Test Bank for Clinical Manifestations & Assessment of Respiratory Disease 9E by Jardins & Burton

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TEST BANK

2023 1

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Clinical Manifestations and Assessment of Respiratory Disease 9th Edition by

Terry Des Jardins George G. Burton 2023 2

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Clinical Manifestations and Assessment of Respiratory Disease 9th Edition by Terry Des Jardins & George G. Burton ISBN-10 032387150X ISBN-13 978-0323871501 Test Bank for Clinical Manifestations and Assessment of Respiratory Disease9th Edition ISBN-10 032387150X ISBN-13 978-0323871501 THIS IS NOT THE ACTUAL BOOK. YOU ARE BUYING it is the Official Test Bank in e-version INSTANT DOWNLOAD >The test bank is what most professors use as a template when making exams for their students, which means there’s a very high chance that you will see the exact questions in the tests! >The file is either in.pdf, excel, or zipped in the package and can easily be read on PCs and Macs. >Delivery is INSTANT. You can download the files IMMEDIATELY once payment is done.

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CONTENTS SECTION I: Bedside Diagnosis Chapter:1. The Patient Interview Chapter:2. The Physical Examination Chapter:3. The Pathophysiologic Basis for Common Clinical Manifestations Observed During Inspection SECTION II: Clinical Data Obtained from Laboratory Tests and Special Procedures — Objective Findings Chapter:4. Pulmonary Function Testing Chapter:5. Blood Gas Assessment Chapter:6. Assessment of Oxygenation Chapter:7. Assessment of the Cardiovascular System Chapter:8. Radiologic Examination of the Chest Chapter:9. Other Important Tests and Procedures SECTION III : The Therapist-Driven Protocol Program — The Essentials Chapter:10. The Therapist-Driven Protocol Program Chapter:11. Respiratory Failure and Ventilatory Management Protocols Chapter:12. Recording Skills and Intra-Professional Communication

PART II: OBSTRUCTIVE LUNG DISEASE Chapter:13. Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, and Emphysema Chapter:14. Asthma Chapter:15. Cystic Fibrosis Chapter:16. Bronchiectasis

PART III: LOSS OF ALVEOLAR VOLUME Chapter:17. Atelectasis

PART IV: INFECTIOUS PULMONARY DISEASE Chapter:18. Pneumonia, Lung Abscess Formation, and Important Fungal Diseases Chapter:19. Tuberculosis

PART V: PULMONARY VASCULAR DISEASE

PULMONARY VASCULAR DISEASE

Chapter:20. Pulmonary Edema Chapter:21. Pulmonary Vascular Disease -Pulmonary Embolism and Pulmonary Hypertension

PART VI: CHEST AND PLEURAL TRAUMA Chapter:22. Flail Chest Chapter:23. Pneumothorax

PART VII: DISORDERS OF THE PLEURA AND OF THE CHEST WALL Chapter:24. Pleural Effusion and Empyema Chapter:25. Kyphoscoliosis

PART VIII: LUNG CANCER Chapter:26. Cancer of the Lung

PART IX: ENVIRONMENTAL LUNG DISEASES Chapter:27. Interstitial Lung Diseases

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PART X: DIFFUSE ALVEOLAR DISEASE Chapter:28. Acute Respiratory Distress Syndrome

PART XI: NEURO-RESPIRATORY DISORDERS Chapter:29. Guillain-Barre Syndrome Chapter:30. Myasthenia Gravis Chapter:31. Cardiopulmonary Assessment and Care of Patients with Neuromuscular Disease

PART XII: SLEEP-RELATED BREATHING DISORDERS Chapter:32. Sleep Apnea

PART XIII: NEWBORN AND EARLY CHILDHOOD CARDIOPULMONARY DISORDERS Chapter:33. The Newborn Assessment and Management Chapter:34. Pediatric Assessment and Management Chapter:35. Meconium Aspiration Syndrome Chapter:36. Transient Tachypnea of the Newborn Chapter:37. Respiratory Distress Syndrome Chapter:38. Pulmonary Air Leak Syndromes Chapter:39. Respiratory Syncytial Virus Infection (Bronchiolitis) Chapter:40. Bronchopulmonary Dysplasia Chapter:41. Congenital Diaphragmatic Hernia Chapter:42. Congenital Heart Diseases Chapter:43. Croup and Croup-like Syndromes-Laryngotracheobronchitis, Bacterial Tracheitis, and Acute Epiglottitis

PART XIV: OTHER IMPORTANT TOPICS Chapter:44. Near Drowning/Wet Drowning Chapter:45. Smoke Inhalation, Thermal Lung Injuries, and Carbon Monoxide Intoxication

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Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

MULTIPLE CHOICE 1. The respiratory therapist is conducting a patient interview. The main purpose of this interview

is to: a. review data with the patient. b. gather subjective data from the patient. c. gather objective data from the patient. d. fill out the history form or checklist.

ANS: B

During the interview, the patient provides his or her opinion (subjective data) on the situation.

The history should be done before the interview. Although data can be reviewed, that is not the primary purpose of the interview.

REF: p. 2 2. For there to be a successful interview, the respiratory therapist must: a. provide leading questions to guide the patient. b. be an active listener. c. reassure the patient. d. use medical terminology to show knowledge of the subject matter.

ANS: B

The personal qualities that a respiratory therapist must have to conduct a successful interview include being an active listener, having a genuine concern for the patient, and having empathy. Leading questions must be avoided. Reassurance may provide a false sense of comfort to the patient. Medical jargon can sound exclusionary and paternalistic to a patient.

REF: p. 2 3. Which of the following would NOT be found on a history form? a. Age b. Chief complaint c. Present health d. Family history e. Health insurance provider ANS: E

Age, chief complaint, present health, and family history are typically found on a health history form because each can impact the patient’s health. Health insurance provider information, while needed for billing purposes, would not be found on the history form.

REF: pp. 1- 2 4. The physical setting for the interview should provide for all of the following EXCEPT: a. minimize or prevent interruptions. b. ensure privacy during discussions. c. interviewer is the same sex as the patient to prevent bias.

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

d. be comfortable for the patient and interviewer.

ANS: C

An interviewer of either gender, who acts professionally, should be able to interview a patient of either gender. The other listed options are important to have a successful interview.

REF: p. 2 5. The respiratory therapist is conducting a patient interview. The therapist chooses to use

open-ended questions. Open-ended questions allow the therapist to do all of the following EXCEPT: a. gather information when a patient introduces a new topic. b. introduce a new subject area. c. begin the interview process. d. gather specific information.

ANS: D

An open-ended question should be used to start the interview, introduce a new section of questions, and gather more information from a patient’s topic. Closed or direct questions are used to gather specific information.

REF: p. 3 6. The direct question interview format is used to:

1. speed up the interview.

2. let the patient fully explain his or her situation.

3. help the respiratory therapist show empathy.

4. gather specific information. a. 1, 4 b. 2, 3 c. 3, 4 d. 1, 2, 3, 4 ANS: A

Direct or closed questions are best to gather specific information and speed up the interview.

Open-ended questions are best suited to let the patient fully explain his or her situation and possibly help the respiratory therapist show empathy.

REF: pp. 3-4 7. During the interview the patient states, “Every time I climb the stairs I have to stop to catch

my breath.” Hearing this, the respiratory therapist replies, “So, it sounds like you get short of breath climbing stairs.” This interviewing technique is called: a. clarification. b. modeling. c. empathy. d. reflection.

ANS: D

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

With reflection, part of the patient’s statement is repeated. This lets the patient know that what he/she said was heard. It also encourages the patient to elaborate on the topic. Clarification, modeling, and empathy are other communication techniques.

REF: pp. 3-5 8. The respiratory therapist may choose to use the patient interview technique of silence in

which of the following situations? a. To prompt the patient to ask a question b. After a direct question c. After an open-ended question d. To allow the patient to review his or her history ANS: C

After a patient has answered an open-ended question, the respiratory therapist should pause (use silence) before asking the next question. This pause allows the patient to add something else before moving on. The patient may also choose to ask a question.

REF: p. 4 9. To have the most productive interviewing session, the respiratory therapist must avoid all of

the following types of verbal messages EXCEPT: a. confrontation. b. giving advice. c. using avoidance language. d. distancing.

ANS: A

With confrontation, the respiratory therapist focuses the patient’s attention on an action, feeling, or statement made by the patient. This may prompt a further discussion. The respiratory therapist should avoid giving advice, using avoidance language, and using distancing language.

REF: pp. 5-6 10. When closing the interview, the respiratory therapist should do which of the following?

a. b. c. d.

1. Recheck the patient’s vital signs.

2. Thank the patient.

3. Ask if the patient has any questions.

4. Close the door behind himself or herself for patient privacy.

2 2, 3 1, 3, 4 1, 2, 3, 4

ANS: B

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

To end the interview on a positive note, the respiratory therapist should thank the patient and ask if the patient has any questions. If there is no need for the vital signs to be checked, they should not be. The door may be left open or closed, depending on the situation.

REF: p. 7 11. The respiratory therapist should be aware of a patient’s culture and religious beliefs for which

of the following reasons? a. To be able to engage in a meaningful conversation b. To change any misguided notions the patient has that may impact his or her health c. To explain to the patient how these beliefs will lead to discrimination and stereotyping d. To better understand how the patient’s beliefs may impact how the patient thinks and behaves ANS: D

Culture and religious beliefs may have a profound effect on how patients think and behave, and this may impact their health or health-care decisions. The role of the respiratory therapist is not to change the patient’s beliefs, engage in sensitive conversations, or discuss discrimination. Rather, the respiratory therapist needs to understand how these beliefs may impact the patient’s health-care decisions.

REF: pp. 2-3 12. Which of the following are the most important components of a successful interview? a. Communication and understanding b. Authority and the use of medical terminology c. Providing assurance and giving advice d. Asking leading questions and anticipating patient responses to questions ANS: A

Communication and understanding are the basis for a good patient interview. Authority, the use of medical jargon, providing assurance, giving advice, asking leading questions, and anticipating are all types of nonproductive communication forms and create barriers to patient communication.

REF: p. 2 13. The respiratory therapist is conducting a patient interview and recording responses in the

patient’s electronic health record. The respiratory therapist should take which of the following into account regarding the use of the computer to record responses? a. The therapist’s attention may be shifted from the patient to the computer. b. The patient will feel more important than if the information is recorded on paper. c. The therapist will be less likely to make spelling errors if using a spell-check program. d. The environment will be more professional and the patient will be more likely to open up if the interview is conducted with paper.

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

ANS: A

The therapist’s use of the computer can be threatening and may, in some cases, be a potential hazard to good patient communication. The patient can be intimidated to the point of “shutting down.” In addition, the therapist who has to shift focus from the patient to the computer can miss important verbal and nonverbal messages.

REF: p. 2

14. The respiratory care practitioner is conducting a patient interview. The main purpose of this interview is to: a. review data with the patient. b. gather subjective data from the patient. c. gather objective data from the patient. d. fill out the history form or checklist.

ANS: B The interview is a meeting between the respiratory care practitioner and the patient. It allows the collection of subjective data about the patient’s feelings regarding his/her condition. The history should be done before the interview. Although data can be reviewed, that is not the primary purpose of the interview.

15. For there to be a successful interview, the respiratory therapist must: a. provide leading questions to guide the patient. b. reassure the patient. c. be an active listener. d. use medical terminology to show knowledge of the subject matter.

ANS: C The personal qualities that a respiratory therapist must have to conduct a successful interview include being an active listener, having a genuine concern for the patient, and having empathy. Leading questions must be avoided. Reassurance may provide a false sense of comfort to the patient. Medical jargon can sound exclusionary and paternalistic to a patient.

16. Which of the following would be found on a history form?

1. Age 2. Chief complaint 3. Present health 4. Family history 5. Health insurance provider a. 1, 4 b. 2, 3 c. 3, 4, 5 d. 1, 2, 3, 4 ANS: D

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

Age, chief complaint, present health, and family history are typically found on a health history form because each can impact the patient’s health. Health insurance provider information, while needed for billing purposes, would not be found on the history form.

17. External factors the respiratory care practitioner should make efforts to provide during an interview include which of the following?

1. Minimize or prevent interruptions.

2. Ensure privacy during discussions.

3. Interviewer is the same sex as the patient to prevent bias.

4. Be comfortable for the patient and interviewer. a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: C External factors, such as a good physical setting, enhance the interviewing process.

Regardless of the interview setting (the patient’s bedside, a crowded emergency room, an office in the hospital or clinic, or the patient’s home), efforts should be made to (1) ensure privacy, (2) prevent interruptions, and (3) secure a comfortable physical environment (e.g., comfortable room temperature, sufficient lighting, absence of noise). An interviewer of either gender, who acts professionally, should be able to interview a patient of either gender.

18. The respiratory therapist is conducting a patient interview. The therapist chooses to use open-ended questions. Open-ended questions allow the therapist to do which of the following?

1. Gather information when a patient introduces a new topic.

2. Introduce a new subject area.

3. Begin the interview process.

4. Gather specific information. a. 4 b. 1, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: C An open-ended question should be used to start the interview, introduce a new section of questions, and gather more information from a patient’s topic. Closed or direct questions are used to gather specific information.

19. The direct question interview format is used to: 1. speed up the interview.

2. let the patient fully explain his/her situation.

3. help the respiratory therapist show empathy.

4. gather specific information. a. 1, 4 b. 2, 3 c. 3, 4

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

d. 1, 2, 3 ANS: A Direct or closed questions are best to gather specific information and speed up the interview.

Open-ended questions are best suited to let the patient fully explain his/her situation and possibly help the respiratory therapist show empathy.

20. During the interview the patient states, “Every time I climb the stairs I have to stop to catch my breath.” Hearing this, the respiratory therapist replies, “So, it sounds like you get short of breath climbing stairs.” This interviewing technique is called: a. clarification. b. modeling. c. empathy. d. reflection.

ANS: D With reflection, part of the patient’s statement is repeated. This lets the patient know that what he/she said was heard. It also encourages the patient to elaborate on the topic. Clarification, modeling, and empathy are other communication techniques.

21. The respiratory therapist may choose to use the patient interview technique of silence in which of the following situations? a. To prompt the patient to ask a question b. After a direct question c. After an open-ended question d. To allow the patient to review his/her history ANS: C After a patient has answered an open-ended question, the respiratory therapist should pause (use silence) before asking the next question. This pause allows the patient to add something else before moving on. The patient may also choose to ask a question.

22. To have the most productive interviewing session, which of the following types of responses to assist in the interview should the respiratory therapist avoid? a. Confrontation b. Reflection c. Facilitation d. Distancing ANS: D With confrontation, the respiratory therapist focuses the patient’s attention on an action, feeling, or statement made by the patient. This may prompt a further discussion. Reflection helps the patient focus on specific areas and continues in his/her own way. Facilitation encourages patients to say more, to continue with the story. The respiratory therapist should avoid giving advice, using avoidance language, and using distancing language.

23. When closing the interview, the respiratory therapist should do which of the following?

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

1. Recheck the patient’s vital signs.

2. Thank the patient.

3. Ask if the patient has any questions.

4. Close the door behind himself/herself for patient privacy. a. 2 b. 2, 3 c. 1, 3, 4 d. 1, 2, 4 ANS: B To end the interview on a positive note, the respiratory therapist should thank the patient and ask if the patient has any questions. If there is no need for the vital signs to be checked, they should not be. The door may be left open or closed, depending on the situation.

24.The respiratory therapist should be aware of a patient’s culture and religious beliefs for which of the following reasons? a. To be able to engage in a meaningful conversation b. To change any misguided notions the patient has that may impact his/her health c. To explain to the patient how these beliefs will lead to discrimination and stereotyping d. To better understand how the patient’s beliefs may impact how the patient thinks and behaves ANS: D Culture and religious beliefs may have a profound effect on how patients think and behave, and this may impact their health or health care decisions. The role of the respiratory therapist is not to change the patient’s beliefs, engage in sensitive conversations, or discuss discrimination. Rather, the respiratory therapist needs to understand how these beliefs may impact the patient’s health care decisions.

25. Which of the following are the most important components of a successful interview? a. Communication and understanding b. Authority and the use of medical terminology c. Providing assurance and giving advice d. Asking leading questions and anticipating patient responses to questions ANS: A Communication and understanding are the basis for a good patient interview. Authority, the use of medical jargon, providing assurance, giving advice, asking leading questions, and anticipating are all types of nonproductive communication forms and create barriers to patient communication.

26. The respiratory therapist is conducting a patient interview and recording responses in the patient’s electronic health record. The respiratory therapist should take which of the following into account regarding the use of the computer to record responses? a. The therapist’s attention may be shifted from the patient to the computer. b. The patient will feel more important than if the information is recorded on paper.

Prof.Exams TB-Clinical Manifestations & Assessment of Respiratory Disease 9E(DesJardins) Chapter:1. The Patient Interview

c. The therapist will be less likely to make spelling errors if using a spell-check program. d. The environment will be more professional and the patient will be more likely to open up if the interview is conducted with paper.

ANS: A The therapist’s use of the computer can be threatening and may, in some cases, be a potential hazard to good patient communication. The patient can be intimidated to the point of “shutting down.” In addition, the therapist who has to shift focus from the patient to the computer can miss important verbal and nonverbal messages.

1. The respiratory care practitioner is conducting a patient interview. The main purpose of this interview is to: a. review data with the patient. b. gather subjective data from the patient. c. gather objective data from the patient. d. fill out the history form or checklist.

ANS: B The interview is a meeting between the respiratory care practitioner and the patient. It allows the collection of subjective data about the patient’s feelings regarding his/her condition. The history should be done before the interview. Although data can be reviewed, that is not the primary purpose of the interview.

2. For there to be a successful interview, the respiratory therapist must: a. provide leading questions to guide the patient. b. reassure the patient. c. be an active listener. d. use medical terminology to show knowledge of the subject matter.

ANS: C

The personal qualities that a respiratory therapist must have to conduct a successful interview include being an active listener, having a genuine concern for the patient, and having empathy. Leading questions must be avoided. Reassurance may provide a false sense of comfort to the patient. Medical jargon can sound exclusionary and paternalistic to a patient.

3. Which of the following would be found on a history form?

1. Age 2. Chief complaint 3. Present health 4. Family history 5. Health insurance provider a. 1, 4 b. 2, 3 c. 3, 4, 5 d. 1, 2, 3, 4 ANS: D Age, chief complaint, present health, and family history are typically found on a health history form because each can impact the patient’s health. Health insurance provider information, while needed for billing purposes, would not be found on the history form.

4. External factors the respiratory care practitioner should make efforts to provide during an interview include which of the following?

1. Minimize or prevent interruptions.

2. Ensure privacy during discussions.

3. Interviewer is the same sex as the patient to prevent bias.

4. Be comfortable for the patient and interviewer. a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: C External factors, such as a good physical setting, enhance the interviewing process. Regardless of the interview setting (the patient’s bedside, a crowded emergency room, an office in the hospital or clinic, or the patient’s home), efforts should be made to (1) ensure privacy, (2) prevent interruptions, and (3) secure a comfortable physical environment (e.g., comfortable room temperature, sufficient lighting, absence of noise). An interviewer of either gender, who acts professionally, should be able to interview a patient of either gender.

5. The respiratory therapist is conducting a patient interview. The therapist chooses to use open-ended questions. Open-ended questions allow the therapist to do which of the following?

1. Gather information when a patient introduces a new topic.

2. Introduce a new subject area.

3. Begin the interview process.

4. Gather specific information. a. 4 9TH b. 1, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: C An open-ended question should be used to start the interview, introduce a new section of questions, and gather more information from a patient’s topic. Closed or direct questions are used to gather specific information.

6. The direct question interview format is used to: 1. speed up the interview.

2. let the patient fully explain his/her situation.

3. help the respiratory therapist show empathy.

4. gather specific information. a. 1, 4 b. 2, 3 c. 3, 4 d. 1, 2, 3 ANS: A Direct or closed questions are best to gather specific information and speed up the interview. Openended questions are best suited to let the patient fully explain his/her situation and possibly help the respiratory therapist show empathy.

