arise from the Schwann cells of the vestibular portion of the eighth cranial nerve and are benign tumors. What is the postauricular incisional approach that offers the best chance of saving the integrity of the facial nerve? a. Transaural b. Supraaural c. Translabyrinthine d. Intravestibular ANS: C The translabyrinthine approach for the removal of an acoustic tumor reduces mortality and morbidity and offers a good chance of saving the facial nerve if the tumor has not directly invaded it. The surgeon makes a postauricular incision slightly longer and more posterior than the incision for mastoidectomy and elevates the periosteum from the mastoid bone.

REF: 402

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10-11

27. The Caldwell-Luc procedure is a radical antrostomy used to establish a large opening into the wall of the inferior meatus leading to the sinuses. Where is this large incisional approach made? a. Proximal to the maxillary artery b. Antrum wall on the affected sinus side c. Canine fossa of the upper jaw d. Intranasally on the affected sinus side ANS: C The purpose of a radical antrostomy is to establish a large opening into the wall of the inferior meatus, which ensures adequate gravity drainage and aeration. This large opening allows removal of the diseased tissues in the sinuses under direct vision. The Caldwell-Luc approach is also used to access the maxillary artery in cases of extreme epistaxis. The procedure requires an incision into the canine fossa of the upper jaw and exposure of the antrum for the removal of bony diseased portions of the antral wall and the contents of the sinus.

REF: 410 28. A nasal polypectomy is the removal of polyps from the nasal cavity. Nasal polyps are benign, grapelike clusters of mucous membrane and connective tissue. When the polyps become large, they obstruct the free passage of air, make breathing difficult, and cause a change in speech quality. Nasal polypectomies are typically performed endoscopically with the use of microdebriders, which remove the polyps by their mechanism of _______________ the polyp and suctioning the tissue. a. ultrasonic cavitating b. morcellating c. radiofrequency ablating d. laser vaporizing ANS: B Performed endoscopically, nasal polypectomies are often done with other sinus procedures that also require removal of diseased tissue. Because of the viscous nature of polyps, microdebriders are particularly helpful in these cases. They can greatly shorten surgical time by their mechanism of morcellating the polyp and removing it by immediate suctioning while controlling bleeding, as opposed to each polyp being manually extracted with an instrument in small pieces.

REF: 411

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Test Bank

10-12

29. Oral malignancies can be linked to specific carcinogens, the most important one being tobacco. Benign or malignant lesions of the tongue, floor of the mouth, alveolar ridge, buccal mucosa, or tonsillar area are excised depending on the extensiveness of disease, involvement of surrounding vessels and nerves, and candidacy for surgery. Benign or small malignant tumors of the oral cavity may be excised without a neck dissection. What indicator would prompt the surgeon to perform a neck dissection for benign or small malignant tumors? a. Evidence of disease in the upper lymphatic chain b. Suspicious metastatic disease c. Presence of diagnosed malignancy d. All of the options would be indications for neck dissection ANS: D Benign or small malignant tumors of the oral cavity may be excised without a neck dissection, though in the presence of diagnosed or highly suspicious metastatic disease, a selective neck dissection may be performed in an effort to control a cancerous growth in the upper jugular lymphatic chain of the neck.

REF: 412 30. During endoscopic sinus surgery, patient eye protection includes: a. taping the eyelids closed. b. placing moist gauze over the eyelids. c. instilling eye lubricant into both eyes. d. All of the options apply ANS: C A consideration that is crucial to a successful outcome in FESS is to maintain the integrity of the patient’s periorbital cavities. The patient’s eyes must be visible to the surgeon at all times to avoid injury to the orbit or to immediately recognize injury if it occurs. The surgeon will monitor for movement of the eyeball or appearance of an intraorbital hematoma.

REF: 408 31. Benign or small malignant tumors of the oral cavity may be excised without a neck dissection, though in the presence of diagnosed or highly suspicious metastatic disease, a selective neck dissection may be performed in an effort to control a cancerous growth in the upper jugular lymphatic chain of the neck. Typically, endotracheal anesthesia is used and a pharyngeal pack of moist gauze may be inserted in the mouth. The perioperative team must be prepared for which additional procedure when head and neck surgery is performed? a. Tracheostomy b. Microscopic free flap graft c. Laryngoscopy d. Difficult airway protocol

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Test Bank

10-13

ANS: A For some tumors of the oral cavity, a tracheostomy is performed to ensure a patent airway after surgery. A percutaneous endoscopic gastric tube, neck dissection, and composite resection of both the mandible and the tongue with free flap reconstruction are considered for extensive disease.

REF: 412 32. Laryngoscopy is direct visual examination of the interior of the larynx by means of a rigid, lighted speculum known as a laryngoscope to obtain a specimen of tissue or secretions for pathologic examination. What action should the surgical technologist take in preparing for the conclusion of the procedure? a. Maintain instrument setup until the patient leaves the OR. b. Determine fire risk score. c. Place O2 tank, nasal cannula, and bag/valve/mask on the transport vehicle. d. Assist anesthesia provider with anesthesia emergence and transfer to the PACU. ANS: A Laryngoscopy instrumentation should remain set up in the OR until the patient is transferred because the equipment may be needed if the patient experiences laryngospasm postoperatively.

REF: 418 33. When laryngoscopy, bronchoscopy, and esophagoscopy are performed in a single session on a patient, the procedure is termed triple endoscopy or panendoscopy. The purpose of triple endoscopy is usually diagnostic. A critical role of the surgical technologist in the scrub role during this complex diagnostic procedure is that of: a. documenting the serial numbers of the scopes in the perioperative record. b. identifying, containing, and labeling all specimens accurately. c. carefully handling and reprocessing the endoscopes. d. assisting the anesthesia provider with maintaining the airway.

ANS: B While inspecting for a malignancy, the surgeon views the structures, takes specimens for biopsy, and possibly makes smears or washings of the suspicious areas. Specimens taken during endoscopic procedures should be labeled and removed from the back table as soon as possible. In some instances, it may be helpful to indicate on the label that the specimens are microscopic.

REF: 420 34. When microlaryngoscopy is performed to remove polyps or nodules from the vocal cords, what important postoperative instruction must be provided to the patient during preparation for discharge?

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Test Bank a. b. c. d.

10-14

Complete voice rest is important.

Coughing and deep-breathing exercises should be performed.

Clearing the throat to remove secretions is advised.

The patient should use a humidifier.

ANS: A Voice rest may be used for minor surgery of the larynx, especially for the removal of polyps or nodules on the vocal cords. The patient is cautioned to observe complete voice rest or to whisper postoperatively. The patient should be provided with a pencil and paper or erasable slate to aid in communication. The patient’s restriction on speaking should be noted on the nursing plan of care and on the front of the chart.

REF: 418 35. During the preoperative assessment for a patient scheduled for nasal surgery using a local anesthetic that includes epinephrine, what important consideration, relevant to epinephrine use, should be explored? a. Coagulopathy b. Renal clearance c. Cardiac status d. Anxiety ANS: C Cardiac status should be noted because many surgeons use epinephrine as an additive to the local anesthetic to achieve vasoconstriction and minimize blood loss. The epinephrine effect may contribute to cardiac dysrhythmias and an increased potential for cardiac arrest.

REF: 390 36. During otolaryngologic procedures using local anesthetic, the perioperative team plans the environment of care as a quiet, warm, and functional domain of healing and comfort.

An important consideration with most otolaryngologic patients identifies their specific _________ needs. a. communication b. anxiety c. airway d. pain ANS: A

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Test Bank

10-15

Patients undergoing otolaryngologic procedures may have special communication needs that must be considered in planning effective care. The perioperative team should determine the best way to communicate with patients who have hearing deficits or impaired vocalization. Information given to the patient should be reinforced as needed throughout the perioperative experience. The OR environment must be quiet.

Intraoperative noises, such as those from suction, electrosurgical units (ESUs), and other equipment, should be explained to the locally anesthetized patient before they are generated. This will help avoid startling the patient and adversely affecting the success of the surgery. Patients receiving local anesthetics need to remain still during the procedure, so providing for comfort measures becomes especially important. The room temperature should be regulated at a comfortable setting, and the patient should be adequately covered to maintain normal body temperature.

REF: 385 37. Sally Andres and her orientee have returned from an airway fire simulation exercise with the otorhinolaryngologic surgeon, fellow, and anesthesia provider. They were amazed at the statistics for OR fires and the threat of serious injury to the patient and team. Patients undergoing otorhinolaryngologic procedures are at greater risk for fire injury because of the proximity of the surgical field to high concentrations of oxygen. The team discussed a plan to change their practices. An example of a risk reduction strategy that involves collaboration of the entire surgical team during otorhinolaryngologic surgery would be: a. placing ESU active electrodes in a secure holster. b. maintaining the laser on standby until needed. c. identifying the fire risk score during the preincision time-out. d. conducting regularly scheduled team simulations that rehearse an airway fire protocol.

ANS: D Specific recommendations that members of the surgical team caring for otorhinolaryngologic patients must consider include awareness of fire risk factors. The perioperative nurse and scrub person should collaborate before procedures to plan for fire risk and ensure that sterile saline is available on the surgical field, the holster is used for the active ESU electrode, and the volumes of music, conversation, and ambient room noise are reasonable so that the audio from the ESU or laser can be heard. A careful review of the facility protocol for handling fire in the OR, including verification of the location of fire pull alarms, extinguishers, and evacuation routes, is essential and should not be minimized.

REF: 389 MULTIPLE RESPONSE 1. Patients scheduled for otologic surgery may have undergone evaluation of their hearing through audiograms to determine whether they have which of these diagnoses? Select all answers that apply.

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Test Bank a. b. c. d.

10-16

Normal hearing Sensorineural hearing loss Conductive hearing loss Mixed loss of hearing from combination of conductive and sensorineural

ANS: A, B, C, D Patients scheduled for otologic surgery may have undergone evaluation of their hearing through audiograms to determine whether they have normal hearing, conductive hearing loss, or sensorineural hearing loss. Two types of audiometric testing, pure tone and speech audiometry, are performed on patients with suspected hearing loss. Mixed loss of hearing is from a combination of conductive and sensorineural hearing loss. A patient with normal hearing would not be a candidate for otologic surgery relative to hearing loss.

REF: 385 2. Functional endoscopic sinus surgery (FESS) provides a more physiologic type of drainage by reducing trauma to normal tissues. FESS involves the endoscopic resection of inflammatory and anatomic defects of the sinuses. Select all of the appropriate indications listed below for FESS. a. Inhibited mucociliary clearance b. Impaired nasal ventilation c. Mucocele d. Sinus infections ANS: A, B, C, D The purpose of FESS is to ensure adequate ventilation and restore mucociliary clearance in the sinuses. If there is contact between the mucosa and the sinus, mucociliary clearance is inhibited and secretions are retained in the sinus. This predisposes the patient to sinus infections and mucocele.

REF: 408

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Rothrock: Alexander's Surgical Procedures Chapter 11: Orthopedic Surgery Test Bank MULTIPLE CHOICE 1. Identify the layer of connective tissue that covers all bone. a. Periosteum b. Calcium c. Cartilage d. Fascia ANS: A A layer of connective tissue called periosteum covers all bone.

REF: 433 2. A long bone fracture in a child can have devastating consequences in terms of the child’s skeletal maturity and potential for limb shortening and malformation when the fracture line involves the: a. epiphysis. b. diaphysis. c. epiphyseal plate. d. cancellous bone.

ANS: C Long bones consist of a shaft (diaphysis) and two ends (epiphyses). The shaft is composed of compact bone. The epiphyses flare out and consist of cancellous bone. They are covered by cartilage, which provides a cushion and offers protection during weightbearing and movement. Until skeletal maturity, a line of cartilage called the epiphyseal plate separates the epiphysis from the diaphysis. Fractures in this region in children can be devastating because they often lead to malformation and permanent limb shortening.

REF: 434 3. The rotator cuff consists of which group of muscles? a. Deltoid, teres major, and teres minor b. Supraspinatus, infraspinatus, teres minor, and subscapularis c. Latissimus dorsi, deltoid, and teres major d. Supraspinatus, subscapularis, pectoralis major, and deltoid ANS: B

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Test Bank

11-2

The muscles immediately surrounding the shoulder joint are the supraspinatus, infraspinatus, teres minor, and subscapularis muscles; together they are referred to as the rotator cuff. These muscles stabilize the shoulder joint, whereas the powerful deltoid, pectoralis major, teres major, and latissimus dorsi muscles move the entire arm.

REF: 435 4. The scaphoid, also called the navicular, links the proximal row of carpal bones as it: a. articulates with each metacarpal head. b. attaches its rough surfaces to the ligaments. c. stabilizes and coordinates the movement of the proximal and distal rows. d. articulates proximally with its matching carpal row.

ANS: C Functionally, the scaphoid links the rows as it stabilizes and coordinates the movement of the proximal and distal rows. The eight carpal bones in the wrist are arranged in two rows. The distal row, proceeding from the radial to the ulnar side, includes the trapezium, trapezoid, capitate, and hamate; the proximal row consists of the scaphoid (also called the navicular), lunate, triquetrum, and pisiform. Each carpal bone consists of several smooth articular surfaces for contact with the adjacent bones, as well as rough surfaces for the attachment of ligaments.

REF: 436 5. The vertebral bodies are connected by several cartilaginous joints. What purpose does this connection enable? a. Communication between the spinous processes and vertebral bodies b. Vertebral flexion, rotation, and extension c. Vertebral flexion and torsion d. Sustains integrity and spinal support ANS: B Vertebrae form the longitudinal axis of the skeleton. The vertebral bodies are connected by several cartilaginous joints that enable the vertebrae to flex, extend, or rotate while being held together. Intervertebral disks and ligaments connect the bodies of adjacent vertebrae. The ligamenta flava bind the laminae of adjacent vertebrae.

REF: 434 6. Select the true statement about application and operation of the pneumatic tourniquet. a. The tourniquet cuff should not overlap less than 3 inches or more than 6 inches. b. Limb exsanguination is optional, using a sterile sequential compression sleeve. c. In a healthy person, inflation time for an arm should not exceed 30 minutes. d. Pneumatic tourniquets are contraindicated in patients with bleeding tendencies.

ANS: A

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Test Bank

11-3

Pneumatic tourniquets are frequently used for procedures involving the extremities.

Limb exsanguination is achieved by elevating the limb or by wrapping it, distally to proximally, with an Ace or Esmarch rubber bandage before tourniquet inflation.

Preoperative assessment of the patient includes determining contraindications for use, including compartment syndrome, McArdle’s disease, hypertension, or other vascular problems. Duration of tourniquet inflation should be kept to a minimum. It is recommended in the average, healthy 50-year-old person to apply continuous tourniquet pressure less than 1 hour on the upper extremity and less than 2 hours on the thigh.

Tourniquet pressure should not exceed the recommended maximum cuff pressure limits of 300 to 350 mm Hg for the thigh and 250 to 300 mm Hg for the arm and the lower leg.

The interval between inflation and deflation should be 5 minutes for every 30 minutes of tourniquet ischemia to minimize detrimental effects on muscle and nerves. Cuffs should overlap a minimum of 3 inches and a maximum of 6 inches; excess overlap can pinch skinfolds. A tourniquet cuff that is too short can loosen after inflation.

REF: 446 7. Polymethyl methacrylate (PMMA, or bone cement) is an acrylic, cement-like substance composed of a liquid methyl methacrylate monomer and a powder methyl methacrylatestyrene co-polymer. What element is added to the powder component to make the finished product radiopaque? a. Radiografinpaque b. Polycrylate sodium c. Barium d. Granular allograft bone ANS: C The powder component is 10% barium sulfate, U.S. Pharmacopoeia (USP), which provides radiopacity to the finished product. The liquid monomer is highly flammable, and the OR should be properly ventilated. Caution should be exercised during mixing of the two components to prevent excessive exposure of OR personnel to the vapors of the monomer.

This exposure can cause irritation of the respiratory tract and eyes.

REF: 451 8. The surgeon may treat distal limb fractures with a closed reduction, rather than open or external fixation, manipulating the fragments into position without incising the skin.

When possible, this is the treatment of choice because it decreases the opportunity for infection, improves results (including bone union of the fracture), and minimizes the recovery period. Closed reduction with local or light anesthesia may permit ambulatory surgery. Select a situation where closed reduction would be performed in addition to open reduction and fixation surgery to a distal limb. a. Significant bone comminution b. Where periosteal damage is evident c. Before an open procedure to reduce the fracture site

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Test Bank

11-4

d. When soft tissue entrapment is suspected ANS: D Closed reduction may take place before an open procedure to reduce the fracture site, because soft tissue entrapped within the fracture site may result in complications after a closed reduction.

REF: 456 9. Open reduction and internal fixation (ORIF) is a method of providing exposure of the fracture site and using pins, wire, screws, a plate and screw combination, rods, or nails to correct the fracture. Surgeons use open reduction and internal fixation when they are unable to reduce a fracture by closed methods and skeletal traction is not indicated. What would be an advantage for an open rather than a closed fracture reduction technique? a. Direct observation and verification of fracture alignment b. Decreased opportunity for surgical site infection c. Improved bone union outcomes d. Ability to rule out comminuted or compound fractures without imaging ANS: A The advantage of ORIF is that anatomic alignment of the fracture can usually be obtained and verified through direct observation. Fractures that are comminuted or difficult to reduce can be more effectively treated using this technique. The incidence of infection and nonunion, however, is increased when the wound is opened.