7. During the interview the patient states, “Every time I climb the stairs I have to stop to catch my breath.” Hearing this, the respiratory therapist replies, “So, it sounds like you get short of breath climbing stairs.” This interviewing technique is called: a. clarification. b. modeling. c. empathy. d. reflection.

ANS: D With reflection, part of the patient’s statement is repeated. This lets the patient know that what he/she said was heard. It also encourages the patient to elaborate on the topic.

Clarification, modeling, and empathy are other communication techniques.

8. The respiratory therapist may choose to use the patient interview technique of silence in which of the following situations? a. To prompt the patient to ask a question b. After a direct question c. After an open-ended question d. To allow the patient to review his/her history ANS: C After a patient has answered an open-ended question, the respiratory therapist should pause (use silence) before asking the next question. This pause allows the patient to add something else before moving on. The patient may also choose to ask a question.

9. To have the most productive interviewing session, which of the following types of responses N R I G B.C to assist in the interview shouUld tShe rNespTiratory tOherapist avoid? a. Confrontation b. Reflection c. Facilitation d. Distancing ANS: D With confrontation, the respiratory therapist focuses the patient’s attention on an action, feeling, or statement made by the patient. This may prompt a further discussion. Reflection helps the patient focus on specific areas and continues in his/her own way. Facilitation encourages patients to say more, to continue with the story. The respiratory therapist should avoid giving advice, using avoidance language, and using distancing language.

10. When closing the interview, the respiratory therapist should do which of the following?

1. Recheck the patient’s vital signs.

2. Thank the patient.

3. Ask if the patient has any questions.

4. Close the door behind himself/herself for patient privacy. a. 2 b. 2, 3 c. 1, 3, 4 d. 1, 2, 4 ANS: B

To end the interview on a positive note, the respiratory therapist should thank the patient and ask if the patient has any questions. If there is no need for the vital signs to be checked, they should not be.

The door may be left open or closed, depending on the situation.

11. The respiratory therapist should be aware of a patient’s culture and religious beliefs for which of the following reasons? a. To be able to engage in a meaningful conversation b. To change any misguided notions the patient has that may impact his/her health c. To explain to the patient how these beliefs will lead to discrimination and stereotyping d. To better understand how the patient’s beliefs may impact how the patient thinks and behaves ANS: D Culture and religious beliefs may have a profound effect on how patients think and behave, and this may impact their health or health care decisions. The role of the respiratory therapist is not to change the patient’s beliefs, engage in sensitive conversations, or discuss discrimination. Rather, the respiratory therapist needs to understand how these beliefs may impact the patient’s health care decisions.

12. Which of the following are the most important components of a successful interview? a. Communication and understanding b. Authority and the use of medical terminology c. Providing assurance and giving advice d. Asking leading questions and anticipating patient responses to questions

N R I G B.C M Communication and understanding areUthe S basiN s foT r a goodOpatient interview. Authority, the use of ANS: A

medical jargon, providing assurance, giving advice, asking leading questions, and anticipating are all types of nonproductive communication forms and create barriers to patient communication.

13. The respiratory therapist is conducting a patient interview and recording responses in the patient’s electronic health record. The respiratory therapist should take which of the following into account regarding the use of the computer to record responses? a. The therapist’s attention may be shifted from the patient to the computer. b. The patient will feel more important than if the information is recorded on paper. c. The therapist will be less likely to make spelling errors if using a spell-check program. d. The environment will be more professional and the patient will be more likely to open up if the interview is conducted with paper.

ANS: A The therapist’s use of the computer can be threatening and may, in some cases, be a potential hazard to good patient communication. The patient can be intimidated to the point of “shutting down.” In addition, the therapist who has to shift focus from the patient to the computer can miss important verbal and nonverbal messages.

Chapter 02: The Physical Examination Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. When would induced hypothermia be indicated? a. During brain surgery b. During bowel surgery c. To break a fever d. To treat carbon monoxide poisoning ANS: A Induced hypothermia may involve only a portion of the body or the whole body. Induced hypothermia is often indicated before certain surgeries, such as heart or brain surgery, or after return of spontaneous circulation after a cardiac arrest.

2. A 50-year-old patient has a heart rate by palpation of 120 bpm. How should this be interpreted? a. Within the normal range for an adult b. An error since a stethoscope was not used c. Bradycardia d. Tachycardia ANS: D In an adult, a heart rate of g N rea ter i nute is considered to be tachycardia. A heart R t han GN/mBto .C M UIconsidered S100 T Palpation rate of less than 60/minute in an adult is be bradycardia. and auscultation are both acceptable to check heart rate.

3. Tachypnea may be the result of: 1. hypoxemia.

2. hypothermia.

3. fever.

4. sedation. a. 2, 4 b. 1, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B Tachypnea may be the result of hypoxemia, fever, and other causes. Hypothermia and sedation will usually result in bradycardia.

4. A 50-year-old patient would be said to have hypotension when her: a. blood pressure is 130/90 mm Hg. b. blood pressure is 85/55 mm Hg. c. heart rate is 55 bpm. d. pulse pressure is 40 mm Hg. ANS: B

Hypotension is said to be present when the patient’s blood pressure falls below 90/60 mm Hg. A heart rate of 55 bpm would be bradycardia. Pulse pressure is normally about 40 mm Hg. 5. A dull percussion note would be heard in which of the following situations?

1. Atelectasis 2. Pleural thickening 3. Chronic obstructive pulmonary disease (COPD) 4. Consolidation a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 2, 4 ANS: D Because of hyperinflation, a patient with COPD would have a hyperresonant percussion note. All of the other listed options would result in a dull percussion note.

6. Coarse crackles are associated with: 1. inspiration typically.

2. air passing through an airway intermittently occluded by mucus.

3. bronchial asthma.

4. expiration typically. a. 2, 4 b. 3, 4 c. 2, 3, 4 d. 1, 2, 3 9TH ANS: A Coarse crackles are associated with air passing through an airway intermittently occluded by mucus; they are more typically heard during inspiration, not expiration. Wheezes are an expiratory sound associated with bronchial asthma.

7. While assessing an unconscious patient, the respiratory therapist observes that the patient’s breathing becomes progressively faster and deeper and then progressively becomes slower and shallower. After that, there is a period of apnea before the cycle begins again. This breathing pattern would be identified as: a. Cheyne-Stokes. b. Tachypnea. c. Kussmaul. d. Hyperventilation.

ANS: A The abnormal breathing pattern called Cheyne-Stokes is identified by progressively faster and deeper breathing that then progressively becomes slower and shallower. After that there is a period of apnea before the cycle begins again. Tachypnea is rapid breathing. Kussmaul breathing is consistently fast and deep breathing. Hyperventilation is confirmed by a low carbon dioxide level.

8. Benefits of pursed-lip breathing include that it:

1. stabilizes airways.

2. offsets air trapping on exhalation.

3. generates a better gas mixing breathing pattern.

4. increases the respiratory rate. a. 1 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: C All of the listed options are benefits of pursed-lip breathing in a patient with an airway obstruction problem such as asthma or COPD. 9. A patient comes into the emergency department with a complaint of centrally located, constant chest pain. What is his most likely problem? a. Pleurisy b. Myocardial ischemia c. Pneumothorax d. Fractured rib ANS: B Often a patient with myocardial ischemia will complain of centrally located, constant chest pain. The pain may also radiate down an arm or up the neck.

10. A patient with bronchiectasis has a productive cough. Which of the following should the respiratory therapist be evaluating about the patient’s sputum?

1. Color 9TH 2. Odor 3. Frequency of cough 4. Consistency a. 3 b. 1, 2 c. 3, 4 d. 1, 2, 4 ANS: D The respiratory therapist should evaluate a patient’s sputum for color, odor, amount, consistency, and any other significant factors. This could include time of greater or smaller amounts or a change in consistency after inhaling a mucolytic medication.

11. The respiratory therapist is monitoring the blood pressure of a patient in the emergency department and notes that the blood pressure is 15 mm Hg less on inspiration than on expiration. Which of the following would most likely result in this finding? a. The patient is hypovolemic. b. The patient has a pulmonary embolism. c. The patient is having a myocardial infarction. d. The patient is having a severe exacerbation of asthma. ANS: D

A change in blood pressure that is more than 10 mm Hg lower on inspiration than on expiration is known as pulsus paradoxus. This exaggerated waxing and waning of arterial blood pressure can be detected with a sphygmomanometer or, in severe cases, by palpating the pulse at the wrist or neck.

Commonly associated with severe asthmatic episodes, pulsus paradoxus is believed to be caused by the major intrapleural pressure swings that occur during inspiration and expiration.

12. The respiratory therapist is examining a patient in the medical ward and notes that the trachea is deviated to the right. Which of the following may be causing the tracheal deviation to the right? a. A right-sided tension pneumothorax. b. A right-sided pleural effusion. c. A tumor mass on the right. d. Atelectasis of the right upper lobe.

ANS: D A number of abnormal pulmonary conditions can cause the trachea to deviate from its normal position. For example, a tension pneumothorax, pleural effusion, or tumor mass may push the trachea to the unaffected side (in this case to the left), whereas atelectasis pulls the trachea to the affected side (in this case to the right).

13. The respiratory therapist is performing palpation on a patient recently admitted to the medical ward. The therapist notes decreased tactile fremitus over the right lung. Which of the following could most likely be the cause for this physical examination finding? a. Right-sided atelectasis b. Right-sided pneumothorax sided pO leural effuNsioRn c.

I G B.C M U SRigNht-T d. Right-sided pleural tumor ANS: A Tactile fremitus decreases when anything obstructs the transmission of vibration. Such conditions include tumors or thickening of the pleural cavity, pleural effusion, and pneumothorax. Tactile fremitus increases in patients with atelectasis.

14. Moderate hypoxemia is indicated with an SpO2 value between a. 95%; 99% b. 91%; 94% c. 86%; 90% d. 80%; 85%

and

.

ANS: C In the adult, normal SpO2 values range from 95% to 99%. SpO2 values of 91% to 94% indicate mild hypoxemia. Mild hypoxemia warrants additional evaluation by the respiratory practitioner but does not usually require supplemental oxygen. SpO2 readings of 86% to 90% indicate moderate hypoxemia. These patients often require supplemental oxygen. SpO2 values of 85% or lower indicate severe hypoxemia and warrant immediate medical intervention, including the administration of oxygen, ventilatory support, or both.

Chapter 03: The Pathophysiologic Basis for Common Clinical Manifestations Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following is considered a normal tidal volume for a normal adult? a. 4 to 6 mL/kg b. 7 to 9 mL/kg c. 9 to 11 mL/kg d. 10 to 12 mL/kg ANS: B In normal adults, the VT is about 500 mL (7 to 9 mL/kg), the ventilatory rate is about 15 (with a range of 12 to 18) breaths per minute, and the I:E ratio is about 1:2. In patients with respiratory disorders, however, an abnormal ventilatory pattern is often present.

2. Which of the following is considered a symptom a patient with pulmonary disease may complain of when in distress? a. Dyspnea b. Tachypnea c. Retractions of intercostal spaces d. Distressed facial expressions ANS: A Dyspnea is defined as the “NbreaRthleUIssn orC“sh M ortness of breath,” or the B” .by SGess, N only T “labored or difficult breathing” felt and described the patient.

The symptoms of dyspnea (“subjective information”) are sensations that can only be experienced by the patient who is having breathing difficulties—not by the observation of the hospital care staff. Signs of dyspnea (“objective information”) include audibly labored breathing, hyperventilation, and/or tachypnea, retractions of intercostal spaces, use of accessory muscles, a distressed facial expression, flaring of the nostrils, paradoxical movements of the chest and abdomen, and gasping.

3. Which of the following terms is used to describe shortness of breath in the reclining position? a. Orthopnea b. Eupnea c. Exertional dyspnea d. Cardiac dyspnea ANS: A

Common types of dyspnea include (1) positional dyspnea, which occurs only when the patient is in the reclining position—and is also known as orthopnea, (2) cardiac dyspnea, which is labored breathing caused by heart disease (e.g., congestive heart failure), (3) exertional dyspnea, which is provoked by physical exercise or exertion, (4) paroxysmal nocturnal dyspnea, which is a form of respiratory distress related to posture (especially reclining while sleeping) and is usually associated with congestive heart failure with pulmonary edema, and (5) renal dyspnea, which is difficulty in breathing due to kidney disease. Eupnea is defined as the normal breathing rate (between 12 and 20 breaths/min) and regular rhythm and moderate depth for an adult.

4. What ventilatory pattern occurs when the compliance of the lungs decreases? a. No noticeable change. b. Rate generally increases while the tidal volume simultaneously decreases. c. Rate and tidal volume generally increase. d. Rate generally decreases while the tidal volume simultaneously decreases.

ANS: B Although the precise mechanism is not clear, the fact that certain ventilatory patterns occur when lung compliance is altered is well documented. For example, when CL decreases, the patient’s breathing rate generally increases while the tidal volume simultaneously decreases.

5. How can work of breathing be quantified? a. Work = resistance × volume b. Work = pressure volume c. Work = flow volume d. Work = pressure × volume ANS: D

9TH

In physics, work is defined as the force multiplied by the distance moved (work = force × distance).

In respiratory physiology, the change in pulmonary pressure (force) multiplied by the change in lung volume (distance) may be used to quantify the work of breathing (WOB) (work = pressure × volume).

6. In patients with chronically high PaCO2 and low PaO2 which of the following is the primary receptor site for the control of ventilation? a. Central chemoreceptors b. Peripheral chemoreceptors c. Juxtapulmonary-capillary receptors d. Aortic and carotid sinus baroreceptors ANS: B When the peripheral chemoreceptors are activated, an afferent (sensory) signal is sent to the respiratory centers of the medulla by way of the glossopharyngeal nerve (cranial nerve IX) from the carotid bodies and by way of the vagus nerve (cranial nerve X) from the aortic bodies. Efferent (motor) signals are then sent to the respiratory muscles, which results in an increased rate of breathing. It should be noted that in patients who have a chronically high PaCO2 and low PaO2, the peripheral chemoreceptors are the primary receptor sites for the control of ventilation.

7. Which of the following are considered accessory muscles of inspiration?

1. Sternocleidomastoids 2. Scalenes 3. Internal obliques 4. Transversus abdominis a. 1, 2 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: A The major accessory muscles of inspiration are the scalenes, sternocleidomastoids, pectoralis major muscle groups, and the trapezius muscle groups. The major accessory muscles of expiration are the rectus abdominis, external and internal obliques, and the transversus abdominis.

8. Which of the following are considered accessory muscles of expiration?

1. Trapezius 2. Scalenes 3. External obliques 4. Transversus abdominis a. 1, 3 b. 2, 4 c. 2, 3 d. 1, 3, 4 ANS: D The major accessory muscles of inspiration are the scalenes, sternocleidomastoids, pectoralis N R I G B.C major muscle grouUps, SandNtheTtrapeziuOs muscle groups. The major accessory muscles of expiration are the rectus abdominis, external and internal obliques, and the transversus abdominis.

9. Which of the following terms describes a patient’s severe resistant to taking a deep breath? a. Splinting b. Pursed-lip breathing c. Retractions d. Pleurisy ANS: A Chest pain is one of the most common complaints among patients with cardiopulmonary problems.

It can be divided into two categories: pleuritic and nonpleuritic. Unlike cough, dyspnea, and sputum production, it is not subtle. Obviously severe resistance to taking a deep breath is a symptom of pleuritic chest pain and is called splinting.

10. A patient is complaining of a constant chest pain that is centrally located, does not worsen with deep inspiration, but does radiate? Which of the following disorders is associated with these complaints? a. Pneumonia b. Lung cancer c. Pulmonary hypertension d. Tuberculosis

ANS: C Nonpleuritic chest pain is described as a constant pain that is usually located centrally. It is not generally worsened by deep inspiration. The pain may also radiate. Nonpleuritic chest pain is associated with the following disorders: • Myocardial ischemia • Pericardial inflammation • Pulmonary hypertension • Esophagitis • Local trauma or inflammation of the chest cage, muscles, bones, or cartilage 11. As you assess the respiratory status of a patient you notice they have jugular venous distention. Which of the following conditions is the most likely cause of this finding? a. Congestive heart failure b. Pneumonia c. Lung cancer d. Pulmonary infarction ANS: A In patients with left heart failure (congestive heart failure), right heart failure (cor pulmonale), severe flail chest, pneumothorax, or pleural effusion, flow from the major veins of the chest that return blood to the right side of the heart may be compromised. When this happens, cardiac venous return decreases and central venous pressure increases. This condition is manifested by distended neck veins also called jugular venous distention.

12. The majority of the mucous blanket consists of: a. glycoproteins. b. carbohydrates. c. lipids. d. water.

9TH

ANS: D A mucous layer, commonly referred to as the mucous blanket, covers the epithelial lining of the tracheobronchial tree. The mucous blanket is 95% water. The remaining 5% consists of glycoproteins, carbohydrates, lipids, DNA, some cellular debris, and foreign particles.

Chapter 04: Pulmonary Function Testing Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Pulmonary function studies are done for which of the following measurements?

1. The patient’s carbon monoxide level 2. Lung volumes and capacities 3. Pulmonary diffusion capacity 4. Forced expiratory flowrates a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C A blood sample must be analyzed by a cooximeter to determine a patient’s carbon monoxide level. All of the other listed options can be measured on a pulmonary function test.

2. In response to a restrictive lung disorder, which of the following is typically found?

1. Decreased lung compliance 2. Increased ventilatory rate 3. Decreased tidal volume 4. Decreased lung rigidity a. 1 9TH b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D With a restrictive lung disorder, there will be increased lung rigidity. This causes decreased lung compliance. As a result, the patient breathes faster and with a smaller tidal volume.

3. A special indirect measurement procedure must be done to find which of the following? a. Inspiratory reserve volume b. Residual volume c. Expiratory reserve volume d. Inspiratory capacity ANS: B Because the residual volume cannot be measured by spirometry, special procedures and equipment must be used to indirectly measure it. The other listed options can be directly measured by spirometry.

4. In a healthy individual, which of the following is considered a normal expiratory time necessary to perform a forced vital capacity? a. Less than 4 seconds b. 4 to 6 seconds

c. 6 to 8 seconds d. 8 to 10 seconds ANS: B A normal adult will exhale a forced vital capacity (FVC) within 4 to 6 seconds.

5. Overall characteristics of pulmonary function testing results on a patient with obstructive lung disease include that the FEV1: a. is reduced and FEV1% is normal. b. and FEV1% are both increased. c. and FEV1% are both reduced. d. is increased and FEV1% is decreased.

ANS: C Because of airway narrowing problems, a patient with obstructive lung disease will have a reduced FEV1 volume and FEV1% flow. A patient with restrictive lung problems may have FEV1 reduced and FEV1% normal. The other combinations are not seen.

6. The FEF25%-75% is used to evaluate: a. flow in large airways. b. lung volumes. c. maximum breathing effort. d. flow in medium-size to small airways.

ANS: D The forced expiratory flow 25%-75% (FEF25%-75%) is the average flowrate generated by the patient during the middle 50% of an FVC measurement. This expiratory maneuver is used to evaluate the status of mediuNmU-RtoS-sImNalGl aTirBw.ayCsOinMobstructive lung disorders. Other tests would be needed to assess the other listed options.

7. Which of the following are true of the peak expiratory flowrate test?

1. It is effort dependent.

2. It is taken from the FVC test results.

3. It is taken from the MVV test results.

4. It assesses large upper airways. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B The maximum voluntary ventilation (MVV) test is used to measure the maximum amount of air that can be breathed in a minute. The peak flow requires maximum effort from the patient, is taken from the FVC test, and assesses flow through the large upper airways.

8. A patient has restrictive lung disease. In response to this, which of the following are typically found?

1. Decreased lung compliance 2. Increased ventilatory rate 3. Increased tidal volume 4. Decreased ventilatory rate

a. b. c. d.