REF: 458 10. Colles’ (wrist) fracture is a dorsally angulated fracture of the distal end of the radius.

Most of these fractures can be managed successfully with closed reduction and immobilization, but external fixation is especially useful in the case of a comminuted intra-articular fracture. Internal fixation with Kirschner wires (K wires) is indicated when the distal end of the radius is severely comminuted and displaced. Select the correct statement for a patient with a Colles’ fracture fixation. a. Position in modified semi-Fowler with the hand table and tourniquet at the operative side. b. Provide soft tissue instruments in OR and casting supplies available outside OR. c. Place tourniquet cuff at mid-forearm level and set to systolic blood pressure level. d. Position affected wrist and take an AP and lateral film before surgeon’s arrival.

ANS: B The patient is in the supine position with the arm extended on a hand table. Traction by means of finger traps may be required. A soft tissue set and a small bone set are required, along with a power drill, small elevator, and the external fixation device of choice.

Fluoroscopy is necessary.

REF: 469

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Test Bank

11-5

11. Vertebroplasty and kyphoplasty are used for the treatment of vertebral compression fractures attributable to osteoporosis or pathologic conditions. Bone cement is injected into the vertebral body to decrease back pain and prevent further vertebral body height loss. Equipment includes C-arm, radiolucent OR bed, and x-ray vests for staff as well as bone biopsy needles, vertebroplasty system, and cement injection system. An important consideration relevant to this interventional radiology–assisted procedure would be: a. shield the patient with a lead apron, covering from thyroid to reproductive organs. b. organize and have casting supplies available outside of the room. c. position patient in prone body alignment with padding to prevent skin and nerve injury. d. abduct both arms less than 90 degrees on attached armboards.

ANS: C Positioning of the patient requires careful vigilance to prevent skin breakdown and nerve damage. After the administration of anesthetic, the patient is positioned prone with hyperextension of the vertebral compression fracture on the radiolucent OR bed. Full body shielding would interfere with radiolucency of the operative site. These procedures do not require postprocedure casting. Armboards would interfere with movement of the C-arm image intensifier.

REF: 525 12. The term hammer toe is most often used to describe an abnormal flexion posture of the proximal interphalangeal joint of one of the four lesser toes. A bunion (hallux valgus) is a soft tissue or bony mass at the medial side of the first metatarsal head. Both of these deformity conditions of the feet share similar surgical positions, instrumentation for fixation, and recovery plans. Which of the following considerations is also shared by both procedures? a. Perform skin preparation of the same toes. b. Position patient supine and apply ankle tourniquet. c. Provide epinephrine for injection into the toes to decrease bleeding. d. None of these options are relevant to both procedures.

ANS: B The goals of surgery are correction of the deformity (cosmesis), resection of the abnormal bony components (reconstruction), and restoration of normal or near-normal range of motion (function). The anesthesia provider administers a general or regional anesthetic, and an ankle tourniquet is applied. The foot and leg are prepped and then draped using a sterile stockinette. A soft tissue set, a small bone set, Kirschner wires, a power wire driver, and a microsagittal saw are required. The foot is prepped and draped. The toes are end organs and epinephrine should be used with caution.

REF: 488

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13. Bone grafting using allografts or autografts may be used to fill cavities after removal of large amounts of bone that might result in instability, or to fill bony defects and to promote the union of fractures at the time of open reduction. Banked bone is available in many shapes of cortical and cancellous tissue. The American Association of Tissue Banks (AATB) accredits and periodically inspects bone-banking programs to ensure that specific standards are followed in the retrieval, processing, storage, and distribution of bone grafts. Bone graft that is sealed in a sterile labeled envelope from a tissue transplant company and stored in a vacuum-sealed freezer, monitored with an alarm, would be considered a(n): a. reengineered human tissue product. b. allograft. c. xenograft. d. autograft.

ANS: B Allografts are frozen until use. Vacuum-sealed freezers are monitored with an alarm.

When requested for a procedure, the bone allograft is delivered to the field, slightly thawed, cultured, and washed with an antibiotic solution. Allografts are used when bone is not available from the patient because of the lack of sufficient quantity or because a secondary procedure is undesirable for the patient. Records are maintained on both donors and recipients. Like other implants, the recipient’s operative record should include the name of the bone bank from which the allograft was received, type of allograft, tissue number, and expiration date if applicable.

REF: 452 14. Osteoporosis is one of the most common and serious of bone diseases and is responsible for more than 2 million fractures a year. Osteoporosis-related fractures most commonly occur in the hip, spine, and wrist, but any bone can be affected. The excessive reduction of total bone mass in osteoporosis is due to the loss of: a. calcified matrix and collagenous fibers. b. exercise and weight-bearing physical activity. c. estrogen and testosterone. d. calcium or vitamin D. ANS: A Osteoporosis is characterized by excessive loss of calcified matrix, bone mineral, and collagenous fibers, causing a reduction of total bone mass. Decreasing levels of estrogen and testosterone in the older adult results in reduced new bone growth and maintenance of existing bone. Inadequate intake of calcium or vitamin D; lack of weight-bearing activities, exercise, and physical activity; smoking; and caffeine intake are other contributing factors. Osteoporotic bone is porous, brittle, and fragile, fracturing easily under stress. This results in susceptibility to spontaneous fractures and pathologic curvature of the spine.

REF: 454

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15. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone, which leads to a reduced absorption of calcium and phosphorus. This malabsorptive condition is due to a deficiency of ______________ that can be treated by __________________. a. calcium; nutritional diet and mineral supplements b. vitamin D; dietary supplements and exposure to sunlight c. phosphorus; nutraceuticals and exposure to therapeutic radiation d. soy protein; weight-bearing exercise and sunlight ANS: B Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone as a result of vitamin D deficiency, which leads to a reduced absorption of calcium and phosphorus. Risk factors for development of osteomalacia include malabsorption problems, vitamin D and calcium deficiencies, chronic renal failure, and inadequate exposure to sunlight. Medical treatment includes dietary supplements and exposure to sunlight.

REF: 454 16. Paget’s disease is a disorder affecting older adults. The bones are weak and poorly constructed. It is characterized by the proliferation of osteoclasts and compensatory increased osteoblastic activity. This degenerative process results in: a. weak and non supported bone matrix. b. replacement of cancellous bone with cortical bone. c. rapid, disorganized bone remodeling. d. immature bone cells with air spaces.

ANS: C Paget’s disease is characterized by proliferation of osteoclasts and compensatory increased osteoblastic activity, resulting in rapid, disorganized bone remodeling.

REF: 454 17. In an open anterior cruciate ligament (ACL) repair, an examination under anesthesia (EUA) is performed immediately after induction of anesthesia, when the ligaments are completely lax, to evaluate the severity of the injury. The surgeon then makes a straight midline or slightly medial incision across the knee. Arthroscopic repair causes less patellar pain and decreased disturbance of extensor mechanisms. What preoperative indicators contribute to selecting the surgical approach (open or arthroscopic) of choice? a. Classification and severity of the tear or capsular instability b. Surgeon experience and preference c. Patient history of a prior failed repair or gross knee joint disruption d. All of the options are contributing factors.

ANS: D

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The selected treatment method depends on the classification and severity of the tear, the experience and preference of the surgeon, and a history of a previous failed repair.

Arthroscopic repair causes less patellar pain and decreased disturbance of extensor mechanisms and therefore is becoming the treatment of choice, if there is no other significant capsular instability or gross disruption of the knee joint.

REF: 514 18. Revision arthroplasty may be indicated if the patient’s original knee replacement wears out or loosens, or fails as a result of repeated dislocation, infection, or trauma. Total joint revision can be a very demanding and complicated procedure. Attention to detail, anticipation, and preparation are essential. Following the induction of anesthesia, the surgeon performs an exam under anesthesia (EUA) to determine the approach. The most difficult aspect of revision surgery is that there is: a. considerable scar tissue and edema. b. a significant challenge ahead with postoperative pain management. c. no clear-cut sequence of events. d. polymethyl methacrylate (PMMA) bone cement that must be drilled out.

ANS: C Although one of the most difficult aspects of revision surgery is that there is no clear-cut sequence of events, it is best, if possible, to approach revision surgery using the same logical sequence for each procedure. This allows all members of the surgical team to anticipate the steps in the procedure and the needs of the patient. Important patient information includes the preoperative x-rays, bone scan, laboratory results (including aspiration results), and physical findings.

REF: 504 19. While not as prevalent as arthroplasty of the shoulder, knee, or hip, total elbow replacement is indicated for patients with traumatic lesions or excessive bone loss from rheumatic or degenerative arthritis, resulting in elbow instability and pain or bilateral elbow ankylosis. The prosthesis may be used with or without PMMA, depending on the quality of the diseased bone and the design of the implant. If PMMA is not used, what replacement product, element, or substance is used? a. Synthetic bone putty b. Autologous bone graft c. Hemostatic gel sponge with thrombin d. Side plates, screws, and circumferential wires ANS: B

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If PMMA is not employed, bone grafting with local bone that has been resected may be used to help seat the ulnar component snugly and achieve adequate bony contact against the porous coating of the metal ulnar component. The design of implants and methods of fixation for postoperative stability have presented challenges that have been overcome in arthroplasty of other joints but remain a challenge in elbow arthroplasty. Postoperative stability of the elbow implant depends largely on the soft tissues surrounding the joint.

Patients with degenerative arthritis generally have better results from elbow arthroplasty than those undergoing this procedure after injury to the elbow joint.

REF: 507 20. Marissa Blanca, a 48-year-old woman with degenerative rheumatoid arthritis, is having a two-joint metacarpophalangeal implant of her left hand. The pneumatic tourniquet is applied to Marissa’s upper left arm and has been inflated to 280 mm Hg for 38 minutes.

The surgery is advancing as planned and the surgeon is preparing to insert the second implant. Celeste, the circulator, has set the time threshold for 60 minutes. During her preoperative assessment with Marissa, she noted no contraindications to pneumatic tourniquet use. While the surgery is going well and Celeste is confident that the second implant will be inserted and the wound closed before the tourniquet alarms, what risk reduction strategy would be appropriate for Celeste to employ? a. Be prepared to increase the time threshold to 90 minutes. b. Suggest a let-down procedure to resanguinate the limb at 60 minutes if the second implant is not yet inserted. c. Wait until the 60-minute alarm sounds. d. Gently remind the team when the 30-, 45-, and 60-minute marks are reached.

ANS: D OR personnel should be aware of the risk of exceeding the time limits and should inform the surgeon at regular intervals of the tourniquet inflation time. All OR personnel responsible for the tourniquet should be familiar with current standards, maximum times for inflation for extremities, and contraindications for tourniquet use.

REF: 447 MULTIPLE RESPONSE 1. An OR fracture bed is used for orthopedic surgical procedures such as femoral neck or shaft fixation. The patient can be positioned in a partially suspended supine or lateral position. This specialized supportive bed provides several therapeutic options that promote a safe, efficient, and ergonomic approach to the area to be repaired. Select all the therapeutic options in the list below that promote the successful accomplishment of a femoral fracture procedure. a. The patient is in proper body and mechanical alignment. b. The femur fracture is reduced in traction to align the bone. c. The entire leg can be prepped circumferentially. d. Multiview images can be taken with the C-arm image intensifier.

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e. The patient can be turned prone for posterior spinal access. f. The patient can have a hip spica cast applied.

ANS: A, B, C, D, F On an OR fracture bed, generally used for femoral neck and shaft fixation, the team places the patient in supine or lateral position to allow exposure of the surgical site while maintaining alignment. The patient’s legs are positioned on outriggers, allowing access by the image intensifier to obtain multiple radiographic views and a circumferential skin prep. Applying or releasing traction can be done to reduce the fracture or aid in intramedullary surgical techniques. Like all positioning devices, the fracture bed must be set up by experienced personnel and padded adequately.

REF: 444 2. A cancellous bone graft consists of spongy bone usually taken from the anterior or posterior crest of the ilium. A cortical bone graft, consisting of hard, dense bone, is removed from the crest of the ilium or the tibia. Why is the ilium a desirable site for graft harvest? Select all responses from the list below that apply. a. It is subcutaneous, making it easily exposed without difficulty. b. It is not a weight-bearing joint. c. It is not an articulating joint. d. It has both cortical and cancellous bone. e. There are two, one on each lateral side. f. It has both allograft and autograft bone.

ANS: A, D The location of the crest of the ilium is subcutaneous, allowing exposure without difficulty. The surgeon makes an incision along the border of the iliac crest, and strips, elevates, and retracts the muscles on the outer table of the ilium. Strips of the iliac crest can be removed with an osteotome or oscillating saw. A cortical window may also be made in the outer table, and the surgeon may use curettes or gouges to remove cancellous bone chips. Autografts are often harvested from the iliac crest, where there is cortical and cancellous bone.

REF: 453 MATCHING Match the skeletal structure with its appropriate description. a. Ligaments b. Tendons c. Cartilage

1. Bands of dense connective tissue that hold bone to bone

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2. Layer of elastic, resilient supporting tissue found at the ends of the bones 3. Tough, long strands of fibers that form the ends of muscles 1. ANS: A

REF: 433

2. ANS: C

REF: 434

3. ANS: B

REF: 433

Match the normal sequence of bone healing shown in the figures below with the list of stages.

Stages: 4. Fibrin network formation 5. Callus formation 6. Hematoma formation 7. Remodeling 8. Invasion of osteoblasts 4. ANS: B

REF: 453

5. ANS: D

REF: 453

6. ANS: A

REF: 453

7. ANS: E

REF: 453

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REF: 453

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Rothrock: Alexander's Surgical Procedures Chapter 12: Neurosurgery Test Bank MULTIPLE CHOICE 1. Which of the following is the anatomical bloodless plane that contains loose areolar tissue and permits mobility of the scalp? a. Subarachnoid space b. Galea aponeurotica c. Subgaleal space d. Diploe table ANS: C The subgaleal space contains loose areolar tissue that permits mobility of the scalp. It is in this bloodless plane that the standard craniotomy scalp flap is created. The subcutaneous tissue, which is exceptionally dense, tough, and vascular, is firmly attached to the galea. Most of the blood vessels lie superficial to the galea. The pericranium, or outer periosteum of the skull, separates the galea from the cranium.

REF: 529 2. Identify the dural fold that separates the right and left cerebral hemispheres. a. Falx cerebri b. Tentorium cerebelli c. Falx cerebelli d. Tentorium cerebri ANS: A The dura mater is a tough, shiny, fibrous membrane that is close to the inner surface of the skull and folds to separate the cranial cavity into compartments. The largest fold is the falx cerebri—an arch-shaped, vertically placed, midline structure separating the right and left cerebral hemispheres.

REF: 531 3. What is the name for the division of the brain that contains the hippocampus and amygdala, which are responsible for learning and memory and regulate perceptive and expressive aspects of emotional and social behavior? a. Basal ganglia b. Brainstem c. Diencephalon d. Limbic system

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ANS: D The hippocampus is critical for learning and memory. The amygdala regulates the perceptive and expressive aspects of emotional and social behavior. The limbic system consists of large parts of the cortex near the medial wall of the cerebral hemisphere (cingulate and parahippocampal gyri) along with the hippocampus, amygdala, and septum. It is closely and significantly connected with the hypothalamus. The limbic system affects endocrine and autonomic functions of the body, recent memory, emotions, behaviors, and motivational and mood states.

REF: 535 4. The brainstem consists of which three structures? a. Dura mater, arachnoid, pia mater b. Midbrain, pons, and medulla oblongata c. Mesencephalon, diencephalon, and cerebellum d. Pons, medulla, and foramen magnum ANS: B The brainstem consists of the midbrain, pons, and medulla oblongata. The short, stocky portion of the brain between the cerebral hemispheres and pons is the midbrain, also referred to as the mesencephalon. The medulla oblongata is continuous with the spinal cord at the foramen magnum. It contains the vital cardiovascular and respiratory regulatory centers. Damage to the brainstem is often devastating and life threatening because it can affect movement, senses, consciousness, perception, and cognition.

REF: 536 5. Which part of paired spinal nerves is responsible for sensory functions? a. Anterior root b. Dermatomes c. Posterior root d. Pyramidal tracts ANS: C The posterior, or sensory, root contains cell bodies that lie in the spinal ganglia located in the intervertebral foramina, the opening through which the nerves exit from the spinal canal and emerge from the cord. The normal segmental sensory distribution is valuable in the anatomic localization of sensory disorders. The anterior, or motor, root contains cell bodies that lie in the anterior horn of the spinal gray matter. Dermatomes are bands of skin innervated by a sensory root of a single spinal nerve. The pyramidal tracts are laterally placed long pathways within the central gray matter of the spinal cord that carry impulses down from the cerebral cortex to the motor neurons of the cord.

REF: 551

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6. Which of the 12 cranial nerves is involved in Bell’s palsy and may be damaged during parotidectomy procedures? a. Third (III) b. Fifth (V) c. Seventh (VII) d. Twelfth (XII) ANS: C The seventh (VII) cranial nerve is the facial nerve and supplies the musculature of the face and the sensation of taste for the anterior two-thirds of the tongue. It originates in the brainstem, passes through the skull with the eighth nerve by way of the internal acoustic meatus, continues along the facial canal, and exits just posterior to the parotid gland. The nerve may be damaged by surgical procedures in the vicinity of the parotid gland. Bell’s palsy, a facial lower motor neuron paralysis, can affect the seventh nerve. The third (III) cranial nerve is the oculomotor nerve and is a motor nerve that innervates the muscles of the eye. The fifth (V) cranial nerve is the trigeminal nerve, which is a mixed nerve with sensory supply to the forehead, eyes, face, jaw, teeth, and other facial structures and innervates the muscles of mastication. The twelfth (XII) cranial nerve is the hypoglossal nerve and innervates the musculature of the tongue.

REF: 548 7. Select the name of the procedure for which this patient is positioned.

a. b. c. d.

Transsphenoidal hypophysectomy Infratentorial craniectomy for acoustic neuroma Supratentorial stereotactic brain biopsy Bilateral parietal craniotomy for subdural hematoma

ANS: C This patient is in the sitting position to undergo a supratentorial stereotactic brain biopsy.

REF: 564 8. Which of the following represents an intractable pain condition of the fifth (V) cranial nerve, also called tic douloureux, often treated with gamma knife radiosurgery, percutaneous rhizotomy, radiosurgery, or posterior fossa microvascular decompression? a. Bell’s palsy b. Sciatica Copyright © 2012 by Mosby, an imprint of Elsevier Inc.

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c. Trigeminal neuralgia d. AV malformation ANS: C Trigeminal neuralgia (tic douloureux) is characterized by excruciating, piercing paroxysms of pain, affecting one or more of the major peripheral divisions. Types of neurosurgical procedures currently recommended for trigeminal neuralgia include percutaneous rhizotomy using glycerol, radiofrequency, or balloon compression; gamma knife radiosurgery; and microvascular decompression.

REF: 588 9. Which of the following types of interventional neuroradiologic endovascular procedures is less invasive than traditional surgical clipping of complex (short-necked) or difficultto-reach intracranial aneurysms? a. Endosaccular coiling b. Endovascular embolization c. Intraarterial thrombolysis d. Balloon angioplasty ANS: A The endovascular approach to the treatment of both ruptured and unruptured cerebral aneurysms is endosaccular occlusion. This is an excellent technique for aneurysms that are complex, have a neck that is too short for clipping, or are difficult to reach via traditional craniotomy. A flexible platinum coil is fed through the transfemoral catheter and is coiled within the body of the aneurysm, conforming to the aneurysm’s shape. The coil is then detached from the catheter. Although surgical excision is still the standard treatment for intracranial arteriovenous malformation (AVM), surgical morbidity may be decreased by using endovascular embolization preoperatively in select cases. Intraarterial thrombolysis is used for treatment of acute ischemic stroke patients who have missed the 3-hour window for therapeutic intravenous thrombolysis. Successful balloon angioplasty has not been evaluated in controlled clinical trials for treatment of intracranial stenosis and documented in mostly academic, high-volume centers.

REF: 575 10. How can a surgical technologist in the scrub role efficiently assist the surgeon in microsurgical procedures so that his or her gaze need not be diverted from the microscope? a. Keep frequently used instruments in close proximity to the surgical field. b. Avoid sagging of the microscope drape into the field of view. c. Hand instruments in a functional manner and guide them back into the field of view. d. Use neutral zone transfer techniques with a basin or magnetic pad.

ANS: C

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Use of the microscope restricts the surgeon’s field of vision and mobility. Each time the surgeon must look away and then back to the surgical field, open wound time and anesthesia time are increased while the surgeon becomes reoriented to the field.

Therefore, the assistance the surgical technologist gives the surgeon saves time and directly benefits the patient.

REF: 578 11. Which of the following is the minimum exposure method frequently used for evacuation of subdural hematomas, placement of ventriculoperitoneal shunts, or stereotactic brain biopsies? a. Craniotomy b. Burr hole c. Craniectomy d. Transsphenoidal ANS: B A burr hole is the minimum exposure made to gain access to the brain. Burr holes are necessary for many neurosurgical procedures and can be used to access the intracerebral ventricles for the placement of a ventricular catheter (VP shunt) to drain obstructed cerebrospinal fluid. Craniectomy is the permanent removal of a section of the cranium using burrs and rongeurs to enlarge one or more burr holes. Craniectomy is indicated as treatment for craniosynostosis in infants and young children. A craniotomy may be performed to evacuate intracranial hematomas, tumors, or vascular lesions not accessible through a burr hole. The bone plate may be separated from the soft tissues, removed from the skull, and set aside for replacement at the end of the procedure. If intracranial swelling at the end of the procedure is a major concern, the bone plate may be frozen and stored in a sterile container according to hospital protocol to be replaced on the patient at a future date when the reduced intracranial pressure and swelling permits. The transsphenoidal route to the pituitary fossa is a less invasive means of removing pituitary or parasellar tumors than the transcranial approach.

REF: 577 12. Which surgical specialist might be asked to assist in providing exposure for the neurosurgeon in a transsphenoidal hypophysectomy (TSH) procedure? a. Cardiothoracic surgeon b. Neuroradiologist c. Orthopedic surgeon d. Otorhinolaryngologist ANS: D

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Otorhinolaryngologic surgeons can be consulted to assist the neurosurgeon with this approach through the sphenoid sinus into the pituitary fossa. Endocrine pituitary disorders (e.g., Cushing’s syndrome, acromegaly, malignant exophthalmos, and hypopituitarism resulting from intrasellar tumors), as well as nonpituitary disorders (e.g., advanced metastatic carcinoma of the breast and prostate, diabetic retinopathy, and uncontrollable severe diabetes), have been successfully treated by TSH. Complete extracapsular enucleation of the pituitary in cases of hypophysectomy and possible complete removal of small pituitary tumors, with the remaining normal portion of the gland left intact, can be achieved.

REF: 578 13. Which chemical hemostatic agent comes in compressed and noncompressed sheets and is often cut into various sizes soaked with topical thrombin and placed on oozing surfaces during neurosurgical procedures? a. Bone wax b. FloSeal c. Gelfoam d. Surgicel ANS: C An absorbable gelatin sponge (Gelfoam) absorbs and holds blood and fluid within its interstices, exerting a physical hemostatic effect. Thrombin is a drug that can be topically applied to bleeding surfaces to achieve hemostasis. Typically, Gelfoam or patties are saturated with thrombin and placed on the oozing surface. Bone wax is a hemostatic material that should be available for all cranial and spinal cord operations. Bone wax may be applied with the surgeon’s fingertip or with the tip of an instrument such as a Freer or Penfield elevator. The surgeon firmly rubs or packs the wax into the bleeding surfaces of bone. The granules in a gelatin matrix (FloSeal) form a composite clot that seals a bleeding site. Regenerated cellulose (Surgicel) allows platelets and aggregates of thrombin and particulate blood elements to cling and form a coagulum that can act as a patch.

REF: 572 14. Which of the following histologic classifications of brain tumors is usually benign, circumscribed and slowly growing and arises from arachnoid cells? a. Astrocytoma b. Craniopharyngioma c. Meningioma d. Oligodendroglioma ANS: C

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Tumors of the meninges (meningiomas) commonly occur in people in the fourth to sixth decades of life. They are usually benign, circumscribed, slow-growing tumors, arising from arachnoid cells with secondary attachment to the dura. They can be very vascular and may adhere to the dural venous sinuses or major arteries, making their complete removal challenging; however, meningiomas often can be totally surgically removed.

Astrocytomas are the most common of all primary brain tumors and are believed to originate from neuroglial cells. Craniopharyngiomas account for 2.5% to 4% of intracranial tumors with 50% occurring in childhood and arise from the region of the pituitary stalk. Oligodendrogliomas are believed to represent 5% to 15% of gliomas and originate from neuroglial cells.

REF: 537 15. Which of the following intracranial structures provides collateral blood flow and continuity of the circulation if any one of the four main channels is interrupted? a. Choroid plexus b. Circle of Willis c. Cerebral aqueduct d. Corpus callosum ANS: B The arterial supply to the brain enters the cranium through the two internal carotid arteries anteriorly and the two vertebral arteries posteriorly. These communicate at the base of the brain through the circle of Willis, which ensures continuity of the circulation if any one of the four main channels is interrupted. The choroid plexuses of the ventricles are vascular structures that allow certain fluid elements of the blood to pass through their ependymal linings, forming cerebrospinal fluid (CSF). The cerebral aqueduct (Sylvius) is a long, narrow channel passing through the midbrain and allows passage of CSF from the lateral ventricles to the fourth ventricle. The corpus callosum is a large transverse bundle of nerve fibers that connects the right and left hemispheres of the brain.

REF: 542 16. What is a common congenital neural tube closure defect that may present as a fluid-filled sac in the lumbar region and contains neural elements? a. Encephalocele b. Chiari malformation c. Hydrocephalus d. Myelomeningocele ANS: D

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The most common congenital lesion encountered is a lumbar meningocele, or myelomeningocele, a failure of the union of the vertebral arches during fetal development. The fluid-filled, thin-walled sac often contains neural elements.

Encephalocele is a neural tube defect that occurs most frequently in the occipital region of the skull. A Chiari malformation is a condition in which there is protrusion of the cerebellar hemispheres and medulla through the foramen magnum, causing hydrocephalus, or excess accumulation of cerebrospinal fluid, resulting in dilation of the intracerebral ventricles.

REF: 554 17. What is the term for softening of brain matter or loss of brain tissue, often caused by cerebral infarct, ischemia, or trauma? a. Abscess b. Encephalomalacia c. Kernicterus d. Neurocysticercosis ANS: B Encephalomalacia is a condition of softening of brain matter or loss of brain tissue.

Cerebral infarct, ischemia, and trauma are common causes. Although less a cause of increased intracranial pressure, encephalomalacia may be observed during craniotomy, noted on diagnostic imaging studies, or as a pathologic finding at autopsy. Brain abscess is defined as an intracerebral collection of pus. Typically, anaerobic bacteria are involved and induce an inflammatory response that encapsulates necrotic brain tissue. Kernicterus, also known as bilirubin encephalopathy, is a rare neurologic condition in neonates.

Severe jaundice in the first 1 to 3 weeks of infancy may result in the excess bilirubin moving from the circulatory system and collecting in brain tissue. Neurocysticercosis is a parasitic infection caused by the pork tapeworm Taenia solium in its larval form. It is the most common infestation of the central nervous system and is mainly seen in developing countries.

REF: 539 18. Which of the following is the tissue most often responsible for spinal nerve root compression in patients with herniated intervertebral disks? a. Annulus fibrosis b. Nucleus pulposus c. Posterior longitudinal ligament d. Spinous process ANS: B

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The nucleus pulposus protrudes beyond the perimeter of the disk space into the epidural space, resulting in nerve root compression and radiculopathy. The annulus fibrosis is made of rings of fibers and disk rupture occurs with radial fissuring of the annulus. The posterior longitudinal ligament runs vertically posterior to the vertebral body and anterior to the intervetebral foramen and assists in maintaining disks in place. The bony spinous process extends posteriorly and can be palpated in most people.

REF: 556 19. Which of the following diagnostic procedures involves placement of fiducials (frameless system) on the patient’s head preoperatively for creation of a virtual image in three dimensions and can be used intraoperatively with a synchronized hand piece for precise targeting of intracranial lesions? a. Digital subtraction angiography b. Electroencephalography c. Stereotactic MRI or CT scan d. Wada’s test ANS: C Placement of a stereotactic head frame (frame-based system) or fiducials (frameless system) before receiving a computed tomography scan or magnetic resonance image produces information that is registered into a computer. The goal of stereotactic surgery is to target a point or volume in space precisely by means of a predefined minimally invasive trajectory. The frameless system allows the neurosurgeon to see beyond the actual operative field by using an optical tracking device. This handheld device depicts in three planes on a computer screen where the surgeon is working in the brain relative to deeper structures beyond view. Digital subtraction angiography allows for examination of selected arterial circulation by injection of contrast media. Electroencephalography records the brain’s continuous electrical activity by means of electrodes placed on the scalp or intraoperatively on the brain. Wada’s test can be used before brain surgery to lateralize language, memory, and the dominant hemisphere.

REF: 560 20. Which of the following are applied along the skin edges for mechanical hemostasis during opening of the scalp for craniotomy? a. Bone wax b. Methylmethacrylate c. Raney clips d. Topical thrombin ANS: C Application of disposable scalp (Raney) clips limits bleeding by applying pressure to the scalp edges. They remain in place until closure. The clips are a mechanical method of hemostasis.

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REF: 569

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Rothrock: Alexander's Surgical Procedures Chapter 13: Plastic and Reconstructive Surgery Test Bank MULTIPLE CHOICE 1. The science of plastic and reconstructive surgery, which means to mold or create form and shape, improves appearance and body image through an understanding of: a. body geometry. b. the anatomy and biology of tissue. c. form and function. d. body image.

ANS: B Plastic and reconstructive surgery is based on a thorough understanding of the anatomy and biology of tissue. Derived from the Greek word plastikos, which means to mold or give form, plastic surgery is a medical specialty that restores or gives shape to the body.

REF: 604 2. Denise Michaelson, a 46-year-old woman with an early-stage second primary cancer in her left breast, has elected to have a bilateral mastectomy with saline implants. She has requested that the surgeon also revise a small unsightly scar on her right knee and pierce her ears. While Denise’s breast tumor could be treated with an excisional biopsy, she has decided to have a mastectomy of both breasts, which is considered an appropriate preemptive (preventative) surgery for a woman of her age with two primary cancers of the breast. The saline implant insertion surgery is considered a _______________ procedure, the scar revision is considered a ___________ procedure, and the ear piercing is considered a _______________ procedure. a. reconstructive; reconstructive; reconstructive b. reconstructive; cosmetic; reconstructive c. cosmetic; reconstructive; cosmetic d. reconstructive, cosmetic and cosmetic ANS: D There are two different subspecialties of plastic surgery. Cosmetic (aesthetic) surgery restores or reshapes normal structures of the body, to improve appearance and selfesteem. Reconstructive surgery treats abnormal structures of the body caused by birth defects, developmental problems, disease, tumors, infection, or injury, to restore function and correct disfigurement or scarring. Scar revision involves the rearranging or reshaping of an existing scar so that the scar is less noticeable; scar revision is considered an aesthetic procedure.

REF: 604

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3. The circulator should verify with the patient that all of the preoperative prescribed skin preparation regimens ordered by the surgeon have been performed. All body jewelry that pierces the skin should be removed before the skin prep. Select the statement that reflects a true special consideration for skin preparation before facial surgery. a. Use chlorhexidine gluconate (CHG) around the ears and eyes. b. Leave the eyebrows and eyelashes intact to preserve facial appearance and expression. c. Prep the skin graft and donor sites together with the same prep set and drape immediately. d. Isolate rashes, open sores, cuts, or lesions in the prep site with a sterile, clear adhesive patch.

ANS: B The eyebrows and eyelashes, in particular, are left intact to preserve facial appearance and expression. The use of CHG should be avoided around the ears and eyes. When prepping for a skin graft procedure, separate skin prep setups are needed for the graft and donor sites.

Inspect for any rashes, bruises, open sores, cuts, or other skin conditions.

REF: 610 4. During the planning phase of a procedure for liposuction or post–bariatric contouring, the perioperative team will assemble and organize supplies and devices because the procedure may require: a. repositioning one or more times during surgery. b. meticulous accounting of fluid loss and blood replacement. c. pressure dressings. d. patient transfer to an alternating-pressure bed.

ANS: A Whereas a majority of plastic surgical procedures are performed in the supine position, many also take place with the patient prone or lateral. Liposuction and post–bariatric body contouring procedures may also require repositioning one or more times during surgery.

REF: 642 5. Skin grafting provides an effective way to cover a wound if vascularity is adequate, infection is absent, and hemostasis is achieved. Skin from the donor site is detached from its blood supply and placed in the recipient site. The best description of a successful skin graft outcome is: a. the skin is a good color match. b. the recipient site develops a new blood supply from the base of the wound. c. capillary refill returns within 24 hours. d. a split-thickness graft is able to regenerate in an area of full-thickness loss.

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ANS: B Skin from the donor site is detached from its blood supply and placed in the recipient site, where it develops a new blood supply from the base of the wound. Color match, contour, and durability of the graft are all considerations in selection of an appropriate donor area.

Color, temperature, signs of infection, blanching of the skin, excessive pain and discomfort, edema, vasoconstriction, and venous congestion should be noted and any change reported to the surgeon.

REF: 619 6. Replantation is an attempt to reattach a completely amputated digit or other body part.

Revascularization is the procedure performed on incomplete amputations, when the part remains attached to the body by skin, artery, vein, or nerve. Good candidates for replantation are those with the following amputations: a. almost any body part of a child. b. proximal portion of the hand at palm level. c. distal to middle foot. d. distal to middle thigh.

ANS: A Good candidates for replantation are those with the following amputations: (1) thumb, (2) multiple digits, (3) distal portion of the hand at palm level, (4) wrist or forearm, (5) elbow and above the elbow, and (6) almost any body part of a child. The success of digital replantation depends primarily on the microsurgical repair of one digital artery and two digital veins.

Replantation of an amputated part is ideally performed within 4 to 6 hours after injury, but success has been reported up to 24 hours after injury if the amputated part has been cooled.