3, 4 2, 3 1, 2 1, 3, 4

ANS: C Restrictive lung disorders result in an increase in lung rigidity, which in turn decreases lung compliance. When lung compliance decreases, the ventilatory rate increases and the tidal volume decreases.

9. The pulmonary diffusion capacity of the carbon monoxide test is used to: a. assess the patient’s blood carbon monoxide level. b. remove carbon monoxide from the patient’s blood. c. measure the residual volume. d. assess the alveolar-capillary membrane.

ANS: D Alveolar-capillary membrane function is measured by the pulmonary diffusion capacity of the carbon monoxide test. A very small amount of carbon monoxide (CO) is inhaled by the patient to perform the test. But the CO level is not measured in the blood, and CO is not removed from the blood.

10. Total lung capacity is composed of which of the following?

1. IRV 2. IC 3. ERV 4. RV 9TH a. 3, 4 b. 2, 3 c. 1, 2 d. 2, 3, 4 ANS: D Total lung capacity (TLC) can be calculated by adding IC, ERV, and RV. 11. A respiratory therapist has just performed a pulmonary function study and notes that the results show obstructive lung disease with a decreased DLCO value. Which of the following is the best interpretation of these results? a. The patient has pulmonary fibrosis. b. The patient has asthma. c. The patient has cystic fibrosis. d. The patient has emphysema.

ANS: D A decreased DLCO is a hallmark clinical manifestation in emphysema because of the destruction of the alveolar pulmonary capillaries and decreased surface area for gas diffusion associated with the disease. The DLCO is usually normal in all other obstructive lung disorders. Pulmonary fibrosis is a restrictive disease, not an obstructive disease.

12. The respiratory therapist is called to the neurologic care unit to assess the muscle strength of a patient diagnosed with myasthenia gravis. Which of the following tests should the therapist recommend to assess the patient’s respiratory muscle strength? a. Maximum inspiratory pressure (MIP) b. Maximum inspiratory flowrate (MIFR) c. Maximum expiratory flowrate (MEFR) d. Vital capacity (VC) ANS: A The most commonly used tests to evaluate the patient’s respiratory muscle strength at the bedside are maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), forced vital capacity (FVC), and maximum voluntary ventilation (MVV).

13. The respiratory therapist is performing a pulmonary function study on a patient who has periodic symptoms of asthma. The pulmonary function results are within normal limits.

What further testing can the therapist recommend to aid in either confirming or negating the possible diagnosis? a. Inhaled methacholine challenge testing b. Body plethysmography c. Inhaled digitalis d. Warm, humid air challenge ANS: A Because some patients have clinical manifestations associated with asthma, but otherwise normal lung function between asthma episodes, measurements of airway responsiveness to inhaled methacholine or histamine, or an indirect challenge test to inhaled mannitol, or to an exercise or cold air challen Nge mRayIbe uGsefBul.inCcoMnfirming a diagnosis of asthma.

U S N T

O

Chapter 05: Blood Gas Assessment Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following would be a normal person’s arterial carbon dioxide pressure (PaCO2)? a. 25 to 35 mm Hg b. 35 to 45 mm Hg c. 45 to 60 mm Hg d. 60 to 80 mm Hg ANS: B The normal PaCO2 range is 35 to 45 mm Hg; below this is hypocapnia, and above this is hypercapnia.

2. Which of the following would be a normal person’s venous oxygen pressure (PaO2)? a. 35 to 45 mm Hg b. 45 to 80 mm Hg c. 80 to 100 mm Hg d. 100 to 120 mm Hg ANS: A A normal person’s PaO2 is 35 to 45 mm Hg. Higher values could only be achieved by giving the person supplemental oxNy geRn. I G B.C M

U

S N T

O

3. Which of the following will likely be seen in the arterial blood gas values of a patient with acute ventilatory failure?

1. Acidic pH 2. Near-normal bicarbonate level 3. Alkaline pH 4. High carbon dioxide level a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 4 ANS: D An alkaline pH could be caused by hyperventilation. Ventilatory failure with a high CO2 level would cause an acidotic pH, with a near-normal bicarbonate level.

4. What causes stimulation of the peripheral chemoreceptors to increase the ventilatory rate? a. Pain or anxiety b. PaCO2 of about 40 mm Hg c. PaO2 of about 60 mm Hg or less d. Venous pH of 7.30 to 7.40 ANS: C

A lower than normal PaO2 of about 60 mm Hg or less will stimulate the peripheral chemoreceptors. These chemoreceptors will not be stimulated by pain or anxiety, normal PaCO2, or normal venous pH. 5. A patient has had chronic ventilatory failure for several years. What is the primary factor that determines her breathing pattern? a. Muscle efficiency b. Ventilatory efficiency c. Heart function d. Work efficiency ANS: D Although the exact mechanism is unclear, the patient slowly develops a breathing pattern that uses the least amount of oxygen for the energy expended. In essence, the patient selects a breathing pattern based on work efficiency rather than ventilatory efficiency.

6. An anion gap of 17 would indicate: a. metabolic acidosis. b. respiratory alkalosis. c. respiratory acidosis. d. metabolic alkalosis.

ANS: A An anion gap of 15 or higher would indicate a metabolic acidosis. The normal gap is 9 to 14 mEq/L.

7.

aRcidIosisGincBlu.deC:

1. diabetic ketoacidosis.

U S N T 2. shallow breathing from a sedative overdose.

3. lactic acidosis.

4. renal failure. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4

Common causes of metabo lic

M O

N

ANS: D Shallow breathing from a sedative overdose would cause a respiratory acidosis. All of the other options would cause a metabolic acidosis.

8. Which of the following would be found in a stable patient with long-standing obstructive lung disease? a. Low bicarbonate level and low carbon dioxide level b. Low bicarbonate level and high carbon dioxide level c. High bicarbonate level and low carbon dioxide level d. High bicarbonate level and high carbon dioxide level ANS: D A high bicarbonate level and high carbon dioxide level are found in a stable patient with long-standing obstructive lung disease. The other options are associated with other acid-base disorders.

9. Common causes of metabolic alkalosis include: 1. renal failure.

2. vomiting.

3. excessive sodium bicarbonate administration.

4. gastric suctioning. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Renal failure does not cause metabolic alkalosis.

10. The most common cause of acute alveolar hyperventilation is: a. hypoxemia. b. metabolic alkalosis. c. tachycardia. d. supplemental oxygen administration.

ANS: A The most common cause of acute alveolar hyperventilation is hypoxemia. The decreased PaO2 seen during acute alveolar hyperventilation usually develops from a decreased ventilation-perfusion ratio, capillary shunting, or venous admixture associated with a pulmonary disorder. The PaO2 continues to drop as the pathologic effects of the disease intensify. Eventually the PaO2 may decline to a point low enough (a PaO2 of about 60 mm Hg) to significantly stimulate the peripheral chemoreceptors, which in turn causesNtheR I G B.C ventilatory rate to increase. TUhe i Sncr Nease Td venti Olatory response in turn causes the PaCO2 to decrease and the pH to increase.

11. Mechanical ventilation is indicated for which of the following ABG results? a. pH 7.56; PaCO2 27; HCO3 23; PaO2 63 b. pH 7.21; PaCO2 68; HCO3 26; PaO2 51 c. pH 7.36; PaCO2 79; HCO3 43; PaO2 63 d. pH 7.52; PaCO2 51; HCO3 40; PaO2 46 ANS: B When an increased PaCO2 is accompanied by acidemia (decreased pH), acute ventilatory failure, or respiratory acidosis, is said to exist. Clinically, this is a medical emergency that may require mechanical ventilation.

12. A respiratory therapist is questioning the accuracy of the ABG results obtained on a patient in the ICU. The results show a pH and PaO2 that seem unreasonably high, while the PaCO2 seems unreasonably low. Which of the following would most likely cause these erroneous results? a. A venous sample was obtained. b. There was excessive heparin in the blood gas syringe. c. The sample was excessively delayed in analysis. d. There was an air bubble in the sample.

ANS: D

An air bubble in the sample would cause an increase in the pH and PaO2 while causing a decrease in PaCO2.

13. The respiratory therapist is assessing a patient with end-stage COPD who was admitted to the medical ward for an exacerbation of COPD due to increasing sputum purulence. The therapist notes the following ABG results in the patient’s electronic medical record: pH 7.52, PaCO2 51; HCO3 40; PaO2 46. Which of the following is the best interpretation of these ABG results? a. Chronic ventilatory failure with hypoxemia b. Acute ventilatory failure with hypoxemia c. Partially compensated metabolic alkalosis with hypoxemia d. Acute alveolar hyperventilation superimposed on chronic ventilatory failure ANS: D An end-stage COPD patient would be expected to have chronic ventilatory failure for baseline ABG results. During an exacerbation, he/she may also experience acute periods of hyperventilation. If able, these patients have the mechanical reserve to increase their alveolar ventilation significantly in an attempt to maintain their baseline PaO2, which has decreased in relation to an acute pulmonary problem, in this case an increase in sputum purulence. When excessive alveolar ventilation occurs, this action causes the patient’s PaCO2 to decrease from its normally “high baseline” level. As the PaCO2 decreases, the arterial pH increases. As this condition intensifies, the patient’s baseline ABG values can quickly change from chronic ventilatory failure to acute alveolar hyperventilation superimposed on chronic ventilatory failure. If the therapist does not know the past history of the patient with acute alveolar hyperventilation superimposed on chronic ventilatory failure, he/she might initially interpret the ABG values as signifying partially compensated metabolic alkalosis with seNvereRhyI miBTa..HCoweMver, the clinical situation that offsets UpoxSGeN this interpretation is the presence of marked hypoxemia. A low oxygen level is not normally seen in patients with pure metabolic alkalosis. Thus whenever the ABG values appear to reflect partially compensated metabolic alkalosis but the condition is accompanied by significant hypoxemia, the respiratory therapist should be alert to the possibility of acute alveolar hyperventilation superimposed on chronic ventilatory failure.

14. Calculate the anion gap using the following data: Na+: 140 mEq/L K+ 4.1 mEq/L Cl-: 105 mEq/L HCO3-: 24 mEq/L a. 31 mEq/L. b. 21 mEq/L. c. 11 mEq/L. d. More information is needed to calculate.

ANS: C The anion gap is the calculated difference between the Na+ ions and the sum of the HCO3 - and Clions. The potassium is not needed in this calculation.

Anion gap

9TH

Chapter 06: Assessment of Oxygenation Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. When a sample of arterial blood is analyzed for the pressure of oxygen (PaO2), the value comes from the: a. blood plasma. b. leukocytes. c. hemoglobin. d. erythrocytes.

ANS: A A small amount of oxygen that diffuses from the alveoli to the pulmonary capillary blood remains in the dissolved form. The term dissolved means that the gas molecule (in this case oxygen) maintains its exact molecular structure and freely moves throughout the plasma of the blood in its normal gaseous state. Clinically, it is the dissolved oxygen that is measured to assess the patient’s partial pressure of oxygen (PO2). Oxygen is chemically bound to the hemoglobin in the erythrocytes and is measured by an oximeter as the saturation, not as a partial pressure. Leukocytes do not carry oxygen.

2. Oxygen consumption: 1. increases with exercise.

2. is the amount of oxygen used by the body.

3. is inversely related to caNrbUonRdSioIxNidGe TprBod.uCctOioMn. 4. is about 250 mL per minute in the resting adult. a. 1, 2 b. 3, 4 c. 2, 4 d. 1, 2, 4 ANS: D Oxygen consumption is the amount of oxygen used by the body and increases with exercise.

At rest, an adult consumes about 250 mL per minute. Oxygen use is not inversely related to carbon dioxide production.

3. A patient has been exposed to smoke during a house fire. An ABG result shows a normal PaO2. How should the patient’s PaO2 value be interpreted? a. The PaO2 is being falsely elevated by the carbon monoxide. b. The PaO2 is being falsely decreased by the carbon monoxide. c. The PaO2 is accurate. d. The PaO2 is a false measurement because the presence of carbon monoxide makes the analyzer unable to determine the PaO2.

ANS: C The patient’s plasma PaO2 value may be normal or high. This can mislead the respiratory therapist because the patient’s total oxygen value (CaO2) is low. Remember that carbon monoxide will prevent hemoglobin from carrying oxygen.

4. A person’s C(a-v)O2 increases in which of the following?

1. Seizures 2. Peripheral shunting 3. Hyperthermia 4. Exercise a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D Peripheral shunting decreases the C(a-v)O2 because less oxygen is extracted by the tissues. All of the other listed options increase oxygen extraction and so will increase the C(a-v)O2.

5. A sample of blood has been taken from a patient’s pulmonary artery. What mixed venous oxygen saturation value (SvO2) would indicate that the patient is normal? a. 40 mm Hg b. 95 mm Hg c. 75% d. 97% ANS: C A normal SvO2 is 75%. Normal PvO2 is 40 mm Hg. Normal arterial blood values for oxygen are SaO2 of 97% and PaO2 of 95 mm Hg. 6. Polycythemia is: NURSINGTB.COM 1. a condition of too many red blood cells.

2. a condition of too few red blood cells.

3. caused by lack of iron in the diet.

4. the body’s response to chronic hypoxemia. a. 1, 2 b. 2, 3 c. 1, 4 d. 2, 4 ANS: C The body’s response to chronic hypoxemia is to produce too many red blood cells; this is polycythemia. Lack of iron in the diet could lead to anemia.

7. A patient has a chronic respiratory disorder and vasoconstriction of her pulmonary vascular system. What is the chief control over this vasoconstriction?

Low PAO2 a.

Low PaO2 b.

High PaCO2 c. d. High pH ANS: A A low PAO2 (pressure of alveolar oxygen) is primarily responsible for pulmonary vasoconstriction. Arterial oxygen and carbon dioxide values and pH are not causes.

8. An increased cardiac output causes the: 1. C(a-v)O2 to decrease.

2. SvO2 to increase.

3. total O2 delivery to decrease.

4. O2ER to increase. a. 1 b. 2, 3 c. 3, 4 d. 1, 2 ANS: D As cardiac output increases, less oxygen is extracted from the blood. Because of this, the C(a-v)O2 decreases and SvO2 increases. Increased cardiac output would also increase total oxygen delivery and decrease the oxygen extraction ratio.

9. A condition that will cause hypoxic hypoxia is: a. cyanosis. b. decreased cardiac output or heart failure. c. hypoventilation from an overdose of a sedative medication. d. carbon monoxide poisoning.

ANS: C Hypoventilation from any cause will cause hypoxic hypoxia because an inadequate amount of oxygen is breathed in. Cyanide poisoning will cause histotoxic hypoxia because the tissue cells will not be able to metabolize oxygen. Decreased cardiac output or heart failure will cause circulatory hypoxia because the heart will not deliver enough blood and oxygen to the tissues. Carbon monoxide pNoisRoninIg wGill cBa.usCe anMemic hypoxia because the hemoglobin cannot carry oxygen.

U S N T O 10. A condition that will cause anemic hypoxia is: a. cyanide poisoning. b. decreased cardiac output or heart failure. c. polycythemia. d. carbon monoxide poisoning.

ANS: D Carbon monoxide poisoning will cause anemic hypoxia because the hemoglobin cannot carry oxygen.

Cyanide poisoning will cause histotoxic hypoxia because the tissue cells will not be able to metabolize oxygen. Decreased cardiac output or heart failure will cause circulatory hypoxia because the heart will not deliver enough blood and oxygen to the tissues. Polycythemia does not cause hypoxia.

11. The respiratory therapist is evaluating a patient in the intensive care unit who shows signs of tissue hypoxia. Laboratory results reveal the following: HgB 14.8 grams, CaO2 19.6 vol.%, PaO2 102 mm Hg, a-v difference 9.8 vol.%, PvO2 24 mm Hg. Based on these results, which of the following types of hypoxia does this patient have? a. Hypoxic hypoxia b. Anemic hypoxia c. Circulatory hypoxia d. Histotoxic hypoxia

ANS: C An increase in the a-v difference is due to a decrease in cardiac output (circulatory hypoxia). The cardiac output and a-v difference are inversely related, and an a-v difference of 9.9 vol.% is evidence of the inadequacy of the cardiac output.

12. The respiratory therapist is reviewing a patient’s electronic medical record to try to verify if the patient has tissue hypoxia. Which of the following laboratory values is most likely to correlate with tissue hypoxia? a. Metabolic acidosis b. Thrombocytopenia c. Hypokalemia d. Bilirubinemia ANS: A When hypoxia exists, alternate anaerobic mechanisms are activated in the tissues that produce dangerous metabolites—such as lactic acid—as waste products. Lactic acid is a nonvolatile acid and causes the pH to decrease, resulting in metabolic acidosis.

13. A patient is mildly hypoxemic. Which of the following signs would the respiratory therapist expect to find in this patient? a. An increase in the patient’s breathing rate and heart rate b. A decrease in systemic blood pressure c. Cardiac dysrhythmias on an EKG d. Anemia ANS: A Clinically, the presence of mild hypoxemia generally stimulates the oxygen peripheral N R I G B.C chemoreceptors to increase thUe pSatieNnt’sTbreathiOng rate and heart rate; consequently blood pressure may slightly increase, not decrease. Cardiac dysrhythmias would not be expected with mild hypoxemia. Anemia is unrelated to mild hypoxemia.

14. Which of the following values is considered a normal hemoglobin level in a healthy adult? a. 0.003–1.34 mEq/L b. 12 to 16 g/dL c. 96% to 100% d. 14 to 20 g/dL. ANS: B Clinically, the weight measurement of hemoglobin, in reference to 100 mL of blood, is known as the grams per deciliter (g/dL). The normal hemoglobin value for men is 14 to 16 g/dL. The normal hemoglobin value for women is 12 to 15 g/dL. The normal hemoglobin value for infants is 14 to 20 g/dL.

Chapter 07: Assessment of the Cardiovascular System Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. The T wave represents: a. depolarization of the ventricles. b. repolarization of the ventricles. c. depolarization of the atria. d. repolarization of the atria.

ANS: B The T wave represents the repolarization of the ventricles. The QRS complex represents the depolarization of the ventricles. The P wave represents the depolarization of the atria. The repolarization of the atria cannot be seen.

2. When reviewing a cardiac rhythm strip, the respiratory therapist notices that there are three large boxes between two QRS complexes. Approximately what is this patient’s heart rate? a. 60 b. 75 c. 100 d. 150 ANS: C Approximate heart rate canNU be Sdete rmi diviMding the number of large Bbinto .y C300.

NIrhythm T Gned boxes between QRS complexes R on the strip Therefore 300 divided by 3 = 100 bpm for a heart rate.

3. Which of the following is found when a patient has sinus arrhythmia?

1. Rate decreases during expiration.

2. Rate decreases during inspiration.

3. Rate varies by more than 10% from beat to beat.

4. Rate increases during inspiration. a. 3 b. 2, 3 c. 1, 4 d. 1, 3, 4 ANS: D Sinus arrhythmia has the following identifying traits: rate decreases during expiration, rate varies by more than 10% from beat to beat, and rate increases during inspiration.

4. A premature ventricular contraction (PVC) can be identified by which of the following?

1. There is no P wave.

2. The QRS is wide.

3. The QRS looks normal.

4. The heart rate is altered. a. 1

b. 3, 4 c. 1, 2, 4 d. 1, 3, 4 ANS: C A PVC would have the following traits: there is no P wave, the QRS is wide and bizarre looking, and the heart rate is altered.

5. A premature ventricular contraction (PVC) can be caused by: 1. sleep.

2. intrinsic myocardial disease.

3. hypoxemia.

4. acidemia. a. 1 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: D Sleep does not cause PVCs. 6. In which of the following is the atrial rate faster than the ventricular rate?