REF: 626 7. Microsurgery, a fundamental tool in reconstructive plastic surgery, allows an almost unlimited choice of reconstructive methods, replacement of lost tissue with similar components, and optimal selection of donor sites with minimal morbidity. Reconstructive microsurgical procedures include replantation of amputated body parts, repair of facial nerves, repair of lacerated nerves and blood vessels, treatment of extensive trauma to extremities and hands, reconstruction following removal of extensive cancers, and female to male transsexual reassignment. Today’s surgeons skilled in microsurgery can successfully anastomose the ends of a vessel or nerve measuring less than: a. 2 mm. b. 1.5 mm. c. 1 mm. d. 0.5 mm.

ANS: C

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Today’s surgeons who are skilled in microsurgery can successfully anastomose the ends of a vessel or nerve measuring less than 1 mm in diameter. The surgeon’s use of an operating microscope or loupes for microsurgical procedures depends on the procedure to be performed, condition of the tissue, and personal preference.

REF: 626 8. Facial fractures are classified according to a system developed by Rene Le Fort in the early 1900s. A fracture that starts at the nasal bones, crosses the frontal process of the maxilla and lacrimal bones, and extends through the orbital floor, infraorbital rim, and lateral maxillary sinus wall is known as a: a. Le Fort I. b. Le Fort II. c. Le Fort III. d. Le Fort IV. ANS: B Le Fort I, or transverse maxillary, fracture—this horizontal fracture includes the nasal floor, septum, and teeth. Le Fort II, or pyramidal maxillary, fracture (unilateral or bilateral)—often involves the nasal cavity, hard palate, and the orbital rim. Le Fort III, or craniofacial dysjunction, fracture—includes fractures of both zygomas and the nose. Like a mandibular fracture, a maxillary fracture also produces malocclusion. In addition, depending on the severity of the fracture, it may produce considerable deformity of the middle of the face, usually perceived as a flattening or smashed-in appearance. Closed reduction with intermaxillary fixation suffices for treatment of Le Fort I and some Le Fort II fractures.

REF: 630 9. Denise Michaelson had a scar revision of her knee performed along with her bilateral mastectomy with saline implants and ear piercing procedures. The knee scar, before revision, was an 8-cm linear, thin scar that extended obliquely across the anterior portion of her knee. The tension of the scar tissue met resistance when she would bend her knee.

The surgeon opted to remove the scar with a procedure to break up the linear scar and rearrange the tissue direction to form a natural line. The proper name of this tissue transfer scar revision is the: a. scar lysis. b. epidermolysis with remodeling. c. scarplasty. d. Z-plasty.

ANS: D

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Z-plasty is the most widely used method of scar revision. It breaks up linear scars, rearranging them so that the central limb of the Z lies in the same direction as a natural skin line. Scar revision involves the rearranging or reshaping of an existing scar so that the scar is less noticeable. The simplest form of scar revision is excision of an existing scar and simple resuturing of the wound.

REF: 633 10. A broad range of implant materials are used in plastic and reconstructive surgery. Select the implant that represents a biologic composition of a surgical implant. a. Autologous human tissue b. Medical-grade sterile silicone c. Gold d. Polypropylene ANS: A The range of materials available for implantation and augmentation in the specialty of plastic and reconstructive surgery has benefited from ongoing research. Biologic materials (autogenous grafts) are preferred when available. Autologous human tissue successfully utilized includes fat, solid dermis, and collagen. Human cadavers are used as a source for acellular collagen (AlloDerm).

REF: 609 11. One of the most popular lasers used in plastic and reconstructive surgery is attracted to the water in the skin cells and ablates the cells at a predetermined depth. Collagen material beneath the skin surface is also heated, resulting in smoother and slightly tighter skin. Several lasers are attracted to areas of darker pigmentation. This treatment has virtually replaced dermabrasion, because of its consistency in terms of depth of penetration and also because this technique is less dependent on user technique or skill.

Select the laser modality that would be the best option for ablation or removal of a pigmented red tattoo. a. CO2 laser b. Erbium:YAG laser c. Nd:YAG laser d. Excimer laser ANS: C The Nd:YAG laser is suited to ablate or remove benign pigmented lesions and red tattoos.

Common uses for lasers in plastic surgery include exfoliation, treatment of vascular malformations, removal of hair and tattoos, and tightening of collagen fibers in aging skin.

Candela dye, diode, and Q-Switch lasers are suited for pigmented benign lesions, tattoos, and hemangiomas.

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REF: 637 12. Dermatomes are used for removing split-thickness skin grafts (STSGs) from donor sites.

The perioperative team preparing for a procedure where STSGs will be taken to cover several large burn areas will need to have available: a. sterile petroleum jelly and sterile impregnated gauze sheets. b. sterile mineral oil, tongue blades, and a mesher dermatome. c. sterile mineral oil and carriers. d. a nitrogen tank, sterile gauze fluffs, and antibiotic ointment.

ANS: B Sterile mineral oil and tongue blades should be available when STSGs are being obtained. Several types of skin meshers are available. Each is designed to produce multiple uniform slits in a skin graft, approximately 0.05 inch apart. These multiple apertures in the graft can then expand, permitting the skin graft to stretch and cover a larger area. Meshing also facilitates drainage through the graft, preventing fluid accumulation under a graft. The graft is placed on the carrier and passed through the mesher.

REF: 606 13. Marissa Walton is a 6-year-old girl with full-thickness burns involving both lower legs, circumferentially, excluding her feet, over less than 2% of her body surface area (BSA) and partial-thickness burns over less than 15% of her BSA, after her clothes caught fire during a camping trip when she stepped into the campfire. Based on the American Burn Association and the “Rule of Nines” classifications, Marissa’s burns would be classified as ______________ with a burn surface area percentage of approximately ______________. a. minor; 17% b. moderate; 17% c. minor; 9% d. major; 18% ANS: C The percentage of body surface area (BSA) system of the American Burn Association uses the following burn classification: Minor burns: Full-thickness burns over less than 2% of BSA; partial-thickness burns over less than 15% of BSA. Both of Marissa’s lower legs were burned circumferentially, giving her a score of approximately 9% for the sum of both lower legs. Moderate burns: Full-thickness burns over 2% to 10% of BSA; partial-thickness burns over less than 15% to 25% of BSA. Major burns: Full-thickness burns over 10% or more of BSA; partial-thickness burns over 25% or more of BSA, including any burns to face, head, hands, feet, or perineum; inhalation and electrical burns; or burns complicated by trauma or other disease processes.

REF: 616

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14. Marissa Walton is transferred to the OR from the burn unit for debridement of the partialthickness burn areas and a dressing change under anesthesia. What important preparation for the procedure will the perioperative team need to perform before Marissa arrives in the OR? a. Procure the allograft skin from the freezer and begin the thaw process. b. Procure a basic plastic instrument set plus a knife dermatome and sterile mineral oil. c. Prewarm the OR to above the ambient high temperature for an adult. d. Collaborate with the anesthesia provider to determine fluid replacement requirements.

ANS: C Because patients who have sustained burns are vulnerable to hypothermia from the loss of BSA, the perioperative nurse should ensure the temperature and humidity in the OR are increased and exposure is limited only to the areas related to the planned surgical event. Throughout the procedure, the temperature in the OR is constantly monitored to prevent hypothermia.

REF: 614 15. Josh Tremain, a 28-year-old firefighter, sustained significant full-thickness burns when he fell through the roof of a burning building while fighting an explosive fire. What surgical treatments may Josh need before he is discharged from the burn center to home? a. Debridement and monitoring of full-thickness skin regeneration b. Debridement, allograft placement during initial healing, and later split-thickness (ST) and full-thickness (FT) skin grafting c. Allograft and xenograft placement as temporary dressings until secondary granulation begins d. Tangential excision of the burn wound with antibiotic-soaked dressings ANS: B Full-thickness burns may require debridement of necrotic tissue (eschar) before healing can occur by skin regeneration or grafting. An allograft may be used to cover the burned area during the initial healing process. A xenograft may also be used for covering the burned area. An alternative method is tangential excision of the burn wound, which is performed with a knife dermatome. This type of excision usually extends only to the bleeding subcutaneous fat, rather than to fascia. Dressings saturated with the topical antimicrobial agent of choice are applied. Although skin grafting may be done at the time of wound debridement, it is usually performed several days later, particularly in burns that are extensive.

REF: 613

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16. When coverage for a defect cannot be achieved through skin grafting, plastic surgeons rely on other techniques to replace tissue. After mastectomy, reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap is one of several options for nonsynthetic prosthetic reconstruction. Another descriptive term for the TRAM flap is the: a. pedicle-based flap. b. free flap. c. mastopexy. d. rotated tunneled flap.

ANS: A The transverse rectus abdominis myocutaneous (TRAM) flap for postmastectomy breast reconstruction is the most common pedicle-based flap used for breast reconstruction. The rectus muscle is the broad, wide abdominal muscle that extends from under the ribs to the pubis, and either one or both sides of the muscle may be used for reconstruction. The blood supply (superior epigastric artery and vein) is carried within the muscle pedicle.

The muscle along with its pedicle is severed at its most distal origins and pulled through a subcutaneous tunnel to the chest to form a breast. Although this procedure has the added benefit of an abdominoplasty, if there is inadequate abdominal tissue the patient may require a small mammary prosthesis.

REF: 624 17. There are approximately 1 million reported cases of skin cancer per year with the majority being the highly curable basal or squamous cell cancers, accounting for more than 50% of all cancers. Not as common is the most serious skin cancer, malignant melanoma, with an estimated 68,720 cases per year. Select the individual who is at the highest risk for skin cancer. a. An African-American outdoor sportsman and airline pilot b. A fair-complected surfer and beach lifeguard who wears sunblock-protective clothing c. A fair-complected person testing positive for exposure to human papillomavirus d. A dark-complected person testing positive for human immunodeficiency virus ANS: C A fair-complected person with exposure to human papillomavirus represents a person with two risk factors. Other risk factors include: excessive exposure to ultraviolet radiation from the sun; fair complexion; occupational exposure to coal tar, pitch, creosote, arsenic compounds, and radium; and human immunodeficiency virus. Skin cancer is negligible in African Americans because of heavy skin pigmentation.

REF: 614 18. The three most common skin cancers are basal cell, squamous cell, and melanoma.

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Treated early, skin cancers such as squamous cell and basal cell carcinomas may be cured by simple excision and closure (with pathologic diagnosis to ensure disease-free margins).

Melanoma is treated much more aggressively because of its high mortality. The A-B-CDs of the warning signs for skin cancer stand for: a. acute, borderline, color, dysplastic. b. asymmetry, blanching, cohesion, depth. c. aplastic, bilateral, chronic, dysplastic. d. asymmetry, border, color, diameter.

ANS: D Any unusual skin conditions, especially a change in the size or color of a mole or other darkly pigmented growth or spot, should be suspicious of skin cancer. The mnemonic AB-C-D stands for the following: A: Asymmetry: One half of the lesion looks different from the other side.

B: Border irregularity: Instead of a smooth edge, the border is ragged or irregular.

C: Color: The color is usually irregular; may have a number of different hues and colors.

D: Diameter: Lesions larger than 6 mm have a greater chance of being a melanoma.

REF: 614 19. Mohs’ surgery is a specialized excision used to treat basal and squamous cell skin cancers. Select the statement about Mohs’ surgery that best reflects the process, procedure, and outcome goal. a. Mohs’ surgery is diagnostic, an ambulatory procedure, and a definitive treatment. b. Lesions are mapped, excised, and examined by frozen section until clear margins are found. c. The procedure can be very time-consuming to accomplish, but typically results in the preservation of the surrounding healthy tissue. d. The segments are excised and microscopically examined and the defect is closed with a drain.

ANS: B The procedure involves excising the lesion layer by layer and examining each layer under the microscope until all the abnormal tissue is removed. Mohs’ surgery is usually completed on an ambulatory basis with the patient administered a local anesthetic.

Because the procedure is lengthy, patient preparation and comfort are essential to facilitate cooperation during the procedure. A horizontal layer of tissue is removed and divided into sections that are color-coded with dyes. A map of the surgical site is then drawn. Frozen sections are immediately prepared and examined microscopically for any remaining tumor. If tumor is found, the location or locations are noted on the map and another layer of tissue is resected. The procedure is repeated as many times as necessary to completely remove the tumor.

REF: 612

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20. A variety of implantable devices are used in aesthetic and reconstructive plastic surgery procedures. Tracking of these devices is critical to patient safety. Institutions must report any incident of death or serious injury relating to the use of a medical device. What regulatory agency, commission, or act mandates this process when medical devices fail or cause injury? a. The Joint Commission agency for sentinel events b. Original Equipment Manufacturer Device Tracking Commission c. Food and Drug Administration Device Failure and Recall Act d. Safe Medical Device Act ANS: D Under the Safe Medical Device Act, institutions must report any incident of death or serious injury relating to the use of a medical device. The manufacturer of the device must have a mechanism to locate implantables after they have been distributed. Devices may be recalled for sterility issues, malfunction, or any event that is found to pose a serious health risk. The U.S. Food and Drug Administration (FDA) regulates the process of tracking medical devices and directs the tracking of devices whose failure would result in serious, adverse health consequences; devices that are intended to be implanted in the human body for more than 1 year; and devices that are life-sustaining and life-supporting and are used outside of a facility such as a hospital, nursing home, or ambulatory surgery center.

REF: 609

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Rothrock: Alexander's Surgical Procedures Chapter 14: Thoracic Surgery Test Bank MULTIPLE CHOICE 1. The thoracic outlet is a junction bound anteriorly by the manubrium, anterolaterally by the first ribs, and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space. The great vessels of the head, neck, and arm pass through this space. What syndrome is caused by the compression of these structures? a. Brachial plexus palsy b. Vertebral tipping syndrome c. Thoracic outlet syndrome d. Thoracic plexus compression ANS: C Compression of these structures causes thoracic outlet syndrome.

REF: 652 2. The nerves of the lungs are a part of the autonomic nervous system. What structures are constricted and relaxed by their influence? a. The bronchi and the blood vessels b. The alveoli and the pulmonary vein c. The pulmonary artery and vein d. The bronchi and bronchioles ANS: A The nerves of the lungs are a part of the autonomic nervous system. They regulate constriction and relaxation of the bronchi and the blood vessels within the lungs.

REF: 654 3. Inspiration normally takes place when the intrathoracic pressure is slightly below atmospheric pressure and when a partial vacuum exists between the parietal and visceral pleural (intrathoracic) surfaces. As the muscles of inspiration contract to enlarge the chest cage, what action by the lungs occurs to facilitate air intake? a. The lungs recoil and expand to draw air into them. b. The lungs are passive and follow the diaphragm and chest wall. c. The lungs produce a pressure gradient that suctions air. d. The alveolar sacs expand when triggered by neural triggers in all 10 lung segments.

ANS: B

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As the muscles of inspiration contract to enlarge the chest cage, the lungs passively follow the diaphragm and chest wall because of decreased intrathoracic pressure. The acts of inspiration and expiration are the result of air moving in and out of the lung, causing pressure to equalize with that of the atmosphere at the end of expiration.

REF: 654 4. Direct visualization of the mucosa of the trachea, the main bronchi and their openings, and most of the segmental bronchi may also include the removal of material for microscopic study, and is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing, hemoptysis, obstruction, and abnormal roentgenographic changes. What diagnostic modality has been described? a. Standard bronchoscopy b. Flexible bronchoscopy c. Rigid bronchoscopy d. All bronchoscopic approaches apply ANS: D Standard bronchoscopy is the direct visualization of the mucosa of the trachea, the main bronchi and their openings, and most of the segmental bronchi. It also includes removal of material for microscopic study if necessary. Bronchoscopy is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing, hemoptysis, obstruction, and abnormal roentgenographic changes. Flexible bronchoscopy on an adult patient may be completed after induction of local anesthesia or monitored anesthesia care; a child usually receives a general anesthetic. Patients undergoing rigid bronchoscopy should be paralyzed and ventilation continued to minimize trauma.

REF: 659 5. Thoracotomy can be performed with the patient in one of three common positions: lateral, semilateral, and supine. While the supine position is used for the median sternotomy approach, which of the lateral positions is used for an anterolateral approach? a. Semilateral b. Lateral c. Prone d. Lateral decubitus ANS: A The type of position used in thoracic surgery is determined by the operative procedure planned. Thoracotomy can be performed with the patient in one of three common positions: (1) lateral for the posterolateral approach, (2) semilateral for the anterolateral approach, and (3) supine for the median sternotomy approach.

REF: 655 6. What is the ideal position for bronchoscopy?

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Test Bank a. b. c. d.

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Supine Left semilateral Supine with a shoulder roll Semi-Fowler with neck extended

ANS: C Bronchoscopy is performed in the supine position with a shoulder roll.

REF: 654 7. Roger Waring, a 46-year-old male with early-stage lung cancer, was listening to his surgeon describe the surgical plan in preparation for signing the informed consent. The surgeon described a procedure that would be done before the thoracoscopic lung surgery.

The surgeon described an examination of Roger’s middle chest lymph nodes and the area below where the bronchi branch into the right and left lungs, and possibly taking biopsies of suspicious tissue. The procedure uses a hollow lighted tube with fiberoptic lightcarrying fibers. What diagnostic procedure will precede Roger’s thoracoscopic lung surgery? a. Thoracoscopy b. Mediastinoscopy c. Bronchoscopy d. Panendoscopy ANS: B Mediastinoscopy is the direct visualization and possible biopsy of lymph nodes or tumors at the tracheobronchial junction, under the carina of the trachea, or on the upper lobe bronchial subdivisions. Mediastinoscopy may precede an exploratory thoracotomy in known cases of lung carcinoma or may be completed to assist in accurately staging the patient’s lymph node status. The mediastinoscope is a hollow tube with a fiberoptic light carrier. A fiberoptic light source with a light-intensity dial provides power and control of illumination.

REF: 662 8. Video-assisted thoracic surgery (VATS) is a minimally invasive operative technique that has evolved over the past decade. It uses an endoscopic approach to visualize the thoracic cavity for diagnosis of pleural disease or treatment of pleural and lung conditions. In the adult, the surgeon creates a 2- to 3-cm incision between the ________ intercostal spaces for insertion of the 10- or 12-mm trocar. The trocar sites can also be used for insertion of a ____________. a. fourth and sixth; robotic EndoWrist grasper b. fifth and seventh; chest tube c. fifth and seventh; zero-degree scope d. sixth and eighth; video camera ANS: C

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The surgeon creates a 2- to 3-cm incision between the fifth and seventh intercostal spaces for insertion of the 10- or 12-mm trocar. The zero-degree telescope is inserted to view the site so that the approach can be determined. After the selected procedure, the surgeon inserts a chest tube through one of the surgical puncture sites and secures it to the skin.

Trocar sites are closed, and small dressings or adhesive skin tapes are applied.

REF: 662 9. Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved spontaneous pneumothorax. The endpoint goal of a pleurodesis is to: a. prevent accumulation of pleuritic secretions. b. bond the parietal pleura to the lung. c. achieve permanent pneumothorax. d. cause adherence of the pleural layers.

ANS: D A variety of chemical agents are used to cause adherence of the pleural layers. Adherence of the pleural layers is thought to prevent the accumulation of pleural fluid in the case of pleural effusion and to prevent subsequent pneumothoraces.

REF: 663 10. During an endoscopic thoracic sympathectomy for hyperhidrosis, what action by the anesthesia provider ensures exposure and minimizes damage to the lung? a. Positions the patient in the anterolateral position with an expandable axillary roll. b. Decreases ventilatory pressure to decrease lung expansion during dissection. c. Deflates the lung on recommendation of the surgeon during dissection and resection. d. Decreases positive end-expiratory pressure until resection is complete.

ANS: C The anesthesia care provider deflates the patient’s lung as directed by the surgeon.

Endoscopic thoracic sympathectomy (ETS) is a thoracoscopic intervention used to surgically treat hyperhidrosis. The surgeon needs an unobstructed view from either side, because the procedure is performed bilaterally.

REF: 664 11. Pneumonectomy is removal of an entire lung, usually to treat malignant neoplasms. What structures are excised or resected in order to remove the entire lung and complete the surgery? a. A section of rib, bronchus, pulmonary artery and vein, and hilar pleura b. The lung, peripheral adhesions, and pulmonary ligament c. Mediastinal lymph nodes, portions of the chest wall or diaphragm, and parietal pleura d. All of these structures may be resected during a pneumonectomy

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ANS: D Other resections are often combined with pneumonectomy, such as resection of mediastinal lymph nodes, resection of portions of the chest wall or diaphragm, and removal of parietal pleura. If a rib is to be excised, bone instruments are required. The surgeon frees any peripheral adhesions to mobilize the lung and divides the pulmonary ligament. The superior pulmonary vein is gently retracted, and the pulmonary artery is dissected. The surgeon clamps and divides the branches of the pulmonary artery and vein of the involved lobe. The inferior pulmonary vein is exposed by incising the hilar pleura and retracting the lung anteriorly. The inferior pulmonary vein is clamped, doubly ligated, and divided. The surgeon divides the bronchus near the tracheal bifurcation. The lung is removed from the chest.

REF: 666 12. An example of a true statement about TNM and staging diagnostic classification for lung cancer is: a. the staging system is based on the TNM classification system. b. the TNM system is based on the staging classification. c. nodal involvement refers to a second primary lung cancer tumor. d. a patient with T1, N0, M0 has a benign tumor.

ANS: A Staging is based on TNM findings. According to the TNM system, lung cancer has the following three stages: Stage I disease includes tumors classified as T1 with or without metastasis to the lymph node in the ipsilateral hilar region. Stage II disease includes those tumors classified as T2, with metastasis only to the ipsilateral hilar lymph nodes. Stage III includes all tumors more extensive than T2 or any tumor with metastasis to the lymph nodes in the mediastinum with distant metastasis.

REF: 665 13. Lung volume reduction surgery (LVRS) is an alternative surgical treatment for patients with which pulmonary condition? a. Chronic pulmonary asthma with oxygen needed to keep saturation at 90% b. Acute unilateral pulmonary emphysema c. Severe bilateral heterogeneous or homogeneous emphysema d. Unsuccessful or failed laser surgery for giant lung bulla ANS: C The National Emphysema Treatment Trial (NETT) suggests the following criteria as patient eligibility for LVRS: high-resolution computed tomography evidence of moderate to severe bilateral heterogeneous emphysema or moderate to severe bilateral homogeneous emphysema; no previous laser surgery or LVRS; no giant bulla. LVRS is an alternative surgical treatment for patients with chronic pulmonary emphysema.

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REF: 670 14. The indications for single-lung transplantation (SLT) include restrictive lung disease, emphysema, pulmonary hypertension, and other nonseptic end-stage pulmonary diseases, while the indications for double-lung transplantation (DLT) include patients with: a. bilateral early-stage sarcoma without systemic disease. b. bilateral chronic infection causing end-stage renal failure. c. cystic fibrosis in end-stage pulmonary failure. d. bilateral disease, recent ex-smoker with a suitable living-related donor.

ANS: C Double-lung transplantation (DLT) is indicated for patients with cystic fibrosis or patients with a chronic infection in end-stage pulmonary failure. Developments in SLT include donor contribution from living relatives for patients who have chronic disease and a high risk for death while waiting on the donor transplantation list.

Contraindications for transplantation include history of carcinoma or sarcoma, significant renal dysfunction, or cigarette smoking within 3 or 4 months.

REF: 674 MULTIPLE RESPONSE 1. The perioperative team will need to collaborate with the anesthesia provider, since continuous hemodynamic monitoring, oximetry, and ventricular function assessment by transesophageal echocardiography (TEE) are all performed intraoperatively.

Cardiopulmonary bypass (CPB) may also be required. Select all the procedures from the list below for which these preparations are indicated. a. Donor harvesting b. Living-related single-lung transplant c. Cadaveric single-lung transplant d. Double-lung transplant ANS: B, C, D Procedural considerations for both single- and double-lung transplants include continuous hemodynamic monitoring, oximetry, and ventricular function assessment by transesophageal echocardiography (TEE) performed intraoperatively. Cardiopulmonary bypass (CPB) may be required.

REF: 675

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Rothrock: Alexander's Surgical Procedures Chapter 15: Vascular Surgery Test Bank MULTIPLE CHOICE 1. What properties enable arteries to compensate for changes in blood pressure and blood volume? a. Regeneration and thick muscularis b. Dilatation and absence of valves c. Contraction and constriction d. Elasticity and distensibility ANS: D The properties of elasticity and distensibility enable arteries to compensate for changes in blood pressure and volume. Because of the thicker muscle layer, severed arteries are capable of contracting and constricting enough to stop hemorrhage.

REF: 679 2. Identify the venous structure that prevents blood backflow. a. Semilunar intimal folds b. Coarctation segments c. Pressure receptors d. Venules ANS: A Another difference between arteries and veins is the presence of semilunar intimal folds, or valves, in veins that prevent backflow.

REF: 679 3. Patients with acute arterial insufficiency with occlusion usually present with the onset of the six P’s: sudden severe pain, pulselessness, paresthesia, paralysis, pallor, and poikilothermia (coolness) of an extremity. This occlusion can be the result of which condition? a. Atrial tachycardia b. Rupture of an unstable atherosclerotic plaque c. Asystole d. Hypothermia ANS: B

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Arterial insufficiency may result from an acute occlusion, as in embolic disease, or from the rupture of an unstable atherosclerotic plaque, causing acute thrombosis of the vessel.

Emboli usually arise from the heart as a result of atrial fibrillation but may occasionally result from a myocardial infarction (MI), where a clot forms on the endocardium (the lining of the heart) in an area of muscle damage. Atherosclerotic plaque can also detach from other areas and result in an acute arterial blockage.

REF: 681 4. Patients with chronic venous insufficiency (CVI) are not typically treated surgically as often as patients with arterial disease because: a. CVI is not life-threatening or limb-threatening. b. venous surgery contributes to thromboembolism. c. surgical interventions for venous valves have not been refined. d. All of the options are correct.

ANS: A Patients with chronic venous insufficiency (CVI) have not been treated surgically as often as patients with arterial disease for several reasons, one of which is that CVI is generally not a life-threatening or limb-threatening condition.

REF: 685 5. What statement regarding risk factors for developing vascular disease is true? a. Cigarette smoking is more of a risk factor for lung disease than vascular disease. b. Advanced age, male gender, and family history are established risk factors for atherosclerosis. c. A sedentary lifestyle can contribute to developing diabetes if one has atherosclerosis. d. Arteriosclerosis is a natural part of the aging process.

ANS: D Arteriosclerosis is a natural part of the aging process and occurs when the walls of the arterial vasculature undergo changes such as increased thickness and hardening, reducing the elasticity of the arteries. Risk Factors for Atherosclerosis: hypercholesterolemia, cigarette smoking, hypertension, and diabetes mellitus; relative risk factors include advanced age, male gender, hypertriglyceridemia, hyperhomocysteinemia, sedentary lifestyle, and family history.

REF: 682 6. While arteriosclerosis is a natural part of the aging process and occurs when the walls of the arterial vasculature undergo changes such as increased thickness and hardening, reducing the elasticity of the arteries, certain risk factors for arteriosclerosis are modifiable by the individual. Select the two modifiable risk factors that could minimize the potential for acute or chronic vascular insufficiency.

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Test Bank a. b. c. d.

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Past surgical history and hypercholesterolemia Cigarette smoking and sedentary lifestyle Hypertension and diabetes Hyperhomocysteinemia and hypertriglyceridemia

ANS: B Cigarette smoking and sedentary lifestyle are modifiable risk factors because the individual can improve his/her chances of avoiding acute and chronic vascular insufficiency by quitting cigarette smoking and becoming more physically active. Risk Factors for Atherosclerosis: hypercholesterolemia, cigarette smoking, hypertension, and diabetes mellitus; relative risk factors are advanced age, male gender, hypertriglyceridemia, hyperhomocysteinemia, sedentary lifestyle, and family history.

REF: 683 7. Why is the change in sound made by a passing train’s whistle similar to the reason the pitch rises quickly in systole and drops quickly in early diastole when measuring arterial sounds? a. Both are explained by B-mode ultrasonography. b. Both involve the science of plethysmography. c. Both are explained by the Doppler effect. d. Both are explained by the science of atomic behavior in a strong magnetic field such as MRI. ANS: C The Doppler effect is the change in the frequency of echo signals that occurs whenever there is a change in the distance between the sources of a sound and the receiving object.

The probe, or transducer, is aimed toward the blood vessel at an angle of 45 to 60 degrees. This directs an ultrasound beam that is reflected back to the probe by moving red blood cells (RBCs). The velocity of the flow of cells is converted into an audible signal heard through a speaker. The signal is described as a swishing sound. The sound is called a signal, not a pulse. The Doppler transducer is the most widely used instrument for vascular study. It has the advantages of being readily available, inexpensive, and easy to use.

REF: 686 8. Vascular surgery patients are at risk for impaired skin integrity and ineffective tissue perfusion related to surgical positioning, presence of vascular disease, and vascular clamping. Positioning of the patient undergoing vascular surgery is of particular importance because of restricted circulation distal to the area of arterial obstruction and a generalized state of poor circulation. An appropriate protective intervention is reflected in which true statement about patient positioning for vascular surgery? a. The patient should be positioned on a radiopaque pressure-reducing mattress on the OR bed. b. The patient’s vulnerable neurovascular bundles should be protected from

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compression. c. There should be warmed sterile saline compresses provided to bony prominences to increase vascular perfusion. d. The weight of instruments on top of the patient should be equally distributed to prevent pressure injuries.

ANS: B Protect vulnerable neurovascular bundles from compression. Position the patient on a pressure-reducing mattress on the OR bed that is radiolucent (x-ray compatible). Keep OR bed sheets dry and wrinkle-free. Pad all bony prominences. Maintain body alignment.

REF: 688 9. The Doppler transducer is the most widely used instrument for vascular study. What statement regarding a Doppler is true? a. Doppler probes are expensive but can be steam sterilized. b. The Doppler probe can provide five different forms of information. c. Water-soluble gel is needed when the Doppler is used on intact skin. d. The Doppler is valuable in detecting accurate findings in the presence of stenosis.

ANS: C When the probe is used on intact skin, a water-soluble gel is needed to conduct a signal.

The Doppler probe can provide information in three forms: the audible signal, a visible graph printout similar to an electrocardiogram (ECG) tracing, and a spectral analysis that appears on a screen and may be recorded on paper as well. It has the advantages of being readily available, inexpensive, and easy to use. The probes are heat-sensitive and must either be sterilized according to manufacturer’s instructions or be inserted into a sterile sleeve or probe cover. The biggest drawback of the Doppler probe is a negative finding in the presence of a stenotic lesion.

REF: 686 10. Assessing blood flow through diseased vessels by palpation is often difficult. Assessment of the patient’s hemodynamic status during surgery can be further complicated by spasm of the vessel walls, the cool environment of the OR, and alterations in blood pressure caused by hemorrhage. Vascular monitoring during carotid endarterectomy (CEA) is critical to determine the quality of cerebral perfusion. What vascular monitoring device is employed during CEA and what important surgical need is determined by its results? a. Doppler, need for embolectomy b. Laser flow cytometry, need for increased IV fluids c. Electromyogram (EMG), need for muscle relaxants d. Electroencephalogram (EEG), need for a shunt ANS: D

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An EEG accurately determines reduced cerebral perfusion during a CEA. This enables the surgeon to decide whether to use a temporary shunt in the carotid artery or if the patient can tolerate clamping.

REF: 691 11. Varicose veins are enlarged and distended veins that are visible and palpable beneath the skin. Secondary varicose veins are believed to be a result of insufficiency of the deep venous system. The primary objective of varicose vein surgery, for the patient with secondary disease, is to prevent: a. thromboemboli, claudication, and unsightly blue clusters of veins. b. ulceration, edema, pain, and fatigue. c. venospasm, phlebitis, and vascular sacculations. d. vasculitis, pitting edema, and sclerosed vein clusters.

ANS: B The objective of surgical intervention is to remove the diseased veins, thus preventing ulceration, secondary edema, pain, and fatigue in the extremity. Disease may prevent the normal functioning of these valves, resulting in distention; as the vein wall weakens and dilates, venous pressure increases and the valves become incompetent. Dilation of the saphenous vein produces venous stasis, which may be followed by secondary complications, such as stasis ulcers.

REF: 705 12. Surgically created arteriovenous fistulas are also referred to as a(n) _________ and are indicated for enabling __________. a. axillo-femoral bypass; end-stage renal disease b. bridge shunt; peritoneal dialysis c. arteriovenous shunt; hemodialysis d. side-to-side anastomosis; cannulation ANS: C Arteriovenous fistulas—direct connections between an artery and a vein—are the standard means of vascular access for long-term renal dialysis. The dilated vein can then be used for direct cannulation with large-bore needles for hemodialysis. This method is preferable to an external shunt, which carries a high risk of thrombosis and infection. The best access is achieved using the patient’s own vessels and creating a subcutaneous connection between the artery and vein, referred to as an arteriovenous shunt, or bridge fistula. Arteriovenous shunts are indicated for long-term renal dialysis access.

REF: 702 13. During an open femoropopliteal bypass with graft, an incision is made into the femoral artery with a #11 knife blade and extended with a Potts angulated scissors. What is the proper name of this surgical approach?

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Test Bank a. b. c. d.

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Potts arterial punch cut Medial vasculotomy Femoral arteriotomy Popliteal arteriostomy

ANS: C An incision is made into the femoral artery with a #11 knife blade and extended with a Potts angulated scissors. An incision is made into the popliteal artery as explained for femoral arteriotomy. Femoropopliteal bypass is the restoration of blood flow to the leg with a graft bypassing the occluded section of the femoral artery. A saphenous vein or a straight synthetic graft can be used as bypass material.

REF: 697 14. Select the statement that best describes the comparative difference between open aortic aneurysm repair and endovascular aneurysm (EVAR) repair. a. The open aneurysm surgery approach has a major abdominal incision and increased patient morbidity. b. In EVAR, the prosthetic endograft or stent-graft is introduced into the aneurysm through a surgically exposed femoral artery. c. In EVAR, self-expanding or balloon-expandable stents are used rather than sutures. d. All the options are correct.