1. Atrial fibrillation 2. Sinus bradycardia 3. Atrial flutter 4. Sinus tachycardia a. 1, 3 9TH b. 2, 4 c. 3, 4 d. 1, 2, 3 ANS: A Atrial fibrillation and atrial flutter both involve an abnormally fast atrial depolarization rate, while the ventricular rate is less than the atrial rate. Sinus bradycardia is a heart rate of less than 60 bpm. Sinus tachycardia is a very fast ventricular rate that matches the atrial rate.

7. Which of the following will be found in a patient with asystole?

1. Increased ventricular activity 2. Absence of electrical activity 3. No blood pressure 4. Highly variable heart rate a. 2 b. 1, 4 c. 2, 3 d. 1, 3, 4 ANS: C Asystole is the complete absence of electrical and mechanical activity in the heart. Because of that, there is no blood pressure. Death is imminent.

8. A pulmonary artery (Swan-Ganz) catheter can be used for which of the following?

1. Measuring cardiac output 2. Arterial blood sampling 3. Measuring left atrial pressure 4. Measuring pulmonary artery pressure a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D A pulmonary artery (Swan-Ganz) catheter can be used to sample mixed venous blood. Arterial blood sampling requires an arterial (radial) catheter. The other listed options can be performed with a pulmonary artery catheter.

9. A central venous pressure (CVP) catheter is used to: a. measure left atrial pressure. b. measure left ventricular work. c. monitor right ventricular function. d. monitor left ventricular function.

ANS: C A central venous pressure (CVP) catheter is used to monitor right ventricular function and measure right atrial pressure and the right ventricular filling pressure. Left ventricular function cannot be measured with a CVP catheter; a pulmonary artery catheter is needed.

10. Which of the following hemodynamic changes are commonly seen in a patient with I G B.C M cardiogenic pulmonary edeNma?R

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1. Increased pulmonary capil lary we dge pressur e (PCWP) 2. Increased pulmonary vascular resistance (PVR) 3. Decreased mean pulmonary artery pressure (PA) 4. Decreased cardiac output (CO) a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: A Patients with pulmonary edema (hypervolemia) will have an increased pulmonary capillary wedge pressure (PCWP) and decreased cardiac output (CO). The lung damage caused by COPD leads to increased pulmonary vascular resistance (PVR). The PA pressure will be increased with pulmonary edema.

11. The respiratory therapist is assessing a patient with sinus tachycardia. Which of the following would least likely be a cause of the sinus tachycardia? a. Hypoxemia b. Severe anemia c. Hyperthermia d. Beta-blocker medications ANS: D

Common abnormal causes of sinus tachycardia include hypoxemia, severe anemia, hyperthermia, massive hemorrhage, pain, fear, anxiety, hyperthyroidism, and sympathomimetic or parasympatholytic drug administration. Beta-blocker medication may lead to sinus bradycardia, not sinus tachycardia.

12. The respiratory therapist is monitoring a patient in the medical ICU and notes multiple premature ventricular complexes (PVCs) on the cardiac monitor. The respiratory therapist elects to review the patient’s medication administration record (MAR) for medications the patient is receiving to rule out medication toxicity as a cause of the PVCs. Which of the following medications should the therapist evaluate as a possibility of inducing PVCs? a. Theophylline b. Beta-blockers c. Vitamin D d. Acetaminophen ANS: A PVCs may be a sign of theophylline or alpha-stimulate or beta-agonist toxicity.

Beta-blockers may lead to sinus bradycardia. Vitamin D and acetaminophen would not cause PVCs. 13. The respiratory therapist is called to a patient’s room as part of the rapid response team (RRT). The patient is unconscious and pulseless. The EKG monitor displays asystole.

Which of the following actions would be indicated at this time?

1. Call a code.

2. Begin CPR. 3. Defibrillate the patient.

4. Administer ACLS medicUNatio I G OB.C M S RNns.T a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Electric shock (defibrillation) is not effective for this rhythm—CPR and ACLS medications are required. The therapist should call a code, begin CPR, and administer ACLS medications that are used to stimulate electrical activity of the heart. Defibrillation is only effective if the heart has no electrical activity.

Chapter 08: Radiologic Examination of the Chest Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following is true of a chest radiograph? a. Lateral films are shot through one side of an upright patient. b. AP films are typically taken in the x-ray department. c. PA films artificially increase the size of the heart shadow. d. Lateral decubitus films are shot with the patient lying supine.

ANS: A A lateral radiograph is filmed with the patient standing upright with either the left (preferred) or right side of the chest against the film plate. AP films are taken by a portable machine at the patient’s bedside. PA films show the heart at its correct size. A lateral decubitus film is taken with the patient lying on either side.

2. Which of the following are evaluated on a chest radiograph?

1. Examination of baby in pregnant women 2. Exposure quality 3. The heart shadow 4. The tracheobronchial tree a. 4 b. 1, 4 c. 1, 2, 4 9TH d. 2, 3, 4 ANS: D An ultrasound, not a chest radiograph, is most associated with the test used to examine a baby in pregnant women. All of the other listed options are evaluated on a chest radiograph.

3. For most chest x-ray studies, what is usually done? a. There is a full exhalation. b. There is a full inspiration. c. Separate inspiratory and expiratory films are taken. d. The patient is told to pant to provide a middle lung volume.

ANS: B The vast majority of chest radiographs are taken at full inspiration when the breath is held. A patient with obstructive lung disease may also have an expiratory film taken to compare the position of the hemidiaphragms. Panting should not be done because the movement would blur the image on the film.

4. The heart shadow on a chest radiograph will show up larger than normal on a(n): a. AP film. b. PA film. c. left lateral film. d. computed tomography (CT) scan.

ANS: A With an AP projection, the heart is enlarged because the x-rays enter from the front and exit from the back to the film. A PA and left lateral film will show the heart at the correct size. The same is true of a CT scan.

5. Which of the following would be normal findings of the heart and its surrounding area?

1. The left hilum is about 2 cm higher than the right hilum.

2. Most of the heart shadow is to the right of the sternum.

3. Calcified lymph nodes indicate an adult patient.

4. The cardiothoracic ratio is less than 1:2. a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: A Normally, the left hilum is about 2 cm higher than the right hilum and the cardiothoracic ratio is less than 1:2. Most of the heart’s shadow should be on the left side of the sternum. Calcified lymph nodes could be a sign of histoplasmosis or tuberculosis.

6. The chest radiograph shows blunting of the patient’s costophrenic angles. What does this suggest? a. The patient did not take a deep enough breath. b. Lung cancer. c. Pleural fluid. d. Underpenetrated exposure on the film.

ANS: C

9TH

When the patient is standing upright for the chest x-ray, any pleural fluid will go to the bases of the lungs and blunt the costophrenic angles. None of the other listed options will affect the costophrenic angles.

7. A patient has a long smoking history and has recently coughed up blood. The physician suspects that there may be lung cancer, but no lesions can be seen on a standard chest radiograph. A CT scan offers which of the following advantages?

1. Bronchial tumors can be seen.

2. Lung tumors as small as 0.4 cm can be seen.

3. A tumor’s metabolism can be identified.

4. A mediastinal mass can be seen. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Only a PET scan can identify a tumor by its metabolic activity. A CT scan can offer the other listed advantages.

8. A PET/CT scan can provide which of the following?

1. Early detection of cancer metastasis

2. Accurate staging of cancer 3. Radiation treatment of the cancer 4. Activation of chemotherapy drugs within the tumor a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3 ANS: A A PET/CT scan is helpful because it provides early detection of cancer metastasis and accurate staging of cancer. Radiation treatment of the cancer and activation of chemotherapy drugs within the tumor are entirely separate from a PET/CT scan.

9. Which of the following can be identified by pulmonary angiography?

1. Pulmonary emboli 2. Coronary artery occlusions 3. Arteriovenous malformations 4. Cause of hemoptysis a. 4 b. 1, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B Pulmonary angiography can identify pulmonary emboli and arteriovenous malformations. A coronary angiogram is needed to find coronary artery occlusions. A bronchoscopy may be needed to find the source oNf B.C M heRmopItysGis.

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10. A patient has had a ventilation-perfusion scan. What would be identified from the ventilation scan? a. Location of a lung abscess b. Alveolar consolidation c. Location of a pulmonary embolism d. Location of an airway obstruction ANS: B A ventilation scan can identify the location of an airway obstruction. A perfusion scan can identify the other listed problems.

11. The respiratory therapist is called to evaluate a patient with a suspected pleural effusion. The respiratory therapist would most likely recommend which of the following chest radiographic views to help determine if the patient has a pleural effusion? a. An AP film b. A PA film c. A left lateral film d. A lateral decubitus film ANS: D

The lateral decubitus radiograph is useful in the diagnosis of a suspected or known fluid accumulation in the pleural space (i.e., a pleural effusion) that is not easily seen in the PA radiograph. A pleural effusion, which is usually more thinly spread out over the diaphragm in the upright position, collects in the gravity-dependent areas while the patient is in the lateral decubitus position, allowing the fluid to be more readily seen.

12. The respiratory therapist is called to evaluate a patient with a suspected pulmonary embolus.

The respiratory therapist would most likely recommend which of the following diagnostic procedures to help determine if the patient has a pulmonary embolus? a. CTPA b. Fluoroscopy c. PET scan d. MRI scan ANS: A Computed tomography pulmonary angiogram (CTPA) (also called a CT pulmonary angiography) with intravenous contrast has largely replaced pulmonary angiography and is fast becoming the firstline test for diagnosing suspected pulmonary embolism. The CTPA is now a preferred choice of imaging in the diagnosis of a pulmonary embolism because the only invasive requirement for the scan is an intravenous line.

13. The respiratory therapist is reviewing the electronic medical record of a patient in the medical ICU. In reading the most recent chest radiograph interpretation, the therapist notes that the cardiothoracic ratio is stated to be less than 1:2 on the PA view. How should the therapist interpret this information? a. This is a normal cardiothoracic ratio. oraI ratioB..C M b. This is a decreased cardUNioth S RN Tcic GO c. This ratio shows hyperinflation of the lung fields with subsequent air trapping. d. This interpretation should be ignored because it is inaccurate in the PA view.

ANS: A On the PA projection the ratio of the width of the heart to the thorax (the cardiothoracic ratio) is normally less than 1:2. In other words, normally the width of the heart should be less than 50% of the width of the thorax.

14. The respiratory therapist is reviewing the transthoracic echocardiogram of a patient. The images are very poor. What other type of imaging study can they suggest to the physician to improve the image quality? a. A transesophageal echocardiogram b. A stress echocardiogram c. A color Doppler d. Fluoroscopy ANS: A Transesophageal echocardiogram (TEE) is commonly used when the quality of the transthoracic echocardiogram images is poor. A flexible tube containing a transducer is passed down the esophagus and positioned close to the heart. The TEE provides a cleaner and sharper image of the heart, since the various structures between the outside of the chest and heart are not between the transducer and the heart.

Chapter 09: Other Important Tests and Procedures Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Culture and sensitivity tests: a. stain a microorganism as gram positive or gram negative. b. determine the shape of the organisms present. c. identify the DNA of organisms present in the sputum. d. determine the antibiotic(s) best suited for combating an infection.

ANS: D Culture and sensitivity tests are performed to diagnose bacterial infection, select an antibiotic, and evaluate the effectiveness of antibiotic therapy. The Gram stain procedure is used to classify bacteria as gram positive or gram negative. Microscopic examination is needed to identify the organism’s shape. DNA analysis requires special laboratory capabilities.

2. Therapeutic bronchoscopy can be used for: 1. bronchiectasis therapy.

2. removal of a foreign body.

3. selective lavage.

4. management of life-threatening hemoptysis. a. 1, 3 b. 1, 2, 4 9TH c. 2, 3, 4 d. 1, 2, 3 ANS: C Bronchoscopy can be used to observe a patient’s airways for bronchiectasis evaluation.

However, this is not a therapeutic procedure to treat the condition. All of the other listed options are therapeutically managed by bronchoscopy.

3. Gram staining is done to: 1. classify organisms as gram positive or gram negative.

2. identify tuberculosis organisms.

3. speed up the organism culturing process.

4. help guide antibiotic therapy. a. 3 b. 1, 4 c. 2, 3 d. 1, 2, 4 ANS: B Gram staining is done to classify organisms as gram positive or gram negative. Often this will help to guide the selection of an antibiotic until the culture and sensitivity results confirm the best drug.

4. Diagnostic thoracentesis can be used to: a. withdraw a secretion sample from the lung for a sputum smear. b. withdraw a secretion sample from the lung for a Gram stain. c. determine the etiology of a pleural effusion. d. remove air from the pleural space.

ANS: C After the pleural effusion fluid is analyzed, the physician will know its etiology. Then the proper treatment can be done. Bronchoscopy is done to get a secretion sample from the airways.

Therapeutic thoracentesis is done to remove air from the pleural space.

5. A patient has pneumonia and a right pleural effusion. If the pleural exudate fluid is infected, it will show: 1. a low protein level.

2. a high white blood cell count.

3. bacteria.

4. many red blood cells. a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: B Infected pleural exudate fluid will show a high white blood cell count and bacteria among other characteristic findings. A transudate will have a low protein level and other characteristic findings.

Many red blood cells would indicate a pulmonary embolism.

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6. After a thoracentesis proce duUre , Sit for: a. bronchospasm. b. hemoptysis. c. increased blood urea nitrogen (BUN). d. pneumothorax.

I N GTB .C OM is im p o rta n t t o monitor the patient

ANS: D Because a needle has to be inserted through the chest wall to perform a thoracentesis, pneumothorax is a possible complication. Bronchoscopy could cause bronchospasm or hemoptysis. Increased BUN is associated with kidney failure.

7. In a normal differential white blood cell (WBC) count, which of the following would have the highest number? a. Neutrophils b. Basophils c. Eosinophils d. Lymphocytes ANS: A Normally, there are 60% to 70% neutrophils in a WBC count. Fewer basophils, lymphocytes, eosinophils, and other WBC types will be seen.

8. A 14-year-old patient has had a serious asthma attack. Her white blood cell count can be expected to show:

a. b. c. d.

decreased neutrophils. decreased erythrocytes. increased eosinophils. increased monocytes.

ANS: C After an asthma attack, there will be an increased eosinophil count. The other types of white blood cells will be increased with a bacterial infection.

9. In response to a viral infection, which of the following can be expected to be seen in the white blood cell count? a. Increased lymphocytes b. Decreased monocytes c. Increased basophils d. Decreased platelets ANS: A Increased lymphocytes will be seen in response to a viral infection. Monocytes and basophils will increase with a bacterial infection. Platelets are involved in blood clotting.

10. For blood urea nitrogen (BUN) and creatinine values: a. serum creatinine is a protein produced in the kidneys. b. BUN and serum creatinine values that are higher than the normal range indicate renal failure. c. urea is a waste product of carbohydrate metabolism in the intestines. d. BUN values that are below normal indicate renal failure.

ANS: B

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BUN and creatinine values will increase with renal failure. All of the other statements are false.

11. The respiratory therapist is called to evaluate a patient for arterial line placement needed for accessibility and repeated ABG sampling. In evaluating the risk for bleeding, the therapist should establish that the patient has a platelet count of at least /mm3 before recommending placement of the arterial line. a. 1000 b. 10,000 c. 20,000 d. 50,000 e. 100,000 f. 200,000 ANS: D Generally, platelet counts greater than 50,000/mm3 are not associated with spontaneous bleeding.

Therefore various diagnostic or therapeutic procedures, such as bronchoscopy or the insertion of an arterial catheter, are usually safe when the platelet count is greater than 50,000/mm3.

12. The respiratory therapist is reviewing the electronic medical record of a patient recently admitted to the medical floor. The therapist notes that a sputum sample was sent to the lab for an acid-fast smear and culture. How should the therapist interpret this information?

a. b. c. d.

Suspect that the patient has Mycoplasma pneumoniae pneumonia.

Suspect that the patient has Rickettsiae pneumonia.

Suspect that the patient has Pneumocystis jiroveci (carinii) pneumonia.

Suspect that the patient has Mycobacterium tuberculosis pneumonia.

ANS: D The acid-fast smear and culture is performed to determine the presence of acid-fast bacilli (e.g., Mycobacterium tuberculosis). Acid-fast testing is used specifically for Mycobacterium tuberculosis, not any of the other listed microorganisms.

13. The respiratory therapist is caring for a patient who is receiving diuretic therapy as part of the medication regimen for her congestive heart failure. Which of the following would the therapist most likely monitor in watching for common side effects associated with diuretic therapy? a. Hypokalemia b. Hyperchloremia c. Hyperbilirubinemia d. Hyponatremia ANS: A Hypokalemia is a side effect of diuretic therapy.

14. The respiratory therapist is caring for a patient with a newly diagnosed pleural lesion.The patient cannot undergo a CT scan due to extreme claustrophobia. Which procedure can be performed to diagnose the cause of the lesion? a. Video-assisted thoracoscopy surgery b. Navigational I G B.C M bronchoscNopyR S N T O c. Therapeutic bronchoscopUy d. Acid-fast smear ANS: A In video-assisted thoracoscopy surgery (VATS), a small incision is made in the chest wall, and a device called a thoracoscope is inserted. This device is equipped with a fiberscope that can examine the pleural cavity. The results are displayed on a video monitor (as in bronchoscopy). When pleural lesions are identified, they can be biopsied under video guidance. This procedure is helpful in the diagnosis of tuberculosis, mesothelioma, and metastatic cancer. Before navigational bronchoscopy is administered, a routine CT scan is performed to locate any masses or infiltrate in the lung. Clinically, therapeutic bronchoscopy is commonly used in the management of bronchiectasis, alveolar proteinosis (with lavage), lung abscess, smoke inhalation and thermal injuries, and lung cancer.

15. Which of the following are primary reasons for which an endobronchial ultrasound (EBUS) is recommended?

1. To detect the presence of tumors or pathologically enlarged lymph nodes 2. To diagnose stridor or localized wheezing 3. To diagnose tumors within the lung or mediastinum 4. To diagnose lymph node abnormalities in the mediastinum or hila a. 1, 2 b. 2, 3 c. 1, 3, 4

d. 2, 3, 4 ANS: C There are four primary reasons for which an EBUS is recommended: • To detect the presence of tumors or pathologically enlarged lymph nodes.

• To diagnose tumors within the lung or mediastinum.

• To diagnose lymph node abnormalities in the mediastinum or hila.

• To identify specific infections or help to diagnose other lung conditions such as sarcoidosis.

9TH

Chapter 10: The Therapist-Driven Protocol Program Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. When performing a therapist-driven protocol (TDP), the severity assessment determines: a. the frequency of performing a treatment modality. b. the baseline dyspnea index. c. the number of hospital days covered by the insurance carrier. d. how urgently the physician wants the patient treated.

ANS: A Under a protocol, the severity assessment refers to the frequency of treatment. If the patient worsens, therapy must be up-regulated; if the patient improves, therapy must be down-regulated.

2. A TDP can be started after: a. the nurse finishes his/her assessment. b. the treatment option is selected. c. a physician’s order for the TDP is received. d. authorization is received from the patient’s insurance carrier.

ANS: C A physician must order a TDP before the respiratory therapist can initiate the ordered protocol.

9TH 3. Postural drainage, percussion, and vibration are part of what TDP? a. Lung expansion protocol b. Bronchopulmonary hygiene therapy protocol c. Aerosolized medication therapy protocol d. Oxygen therapy protocol ANS: B Postural drainage, percussion, and vibration are treatment modalities in the bronchopulmonary hygiene therapy protocol. Increased hydration, cough and deep breathing, incentive spirometry, and suctioning are among other treatment options in this protocol.

4. When a patient has an acute MI, which of the following protocols should the respiratory therapist initiate? a. Hyperinflation therapy protocol b. Oxygen therapy protocol c. Bronchopulmonary hygiene therapy protocol d. Aerosolized medication therapy protocol ANS: B Acute myocardial infarction is one of the clinical indicators specified on the oxygen therapy protocol. Oxygen therapy will reduce myocardial work.

5. According to the aerosolized medication therapy protocol, the respiratory therapist may select medications from which of the following categories?

1. Antiinflammatory agents 2. Sympathomimetic agents 3. Parasympatholytic agents 4. Antimicrobial agents a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Antimicrobial agents are not among the medication selections on the aerosolized medication therapy protocol. When warranted, antimicrobial agents would be prescribed by a physician.

6. An obese patient had upper abdominal surgery 2 days earlier. He has a weak nonproductive cough and a pulse oximeter (SpO2) reading of 84% on room air. Which therapist-driven protocols should be implemented?

1. Bronchopulmonary hygiene therapy 2. Lung expansion 3. Oxygen therapy 4. Aerosolized medication therapy a. 1, 2 b. 3, 4 c. 2, 3 d. 1, 3, 4 ANS: C

9TH

Upper abdominal surgery is specified as one of the clinical indications for implementation of the lung expansion protocol. The oxygen therapy protocol would be indicated since the SpO2 is less than 90% on room air.

7. Which of the following are associated with the bronchospasm clinical scenario?

1. Increased airway resistance 2. Decreased FRC 3. Bronchial breath sounds 4. Hyperresonant percussion note a. 2, 3 b. 1, 4 c. 3, 4 d. 1, 3, 4 ANS: B A patient with bronchospasm would have increased airway resistance and air trapping. The air trapping would result in a hyperresonant percussion note.

8. Which of the following are associated with the alveolar consolidation clinical scenario?

1. Increased opacity on the chest radiograph 2. Decreased FRC 3. Bronchial breath sounds

4. Hyperresonant percussion note a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C Alveolar consolidation would cause decreased lung volume resulting in a decreased FRC. Opaque lung fields would appear on the chest radiograph. Bronchial breath sounds would be expected with alveolar consolidation.

9. Which of the following pathophysiologic mechanisms would be expected in the excessive bronchial secretions clinical scenario?

1. Decreased ventilation/perfusion ratio 2. Increased airway resistance 3. Stimulation of the deflation reflex 4. Stimulation of the irritant reflex a. 1, 2 b. 1, 4 c. 1, 2, 3 d. 1, 2, 4 ANS: D When excessive bronchial secretions are present, the ventilation/perfusion ratio is decreased. Increased airway resistance would result from the excessive secretions which would stimulate the irritant reflex.

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10. Which of the following wo ulUd beSa ssNo ciTat ed w itOh the distal airway and alveolar weakening clinical scenario?

1. Depressed diaphragm on chest radiograph 2. Use of accessory muscles of inspiration 3. Rhonchi and wheezing 4. Increased PEFR a. 1, 2 b. 1, 3 c. 1, 2, 3 d. 1, 3, 4 ANS: A When distal airway and alveolar weakening is present, air trapping occurs, resulting in the depressed diaphragm on the chest radiograph and use of accessory muscles of inspiration.

11. Which of the following protocols would be indicated when a patient with increased alveolar-capillary membrane thickening has increased opacity on the chest radiograph, bronchial breath sounds, and a dull percussion note? a. Aerosolized medication protocol b. Lung expansion protocol c. Oxygen therapy protocol d. Bronchopulmonary hygiene protocol ANS: B

Increased opacity on the chest radiograph, bronchial breath sounds, and a dull percussion note would result from increased lung density. Therapeutic hyperinflation modalities via the lung expansion protocol would be indicated.

9TH

Chapter 11: Respiratory Insufficiency, Respiratory Failure and Ventilatory Management Protocols Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. What is the primary pathophysiologic mechanism in alveolar hypoventilation? a. Decreased minute ventilation b. Increased ventilation/perfusion ratio c. Decreased venous admixture d. Decreased inspired oxygen pressure ANS: A Alveolar hypoventilation would result from a decreased minute ventilation. Among the many possible causes are oversedation, head trauma, drug overdose of respiratory depressants, and myasthenia gravis.

2. Which of the following are contraindications for noninvasive ventilation?

1. Facial and head trauma 2. Community-acquired pneumonia 3. Copious, viscous sputum 4. Severe upper GI bleeding a. 1 b. 2, 3 c. 2, 3, 4 9TH d. 1, 3, 4 ANS: D Community-acquired pneumonia is an indication for NIV. NIV would not be recommended for patients with facial and head trauma, large amounts of secretions or thick secretions, or upper GI bleeding.

3. Which of the following are clinical indicators of type I respiratory failure?

1. Decreased PaO2 2. Increased P(A-a)O2 3. Decreased PaO2/FIO2 4. Decreased a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C Type I respiratory failure is also called oxygenation failure. It is characterized by decreased PaO2, an increased P(A-a)O2 gradient, and a decreased PaO2/FIO2 ratio.

4. Which of the following is a critical value for the key clinical indicators in hypercapnic respiratory failure in an adult?

1. pH 7.19 2. Ventilatory rate 35 breaths/min 3. MIP 80 cm H2O 4. VD/VT 35% a. 1, 4 b. 2, 3 c. 1, 2 d. 3, 4 ANS: C In an adult, a respiration of more than 30 or fewer than 10 breaths/min may be a key clinical indicator of hypercapnic ventilatory failure. Refer to Table 11.10.

5. What effect would a pulmonary embolism have on the VD/VT and the would decrease. a. The VD/VT would increase and the would increase. b. The VD/VT would decrease and the ratios would both increase. c. The VD/VT and the ratios would both decrease. d. The VD/VT and the

ratios?

ANS: D A pulmonary embolism would reduce or block blood flow to a portion of the lungs. The alveoli would ratio. The ventilation be ventilated but not perfused in the affected area, resulting in an increased in nonperfused alveoli is “wasted,” so the VD/VT ratio would also increase.

6. Which of the following are causes of hypercapnic respiratory?

1. Impending ventilatory faNilUurRe SINGTB.COM 2. Apnea 3. Severe refractory hypoxemia 4. Acute ventilatory failure a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Hypoxemic respiratory failure results when severe refractory hypoxemia is present. Invasive ventilatory support may be required to treat profound refractory hypoxemia.

7. Which of the following are abnormal causes of anatomic shunt?

1. Bronchial venous drainage 2. Congenital heart disease 3. Intrapulmonary fistula 4. Vascular lung tumors a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C

This normal shunting is caused by nonoxygenated blood completely bypassing the alveoli and entering (1) the pulmonary vascular system by means of the bronchial venous drainage and (2) the left atrium by way of the thebesian veins. These natural anatomic shunts explain the small normal difference between the partial pressure of oxygen in the alveoli (PAO 2) and to the arterial blood (PaO2)—i.e., the normal P(A-a)O2 difference of 7 to 15 mm Hg. Common abnormal causes of anatomic shunt include the following: • Congenital heart disease • Intrapulmonary fistula • Vascular lung tumors 8. Which of the following values is the VD/VT value if the PaCO2 is 40 mm Hg and the is 30 mm Hg? a. 0.25 or 25%. b. 0.33 or 33%. c. 0.4 or 40%. d. Need more information to determine the value. ANS: A

NURSINGTB COM %.

9. What VD/VT ratio range would you expect to see in a patient receiving mechanical ventilation? a. 20% and 40% b. 30% and 50% c. 40% and 60% d. 50% and 70% ANS: C The VD/VT ratio in the normal adult breathing spontaneously ranges between 20% and 40%. For patients receiving mechanical ventilation, the normal VD/VT ratio ranges between 40% and 60%, because of the “mechanical dead space” added by the endotracheal tube, etc. The VD/VT ratio increases with diseases that cause significant dead space, such as pulmonary embolism.

10. You are the respiratory therapist managing an adult male patient receiving mechanical ventilation as a result of hypoxemic respiratory failure. The patient has a pressure time index of 0.16, and rapid shallow breath index of 95, and the cuff-leak test demonstrated the patient could breathe when it was deflated. What would your recommendations to the physician be regarding weaning this patient based on this data?

a. b. c. d.

Do not attempt to wean.

Attempt to wean.

Reattempt a spontaneous breathing trial to see if RSBI improves before weaning.

Cannot determine.

ANS: B Once the original reason for placing the patient on the ventilator has been resolved, there are a number of bedside studies that can be used to help determine the patient’s readiness to be weaned from the ventilator. That said, common tools used to assess the patient’s readiness for ventilator weaning include the arterial oxygen tension to fractional concentration of oxygen ratio (PaO2/FIO2 ratio), the alveolar-to-arterial partial pressure of oxygen difference [P(A-a)O2], the maximum inspiratory pressure (MIP), the airway occlusion pressure at 0.1 second (P0.1), the P0.1/MIP ratio, the vital capacity (VC), spontaneous minute ventilation (VEsp), maximum voluntary ventilation (MVV), the pressure time index (PTI), and the rapid shallow breathing index (RSBI). The cuff-leak test is another semiquantitative measure of readiness to discontinue ventilator support. If the patient can breathe around a deflated endotracheal tub cuff, he probably will be able to breathe even easier once it is removed. The normal range for a PTI is 0.5 to 1.2. Criteria for successful ventilator weaning is less than 0.15 to 0.18. The successful discontinuance from mechanical ventilation is more likely to occur when the RSBI is less than 105 breaths/min/L.

9TH

Chapter 12: Recording Skills and Intra-professional Communication Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are basic methods to record assessment data?

1. Computer documentation 2. Block chart 3. Traditional chart 4. Problem-oriented medical record a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: C Three basic methods are used to record assessment data: the traditional chart, the problemoriented medical record (POMR), and computer documentation.

2. A problem-oriented medical record is used by health care practitioners to: 1. systemically gather clinical data.

2. communicate with the patient’s family.

3. develop a treatment plan.

4. formulate an assessment. a. 1, 2 9TH b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C The organization of the POMR is based on an objective, scientific, problem-solving method. The POMR is one of the most important medical records used by the health care practitioner to (1) systematically gather clinical data, (2) to formulate an assessment, and (3) to systematically develop an appropriate treatment plan.

3. When reviewing a SOAPIER progress note, all of the following would be found in the S area? a. Hemodynamic data b. Patient’s admission complaint c. Blood pressure d. Sputum production ANS: B The subjective information refers to information about the patient’s feelings, concerns, or sensations presented by the patient. The patient’s admission complaint would not be recorded in the objective data but would be located on the admission note or history section of the medical record.

4. When the respiratory therapist is entering a SOAPIER progress note in a patient’s chart, the A stands for: a. application of the data. b. acceptance of the treatment options by the patient. c. affect of the patient. d. assessment of the data by the respiratory therapist.

ANS: D The A represents assessment of the data. The respiratory therapist would assess the patient’s subjective and objective data to identify the cause of their condition.

5. When reviewing a SOAPIER progress note, the R stands for: a. revisions made in the original plan. b. reimbursement by the insurance carrier. c. respiratory care notes. d. resuscitation status of the patient.

ANS: A The R stands for revisions that need to be made to the original care plan. The treatment plan may require modification or treatment modalities may need to be up-regulated or down-regulated.

6. Computer-based records are commonly used for which of the following?

1. Retrieving pulmonary function studies 2. Storing treatment information 3. Storing admission data 4. Ordering patient supplieNs R I G B.C M a. 3, 4 b. 1, 2 c. 1, 2, 3 d. 2, 3, 4

U S N T

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ANS: C Computer-based records are commonly used for retrieving data such as pulmonary function studies, storing treatment information, storing admission data, and ordering patient supplies. Electronic health records are now the standard in most care settings.

7. Which of the following statements is true regarding Health Insurance Portability and Accountability Act (HIPAA) regulations? a. A bank can check for a preexisting condition. b. The patient controls access to his/her medical records. c. Psychotherapy and medical records are treated equally. d. An employer can check for a preexisting condition.

ANS: B With the HIPAA, the patient controls access to his/her medical records. Banks and employers are prevented from accessing the patient’s medical information without permission.

Psychotherapy records are given extra protection.

8. In which section of the SOAPIER format should the patient’s response to a specific treatment modality be recorded?

a. b. c. d.

Assessment Implementation Observation Evaluation

ANS: D Measurable data regarding the effectiveness of a therapy plan and the patient’s response to the treatment would be recorded under “E”—evaluation.

9. Which agency should be notified if violations of HIPAA regulations have occurred? a. HHS b. FDA c. CDC d. The Joint Commission ANS: A Alleged breaches of HIPAA regulations should be reported to the US Department of Health and Human Services (HHS). Privacy breaches may be subject to civil and criminal action. Significant fines may be imposed for proven violations.

10. Which of the following statements are true regarding a patient’s chart?

1. The patient’s chart is a legal record and can be used in court.

2. Accreditation agencies may access a patient’s chart to assess appropriateness of care.

3. The patient’s insurance company may review the patient’s chart before providing reimbursement.

4. The patient’s spouse may access the patient’s chart without authorization by the patient. a. 1 9TH b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D While patients can expect a certain degree of privacy surrounding medical records, patient charts may be accessed under specific circumstances by select agencies for accreditation reviews, reimbursement claims, and legal cases. The patient controls his/her privacy, and unless a documented release has been granted, a spouse would be denied access to information in the chart.

11. Telemedicine allows health care practitioner the ability to do which of the following?

1. Perform remote procedures using robotics.

2. Attend medical education seminars.

3. Send and receive patient medical files, radiologic images, and health informatics data.

4. Conduct real-time interactive videoconferencing with patients, other care givers, and consultants. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: C

Telemedicine allows the health care practitioner the ability to (1) conduct real-time interactive videoconferencing with patients, other care givers, and consultants, (2) send and receive patient medical files, radiologic images, and health informatics data, (3) perform remote monitoring (e.g., vital signs or sleep apnea episodes), (4) attend medical education seminars, (5) consult with other experts when needed, and (6) attend patient case conferences (grand rounds) without having to travel from one location to another, or to take away valuable time from their patients.

9TH

Chapter 13: Chronic Obstructive Pulmonary Disease, Chronic Bronchitis and Emphysema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following statements accurately describes the anatomic alterations of the lungs associated with emphysema?

1. It is the weakening and permanent enlargement of the air spaces distal to the terminal bronchioles.

2. It is most closely associated with cystic fibrosis.

3. The distal airways tend to collapse during expiration in response to increased intrapleural pressure.

4. It is characterized by thick secretions and mucus plugging. a. 2, 4 b. 3, 4 c. 1, 3 d. 1, 2, 4 ANS: C Emphysema is characterized by a weakening and permanent enlargement of the air spaces distal to the terminal bronchioles and by destruction of the alveolar walls. As these structures enlarge and the alveoli coalesce, many of the adjacent pulmonary capillaries also are affected, and this results in a decreased surface area for gas exchange across the alveolar-capillary membranNeU. FRuSrthIeNrmGoTreB, .thCe OdiMstal airways, weakened in the process, tend to collapse during expiration in response to increased intrapleural pressure. This traps gas in the alveoli.

2. According to the GOLD report, which of the following is the greatest worldwide risk factor for COPD? a. Exposure to fungal spores in the soil b. Genetic predisposition c. Exposure to influenza viruses d. Cigarette smoking ANS: D Cigarette smoking is the most commonly encountered risk factor for COPD worldwide.

3. A genetically linked cause of panlobular emphysema is: a. bronchiectasis. b. alpha1-antitrypsin deficiency. c. cystic fibrosis. d. bronchial asthma.

ANS: B A severe deficiency of alpha1-antitrypsin poses a strong risk factor for early onset ofemphysema— especially panacinar emphysema.

4. Emphysema may be caused by which of the following?

1. Inhaling asbestos fibers 2. Alpha1-antitrypsin deficiency 3. Secondhand cigarette smoke 4. Air pollution a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Exposure to airborne asbestos fibers is associated with asbestosis and mesothelioma but not emphysema.

5. The genetic reference to a person with a normal level of alpha1-antitrypsin is phenotype. a. Z b. MZ c. MM d. ZZ ANS: C Individuals who have the genetic phenotype MM (or M phenotype) have normal levels alpha1antitrypsin.

6. Which of the following are anatomic alterations found with chronic bronchitis?

1. Increased size of submucNosaRl brIoncGhialBg.lanCds M U S

2.

O

Destruction of pulmonary

N

T

capi llar ies

3. Chronic bronchial wall inflammation and thickening 4. Bronchospa sm a. 2, 3 b. 3, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: D Chronic bronchial wall inflammation and thickening, enlargement of the submucosal bronchial glands with increased numbers of goblet cells, and bronchospasm are pathologic alterations associated with chronic bronchitis.

7. Which of the following are pathologic alterations found with emphysema?

1. Air trapping and hyperinflation 2. Mucus plugs 3. Decreased surface area for gas exchange 4. Weakened respiratory bronchioles a. 1, 2 b. 2, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C

Patients with emphysema have weakened distal airways with permanent enlargement and destruction of the airspaces distal to the terminal bronchioles. This results in hyperinflation, destruction of the alveolar-capillary membrane, and decreased surface area available for gas exchange.

8. The management of COPD may include: 1. bi-annual influenza immunization.

2. bronchopulmonary hygiene procedures.

3. bronchodilators.

4. smoking cessation. a. 1, 2 b. 2, 3 c. 3, 4 d. 2, 3, 4 ANS: D Because COPD is a mixture of emphysema and chronic bronchitis, all of the listed options may prove beneficial in the overall management of COPD. Additional therapeutic options are available but must be tailored to each patient.

9. Which of the following term(s) is/are commonly applied to a patient with emphysema?

1. Pink puffer 2. Blue bloater 3. Type A COPD 4. Type B COPD a. 1 b. 2 9TH c. 1, 3 d. 2, 4 ANS: C The expression “pink puffer” and the medical term “Type A COPD” are applied to patients with emphysema.

10. Which of the following clinical manifestations are associated with late-stage chronic bronchitis?

1. Rhonchi 2. Cor pulmonale 3. Digital clubbing 4. Severe weight loss and thin build a. 1, 2 b. 2, 4 c. 1, 3, 4 d. 1, 2, 3 ANS: D Patients with end-stage chronic bronchitis will typically have a stocky, overweight build, rhonchi on auscultation of the chest, cor pulmonale, and digital clubbing.

11. Which of the following clinical manifestations would be expected in a patient with emphysema?

1. Polycythemia 2. Barrel chest 3. Pursed-lip breathing 4. Normal percussion note a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B Because of air trapping and hyperinflation of the lungs, patients with emphysema will often have a barrel chest and use pursed-lip breathing.

12. Which of the following is true of the diffusing capacity test (DLCO) findings in a patient with COPD? a. Normal in all cases b. Decreased in emphysema c. Decreased in chronic bronchitis d. Increased in all cases ANS: B Because of alveolar destruction, patients with emphysema will have decreased gas diffusion.

A decreased DLCO is a classic diagnostic sign of emphysema. The DLCO is normal in pure chronic bronchitis.

N

R

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G

B.C

M

13. Which of the following are cUlin icSa l fNin diTng s a ssOoc iated with chronic bronchitis?

1. Fever 2. Purulent sputum 3. Right heart failure 4. Elevated CO2 level a. 1, 2 b. 3, 4 c. 1, 3 d. 2, 3, 4 ANS: D Patients with chronic bronchitis may demonstrate cyanosis, purulent sputum, right heart failure, and hypercarbia.

14. According to GOLD, at what age can the initial diagnosis of COPD be made? a. 35 years b. 40 years c. 45 years d. 50 years ANS: B GOLD recommends that COPD be considered in any patient over 40 years of age who has dyspnea, chronic cough, sputum production, and a history of exposure to risk factors for the disease— especially cigarette smoking—and a family history of COPD.

15. Which of the following are used to confirm the diagnosis of COPD? 1. Presence of a chronic cough 2. Chronic exposure to environmental smoke 3. FEV1/FVC ratio greater than 0.70 4. FEV1 < 80% a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 3, 4 ANS: C A chronic cough, chronic exposure to environmental smoke, and FEV1 below 80% are constant with COPD. 16. What is the term for the inward movement of the lateral chest wall during inspiration? a. Truman’s sign b. Burton’s sign c. Carr’s sign d. Hoover’s sign ANS: D Hoover’s sign, the inward movement of the lateral chest wall during inspiration, is indicative of hyperinflation.