ANS: D Endovascular aneurysm repair (EVAR) differs from open surgical repair in that the surgeon introduces the prosthetic endograft or stent-graft into the aneurysm through a surgically exposed femoral artery and fixes it in place to the nonaneurysmal infrarenal neck and iliac arteries with self-expanding or balloon-expandable stents rather than sutures. A major abdominal incision is thus avoided, and patient morbidity related to the procedure is much reduced.

REF: 694 15. Substituting a cryo-preserved cadaveric vein or an in situ or reversed vein graft from the patient for an arterial bypass graft is an option for patients who have healthy, easily accessed saphenous veins. How does an in situ vein graft differ from a reversed vein graft? a. With the in situ method, the vein segment is resected, reversed, and anastomosed into position. b. The in situ method leaves the vein in its position and the valves are removed. c. Arteriovenous fistulas are a common complication with the reversed vein graft method. d. Valvulotomes are used to remove the valves in both methods.

ANS: B

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Two methods of grafting veins are the in situ graft and the reversed vein graft. The in situ method leaves the vein in its place, side branches are ligated to prevent arteriovenous fistulas, and the valves that would impede arterial flow are disrupted with instruments specifically designed to cut valves, called valvulotomes. Autogenous vein grafting for infrainguinal bypass is considered the criterion standard. Reoperation is more frequent with the in situ method because of missed valves and residual arteriovenous fistulas.

Reversal of a vein graft is performed per the surgeon’s preference or when it must be harvested from the contralateral limb.

REF: 691 16. Heparin sodium is an anticoagulant. The basic mechanism of heparin’s action is best described as: a. it blocks the conversion of prothrombin to thrombin and fibrinogen to fibrin. b. it acts as an enzyme by lysing the fibrin-thrombin matrix. c. it extends the activated partial thromboplastin time (APTT). d. it dissolves and liquefies existing blood clots and thromboemboli.

ANS: A Heparin sodium is an anticoagulant that interferes with blood coagulation by blocking conversion of prothrombin to thrombin and fibrinogen to fibrin. It has no effect on a blood clot that has already formed or on ischemic tissue injured as a result of inadequate blood supply caused by a clot. It is used for prophylaxis and/or treatment of vascular thromboembolic disorders, such as venous thrombosis and peripheral arterial embolism, and for prevention of thromboembolus during vascular surgical procedures.

REF: 690 17. What drug is used to reverse the effects of heparin? a. Prostigmine b. Protonics hydrochloride c. Protamine sulfate d. Prothrombin ANS: C The effects of heparin can be reversed by the administration of protamine sulfate. Since protamine sulfate is derived from fish sperm and testes, caution is advised when administering it to patients who are allergic to fish or who have received protaminecontaining insulin. One milligram of protamine neutralizes 100 mg of heparin.

REF: 689

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18. Karen Masterson, circulator, is preparing the OR for a vascular procedure where heparin will be used. She has obtained the heparin from the medication dispensing system and is preparing to mix the heparin in IV saline according to the dosage on the surgeon’s preference/pick list. The scrub person, Judy Rothman, a surgical technologist, is preparing the sterile back table. What expected and appropriate risk reduction strategies related to the use of heparin would both Karen and Judy perform? a. Label syringe, medicine cup, and IV saline bag with the drug name, dosage, strength, date, and expiration date. b. Verify the drug and labels with three qualified individuals including the surgeon. c. Be aware of sound-alike cautions by not placing the heparin vial next to Hespan. d. Comply with the 7 rights of medication storage and documentation.

ANS: A Heparin sodium is considered a high-alert drug, so designated by The Joint Commission and the Institute for Safe Medication Practices (ISMP) because it may cause lifethreatening or permanent harm to the patient if administered incorrectly. Sound-alike caution: Hespan. Institutions should identify and at a minimum annually review lookalike/sound-alike drugs to prevent errors involving the interchange of such drugs.

Labeling requirements: Any medication container, such as a syringe, medicine cup, or basin, containing heparin or a heparin solution must be labeled on or off the sterile field.

The following risk reduction strategies are included: ensure concurrent verification, both verbally and visually, between the perioperative nurse and scrub person of all medications introduced to the sterile field, including medication name, strength, dose, and expiration date. Labels should be verified by two qualified individuals if the person preparing the medication is not the person administering it; this may be the case during relief of OR personnel.

REF: 690 MULTIPLE RESPONSE 1. When selecting a vascular graft for a vascular bypass or replacement procedure, what are the desirable characteristics that influence the surgeon’s choice of graft? Select all that apply from the listed options. a. Thrombo-resistant, biocompatible, and easy to handle b. Fairly priced, variety of sizes, and ability to clot blood c. Sterilizable, nonantigenic, and last a lifetime d. Reasonably priced, permit blood passage without clotting, and hypoallergenic ANS: A, C, D Desirable characteristics for vascular grafts are that they are reasonably priced, readily available in a variety of sizes, suitable for use anywhere in the body, biocompatible and hypoallergenic, and able to survive repeated sterilizations. Grafts should be easy to handle and last a lifetime while permitting blood passage without clotting or infection.

Prosthetic grafts are nonantigenic; tissue incorporates well, which helps prevent infection, and such grafts generally resist thrombosis.

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REF: 690 2. During the 4-hour vascular procedure, the circulating nurse, Karen, and the surgical technologist, Judy, have each had a coffee break and a lunch break. Judy has returned from lunch to find four medicine cups with clear fluid, each unlabeled. The outgoing relief scrub person, during her hand-off report to Judy, points to each cup and states; “The first one is contrast dye, the second cup is heparin, the third is heparinized saline and the fourth is papaverine; it’s easy, they’re in alphabetical order.” Judy discarded all four medications and Karen replaced them into appropriately labeled medicine cups.

After the procedure, Karen completed an unusual occurrence report. What recommendations should she include in her corrective action plan that the relief scrub person should have done? Select all that apply from the listed options. a. Ensure concurrent medication verification, both verbally and visually; include medication name, strength, dose, and expiration date. b. Verify all medications concurrently with the entering and exiting personnel at shift change or break relief. c. Remove any unlabeled medication or solution from the field. d. Keep all medication containers used during the procedure in the OR until the conclusion of the procedure.

ANS: A, B, C, D The following risk reduction strategies are included: ensure concurrent verification, both verbally and visually, between the perioperative nurse and scrub person of all medications introduced to the sterile field, including medication name, strength, dose, and expiration date; remove any unlabeled medication or solution from the field; for reference, keep all containers from medications used during any procedure in the OR until the conclusion of the procedure; verify all medications concurrently with the entering and exiting personnel at shift change or break relief.

REF: 691

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Rothrock: Alexander's Surgical Procedures Chapter 16: Cardiac Surgery Test Bank MULTIPLE CHOICE 1. The internal mammary arteries are frequently used as grafts during coronary bypass surgery. Where are they located? a. They diverge from the anterior interventricular branch of the right coronary artery. b. They diverge from the subclavian arteries behind the sternum. c. They diverge from the subclavian arteries anterior to the sternum. d. They diverge from the innominate artery.

ANS: B The right and left internal (thoracic) mammary arteries, used as grafts during coronary bypass surgery, branch off the subclavian arteries and course behind and parallel to the edges of the sternum.

REF: 713 2. In the pulmonary circulatory system, blood is pumped from the right ventricle (RV) through the pulmonary valve into the main pulmonary artery (PA). The PA divides into the right and left pulmonary arteries, which further subdivide into the arterioles and capillaries of the lungs. Where does the blood from the lungs flow next? a. Into the capillary beds b. Into the alveoli c. Through the pulmonary artery to the left atrium d. Through the pulmonary veins to the left atrium ANS: D External respiration occurs in the capillary beds and the alveoli, where carbon dioxide is exchanged for oxygen. Freshly oxygenated blood from the lungs flows through the pulmonary veins into the left atrium.

REF: 713 3. Identify the correct path of the cardiac conduction system. a. From the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches b. From the SA node to the AV node to the bundle of His to the Purkinje system c. Both from the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the

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interventricular system into a network of fibers by way of the right and left bundle branches, and from the SA node to the AV node to the bundle of His to the Purkinje system d. Neither from the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches, and from the SA node to the AV node to the bundle of His to the Purkinje system ANS: C The conduction system process of excitation and contraction originates in the sinoatrial (SA) node, located in the area where the superior vena cava (SVC) meets the right atrium. The impulse spreads to the atria through intermodal pathways and travels to the AV junction (which contains the AV node) located medial to the entrance of the coronary sinus in the right atrium, close to the tricuspid valve. From the AV junction, the impulse spreads to the bundle of His, which extends down the right side of the interventricular septum. The bundle of His divides into the right and left bundle branches, which terminate in a network of fibers called the Purkinje system. Purkinje fibers are spread throughout the inner surface of both ventricles and the papillary muscles, which when stimulated produce contraction of the heart muscle.

REF: 713 4. The blood is oxygenated in the lungs and returns to the left atrium through the pulmonary veins. Where does the blood flow after leaving the left atrium? a. Through the mitral valve into the left ventricle b. Through the tricuspid valve into the left ventricle c. Through the aortic valve into the left ventricle d. Through the aorta into the systemic circulation ANS: A The blood is oxygenated in the lungs and returns to the left atrium through the pulmonary veins. From the left atrium, it flows through the mitral valve into the left ventricle, where it is ejected through the aortic valve into the aorta and the systemic circulation.

REF: 711 5. Select the noninvasive diagnostic test that illustrates heart wall motion and blood flow through the heart and quantifies cardiac function. a. Radionuclide imaging b. Cardiac catheterization c. Echocardiography d. Cardiac function studies ANS: A

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Radionuclide imaging is employed to illustrate wall motion and blood flow through the heart and to quantify cardiac function. These noninvasive techniques are generally well tolerated by patients, especially when patients may be too unstable to withstand a cardiac catheterization. These techniques may also be used as a complement to catheterization.

Cardiac catheterization provides definitive information about the extent and location of ischemic heart disease and is an adjunct to echocardiography for diagnosing valvular heart disease.

REF: 718 6. Select the diagnostic test that represents an invasive cardiac study. a. Resting MUGA b. Exercise MUGA c. Cardiac function d. Electrophysiology studies ANS: D The following are invasive diagnostic tests commonly performed for cardiovascular disorders: electrophysiology studies, aortography, arteriography, digital subtraction angiography, cardiac catheterization, ventriculography, endomyocardial biopsy.

REF: 718 7. This retractor is used to elevate the sternal border to expose the:

a. b. c. d.

internal mammary artery. aortic arch. superior vena cava and right atrium. anterolateral coronary arteries.

ANS: A The IMA retractor is used to elevate the sternal border for exposure of the internal mammary artery.

REF: 721

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8. Disturbances of the conduction system affect the rate, rhythm, and effectiveness of the contracting heart. Surgical techniques have been developed to treat a variety of supraventricular dysrhythmias and both ischemic and nonischemic ventricular tachydysrhythmias. Preprocedural electrophysiologic mapping of the patient’s conduction pathways identifies and locates aberrant pathways, or ectopic foci. A catheter is inserted percutaneously into the femoral vein or artery and threaded retrograde to the right or left atrium and ventricle. Various areas of the heart are tested in an attempt to reproduce the dysrhythmia; then the area of the heart where the rhythm disturbance originates is ablated. What directed energy source is employed to produce this selective ablation effect? a. Cryotherapy b. Ultrasonic energy c. Radiofrequency energy d. All three energy sources can produce the desired ablative effect.

ANS: D Currently, the focus is on the selective ablation (with cryotherapy, ultrasonic energy, or radiofrequency [RF] energy sources) of tissues surrounding, for example, the pulmonary veins to reestablish normal conduction pathways.

REF: 774 9. Complete heart block and bradydysrhythmias are the most common indications for pacemaker implantation. A permanent pacemaker (pulse generator and electrodes) initiates atrial or ventricular contraction, or both. What therapy might be used for acute forms of heart block and dysrhythmias that occasionally occur during and after cardiac surgery? a. Transvenous endocardial stimulation b. A temporary pacemaker c. Epicardial cardioversion d. Resynchronization therapy ANS: B A temporary pacemaker may be used for acute forms of heart block and dysrhythmias that occasionally occur during and after cardiac surgery. The transvenous or the epicardial approach may be used to place the electrodes. Cardiac resynchronization therapy (CRT), dual-site pacing, employs leads placed on the right atrium and the right ventricle.

REF: 775

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10. Among the treatment options for tricuspid valve disease are suture annuloplasty, ring annuloplasty, and valve replacement with either a biologic or a mechanical prosthesis.

Like the mitral valve, the tricuspid annulus is saddle-shaped and techniques to repair the valve should consider this anatomic configuration for optimal repair. Patients with significant tricuspid stenosis, regurgitation, or failed tricuspid (suture or ring) annuloplasty may require insertion of a prosthetic biologic or mechanical valve. Because there are no specific tricuspid prosthetic valves available, what type of prosthetic graft would be created or implanted? a. An annuloplasty with a felt-pledgetted suture b. A tricuspid annular permanent dilator c. A mitral prosthesis d. An annuloplasty ring ANS: C There are no specific tricuspid prosthetic valves; rather, a mitral prosthesis would be implanted.

REF: 761 11. Patients with chronic, severe angina who cannot be revascularized with either coronary bypass surgery or PCI may be appropriate candidates for laser transmyocardial revascularization (TMR). Channels are created in the left ventricular wall with laser energy (e.g., CO2, holmium:yttrium-aluminum-garnet [Ho:YAG]). What relevant intervention must accompany this procedure? a. Prep the patient for possible emergency coronary artery bypass. b. Prepare for insertion of a ventricular assist device. c. Employ laser safety precautions. d. Prepare provisions for an endoscopic or robot-assisted approach.

ANS: C Laser safety precautions should be followed. Endoscopic, laser, robot-assisted TMR can further enhance the role of TMR as a surgical treatment or as an adjunct to PCI. REF: 754 12. An aneurysm of the left ventricle (LV) can develop after a severe myocardial infarction.

The affected area of the myocardium is replaced by thin scar tissue that can rupture. The LV undergoes remodeling when the scar stretches as a result of the left ventricular pressure and forms an aneurysm. Left ventricular aneurysmectomy (LVA) is the excision of an aneurysmal portion of the left ventricle. LVA is a form of left ventricular reconstruction undertaken to optimize cardiac function. Select the appropriate actions in preparation for LVA surgery. a. Place the patient in supine position. b. Prepare for the procedure in the same manner as typical open-heart surgery. c. Have Teflon felt pledgets, woven Dacron patches, and cardiovascular sutures available.

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d. All of the options are appropriate for LVA. ANS: D The patient is placed in the supine position. The setup is the same as that described for open-heart surgery, with the addition of synthetic patch material, Teflon felt pledgets, and 0, 3-0, and 4-0 cardiovascular sutures. Occasionally, Teflon felt strips are required to bolster the suture lines. Patch closure of the ventriculotomy (endoaneurysmorrhaphy) is performed more often than the traditional excision, plication, and oversewing of the ventricular tissue. Patch closure better preserves the geometry of the left ventricle. A circular cuff of scar tissue is left, through which a purse-string suture with felt pledgets is placed through the rim of the scar. A patch of woven Dacron is sewn to the rim with interrupted sutures. A second (internal) patch of pericardium may be placed for hemostasis.

REF: 754 13. Thoracic aortic aneurysmectomy is excision of an aneurysmal portion of the ascending aorta, aortic arch, or descending thoracic aorta and replacement with a prosthetic graft, valve-graft conduit, or intra-aortic prosthesis. Aneurysms may be caused by atherosclerosis, trauma, infection, or cystic medial degeneration. What presenting conditions will indicate that surgical intervention is necessary? a. Compromised circulation or danger of rupture b. Circumferential involvement c. Spindle-shaped morphology d. Combined saccular and fusiform morphology without dissection ANS: A Surgical intervention becomes necessary when presenting symptoms indicate a compromised circulation or danger of rupture; generally, medical management with hypotensive agents to reduce stress on the vessel is the preferred initial treatment until surgical repair can be performed.

REF: 765 14. The temporary substitution of a pump oxygenator for the heart and lungs allows the surgeon to stop the heart and perform cardiac procedures under direct vision in a relatively dry, motionless field. It also allows the surgeon to manipulate the heart without the risk of producing ventricular fibrillation and reduced cardiac output that jeopardize perfusion to the myocardial, peripheral, and cerebral tissues. In traditional cardiopulmonary bypass (CPB), systemic venous return to the heart flows by gravity drainage through cannulae placed in the superior and inferior venae cavae or through a single two-stage cannula in the right atrium into tubing connected to the bypass machine.

Blood is oxygenated, filtered, warmed or cooled, and pumped back into the systemic circulation through a cannula placed in the: a. femoral artery. b. axillary artery.

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c. ascending aorta. d. All of the arteries could be used for return flow.

ANS: D In traditional cardiopulmonary bypass (CPB) circuits, systemic venous return to the heart flows by gravity drainage through cannulae placed in the superior and inferior venae cavae (Figure 16-36) or through a single two-stage cannula in the right atrium (Figure 1637) into tubing connected to the bypass machine. Blood is oxygenated, filtered, warmed or cooled, and pumped back into the systemic circulation through a cannula placed in the ascending aorta or occasionally in the femoral artery (Figure 16-38) or the axillary artery.

REF: 735 15. Formerly, ventricular assist devices were reserved for those patients who could not be weaned from CPB after open-heart operations, or who had end-stage cardiomyopathy.