17. The primary goals of COPD assessment should: 1. include the establishment of the degree of air flow limitation.

IilyGmNB.C 2. include the assessment ofNfUR amS emTbers likOely to be affected.

3. determine the impact of the COPD on the patient’s health status.

4. include retrospective chart examination to determine any missed exacerbations. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A According to GOLD, before an effective treatment plan for COPD can be outlined, a thorough COPD assessment must first be performed. The primary goals of COPD assessment are to (1) establish the degree of air flow limitation, (2) determine the impact of the COPD on the patient’s health status, and (3) ascertain the risk for future events (e.g., exacerbations or hospital admissions).

18. Nonpharmacologic treatment of COPD includes which of the following? a. Limiting physical activity b. Avoidance of pneumococcal vaccine as it can trigger exacerbations c. Interventional bronchoscopy and surgery d. Administration of long-acting antimuscarinic antagonist ANS: C See Box 13.3.

Chapter 14: Asthma Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are associated with extrinsic asthma?

1. Furred animal dander 2. Mold 3. Emotional stress 4. Male gender a. 1, 2 b. 2, 3 c. 1, 2, 3 d. 1, 3, 4 ANS: A When an asthmatic episode can clearly be linked to exposure to a specific allergen (antigen), the patient is said to have extrinsic asthma (also called allergic or atopic asthma). Common indoor allergens include house dust mites, furred animal dander (e.g., dogs, cats, and mice), cockroach allergen, fungi, molds, and yeast. Outdoor allergens include pollens, fungi, molds, and yeast.

2. What term is used to describe the situation when an initial asthmatic response occurs within 1 hour of exposure to an allergen followed by a delayed asthmatic response hours later? a. Deferred dyspneic respNonUseRSINGTB.COM b. Asynchronous activation response c. Biphasic response d. Bipolar response ANS: C The patient with extrinsic asthma may demonstrate an early asthmatic (allergic) response, a late asthmatic response, or a biphasic asthmatic response. The early asthmatic response begins within minutes of exposure to an inhaled antigen and resolves in about 1 hour.

3. Which of the following factors are associated with intrinsic asthma?

1. Emotional stress 2. Cockroach allergen 3. GERD 4. Dust mites a. 2, 4 b. 1, 3 c. 3, 4 d. 2, 3, 4 ANS: B Emotional stress and gastroesophageal reflux disease (GERD) are associated with intrinsic asthma.

4. If a beta2-agonist agent and an anticholinergic agent were administered concurrently to a patient during an acute asthma episode, what result would be expected? a. Bronchial smooth muscle contraction will occur. b. Airway edema will increase. c. The medications oppose each other, resulting in no airway changes. d. Bronchial smooth muscle relaxation will occur.

ANS: D Beta2-agonists and anticholinergic medications may both be required to treat a severe asthma episode and can be administered concurrently. Both of these medications are considered to be reliever medications in asthma management.

5. After the inhalation of a bronchodilator, what percentage change in peak expiratory flow (PEFR) would be required to demonstrate reversible air flow limitation consistent with asthma? a. 5% b. 10% c. 15% d. >20% ANS: D After a bronchodilator, an improvement of 20% or greater in the PEFR would demonstrate positive airway response to the bronchodilator, consistent with asthma.

6. Which of the following would be expected when a chest assessment is performed on a patient during an asthmatic episode?

1. Inverse I:E ratio N R I G B.COM 2. Decreased vocal fremitus U S N T 3. Increased vesicular breath sounds 4. Hyperresonant percussion note a. 1, 4 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Because of air trapping, which occurs during an asthma episode, decreased vocal (and tactile) fremitus and a hyperresonant percussion note would be expected.

7. Which of the following ABG values would be consistent with ventilatory failure with hypoxemia in a patient with severe status asthmaticus?

1. Increased PaCO2 2. Decreased SaO2 3. Increased pH 4. Decreased pH a. 1, 2 b. 2, 3 c. 1, 2, 4 d. 1, 3, 4 ANS: C

During a severe asthmatic episode, the PaCO2 will increase, the pH will decrease, and the SaO2 will fall. Swift action must be taken to aggressively treat the patient.

8. A sputum sample from a patient has been sent to the laboratory for analysis. Which of the following findings could help confirm the diagnosis of extrinsic asthma? a. Increased IgE level b. Increased erythrocyte count c. Colonization of Pseudomonas aeruginosa d. Decreased IgE level ANS: A Patients with extrinsic asthma will demonstrate increased immunoglobulin E (IgE) levels.

9. What findings on a chest radiograph would be expected during a prolonged asthma episode?

1. Depressed diaphragm 2. Increased anterior-posterior diameter 3. Asymmetric lung inflation 4. Translucent lung fields a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3 ANS: C Because of the air trapping that occurs during an asthma attack, the lungs are hyperinflated. The diaphragm is depressed or flattened by the trapped air and the anterior-posterior diameter would be increaseNd. ARmIore GsubtBle.cChanMge would be darkened lung fields caused by the increased air within thUe alSveoNli. T

O

10. What is the name for the microscopic structures formed from the breakdown of eosinophils in allergic asthma? a. Charlene-Lichty crystals b. Charcot-Leyden crystals c. Colleen-Lyndahl clusters d. Charles-Lahr casts ANS: B In allergic asthma, the airway mucosa is infiltrated with eosinophils and inflammatory cells. When the eosinophils break down, microscopic crystals, called Charcot-Leyden crystals, form.

11. At what age does asthma severity peak in males? a. 1 to 3 years b. 5 to 7 years c. 18 to 20 years d. 30 to 32 years ANS: B Asthma is more prevalent in young boys than young girls. Asthma severity peaks between ages 5 and 7 years and continues to lessen significantly during puberty.

12. Which of the following recurrent symptoms are commonly associated with asthma?

1. Cough 2. Chest tightness 3. Fever 4. Wheeze a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B A recurrent cough, recurrent chest tightness, and recurrent wheeze are symptoms associated with asthma.

13. What is the term for an inspiratory fall in systolic blood pressure exceeding 10 mm Hg? a. Pulsus paradoxus b. Stage I hypotension c. Swanson’s phenomenon d. Hoover’s sign ANS: A Pulsus paradoxus is defined as systolic blood pressure that is more than 10 mm Hg lower on inspiration than on expiration.

14. How many components of care are included in the NAEPP asthma management guidelines? a. Three b. Four 9TH c. Five d. Six ANS: B The first evidence-based asthma guidelines were published in 1991 by NAEPP, which was under the direction of the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH). Today, these guidelines are structured around the following four components of care: (1) assessment and monitoring of asthma, (2) patient education, (3) control of factors contributing to asthma severity, and (4) treatment medications.

15. Which of the following is the acronym for the bronchospasm and airway inflammation resulting from the Aspergillus fungus? a. ABPA b. AGA c. ACOS d. AEC ANS: A Allergic bronchopulmonary aspergillosis (ABPA) is associated in patients with cystic fibrosis and asthma. It can result in wheezing, cough, shortness of breath, and decreased exercise tolerance.

16. A fractional concentration of exhaled nitric oxide level greater than ppb is an indication of airway inflammation requiring controller medication increase. a. 20 b. 30 c. 40 d. 50 ANS: D Clinicians are now able to judge the control of eosinophilic airway inflammation caused by asthma by measuring fractional concentration of exhaled nitric oxide (FENO). In adults, the normal FENO is less than 25 ppb. The normal FENO in children is less than 20 ppb. The FENO levels rise with eosinophilic airway inflammation; a high FENO (greater than 50 ppb) suggests a need to increase the patient’s controller medication.

17. The physician asks you to suggest an inhaled corticosteroid for a patient with asthma.

Which of the following medications are appropriate? a. Flovent HFA b. Solu-Medrol c. Serevent d. Montelukast ANS: A See Table 14.2.

9TH

Chapter 15: Cystic Fibrosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. During the advanced stages of cystic fibrosis, the anatomic alterations cause the patient to have: a. a primarily restrictive lung disease. b. a primarily obstructive lung disease. c. equal parts restrictive and obstructive lung disease. d. normal airways with emphysema.

ANS: B Patients with advanced cystic fibrosis primarily have obstructive lung disease changes.

Restrictive changes play a minor role.

2. Which of the following are commonly cultured from the mucus in the tracheobronchial tree of a patient with cystic fibrosis?

1. Klebsiella 2. Pseudomonas aeruginosa 3. Haemophilus influenzae 4. Staphylococcus aureus a. 1, 2 b. 2, 4 c. 1, 2, 3 9TH d. 2, 3, 4 ANS: D The bacteria P. aeruginosa, H. influenza, and S. aureus are commonly found in the mucus of patients with cystic fibrosis. Although other bacteria are also found, Klebsiella is not among them.

3. The major pathologic or structural changes associated with cystic fibrosis include: 1. partial airway obstruction leading to hyperinflation.

2. bronchospasm.

3. thick, tenacious mucus.

4. total airway obstruction leading to atelectasis. a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C Patients with cystic fibrosis have thick, tenacious mucus. This can lead to either a partial airway obstruction (and hyperinflation) or total airway obstruction (and atelectasis).

Bronchospasm is only occasionally found.

4. How can the genetic mutation found with cystic fibrosis (CF) be characterized?

1. There are many variations in the mutation.

2. CF is the most common fatal childhood inherited disorder.

3. The mutation is a dominant trait.

4. The mutation stops ciliary function. a. 1, 2 b. 3, 4 c. 1, 3 d. 2, 3, 4 ANS: A There are many variations in the genetic mutation that causes CF, the most common childhood inherited disorder. The defective CF gene is recessive, not dominant. It causes the dehydration of secretions. The cilia are normal.

5. Cystic fibrosis patients can have: 1. malnutrition.

2. a meconium ileus (bowel obstruction).

3. excessive, viscous pulmonary secretions.

4. a tendency for status asthmaticus. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Asthma is a separate condition that is not associated with cystic fibrosis. All of the other listed options can be foundNin pRatieIntsGwithBc.yCsticMfibrosis.

U S N T

O

6. Men with cystic fibrosis have difficulty reproducing because the: a. fallopian tubes are blocked. b. vas deferens is missing or underdeveloped. c. men are impotent. d. women do not ovulate.

ANS: B Men with cystic fibrosis are usually infertile because the vas deferens is missing or underdeveloped.

7. If both the mother and the father are carriers for the cystic fibrosis gene, what are the chances that their child will be a cystic fibrosis carrier? a. 0% b. 25% c. 50% d. 75% ANS: C As shown in Fig. 15.2, if this couple had four children, the odds are that one would have cystic fibrosis (one in four chance, 25%), two would be carriers (two in four chance, 50%), and one would not be a carrier (one in four chance, 25%).

8. Which ethnic group has the greatest number of people with cystic fibrosis?

a. b. c. d.

African-Americans Asians Hispanics Caucasians

ANS: D Although cystic fibrosis is a rare disease in all ethnic groups, Caucasians have the greatest risk for having cystic fibrosis.

9. Which of the following can be used in the diagnosis of cystic fibrosis?

1. An elevated potassium level in the sweat 2. An elevated chloride level in the sweat 3. Genetic testing of the parents 4. An elevated blood level of immunoreactive trypsin a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C There is no change in the potassium level in the sweat. All of the other listed options can be used to help in the diagnosis of a person with cystic fibrosis.

10. Which of the following are commonly used in the management of cystic fibrosis?

1. Pancreatic enzymes and vitamins 2. Antibiotics 3. Postural drainage 9TH 4. Antitussives a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: C Antitussives are not used in the treatment of cystic fibrosis.

11. A patient has a lung infection with Pseudomonas aeruginosa. What antibiotic should be used against it? a. Tobramycin (TOBI) b. Dornase alpha (Pulmozyme) c. Levalbuterol (Xopenex) d. Pentamidine (NebuPent) ANS: A The antibiotic tobramycin (TOBI) is used against P. aeruginosa. The other drugs are used in a variety of situations.

12. A cystic fibrosis patient in generally good condition may be a candidate for which of the following? a. Cryosurgery b. Total DNA replacement

c. Diaphragmatic pacemaker d. Lung transplant ANS: D Although a lung transplantation is still a relatively rare procedure, it does provide the recipient with normal lungs. Cryosurgery is not used with cystic fibrosis. There is no way to replace DNA. A diaphragmatic pacemaker has been rarely used in a paralyzed patient.

13. Common chest assessment findings in a patient with cystic fibrosis include: 1. tracheal deviation.

2. breath sounds reveal crackles and rhonchi.

3. dull percussion note.

4. hyperresonant percussion note. a. 1, 3 b. 2, 4 c. 1, 2 d. 2, 3, 4 ANS: B Because of secretions, breath sounds will reveal crackles and rhonchi. Air trapping will result in a hyperresonant percussion note. Because of bilateral lung problems, the trachea will not deviate to one side.

14. What complicating pulmonary problem is likely to happen to a patient with cystic fibrosis? a. Pulmonary edema b. Pleural effusion c. Spontaneous I G B.C M pneumothNoraxR d. Cardiac tamponade U S N T O ANS: C

About 20% of patients with cystic fibrosis will develop a spontaneous pneumothorax. The other listed problems are not typically associated with cystic fibrosis.

15. Which of the following pulmonary function findings would be expected in a patient with moderate to severe cystic fibrosis?

1. Increased FVC 2. Increased RV 3. Decreased PEFR 4. Decreased FEF50% a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C Because of the obstructive lung problems associated with cystic fibrosis, the FVC will be decreased, not increased. Obstruction will lead to all expiratory flows being low. Air trapping will cause the RV to be increased.

16. Which of the following may be recommended to reduce bronchial inflammation in a 10-year-old child with cystic fibrosis?

a. b. c. d.

High-dose ibuprofen High-dose acetaminophen High-dose naproxen High-dose corticosteroids

ANS: A High-dose ibuprofen is recommended in children and young adolescents with mild CF who have good lung function (an FEV1 > 60% predicted) and no contraindications (e.g., gastrointestinal bleeding or renal impairment). Ibuprofen has been shown to reduce bronchial inflammation without hindering bacterial clearance—resulting in the decline of the patient’s FEV1 per year—with no remarkable side effects except painless gastrointestinal bleeding in 1% to 2% of patients. High-dose ibuprofen is thought to work by decreasing neutrophil migration and inflammation in the lungs. The initiation of ibuprofen is not recommended after the age of 13 years.

17. Which of the following are recommended in children with cystic fibrosis?

1. Systemic corticosteroids 2. High-dose ibuprofen 3. Inhaled antibiotics 4. Inhaled DNase (Dornase alpha) (Pulmozyme) a. 1, 3 b. 1, 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: D Systemic glucocorticoids are not recommended in children and adolescents with CF. The N R I G B.C benefits of systemic glucocorUticoSidsNare ToutweigOhed by the adverse effects on growth retardation, glucose metabolism, development of CF-related diabetes, and cataract risks. High-dose ibuprofen is recommended in children and young adolescents with mild CF. Ibuprofen has been shown to reduce bronchial inflammation without hindering bacterial clearance. Antibiotics are commonly administered to prevent or combat chronic respiratory tract infections. Inhaled DNase (Dornase alpha) (Pulmozyme) has been shown to be especially helpful in the management of patients with moderate to severe CF. This aerosolized agent is an enzyme that breaks down the DNA of the thick bronchial mucus associated with chronic bacterial infections with CF. 18. Which of the following chest assessment findings may be seen in a patient with cystic fibrosis?

1. Decreased tactile and vocal fremitus 2. Dull percussion note 3. Diminished breath sounds 4. Decreased heart sounds a. 1, 2 b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B

Due to the airway obstruction and retained secretions, the following chest assessment findings would be expected: decreased or increased tactile and vocal fremitus, hyperresonant percussion note, diminished breath sounds, diminished heart sounds, and bronchial breath sounds (over atelectasis). A hyperresonant percussion note would be expected with the hyperinflation of alveoli, not a dull percussion note.

19. A common nonrespiratory clinical manifestation of cystic fibrosis is: a. sinusitis. b. hyperpigmentation. c. rheumatoid arthritis. d. glaucoma.

ANS: A Nasal polyps are seen in between 10% and 30% of patients with CF. The other listed medical conditions are not associated with cystic fibrosis.

20. Cystic fibrosis is a gene disorder caused by mutations in a pair of genes located on chromosome . a. 3 b. 7 c. 21 d. 23 ANS: B CF is an autosomal recessive gene disorder caused by mutations in a pair of genes located on chromosome 7.

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21. Which of the following are cUon siSde rNed cTla ss ifi caOti ons of CFTR mutations?

1. Gating defect 2. Conductance defect 3. Sol layer defect 4. Periciliary defect a. 1, 2 b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A The CFTR mutations are also classified as either a gating defect where the channel does not open or a conductance defect where the channel is open, but chloride does not move efficiently.

Chapter 16: Bronchiectasis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Patients with bronchiectasis can have which of the following anatomic alterations?

1. Hyperinflation 2. Pulmonary embolism 3. Consolidation 4. Pneumothorax a. 1, 3 b. 1, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A Hyperinflation will be caused by mucus plugs acting as an expiratory check-valve obstruction.

Consolidation will occur when fluid fills alveoli during an infection. Neither pulmonary embolism nor pneumothorax is associated with bronchiectasis.

2. Rigid and dilated bronchi are the key anatomic alterations found in which type of bronchiectasis? a. Varicose b. Cystic c. Emphysematous 9TH d. Cylindrical ANS: D Cylindrical (tubular) bronchiectasis is differentiated by rigid and dilated bronchi. Varicose (fusiform) bronchiectasis is differentiated by irregularly dilated and constricted bronchi.

Cystic (saccular) bronchiectasis is differentiated by large, cystlike sacs in the lung parenchyma. There is no such thing as emphysematous bronchiectasis.

3. Irregularly dilated and constricted bronchi are the key anatomic alterations found in which type of bronchiectasis? a. Cystic b. Varicose c. Cylindrical d. Saccular ANS: B Varicose (fusiform) bronchiectasis is differentiated by irregularly dilated and constricted bronchi.

Cystic (saccular) bronchiectasis is differentiated by large, cystlike sacs in the lung parenchyma.

Cylindrical (tubular) bronchiectasis is differentiated by rigid and dilated bronchi.

4. Which form of bronchiectasis causes the greatest amount of damage to the tracheobronchial tree?

a. b. c. d.

Triphasic Varicose Cystic Fusiform

ANS: C Cystic (saccular) bronchiectasis is more damaging than varicose (fusiform) or cylindrical (tubular) bronchiectasis because the bronchial walls are only composed of fibrous tissues. There is no such thing as triphasic bronchiectasis.

5. Congenital causes of bronchiectasis include: a. influenza. b. cystic fibrosis. c. COPD. d. rheumatic disease.

ANS: B A congenital (genetic) cause of bronchiectasis is cystic fibrosis. Influenza, COPD, and rheumatic disease can lead to acquired bronchiectasis.

6. A mother brought her 2-year-old son to the physician. He has been coughing up secretions and having wheezy breathing ever since choking on food 6 months ago. The physician diagnosed the boy with bronchiectasis. What could be the cause? a. Cystic fibrosis b. Measles c. Asthma d. Aspiration

9TH

ANS: D The patient’s history and physical signs indicate aspiration of food. The airway blockage can lead to bronchiectasis. Although cystic fibrosis and measles can lead to bronchiectasis, the patient’s presentation does not match with either. Asthma is not related to bronchiectasis.

7. For religious reasons, a young couple has not given their 4-year-old daughter the usual childhood immunizations. She has been repeatedly hospitalized with pulmonary infections.

What should the respiratory therapist caring for the child tell the parents that the child is at risk for developing? a. Chronic bronchitis b. Asthma c. Bronchiectasis d. Left ventricular hypertrophy ANS: C Repeated childhood pulmonary infections can result in bronchiectasis in later life. Chronic bronchitis has similarities to bronchiectasis but is usually associated with smoking. Neither asthma nor left ventricular hypertrophy is related to bronchiectasis.

8. Management of the patient with bronchiectasis may include: 1. expectorants.

2. early childhood immunizations.

3. lung resection.

4. lung transplant. a. 1, 3 b. 3, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C Expectorants can help to keep secretions “thinner” (less viscosity) for coughing out. Early childhood immunizations will prevent many pulmonary infections. A lung resection may be necessary to remove a severely damaged and infected lung segment or lobe. Lung transplants are rarely performed for any condition, including bronchiectasis.

9. Which of the following should a patient with bronchiectasis do to reduce the risk for the condition worsening?

1. Avoid air pollution.

2. Get an influenza vaccination.

3. Take an antibiotic every day.

4. Avoid smoking. a. 3, 4 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B It is important for a patient with bronchiectasis to avoid any airway irritants, including air pollution and smoking, and to prevent the flu by being immunized each year. An antibiotic N R I G B.C should only be taken against Ua spSecifNic iTnfectiouOs organism for a set time period.

10. Severe bronchiectasis is associated with: 1. vesicular breath sounds.

2. cor pulmonale.

3. distended neck veins.

4. polycythemia. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C Normal, vesicular breath sounds would not be heard in a patient with the secretion problems found with bronchiectasis. Rather, crackles (rhonchi) and wheezes would be heard. The other three conditions are not associated with bronchiectasis.

11. Which of the following pulmonary function testing values would be found in a patient with severe, obstructive bronchiectasis?

1. Decreased RV/TLC ratio 2. Increased PEFR 3. Increased FEF25%-75% 4. Decreased FEF25%-75%

a. 4 b. 2, 3 c. 1, 4 d. 1, 2, 3 ANS: A A decreased FEF25%-75% would be found because the patient’s secretions will reduce expiratory air flow. Air trapping will result in an increased RV/TLC ratio. PEFR will be reduced because of airway secretions.

12. A patient with long-standing bronchiectasis also has pneumonia. Which of the following hematology test results would be expected?

1. Decreased red blood cell (RBC) count 2. Decreased white blood cell (WBC) count 3. Elevated WBC count 4. Increased hemoglobin and hematocrit a. 1, 2 b. 3, 4 c. 2, 4 d. 1, 3, 4 ANS: B An elevated WBC (leukocyte) count will result from the body’s reaction to infection. Chronic hypoxemia from bronchiectasis will cause the body to increase RBC (erythrocyte) production, resulting in increased hemoglobin and hematocrit levels.

13. The preferred imaging met hod to d iag nose a p atie nt’s with noncystic fibrosis N R I G B.C M bronchiectasis is: U S N T O a. posterior-anterior radiograph (x-ray). b. anterior-posterior radiograph (x-ray). c. high-resolution computed tomography (HR-CT). d. bronchogram.

ANS: C Today, the high-resolution computed tomogram (HR-CT) scan has virtually replaced bronchography as the best tool for diagnosing NCFB. 14. One of the main challenges in caring for a patient with bronchiectasis is: a. contending with bronchospasm. b. removing excessive bronchopulmonary secretions. c. returning the FRC to within normal limits. d. maximizing gas exchange across the alveolar-capillary membrane. e. rehydrating dried secretions.

ANS: B The main challenge facing the respiratory therapist caring for the patient with bronchiectasis is the efficient removal of excessive bronchopulmonary secretions.

15. In developed countries, the most common cause of acquired bronchiectasis is: a. emphysema. b. lung abscess.

c. cystic fibrosis. d. pulmonary fibrosis.

ANS: C In developed countries, cystic fibrosis is the most common cause of bronchiectasis.

16. Which of the following is the hallmark of bronchiectasis? a. Chronic cough with production of large quantities of foul-smelling sputum b. Bronchospasm c. Decreased DLCO with normal to decreased expiratory flowrates on pulmonary function d. Dyspnea on exertion ANS: A Chronic cough with production of large quantities of foul-smelling sputum is a hallmark of bronchiectasis.

17. Which of the following is the usual characteristic of the sputum of a patient with bronchiectasis? a. It is usually sweet or musky smelling. b. When examined microscopically there are Kirshman’s spirals. c. It contains eosinophils. d. It is usually voluminous and tends to settle into several different layers.

ANS: D A 24-hour collection of sputum is usually voluminous and tends to settle into several different layers.

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2. pitting edema.

3. enlarged and tender liver.

4. S3 heart sound. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3

ANS: D Because polycythemia and cor pulmonale are associated with severe bronchiectasis, the following may be seen: distended neck veins, pitting edema, and enlarged and tender liver.

The S3 heart sound is associated with congestive heart failure. There would be no reason to suspect this in a patient with bronchiectasis.

19. Hemodynamic findings in a patient with severe bronchiectasis may show: 1. decreased CVP. 2. increased RAP. 3. normal cardiac output.

4. increased PVR. a. 1 b. 2, 3

c. 2, 3, 4 d. 1, 2, 3 ANS: C Hemodynamic Indices With Bronchiectasis Moderate to Severe Stages CVP RAP PCWP CO N N SVI CI RVSWI LVSWI PVR N N N

SV N SVR N

20. Which of the following is the term used to describe the parallel or curved opacity lines of varying length caused by branchial wall thickening that are seen in patients with cylindrical bronchiectasis? a. Tram-lines b. Infiltrates c. Reid lines d. Tubular lines ANS: A Although the chest radiograph is not as valuable as the CT scan in identifying a specific type of bronchiectasis (i.e., cystic, varicose, or cylindrical), a careful analysis of chest radiographs usually reveals abnormalities in the majority of cases. For example, tram-track opacities (also called tramlines) may be seen in cylindrical bronchiectasis. Tram-tracks are parallel or curved opacity lines of varying length caused by bronchial wall thickening.

9TH

Chapter 17: Atelectasis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. What definition of primary atelectasis would best fit that of a premature infant with respiratory distress syndrome (RDS)? a. Partial or total collapse of previously expanded lung regions b. Free pleural air compressed the lungs c. Congenital heart defect causing compression of the lungs d. The failure of the lungs to expand at birth ANS: D Atelectasis is an abnormal condition of the lungs characterized by the partial or total collapse of previously expanded alveoli—thus resulting in (1) the prevention of respiratory exchange of carbon dioxide and oxygen in that part of the lung and (2) reduced lung compliance. The failure of the lungs to expand at birth, most commonly seen in premature infants or those narcotized by maternal anesthesia, is known as primary atelectasis.

2. Examples of the types of surgical procedures that often result in atelectasis include: 1. open heart surgery.

2. craniotomy.

3. gallbladder removal.

4. splenectomy. a. 1 9TH b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D A craniotomy or other head surgery does not increase the risk for atelectasis. Thoracic surgery (e.g., open heart surgery) and upper abdominal surgery (e.g., gallbladder removal or splenectomy) increase the risk for atelectasis.

3. The development of immediate postoperative atelectasis is commonly related to which of the following? a. Inappropriate tidal volumes settings during surgery b. The patient’s comorbidities c. Medication reactions and side effects d. Excessive bronchial secretions ANS: D The development of immediate postoperative atelectasis is almost always related to excessive bronchial secretions.

4. Which of the following conditions is least likely to lead to atelectasis? a. Chronic obstructive pulmonary disease (COPD) b. Acute respiratory distress syndrome (ARDS)

c. Pleural effusion d. Pneumothorax ANS: A COPD does not usually lead to atelectasis. All of the other listed conditions are restrictive in nature and can lead to atelectasis.

5. Which of the following are precipitating factors that can decrease the patient’s ability to generate a negative intrapleural pressure?

1. Supine position 2. Large tidal volume on the mechanical ventilator 3. Malnutrition 4. Obesity a. 2, 4 b. 1, 3, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: B A small tidal volume on the mechanical ventilator and all of the other listed options can decrease a patient’s ability to generate a negative intrapleural pressure.

6. Which of the following are precipitating factors for retained secretions that commonly lead to atelectasis?

1. Asthma 2. General anesthesia 3. Gastric aspiration 9TH 4. Smoking history a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: D All of the listed options are precipitating factors for retained secretions that can lead to atelectasis.

7. A patient has a tumor blocking the left mainstem bronchus. What additional factor would favor the development of atelectasis? a. Breathing a nitric oxide mix (iNO) b. Breathing a helium/oxygen mix (heliox) c. Breathing a high percentage of oxygen d. Breathing a low percentage of oxygen ANS: C Alveolar degassing can occur if the patient has inhaled a high-oxygen percentage and the bronchus is then blocked. When all of the oxygen is absorbed from the alveoli, they will develop atelectasis.

8. After open heart surgery, a patient has developed bronchitis with increased secretions and atelectasis. What respiratory therapy procedures should initially be recommended?

1. Chest physical therapy 2. Continuous positive airway pressure (CPAP) 3. Incentive spirometry 4. Inhaled sympathomimetic medication a. 3, 4 b. 2, 4 c. 1, 3 d. 1, 2, 4 ANS: C Chest physical therapy will help to mobilize the secretions to avoid mucus plugs. Incentive spirometry will encourage the patient to inhale deeply to open up areas of atelectasis. The short-term use of CPAP may be needed if incentive spirometry is not effective.

Sympathomimetic medications will not reduce secretions or treat atelectasis.

9. A 40-year-old patient was in a motor vehicle accident. Among his injuries and related problems are three broken ribs on the right side, pleural fluid in the right pleural space, and atelectasis of both lungs. What should be done to help with the atelectasis problem?

1. Adequate pain management 2. Mechanical ventilation to stabilize the broken ribs 3. Remove the pleural fluid 4. Selective intubation of the right mainstem bronchus a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: A

9TH

Adequate pain management will help the patient to mobilize and take in a deep breath to cough effectively. Removal of the pleural fluid will enable the lung to reexpand. Mechanical ventilation would only be needed if the patient had a flail chest. Selective right bronchial intubation could lead to atelectasis of the left lung.

10. Which of the following patients should be placed on short-term mechanical ventilation because of the high risk for postoperative atelectasis? a. Appendectomy b. Tracheostomy c. Bronchoscopy for tumor biopsy d. Cardiac surgery ANS: D Most patients who have cardiac surgery are placed on mechanical ventilation until it is shown that they are stable and awake enough to wean from the ventilator. None of the other procedures should require ventilator support for the patient.

11. After gastric bypass surgery, a patient is showing tachypnea. What is the best explanation for this? a. Diaphragmatic apraxia b. Postoperative pain c. Low-grade fever

d. Anesthetic sedation ANS: B Postoperative pain will limit the depth of a patient’s breath. As a result, the patient breathes faster than normal. Diaphragmatic apraxia and anesthetic sedation will lead to shallow breathing and a slow respiratory rate. A low-grade fever does not usually lead to tachypnea.

12. Common chest assessment findings in a patient with atelectasis include: 1. decreased tactile fremitus.

2. dull percussion note.

3. crackles.

4. bronchial breath sounds. a. 4 b. 1, 2 c. 3, 4 d. 2, 3, 4 ANS: D Bronchial breath sounds and crackles are commonly heard in a patient with atelectasis. Increased tactile fremitus and a dull percussion note are also commonly found because there is less air in the lungs.

13. The following would be found in a patient with atelectasis: 1. Normal shunt fraction 2. Whispered pectoriloquy 3. Chest radiograph shows increased density in areas of atelectasis 4. Diminished breath sao.u1ndNs R I G B.C M b. 2, 3

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c. 2, 3, 4 d. 1, 2, 4 ANS: C The shunt fraction is increased in a patient with atelectasis. All of the other listed findings will be found in a patient with atelectasis.

14. A patient with atelectasis is being monitored by bedside spirometry. What findings would correspond with atelectasis?

1. Decreased IC 2. Increased PEFR 3. Decreased VC 4. Increased DLCO a. 2 b. 1, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: B A patient with atelectasis will have a decreased IC (inspiratory capacity) and VC (vital capacity) because there is less air in the lungs to blow out. The PEFR (peak expiratory flowrate) and DLCO (diffusion of lung carbon monoxide) values will also be decreased.

15. After surgery, a patient must lie supine in bed. Because of this, atelectasis is thought to have developed. What chest radiograph finding would confirm this? a. Depression of the hemidiaphragms b. Pulmonary interstitial emphysema (PIE) c. Increased density in both upper lobe areas d. Increased density in both posterior lower lobe areas ANS: D If atelectasis develops in a supine patient, the chest radiograph will show increased density in both posterior lower lobe areas where the atelectasis is located. Depression of the hemidiaphragms and PIE are associated with lung hyperinflation. A supine patient is unlikely to develop atelectasis in the upper lobes and show increased density in those areas.

16. Precipitating factors for retained secretions include: 1. decreased mucociliary transport.

2. excessive secretions.

3. overhydration.

4. general anesthesia. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Precipitating factors for retained secretions include (1) decreased mucociliary transport, (2) excessive secretions, (3) inadequate hydration, (4) weak or absent cough, (5) general N R I G B.C anesthesia, (6) smoking histoUry, S(7) gNastTric aspirOation, and (8) certain preexisting conditions.

17. Several pathophysiologic mechanisms operating simultaneously may lead to an increased ventilatory rate. These may include which of the following?

1. Stimulation of central chemoreceptors 2. Decreased lung compliance–increased ventilatory rate relationship 3. Stimulation of J receptors 4. Pain a. 1, 3 b. 1, 2 c. 2, 3, 4 d. 1, 3, 4 ANS: D Several pathophysiologic mechanisms operating simultaneously may lead to an increased ventilatory rate: stimulation of peripheral chemoreceptors (hypoxemia), decreased lung compliance–increased ventilatory rate relationship, stimulation of J receptors, pain, anxiety, or fever.

18. The respiratory therapist is performing chest assessment on a post-op cholecystectomy patient who has developed cough, fever, and tachypnea. Which of the following would the therapist expect to find confirming the suspicion of post-op atelectasis in this patient? a. Decreased tactile and vocal fremitus

b. Hyperresonant percussion note c. Bronchial breath sounds d. Wheezes ANS: C Chest assessment findings in atelectasis include increased tactile and vocal fremitus, dull percussion note, bronchial breath sounds, diminished breath sounds (common when atelectasis is caused by mucous plugs), and crackles (usually heard initially in the dependent lung regions and during late inspiration). Wheezing would not be expected.

9TH

Chapter 18: Pneumonia, Lung Abscess Formation, and Important Fungal Diseases Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. When a patient has pneumonia, which of the following would be found in the alveolar effusion fluids?

1. Mucus 2. Macrophages 3. Saliva 4. Red blood cells a. 1, 3 b. 2, 4 c. 2, 3 d. 1, 3, 4 ANS: B Polymorphonuclear leukocytes move into the infected area to engulf and kill invading bacteria on the alveolar walls. Increased numbers of macrophages also appear in the infected area to remove cellular and bacterial debris. If the infection is overwhelming, the alveoli become filled with fluid, RBCs, polymorphonuclear leukocytes, and macrophages. Saliva is found in the mouth, and mucus is found in the airways. Neither will be found in the alveoli.

2. A patient has a bacterial pneumonia. What kills the invading bacteria? a. Macrophages 9TH b. Red blood cells c. Polymorphonuclear leukocytes d. Serum fluid ANS: C Polymorphonuclear leukocytes enter the alveoli to engulf and kill the invading bacteria. Serum fluid and red blood cells will be found in the alveoli but do not kill the bacteria. Macrophages will be found in the alveoli and remove any cellular and bacterial debris.

3. Which of the following can cause pneumonia?

1. Bacteria 2. Viruses 3. Prions 4. Fungi a. 1, 2 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: C Many types of bacteria, viruses, and fungi can cause pneumonia. Prions are associated with some neurologic conditions, but not pneumonia.

4. If a patient has pneumonia, which of the following can increase the risk for life-threatening illness or death?

1. Weakened immune system 2. COPD 3. Marfan’s syndrome 4. Heart disease a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 1, 2, 4 ANS: D A weakened immune system can make the patient less able to naturally fight off an infection. The chronic damage found with COPD makes the lungs and airways more prone to infection and less able to recover from infection. Heart disease can adversely affect lung function and decrease oxygen delivery to the body. Marfan’s syndrome is not associated with pneumonia or lung function.

5. Overall, most cases of pneumonia are caused by: a. viruses. b. gram-negative bacteria. c. protozoa. d. fungi.

ANS: A About half of all pneumonia cases are caused by viruses.

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6. Which of the following pul mUon aSry iNnf ecTti on s commonly seen in patients with AIDS? a. Anaerobic b. Pneumocystis jiroveci c. Streptococcus pneumoniae (Diplococcus pneumoniae) d. Legionella pneumophila

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ANS: B Historically, the fungus Pneumocystis jiroveci has caused most cases of pneumonia in AIDS patients.

Because AIDS patients have a compromised immune system, they are prone to many other infectious organisms.

7. A 28-year-old patient who has dogs, parakeets, and cats as pets has been admitted with pneumonia. It is suspected that she acquired the infection from one of her pets. What organism is likely to be found in her sputum? a. Bacteroides melaninogenicus b. Staphylococcus aureus c. Chlamydia psittaci d. Haemophilus influenzae ANS: C C. psittaci bacteria are found in the feces of parakeets and other birds. When parakeet feces are dried, aerosolized, and inhaled, pneumonia can result. Although the other organisms can cause pneumonia, they are not associated with household pets.

8. Ventilator-acquired pneumonia (VAP) is defined as pneumonia that develops: a. between 24 and 48 hours after endotracheal intubation. b. more than 48 to 72 hours after endotracheal intubation. c. less than 24 hours after mechanical ventilation is started. d. more than 72 hours after mechanical ventilation is started.

ANS: B When a patient is intubated and develops pneumonia more than 48 to 72 hours later, he/she is found to have VAP. The patient may not actually need mechanical ventilation. The likely cause of the pneumonia is microaspiration of oral secretions around the endotracheal tube cuff.

9. A patient has a pleural effusion and atelectasis related to her pneumonia. Which of the following therapies should the respiratory therapist recommend as treatment for the pleural effusion? a. Hyperinflation therapy b. Supplemental oxygen c. Thoracentesis d. Percussion and postural drainage ANS: C The thoracentesis procedure involves placing a needle through the chest wall to withdraw the pleural effusion fluid. This allows the lung to reexpand. Although the other listed options may be used in the care of a patient with pneumonia, they will not help to remove the pleural fluid.

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2. whispered pectoriloquy.

3. dull percussion note.

4. increased vocal fremitus. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3

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ANS: C Patients with pneumonia usually have tachycardia, not bradycardia. Whispered pectoriloquy, dull percussion note, and increased vocal fremitus are all the result of alveolar consolidation.

11. A patient has bilateral pneumonia. What findings can be expected on the CT scan?

1. Depressed diaphragms 2. Elongated heart 3. Air bronchograms 4. Consolidation a. 3, 4 b. 1, 2 c. 2, 3, 4

d. 1, 2, 3 ANS: A Frequently, the CT scan results on a patient with pneumonia will show air bronchograms and consolidation because the alveoli are filled with fluids while the airways are patent. Depressed diaphragms and elongated heart are seen in patients with COPD because of air trapping.

12. Which of the following are considered to be normal causative agents for community-acquired pneumonia?

1. Staphylococcal pneumonia 2. Haemophilus influenza 3. Legionella pneumophila 4. Candida albicans a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Staphylococcal pneumonia, Haemophilus influenza, and Legionella pneumophila are all causes of community-acquired pneumonia. Candida albicans is an opportunistic yeast infection.

13. During the early stages of a lung abscess, the pathologic process is identical to that of: a. pulmonary edema. b. bronchopulmonary G B.C M dysNplasRia. I c. acute pneumonia.

U S N T O d. pulmonary fibrosis.

ANS: C

Because lung abscess and pneumonia are both caused by microorganisms, the pathology is initially the same. Phagocytic cells move to the infected site to engulf the invading organisms. An inflammatory reaction results and consolidation can occur.