Current indications and choices have expanded and a variety of active and passive devices are available to support the circulation for short-, intermediate-, and long-term support. Select the statement that best describes a passive method of assisted circulation. a. The latissimus dorsi muscle is wrapped around the heart and paces the heart with natural electrical stimulation in patients who are not candidates for transplant. b. The intra-aortic balloon pump counterpulses with diastole to flood the aorta with oxygenated blood in patients who are not candidates for CPB. c. Ventricular assist devices augment blood flow by diverting blood from the systemic circulation into the ventricles for patients waiting for a suitable donor heart. d. The Thoratec HeartMate LVAD is an axial flow permanent replacement heart for patients who are not candidates for heart transplant surgery.

ANS: A Biologic assistance in the form of an autogenous muscle wrap (cardiomyoplasty) may be useful in some patients who may not be candidates for transplantation, but the procedure is used infrequently. The left latissimus dorsi muscle is dissected from the back and repositioned around the heart, where it is sewn around the ventricle. This (skeletal) muscle is then transformed into a continuously beating muscle by a cardiomyostimulator that paces the muscle with increasing frequency, allowing the muscle to become fatigueresistant. The muscle wrap squeezes the heart in synchronization with natural electrical impulses moving through the heart muscle.

REF: 769 16. During Shelbie Wilson’s valve repair, the surgeon realized that the torn leaflet was too damaged to be repaired and Shelbie would be better served with a bioprosthetic replacement valve. The circulator selected the implant from its secure storage area and transferred it in its storage solution to the sterile back table. What is the appropriate risk reduction strategy the surgical technologist needs to perform to prepare the bioprosthetic valve for implantation?

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Test Bank a. b. c. d.

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Rinse the biovalve in sterile albumin.

Rinse according to the biovalve manufacturer’s instructions.

Rinse the biovalve in 5 baths of sterile saline.

Rinse the biovalve in glutaraldehyde.

ANS: B Both the amount of rinsing solution in each rinsing basin and the time for each rinse (total of three rinsing baths) should be followed according to each manufacturer’s instructions.

Safety considerations include storing prosthetic materials in a clean, protected environment and using them according to manufacturers’ instructions.

REF: 730 MULTIPLE RESPONSE 1. What statements regarding vascular clamps are true? Select all that apply from the options listed below. a. Vascular clamps are designed to partially occlude blood flow. b. Vascular clamps are designed to totally occlude blood flow. c. All vascular clamps are designed to hold vessels securely without trauma. d. All vascular clamps have similar angles, box locks, ring handles, and ratchets.

ANS: A, B, C Vascular clamps, which are designed to occlude blood flow partially or completely, must be maintained in good condition if they are to prevent fracture of the delicate tunica intima of the blood vessels and still retain their specific holding qualities. There are many variations in construction of vascular instruments. The jaws may consist of single or double rows of fine, sharp, or blunt teeth or have special crosshatching or longitudinal serrations. The working angles of the clamps also vary. All clamps are designed to hold the vessels securely and without trauma.

REF: 721 2. Surgery for atrial fibrillation (AF) may also be performed through an open sternotomy or right mini-thoracotomy incisions. By creating small areas of scar tissue in the cardiac muscle, electrical impulses are forced to follow an alternative conduction path or “maze.”

Select all the statements for the maze procedure that are true. a. Monitor for heart rhythm problems. b. Infuse cardioplegic solution through the aortic root and into the coronary arteries. c. Monitor for bleeding, infection, and potential complications related to heart surgery. d. Strip the chest tubes and test the pacing wires every 4 hours postoperatively.

ANS: A, C

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Postoperatively, patients are monitored for heart rhythm problems. In patients treated for AF, it may take up to 3 months for the heart to resume beating in a normal manner.

Additional postoperative considerations include monitoring for bleeding, infection, and other potential complications related to heart surgery.

REF: 775 3. An implantable cardioverter defibrillator (ICD) is an electronic device designed to monitor cardiac electrical activity and deliver prompt defibrillation. These devices are capable of pacing as well as defibrillating, consisting of a generator and sensing and defibrillator electrodes. Myocardial or thoracic subcutaneous patches may be added if the transvenous catheters alone do not adequately defibrillate the heart. Patients with previously implanted defibrillator patches may present for removal of a patch or patches.

What action would be appropriate during this procedure? Select all that apply from the options listed below. a. Be prepared for emergency intervention if there is electrical overdrive. b. Be prepared for emergency intervention if there is excessive bleeding. c. Be prepared for emergency intervention if there is a lethal dysrhythmia. d. Be prepared for emergency intervention if there is a generator failure.

ANS: B, C The team should be prepared for emergency intervention if there is excessive bleeding or lethal dysrhythmia. Many ICD electrodes currently employed consist of transvenous electrodes inserted into the generator, much like a transvenous pacemaker system.

Myocardial or thoracic subcutaneous patches may be added if the transvenous catheters alone do not adequately defibrillate the heart. Patients with previously applied defibrillator patches may present for removal of a patch or patches; nurses should be prepared for emergency intervention if there is excessive bleeding or lethal dysrhythmia.

REF: 778 4. Open commissurotomy of the mitral valve, which is performed for mitral stenosis, is the separation of fused, adherent leaflets of the mitral valve. The circulator assists in placing the patient in the supine position for a median sternotomy. The setup is the same as that described for open-heart procedures, with mitral valve instruments. Select two additional actions that are relevant to the patient with open commissurotomy from those listed below. a. Have valve replacement instruments available. b. Have tricuspid prosthetic implants available. c. Have a transesophageal echocardiogram (TEE) probe and machine available. d. Have anterolateral positioning devices available if valve replacement is needed.

ANS: A, C

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Because there is a possibility that the valve may have to be replaced, instruments (and mitral prostheses) for replacement as well as repairs should be available. TEE is used to establish a cardiac functional baseline and to confirm efficacy of the repair both after the cross-clamp is removed and the heart resumes beating and after bypass is discontinued.

REF: 757 5. A percutaneous method of instituting femoral vein–femoral artery CPB can be used for minimally invasive (or conventional open) procedures and in emergency situations where the environment is not conducive to traditional CPB methods. Select all the areas where percutaneous CPB would be indicated from the list below. a. Renal dialysis unit and postoperative cardiac transplant unit b. Neonatal intensive care unit and emergency department c. Cardiac catheterization unit and intensive care unit d. Battlefield trauma/triage unit ANS: B, C A percutaneous method of instituting femoral vein–femoral artery CPB can be used for minimally invasive (or conventional open) procedures (Figure 24-41) and in emergency situations where the environment is not conducive to traditional CPB methods (e.g., in the cardiac catheterization laboratory, the intensive care unit, and the emergency department).

REF: 735

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Rothrock: Alexander's Surgical Procedures Chapter 17: Pediatric Surgery Test Bank MULTIPLE CHOICE 1. It is important to recognize that the difference between pediatric care and adult care is not just a size issue. Major areas of distinction are the airway and pulmonary status, cardiovascular status, temperature regulation, metabolism, fluid management, and psychologic development. The most significant consideration when caring for pediatric patients that is not of concern when caring for adults is: a. congenital birth anomalies and conditions are the most frequent surgical diagnoses. b. from birth onward, the child is in a continual state of development and physiologic change. c. thorough knowledge of the differences between children and adults is integral to the provision of nursing care. d. a proportionally large head, short neck, and large tongue influence anesthesia care.

ANS: B From birth onward, the body and organs exist in a continual state of development, and multiple physiologic changes occur with age. A thorough knowledge of these differences is integral to the provision of nursing care for the pediatric patient in the OR. REF: 784 2. Young children are predisposed to parasympathetic hypertonia (increased vagal tone), which can be induced by: a. painful stimuli such as eye surgery or abdominal retraction. b. anxiety stimuli such as separation from a parent. c. environmental stimuli such as loud noise or flashes of light. d. thermal stimuli such as ambient excessive heat or cold.

ANS: A Young children are predisposed to parasympathetic hypertonia (increased vagal tone), which can be induced by painful stimuli such as laryngoscopy, intubation, eye surgery, or abdominal retraction.

REF: 785 3. The immature blood-brain barrier and decreased protein binding in infants increase their sensitivity to which group of drugs? a. Anticholinergics, parasympatholytics b. Antidysrhythmic agents c. Opioids and hypnotics

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d. Adrenergics ANS: C Drug distribution is different in neonates and infants compared with older children and adults because of an increased percentage of total body weight and extracellular body fluid. Infants have an immature blood-brain barrier and decreased protein binding, which results in an increased sensitivity to sedatives, opioids, and hypnotics.

REF: 785 4. A child’s comprehension of, and responses to, the environment are based on his or her developmental age. The works of Drs. Jean Piaget and Erik Erikson provide excellent guidelines for assessing the pediatric patient’s developmental level in order to use appropriate interventions. The infant develops the belief that the world can be counted on to meet basic needs through the trust vs. mistrust concept based on the stages of psychosocial and emotional needs. This theoretical framework of stages was described by ______________, while the stages based on changes in cognition and ability to think were described by _____________. a. Dr. Erick Erikson; Dr. Jean Piaget b. Dr. Geoffery Barns; Dr. Jules Junger c. This statement is a combined consensus of both of their theories. d. Neither theory is represented by this statement.

ANS: A Dr. Jean Piaget described the stages by changes in cognition and the ability to think, and Dr. Erik Erikson based the stages on psychosocial and emotional needs. For example, according to Erikson, infancy to 1 year: trust vs. mistrust; infant develops belief that world can be counted on to meet basic needs. According to Piaget, infancy to 2 years: Who to trust? Identifies strangers at 7 to 8 months of age.

REF: 786 5. The toddler uses symbols and engages in creative play. Toddlers are beginning to develop free will and control over their bodies. Which of the interventions below is ageappropriate for toddlers? a. Sing songs from your own childhood that the child may be able to learn. b. Give only simple choices and involve them in actions when possible. c. Make up a story about their personal comfort item as you give it to their parent to keep. d. Ask them about their concerns and offer information to decrease their fears.

ANS: B Toddlers are very egocentric. They develop free will and increasing control of their body and feel regret and sorrow for inappropriate behavior. Give only simple choices; involve child in actions when possible; use distractions; sing songs the child may recognize.

Allow personal item into OR for comfort/security.

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REF: 786 6. Children classified in the early childhood phase or who are preschool age begin to imagine and explore. Their thinking is dominated by perceptions and, often, distorted reasoning. They are magical thinkers. What would be an appropriate intervention for preschool age children? a. Allow them to play with a saline-filled syringe to decrease their fear of injections. b. Allow them to play with their own mask and place on their stuffed bunny’s face. c. Tell them a scary story during anesthesia induction. d. Draw faces on inflated latex gloves and give each glove a name of a surgical team member.

ANS: B For the preschool, early childhood patient, use stories during induction. They like colorful Band-Aids. Allow the child to handle unfamiliar objects to decrease stress (e.g., mask, pulse oximeter probe). Allow personal item into OR for comfort/security.

REF: 786 7. Personal comfort or security items should be permitted to accompany children to the OR who are in which developmental age? a. Infancy to 1 year b. Toddler to early childhood c. Adolescence d. All of options are correct.

ANS: D Allow personal items into the OR for comfort/security in all developmental age groups.

REF: 786 8. Improvements in instrumentation and the development of equipment in smaller sizes have resulted in the evolution of minimally invasive surgery (MIS) from that of a rapidly growing field to one of routine practice in the pediatric surgical arena. The advantages of MIS for the pediatric population include which true statement? a. There is less risk for injury or complications with pneumoperitoneum insufflation. b. Pediatric patients having MIS procedures have less prevalence of adhesion formation. c. There is less possibility for abdominal injury from Foley catheter decompression. d. MIS procedures on children do not require the use of thromboembolic devices.

ANS: B

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Advantages of minimally invasive surgery include diminished postoperative pain, improved cosmetic results, decreased prevalence of adhesion formation, and accelerated recovery periods and shorter hospital stays. Despite the technical congruence with adult MIS procedures, the pediatric populations undergoing these procedures have specific needs. Anesthesia providers must consider the size and age of the patient because of the risk of physiologic compromise related to insufflation. Likewise, steps are taken intraoperatively to decrease the likelihood of intra-abdominal injury, such as insertion of an appropriate size Foley catheter to decompress the bladder or application of thromboembolic hose or sleeves to prevent deep vein thrombosis.

REF: 796 9. Infants and children with severe gastroesophageal (GE) reflux can have life-threatening complications, including obstructive apnea, aspiration pneumonia, esophagitis, and failure to thrive. What is the name of the procedure, performed open or laparoscopically, that is designed to create a competent antireflux barrier? a. Nissen fundoplication b. Roux-en-Y bypass c. Pyloromyotomy with pyloroplasty d. Sphincterotomy ANS: A Nissen fundoplication is indicated for infants and children who experience severe gastroesophageal (GE) reflux. The goal of the Nissen fundoplication is to create a competent antireflux barrier.

REF: 797 10. An orchiopexy is the surgical placement and fixation of the testicle in a normal anatomic position in the scrotal sac. If the testis fails to descend into the scrotum during gestation, it is considered undescended. Which statement regarding indications for orchiopexy is true? a. The normal path of the testis becomes obstructed. b. The testis is strangulated by contraction of the cremaster muscle. c. All testes that are undescended after 1 year require surgical placement in the scrotum. d. Retractile testes require surgical or hormonal treatment.

ANS: C All testes undescended after 1 year require surgical placement in the scrotum for optimum maturation. Retractile testes require no surgical or hormonal treatment.

Laparoscopic exploration may also be used to determine position, existence, or size of a “hidden” testis.

REF: 820

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11. Neuropathologic conditions requiring surgical intervention can be found in any age group. What are the most common problems requiring neurosurgical procedures in infants and children? a. Meningocele, myelomeningocele, and encephalocele b. Craniosynostosis and hydrocephalus c. Brain tumors and trauma d. All of the options are correct.

ANS: D The most common problems requiring neurosurgical procedures in infants and children include meningocele, myelomeningocele, encephalocele, craniosynostosis, hydrocephalus, brain tumors, and trauma.

REF: 826 12. This orthopedic diagnosis is a complex deformity that is diagnosed prenatally through ultrasound or at birth. It may occur unilaterally or bilaterally and may be idiopathic or one in a combination of other syndromes with associated anomalies. The general characteristic for all cases includes inversion of the foot such that the anterior foot is located in the typical position of the posterior foot; often there is a deep crease in the midfoot. Select the orthopedic diagnosis. a. Foot dystonia b. Clubfoot c. Orthopedia d. Subtalar orthopnea ANS: B Clubfoot is a complex deformity that is diagnosed prenatally through ultrasound or at birth. According to the American Academy of Orthopedic Surgeons (AAOS), clubfoot may occur unilaterally or bilaterally and may be idiopathic or one in a combination of other syndromes with associated anomalies (AAOS, 2007).

REF: 829 13. Cleft lip is usually associated with a notch or cleft of the underlying alveolus and a cleft of the palate. Cleft lip repair is most often performed when the infant is about 3 months of age. Cleft lip is described as: a. two skin ridges situated near the midline of the central philtrum of the lip. b. absence of one or both philtral clefts with a notch in the alveolus. c. a deficiency of tissue (skin, muscle, and mucosa) along one or both sides of the upper lip. d. disarrangement of existing lip tissues associated with a cleft of the palate.

ANS: C A deficiency of tissue (skin, muscle, and mucosa) along one or both sides of the upper lip or, rarely, in the midline results in a cleft at the site of this deficiency.

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REF: 830 14. Any misalignment of the eyes is called strabismus. The goal for treatment of strabismus is to straighten the eyes so that binocular vision functions appropriately. Surgery may be recommended to change the alignment of the eyes relative to each other by: a. strengthening the eye muscles b. weakening the eye muscles c. repositioning the eye muscles d. All of the options are correct.

ANS: D Surgery may be recommended to change the alignment of the eyes relative to each other by strengthening, weakening, or repositioning the eye muscles.

REF: 835 15. Sienna Morgan is a 7-year-old girl who was involved in a hit and run accident while riding her bike to school. She is attended by paramedics and has an unstable airway; blood pressure less than 50 mm Hg (systolic); a major open, penetrating wound; and open, multiple fractures of both legs. Sienna is comatose. During transport she is intubated and demonstrates persistent physiologic demise and possible traumatic brain injury. A significant risk reduction strategy for Sienna would be to: a. consider transport to a pediatric trauma center. b. transport to the nearest emergency department. c. transport immediately to a pediatric trauma center. d. transport to the ambulatory surgery center across the street for stabilization.

ANS: C Trauma Transfer Criteria for Pediatric Patients Ages 14 or Younger—Consider transfer to pediatric trauma center: nonoperative management of solid organ injury; assessment of any of the following “negative points” on the pediatric trauma scale: weight less than 10 kg, unstable airway, blood pressure less than 50 mm Hg (systolic), coma, major open, penetrating wound, open multiple fractures, injury severity score greater than 9; victim or nonaccidental injury that requires intervention from child protective team or other resources; anticipated complexity of care exceeds the capabilities of local resources at adult trauma center. Should transfer to pediatric trauma center: persistent physiologic demise, traumatic brain injury, intubation and mechanical ventilation with no expectation to wean within 24 hours, children with special needs or other co-morbid conditions.

REF: 840

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16. Baby Boy Doe is a newborn found outside of the emergency department (ED). He is hypothermic and has several deep lacerations across his back, abdomen, and legs that will require surgical repair. He is transferred to the surgical bay of the ED and prepared for anesthesia induction. What risk reduction strategies are appropriate during the preanesthetic phase to achieve and maintain normothermia? a. Adjust room temperature to 23 to 24 C (73.4 to 75.2 F). b. Provide a radiant heat lamp during placement of monitoring lines and induction. c. Wrap lower extremities in elastic bandages and encase in a plastic bag for newborns. d. Keep child exposed as much as possible to benefit from the heat lamp.

ANS: B Adjust room temperature approximately 1 hour before arrival of the child: 26 to 27 C (78.8 to 80.6 F) for infants and newborns; 23 to 24 C (73.4 to 75.2 F) for older children. Provide radiant heat lamp for use during placement of monitoring lines, induction of anesthesia, positioning, skin prep, and draping. Keep child covered as much as possible. Consider wrapping lower extremities in soft gauze or stockinette and encasing in plastic bag for newborns and infants.

REF: 841 MULTIPLE RESPONSE 1. Much like the adult population, many traditional “open” pediatric surgical procedures are being replaced by minimally invasive surgery (MIS) procedures. Because the field of pediatric MIS is relatively new, surgeons are at an advantage because they are able to combine virtual reality techniques and robotics with the most current technology and instrumentation. Select all of the MIS procedures commonly performed in pediatric patients from the options listed below. a. Living-related donor kidney transplant b. Gastric fundoplication c. Correction of pectus excavatum d. Closure of patent ductus arteriosus ANS: B, C, D Common pediatric MIS procedures for general surgery include diagnostic laparoscopy, pyloromyotomy, splenectomy, gastric fundoplication, and cholecystectomy.

Thoracoscopic approaches may be used for correction of pectus excavatum, lung biopsy, sympathectomy, and closure of a patent ductus arteriosus (PDA).

REF: 796 2. Select all the injuries or conditions that reflect probable child abuse or neglect from the list below. a. Abrasions of both knees b. Multiple bug bites

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c. Severe injuries inconsistent with the history d. Severe diaper rash with the presence of ammonia burns ANS: C, D If a child is reported to have experienced a routine fall but appears to have severe injuries, the inconsistency of the history with the trauma sustained indicates suspected child abuse. The symptoms of neglect reflect a lack of both physical and medical care.

Manifestations include failure to thrive without a medical explanation, multiple cat or dog bites and scratches, feces and dirt in the skinfolds, severe diaper rash with the presence of ammonia burns, feeding disorders, and developmental delays.

REF: 787 3. Vascular access in pediatric patients may be established intraoperatively for short-term (weeks) or long-term (months, years) use. Select all the examples of a long-term (months, weeks) use vascular access catheter from the list below. a. Central venous line b. Implanted port c. Peripherally inserted central venous catheter (PICC) d. Power injection port ANS: A, B Central venous lines or implanted ports are placed for long-term access to provide parenteral nutrition, chemotherapy, bone marrow transplantation, or multiple IV access lines for the critically ill patient. An example of a device inserted for short-term use includes peripherally inserted central venous catheters (PICC lines) for antibiotic therapy.

REF: 795 4. Pharyngeal obstruction is revealed by a history of sleep-disordered breathing. Mouth breathing, snoring, pauses in breathing, restless sleep, waking at night, and enuresis may be related to obstruction. Pharyngeal obstruction may also be caused by recurrent pharyngitis or tonsillitis. Select all the procedures that are designed for the relief of pharyngeal obstruction from those listed below. a. Tonsillectomy b. Adenoidectomy c. Flexible nasolaryngoscopy d. Pharyngotomy ANS: A, B A tonsillectomy and adenoidectomy is indicated primarily either for relief of pharyngeal obstruction or for recurrent pharyngitis or tonsillitis. Flexible nasolaryngoscopy and lateral neck radiography can aid in diagnosis of nasopharyngeal obstruction.

REF: 823

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Rothrock: Alexander's Surgical Procedures Chapter 18: Trauma Surgery Test Bank MULTIPLE CHOICE 1. Traumatic deaths may occur in three phases, or time frames. The first phase occurs immediately after the injury, the second phase within the first 1 to 2 hours after the injury, and the third phase occurs days to weeks after the injury. Approximately 30% of total fatalities from trauma could be prevented with definitive trauma care, including appropriate and aggressive resuscitation with rapid transport to an appropriate facility.

Which phase, or timeframe, of potential for trauma death, does this group represent? a. Phase I b. Phase II c. Phase III d. This represents all phases of trauma, not one distinct phase.

ANS: B The second phase occurs within the first 1 to 2 hours after the injury, representing approximately 30% of total fatalities. These patients have injuries to the spleen, liver, lung, or other organs that result in significant blood loss. This is the group in which definitive trauma care (i.e., appropriate and aggressive resuscitation with adequate volume replacement) may have the most significant effect (the golden hour).

REF: 857 2. What statement regarding level I and level II trauma centers best describes the difference between the two types of centers? a. A level I trauma center is staffed 24 hours/7 days, while a level II has many support services that are open and staffed 8 hours/5 days. b. A level I trauma center has a transplant program, while a level II is only able to complete organ procurements. c. A level I trauma center provides care for every type of injury, while a level II lacks some specialized resources. d. A level I trauma center requires trauma certification and 8 hours of annual trauma education for all staff, while a level II does not.

ANS: C Trauma centers (TCs) are classified based on the scope of services and resources that are available. A level I TC is capable of providing total care for every type of injury. A level II TC provides comprehensive care for all injuries but lacks some of the specialized clinicians and resources required for the level I designation. Accepting the designation of level I commits the TC to providing qualified personnel and equipment necessary for rapid diagnosis and treatment on a 24-hour basis.

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REF: 857 3. Which statement regarding level III and level IV trauma centers best describes the difference between the two types of centers? a. A level III trauma center provides advanced cardiac life support (ACLS), surgery, stabilization, and transfer, while a level IV only provides ACLS services before immediate transfer to a higher level center. b. A level III trauma center immediately transfers to a higher level center, while a level IV does not accept trauma patients. c. A level III trauma center determines severity of injury and provides ACLS support before transfer to a level IV center, while a level IV provides all comprehensive services. d. A level III trauma center provides all types of trauma services but is located in a rural setting, while a level IV provides post-hospital convalescent care for trauma patients.

ANS: A A level III facility provides prompt evaluation, resuscitation, emergency surgery, and stabilization, as needed, before transfer to a higher-level facility. A level IV trauma center has the ability to provide advanced trauma life support before patient transfer. These facilities may be located in rural areas with limited access and may be a clinic or a hospital.

REF: 857 4. When the patient arrives in the ED, the trauma team initiates a primary assessment. This is a logical, orderly process of patient assessment for potential life threats. These assessment activities are based on established protocols for advanced trauma life support (ATLS). The mnemonic “ABCDE” is used, representing assessment of the following: Airway, Breathing, Circulation, Disability, and Exposure. The D and E represent what degree of investigation? a. D = musculoskeletal impairments; E = environmental issues b. D = a brief reflex examination; E = extraneous sensory impairments c. D = history of prior impairments; E = events that contributed to the injury d. D = a brief neurologic examination; E = exposure to reveal all life-threatening injuries ANS: D The mnemonic “ABCDE” is used, representing assessment of the following: Airway (with cervical spine precautions), Breathing, Circulation, Disability (brief neurologic examination), Exposure (to reveal all life-threatening injuries, including Environmental control [thermoregulation]).

REF: 862

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5. If cervical spine precautions were not implemented before arrival at the hospital, the emergency department team initiates them before performing any other procedures on the patient. A trauma team member can stabilize the head and neck, if necessary, until a cervical collar is placed. What event needs to take place before the team removes the cervical collar and continues care? a. A halo traction apparatus is applied. b. A cervical radiograph is obtained to rule out injury to the neck. c. A CT scan with contrast of the upper body is obtained to rule out vascular involvement. d. A myelogram of the cervical spinal canal is obtained to rule out injury to the spinal cord.

ANS: B Once placed, the team does not remove the collar until a cervical radiograph clears the neck of injury.

REF: 862 6. Blunt trauma injuries may not fully reveal the degree or depth of injury. What noninvasive diagnostic test is critical to diagnosis in potential traumatic brain injury? a. Pupil reflex and response to light b. Skull radiograph c. CT scan of the head d. Neurovascular arteriography ANS: C Depending on the MOI, such as a fall, CT scans of the head and abdomen may be performed. A CT scan of the brain may reveal an injury incompatible with life. Because injuries in blunt trauma are very difficult to diagnose, the CT scan is frequently done before patient transfer to the OR. REF: 865 7. Focused assessment with sonography in trauma (FAST) may assist with diagnosis in difficult situations. What group of scans is performed and what do they identify? a. A chest, pelvic, and four abdominal scans; collections of fluid and free air b. A chest, abdominal, and cervical spine scans; hemorrhage c. A full body scan; midline shifts d. A full body CT, MRI, and PET scans; life-threatening and secondary injuries ANS: A

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FAST is a portable, noninvasive scan that can be used to determine the presence of free fluid in the chest or abdomen. The typical FAST scan consists of chest, pelvic, and four abdominal scans. The chest scan examines right and left chest views and can determine the presence of pericardial fluid. The upper right abdominal scan evaluates the hepatorenal area, the first area that shows the presence of air. The left upper scan examines the splenorenal area. The left and right paracolic gutters are also scanned. The pelvic scan assesses for free fluid near the bladder.

REF: 865 8. What is the description of damage control surgery, and what conditions may be present? a. Trauma surgery performed by a nontrauma surgeon; lack of specialty training b. Surgery performed during ambulance or helicopter transfer; patient movement c. Surgery at a non–level I center before transfer to a level I; intentional retained sponges d. Surgery performed in the emergency department; inadequate sterile technique ANS: C If counted sponges are intentionally left in the patient (e.g., in a damage control procedure at a level II, III, or IV center before transfer to a level I facility), the number and type of sponges left in the wound should be documented on the perioperative nursing record.

REF: 871 9. Blunt force to the larynx can result in a fracture and impose immediate airway obstruction. These patients are at risk for a lost airway and may require immediate tracheotomy followed by repair of the fracture when the fracture is unstable or displaced.

It is also important to consider that a trauma patient is assumed to have a full stomach; thus these patients are at high risk for aspiration and resultant pneumonia. What is an appropriate action in the event of a lost airway after anesthesia induction and before intubation? a. Assist the anesthesia provider with securing the airway while applying cricoid pressure. b. Assist the anesthesia provider by inserting a nasogastric tube and connecting to suction. c. Leave the room to get the emergency tracheostomy tray and trach tubes. d. Increase the oxygen delivery and perform a head tilt–chin lift.

ANS: A Under the direction of the anesthesia provider, a member of the perioperative team applies cricoid pressure. This pressure is maintained over the cricoid area until the cuff on the endotracheal (ET) tube is inflated and tube placement is verified by the anesthesia provider.

REF: 872

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10. Trauma to the chest area is the primary cause of death in approximately 25% of trauma victims. Involvement of the heart, great vessels, lungs, and diaphragm, attributable to penetrating or blunt injury, can provide multiple unexpected findings when the chest is opened. Because of the nature of the potential findings and expected surgical intervention, what would be an appropriate preparatory action for the surgical technologist to take? a. Assist in setting up the autotransfusion system and resuscitation equipment. b. Prepare the rapid response team and chaplain to be on alert. c. Call for the small fragment set for rib fracture fixation at closure. d. Prep the patient from the xiphoid to mid-thigh.

ANS: A Autologous blood salvage units should also be considered during patient care preparation, because blood salvage will be done if not contraindicated by the nature of the injury.

Because of the unexpected nature of trauma, planning perioperative care is of the utmost importance. Equipment, instruments, and supplies that have a high probability of use must be immediately available. When the trauma patient is transferred to the OR, the extent of injury is not always known.

REF: 869 11. A trauma patient is rushed to the OR after a primary survey is completed in the emergency department. He is a 36-year-old male with multiple penetrating gunshot and knife wounds to the abdomen. He is bleeding profusely. What appropriate actions are critical in the rapid preparation for this procedure? a. Set up the autotransfusion system. b. Prep the patient from the suprasternal notch to the mid-thigh. c. Place the aortic cross-clamp on the Mayo stand. d. Open a silo-bag closure system on the sterile field.

ANS: B The circulator should prep the patient from the suprasternal notch to the midthigh. This allows for rapid access to the chest to clamp the aorta should massive hemorrhage control be indicated; it also allows for exposure of the femoral arteries for potential cannulation and access to the thigh for harvesting a saphenous vein.

REF: 871 12. A 26-year-old woman is rushed to the operating room after a primary and secondary survey in the emergency department. She was hit by a small truck as she was riding her bicycle through a busy intersection. She has sustained rib fractures and several fractured transverse vertebral processes. Renal injury is suspected. As the circulator prepares to insert a urinary catheter, she notices blood at the urinary meatus. What should the circulator’s next action be? a. Place a gauze dressing over the perineum after inserting the urinary catheter.

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b. Insert the catheter and notify the surgeon. c. Discontinue the catheter insertion. d. Insert a latex-free straight catheter to empty the bladder and then remove it.

ANS: C In these instances an indwelling urethral catheter should not be inserted. Laceration of the kidney is closely associated with fracture of the ribs and transverse vertebral processes.

This injury is detected by the presence of blood at the urinary meatus. Blood at the urinary meatus may indicate a tear in the anterior urethra.

REF: 885 13. If the injury to the patient is a result of a violent crime, the team must give special attention to preservation of evidence during the course of patient care. When clothing is removed from the patient, why must it be placed and secured in a paper bag rather than a plastic bag? a. Plastic bags may trap moisture and allow mold growth, destroying evidence. b. It is easier to write identifying information on paper rather than plastic. c. Plastic bags trap air, which could kill anaerobic microorganisms needed as evidence. d. Paper bags are more secure as they cannot be untied and retied.

ANS: A Clothing is placed in paper bags, labeled appropriately, and given to law enforcement personnel. Plastic bags trap moisture and may facilitate growth of mold, which could destroy evidence. The transport vehicle sheet should also be handled in a similar manner, since evidence may be present.

REF: 871 14. What special consideration should be made when assessing a pediatric trauma patient for level of consciousness? a. Use the modified Glasgow Coma Scale for children. b. Use the Broslow tape. c. Stimulate the child gently in case he or she is a victim of shaken baby syndrome. d. Use the universal Glasgow Coma Scale for all ages.

ANS: A Special considerations for infants and children who have sustained a trauma is based on use of a modified Glasgow Coma Scale.

REF: 877 15. What special consideration should be made when assessing a geriatric trauma patient before surgery? a. They may have preexisting diseases and conditions.

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b. They may take many prescription and nonprescription drugs. c. They have decreased physiologic reserves. d. All of the options can negatively impact the geriatric patient’s perioperative experience.

ANS: D Preexisting medical conditions, medication use, decreased physiologic reserves, and the physical and psychologic stress experienced during surgical interventions place elderly trauma victims at increased risk for perioperative complications. The physiologic effects of aging combined with the preinjury health status of many elderly patients significantly affect their ability to respond to initial treatment for traumatic injuries and subsequent surgical intervention.

REF: 875 16. What special consideration should the perioperative team be alert to in order to prevent a negative surgical outcome in bariatric trauma patients? a. They may have decreased self-esteem and suffer from societal prejudice. b. They are at risk for retained foreign bodies related to the size of the abdominal cavity. c. Several persons will be needed to position the patient. d. They may not be able to fit into the CT or MRI scanner.

ANS: B Bariatric trauma patients are at increased risk for retention of foreign bodies (soft goods, sponges, instruments) related to the size of the abdominal and other cavities..

REF: 875 17. Autotransfusion can present a vital asset in trauma care, when considering the high blood loss associated with many traumatic injuries. This process provides immediate volume replacement, decreases the amount of bank blood used, and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens. What are the contraindications to using autotransfusion as a blood replacement source? a. Clean, hemodiluted blood b. Blood contaminated with food, bowel contents, or antibiotic irrigation c. Blood and fluids squeezed out of sterile bloody sponges d. Pooled blood from a ruptured aortic aneurysm ANS: B The blood collected in the salvage unit must be free from contamination. If the abdomen is contaminated with free food particles or colonic perforation is present, the blood cannot be used. Similarly, once antibiotic irrigation is initiated, the blood salvage unit is not used. During autologous blood salvage the surgical technologist squeezes out additional blood and fluid from saturated sponges before discarding them from the surgical field.

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REF: 871 MULTIPLE RESPONSE 1. The emergency medical services system consists of trained prehospital personnel who arrive at the scene and perform definitive interventions designed to reduce morbidity and mortality. What is the primary role of the prehospital personnel? Select all that apply from the list below. a. Scoop and run to the nearest hospital emergency department while performing ABCs. b. Deliver the victim to the hospital before the end of the golden hour. c. Determine the severity of injury and initiate medical treatment. d. Identify the most appropriate facility to which to transport the victim.

ANS: C, D The golden hour starts at the scene, where prehospital personnel determine the severity of injury, initiate medical treatment, and identify the most appropriate facility to which to transport the patient.

REF: 856

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