14. What is the term for the fibrinous membrane that surrounds a lung abscess? a. Serous membrane b. Sclerotic membrane c. Alveolar membrane d. Pyogenic membrane ANS: D The pyogenic membrane that surrounds the air-fluid filled cavity of a lung abscess is composed of fibrin, inflammatory cells, and granulation tissue.

15. Which of the following can occur when tissue necrosis occurs in a lung abscess?

1. Fluid can rupture into a bronchus.

2. Broncholithiasis can occur.

3. Bronchospasm can close off the affected bronchi.

4. Fluid can rupture into the intrapleural space. a. 1, 2

b. 1, 4 c. 3, 4 d. 1, 2, 3 ANS: B Necrotic fluid in an abscess can rupture into a bronchus and/or the intrapleural space.

16. An unconscious patient aspirated gastric contents. Which of the following anaerobic microorganisms would likely now be found in her lower respiratory tract?

1. Legionella pneumophila 2. Pseudomonas aeruginosa 3. Peptococci 4. Bacteroides fragilis a. 1, 3 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: B Peptococci and B. fragilis are anaerobic microorganisms and may be present in the lower respiratory tract following aspiration.

17. Which of the following are predisposing factors to aspiration of oropharyngeal secretions and/or gastric contents into the lower respiratory tract?

1. General anesthesia 2. Asthma 3. Seizure disorder 9TH 4. Alcohol abuse a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: D Aspiration often occurs in the patient with a decreased level of consciousness. Predisposing factors include (1) alcohol abuse, (2) seizure disorders, (3) general anesthesia, (4) head trauma, (5) cerebrovascular accidents, and (6) swallowing disorders.

18. Which of the following conditions can result in a lung abscess?

1. Penetrating chest wound 2. Septic embolism 3. Swallowing disorders 4. Bronchogenic cyst a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: C

A lung abscess may also develop as a result of (1) bronchial obstruction with secondary cavitating infection (e.g., distal to bronchogenic carcinoma or an aspirated foreign body), (2) vascular obstruction with tissue infarction (e.g., septic embolism, vasculitis), (3) interstitial lung disease with cavity formation (e.g., pneumoconiosis [silicosis], Wegener’s granulomatosis, and rheumatoid nodules), (4) bullae or cysts that become infected (e.g., congenital or bronchogenic cysts), or (5) penetrating chest wounds that lead to an infection (e.g., bullet wound).

19. Following a cerebrovascular accident, a patient lying in the supine position aspirated gastric contents. In what area(s) of the lungs would a lung abscess be most likely to develop?

1. Posterior segments of the upper lobes 2. Apical segments of the upper lobes 3. Superior segments of the lower lobes 4. Anterior segments of both lower lobes a. 1 b. 1, 3 c. 1, 4 d. 1, 2, 3 ANS: B In the supine position, gastric contents would likely enter the superior segment of the lower lobes or posterior segment of the upper lobes, the gravity-dependent segments in the supine position.

20. Which of the following are considered to cause an opportunistic fungal infection?

1. Candida albicans 2. Aspergillus 9TH 3. Coccidioides immitis 4. Cryptococcus neoformans a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 4 ANS: D Opportunistic yeast pathogens such as Candida albicans, Cryptococcus neoformans, and Aspergillus also are associated with lung infections in certain patients.

21. The respiratory therapist heard a pleural friction rub while performing a chest assessment on a patient with a lung abscess. What does this likely indicate? a. The lungs are hyperinflated. b. Hemoptysis has developed. c. The abscess is located near the pleural surface. d. A pneumothorax has developed.

ANS: C When an abscess is near the pleural surface, the inflamed membranes rub together. The sound produced is heard through a stethoscope and called a pleural friction rub.

22. What is the standard treatment for a lung abscess caused by an anaerobic pathogen?

a. Clindamycin b. Penicillin c. Neomycin d. Omalizumab ANS: A The standard treatment for a lung abscess caused by an anaerobic pathogen is clindamycin. Other drugs that may be used are any combination of beta-lactam–beta-lactamase inhibitors (e.g., ampicillinsulbactam), penicillin plus metronidazole, or a carbapenem.

23. What is the recommended treatment for a lung abscess caused by methicillin-resistant Staphylococcus aureus (MRSA)? a. Neomycin b. Linezolid c. Penicillin d. Clindamycin ANS: B When the lung abscess is caused by methicillin-resistant Staphylococcus aureus (MRSA), linezolid is recommended.

24. Fungal diseases can cause which type of pulmonary disorder? a. An acute restrictive disorder b. A chronic restrictive disorder c. An acute obstructive disorder d. A chronic obstructive disorder ANS: B

N R I G B.C M

U Sa chronic N T restrictive O pulmonary disorder.

Fungal diseases of the lung cause 25. What is considered to be the gold standard for the diagnosis of histoplasmosis? a. Fungal culture test b. Blood serum antigen levels c. Chest x-ray d. Fungal culture ANS: D The fungal culture test is considered the gold standard for detecting histoplasmosis. A small amount of blood, sputum, or tissue from a lymph node, lung, or bone marrow is cultured.

26. Anatomic alterations found in the lungs of patients with a fungal infection include: 1. fibrosis of lung parenchyma.

2. alveolar-capillary destruction.

3. hyperinflation.

4. mucosal edema. a. 1, 2 b. 2, 3 c. 3, 4 d. 1, 2, 4 ANS: A

Fibrosis of lung parenchyma and alveolar-capillary destruction will be among the changes found in the lungs of patients with a fungal infection. Hyperinflation and mucosal edema are not typically found.

27. Which of the following is a disadvantage of the fungal culture test? a. A large amount of blood is needed. b. It has a high false-positive and is not very accurate. c. It takes 4 weeks or longer for the fungus to grow. d. A large amount of lymph node tissue is needed.

ANS: C The fungal culture test is considered the gold standard for detecting histoplasmosis. A small amount of blood, sputum, or tissue from a lymph node, lung, or bone marrow is cultured.

The disadvantage of this test is that it takes time for the fungus to grow—4 weeks or longer.

28. Which parts of the lungs are most commonly affected by a fungal infection? a. Mainstem bronchi b. Lingula c. Lower lobes d. Upper lobes ANS: D In most patients who have a fungal lung infection, the apical and posterior segments of the upper lobes are affected.

29. Fungal lung infections are usually spread by: a. inhaling spores.

9TH b. blood. c. contact with infected sputum. d. inhaling infected droplets.

ANS: A A fungal infection of the lungs can occur when spores are inhaled. Bacterial pneumonia may occur if droplets containing bacteria are inhaled.

30. A patient lives in Cleveland and has HIV and a weakened immune system. What fungal infection is the patient at risk for developing? a. Mycoplasma infection b. Blastomycosis c. Streptococcal infection d. Disseminated histoplasmosis ANS: D Disseminated histoplasmosis is most likely to occur in patients with HIV or another condition that decreases the immune response to an infection. Asymptomatic histoplasmosis and the other listed infections can occur in any patient. In the United States, the prevalence of histoplasmosis is especially high along the major river valleys of the Midwest and South (e.g., in Ohio, Michigan, Illinois, Mississippi, Missouri, Kentucky, Tennessee, Georgia, and Arkansas).

31. Which type of fungal lung infection frequently results in productive cough with purulent sputum? a. Staphylococcal infection b. Blastomycosis c. Klebsiella infection d. Histoplasmosis ANS: B Blastomycosis is the only fungal lung infection that results in a productive cough with purulent sputum. Histoplasmosis does not cause a large increase in mucus. The other two organisms are bacteria and do cause an increase in mucus.

32. A skin test is available to confirm which of the following fungal infections? a. Coccidioidomycosis b. Blastomycosis c. Tuberculosis d. Pseudomonal infection ANS: A There is a skin test to confirm coccidioidomycosis (and histoplasmosis), but not blastomycosis. There is a skin test for tuberculosis, which is caused by bacteria.

33. After cleaning out his chicken coop, a farmer has developed a fungal lung infection.

What type of infection is it most likely to be? a. Coccidioidomycosis b. Blastomycosis c. Histoplasmosis 9TH d. Cryptococcal infection ANS: C Histoplasma capsulatum is found in chicken (and other bird) excreta as well as soil.

34. Which of the following are identified as opportunistic yeast pathogens?

1. Candida albicans 2. Cryptococcus neoformans 3. Aspergillus 4. Mycoplasma a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Mycoplasma is an organism that has traits of both bacteria and viruses. The other listed options are yeasts.

35. In the Midwestern part of the United States, what is the most common fungal infection of the lungs? a. Cryptococcosis b. Histoplasmosis c. Blastomycosis

d. Coccidioidomycosis ANS: B Histoplasma capsulatum is found in major river valleys of the Midwest. Other fungi will be found in the other areas of the country.

36. Severe acute respiratory syndrome is believed to be caused by: a. an arthropod. b. HIV infection. c. a coronavirus. d. H5N1.

ANS: C Health officials believe that the cause of SARS is a newly recognized virus strain called a coronavirus. Q fever can cause pneumonia as well as a prolonged febrile illness, an influenza-like illness, and endocarditis. The organism is commonly transmitted by arthropods (lice, fleas, ticks, mites). However, in Hong Kong in 1997, the first avian influenza virus to infect humans directly was reported. This outbreak was linked to chickens and classified as avian influenza A (H5N1).

37. Pulmonary function testing results on a patient with advanced fungal pneumonia will display which of the following?

1. Increased ERV 2. Decreased IRV 3. Decreased IC 4. Increased TLC a. 1, 4 9TH b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B RV will be decreased rather than increased. Because advanced fungal pneumonia causes a restrictive lung disease pattern, volumes and capacities will be decreased.

38. During the advanced stages of a fungal lung infection, which of the following is commonly seen on the chest radiograph? a. Hyperinflation b. Spherical nodules c. Right shift of the heart d. Cavities ANS: D Cavities are commonly seen in the advanced stages of a fungal lung infection. Spherical nodules may be seen early in the disease process. The other options are not seen.

Chapter 19: Tuberculosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. A patient has been found to have tuberculosis (TB) in several organs of the body. What term is used to describe this situation? a. Primary TB b. Postprimary TB c. Disseminated TB d. Multiorgan TB ANS: C Disseminated TB refers to the spread of tuberculosis throughout the body. When a person is initially infected with tuberculosis, the term primary TB is applied. Postprimary TB refers to the reactivation of dormant tubercle bacilli after the initial infection. Multiorgan TB is not a recognized term.

2. Mycobacterium tuberculosis is particularly damaging to the lungs because of the: a. healing of a tubercle. b. formation of micropulmonary emboli. c. increased mucus production. d. irreversible bronchospasm that it causes.

NURSING TB.COM As the lung undergoes the healing process, tissue fibrosis and calcification occur in each of the ANS: A

tubercle sites. This results in lung retraction and scarring and the distortion of bronchi.

3. A patient has postprimary TB. What are the major pathologic or structural changes associated with it?

1. Cavity formation 2. Laryngeal edema 3. Dilated and distorted bronchi 4. Fibrosis of lung parenchyma a. 2, 3 b. 3, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: D The major pathologic and structural changes associated with postprimary TB include, but are not limited to, cavity formation, dilated and distorted bronchi, and fibrosis of lung parenchyma.

4. A patient who has an uncontrolled tuberculosis infection will show: 1. weight loss.

2. high fever.

3. bloody sputum.

4. night sweats. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D Patients typically will have a low-grade fever with this infection. All of the other listed items, and others, will be found.

5. A negative tuberculin test would be demonstrated by an induration (wheal) of what size? a. Less than 2 mm b. Less than 5 mm c. Greater than 8 mm d. Greater than 10 mm ANS: B A TB skin test is negative when the wheal (induration) is 5 mm or less. Between 5 and 9 mm is suggestive of TB and should be retested, and greater than 10 mm is positive for recent or past infection or disease.

6. Mycobacterium tuberculosis is most readily transmitted through: a. drinking milk from or the milking of infected cows. b. shaking hands and then rubbing your eye. c. coughing. d. accidental direct inoculation.

ANS: C

NURSING TB.COM

This disease is usually spread by inhaling the bacilli in droplets that have been coughed out by an infected person. Accidental direct inoculation can rarely occur. The type of TB that can infect cows does not cause human disease.

7. The preferred stain that is used to identify the TB organism is called: a. Gram stain. b. fluorescent acid-fast stain. c. Ziehl-Neelsen. d. gentian violet.

ANS: B The fluorescent acid-fast stain is preferred over the Ziehl-Neelsen stain. The other stains are not used with this infection.

8. When a person has TB spread throughout the body, it can be found in which of the following locations?

1. Upper lobes of the lungs 2. Kidneys 3. Brain 4. Lower lobes of the lung a. 1 b. 2, 3 c. 2, 3, 4

d. 1, 2, 3 ANS: D TB does not usually occur in the lower lobes because they have less oxygen in them than the upper lobes. Other high-oxygen organs include the kidneys and brain.

9. Nontuberculous mycobacteria such as Mycobacterium avium and Mycobacterium kansasii are associated with which one of the following diseases? a. COPD b. Bronchiectasis c. Status asthmaticus d. Cystic fibrosis ANS: A Patients with COPD are prone to getting an M. avium or M. kansasii infection. There is no greater risk associated with the other lung problems.

10. What medication is used to treat a person who has converted to a positive TB skin test but does not have active disease? a. Virazole b. Isoniazid c. Rifampin d. Tetracycline ANS: B Isoniazid is taken as a prophylactic drug each day for 1 year by anyone who has been exposed to the disease or has a positive skin test.

N R I G B.C M

N TduringOthe entire 9 months of the nine-month 11. A medication used to treat a U TB S infection treatment protocol are: a. gentamycin and isoniazid. b. penicillin and pyrazinamide. c. streptomycin and ethambutol. d. isoniazid and rifampin.

ANS: D Isoniazid (INH) and rifampin (Rifadin) are first-line agents prescribed for the entire 9 months.

Isoniazid is considered to be the most effective first-line antituberculosis agent.

12. Risk factors predisposing a person to TB include: 1. having HIV/AIDS. 2. being immunosuppressed.

3. African-American or Hispanic heritage.

4. malnutrition. a. 1, 3 b. 2, 4 c. 1, 2, 4 d. 1, 2, 3 ANS: C

Individuals of African-American or Hispanic heritage are not predisposed to TB. People with HIV/AIDS or who are immunosuppressed or malnourished are at greater risk for getting TB when exposed to it.

13. Which of the following clinical manifestations are associated with TB? 1. Dull percussion note 2. Bronchospasm 3. Hyperresonant percussion note 4. Crackles a. 1, 4 b. 2, 3 c. 1, 2 d. 2, 3, 4 ANS: A Clinical manifestations that are associated with TB include, but are not limited to, dull percussion note and crackles for breath sounds.

14. Pulmonary function testing results on a patient with an advanced case of TB will display which of the following? a. Decreased RV b. Increased IRV c. Increased VC d. Increased TLC ANS: A RV will be decreased. Beca use TB cau ses a re stri ctive lung disease pattern, N R I G B. C M volumes and O capacities will be decreased.U S N T 15. A patient with an advanced case of TB may have which of the following radiologic findings?

1. Bronchial tumors 2. Hyperlucent lung fields 3. Retraction of lung segments 4. Right-sided heart enlargement a. 2 b. 2, 3 c. 3, 4 d. 1, 3, 4 ANS: C Chest radiology findings will include, but are not limited to, retraction of lung segments secondary to fibrosis and scarring and right-sided heart enlargement due to cor pulmonale.

16. A respiratory therapist has a positive TB skin test after having contact with a patient with active TB. Which of the following actions would most likely be taken regarding the positive skin test? a. The therapist will be started on a 1-year course of isoniazid prophylactically. b. The test will be followed with monthly chest x-rays to detect changes in the lung parenchyma.

c. The therapist will be on paid administrative leave for 3 months until it is ensured that she is noncontagious. d. The therapist will be required to wear a mask at work for 3 months until it is established that she is noncontagious.

ANS: A The prophylactic use of isoniazid is often prescribed as a daily dose for 1 year in individuals who have been exposed to the TB bacilli or who demonstrate a positive tuberculin reaction (even when the acid-fast sputum stain is negative). Patients with TB usually are not contagious after a few weeks of treatment.

17. The respiratory therapist is educating a patient just diagnosed with tuberculosis. Which of the following statements should the therapist tell the patient regarding tuberculosis? a. Take the medication with a glass of water hour before meals. b. If you skip a dose of medication, double up at the next dose. c. Don’t take the medication if you have a fever or flu like symptoms. d. Make sure to take the full prescribed course of therapy.

ANS: D It is important to take the full prescribed course of therapy. Failure to adhere to an antibiotic regimen often leads to antibiotic resistance in the slow-growing microorganism. The other choices are medication specific, and the patient should always follow the directions on the medication bottle.

18. In which of the following ways is tuberculosis generally spread?

1. Inhaling droplets of aerosol from an infected person 2. Drinking unpasteurized milk from cattle infected with the pathogen NUinfe R S IcteGNdB.C 3. Laceration with contact of seTcretionsOduring postmortem autopsy 4. Sharing utensils and glassware with an infected person a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The M. tuberculosis organism is almost exclusively transmitted within aerosol droplets produced by the coughing, sneezing, or laughing of an individual with active TB. Other possible ways of contracting TB include the ingestion of unpasteurized milk from cattle infected with the TB pathogen (usually Mycobacterium bovis) and, in rare cases, direct inoculation through the skin (e.g., a laboratory accident during a postmortem examination).

Sharing utensils or glassware would not lead to the spread of tuberculosis.

Chapter 20: Pulmonary Edema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. As pulmonary edema progressives, the fluid moves in which of the following sequences? a. Peribronchial interstitial spaces, bronchi, trachea b. Alveoli, bronchioles, bronchi c. Bronchioles, bronchi, trachea d. Pulmonary capillaries, alveoli, bronchioles ANS: B Pulmonary edema results from excessive movement of fluid from the pulmonary vascular system to the extravascular system and air spaces of the lungs. Fluid first seeps into the perivascular and peribronchial interstitial spaces; depending on the degree of severity, fluid may progressively move into the alveoli, bronchioles, and bronchi.

2. Pulmonary edema produces: a. a restrictive pulmonary disorder. b. an obstructive pulmonary disorder. c. both a restrictive and obstructive disorders. d. obstructive cardiac disease.

ANS: A Pulmonary edema produceNs a rRes trIic tivGe pBul.mCon aMry disorder.

U

S

N

T

O

3. The major pathologic or structural changes seen in the lungs with pulmonary edema include: 1. atelectasis.

2. bronchospasm.

3. high surface tension of alveolar fluids.

4. alveolar flooding. a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 1, 3, 4 ANS: D Major pathologic or structural changes seen in the lungs with pulmonary edema include atelectasis, high surface tension of alveolar fluids, and alveolar flooding. Bronchospasm is not associated with pulmonary edema.

4. Which of the following are causes of cardiogenic pulmonary edema?

1. Myocardial infarction 2. Mitral valve disease 3. Allergic reaction to drugs 4. Congenital heart defects a. 1, 3 b. 1, 2, 4

c. 2, 3, 4 d. 1, 2, 3 ANS: B Allergic reaction to drugs can cause noncardiogenic pulmonary edema. The other listed options, and others, can cause cardiogenic pulmonary edema.

5. What is the normal hydrostatic pressure in the pulmonary capillaries? a. 0 to 5 mm Hg b. 5 to 10 mm Hg c. 10 to 15 mm Hg d. 15 to 20 mm Hg ANS: C Ordinarily, hydrostatic pressure of about 10 to 15 mm Hg tends to move fluid out of the pulmonary capillaries into the interstitial space.

6. Which of the following are risk factors for coronary heart disease?

1. Elevated homocysteine level 2. Elevated vitamin E level 3. Hypertension 4. Diabetes mellitus a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D

NURSING TB.COM

The vitamin E level does not affect the coronary arteries. Several factors can lead to CHD, including elevated homocysteine level, hypertension, and diabetes mellitus.

7. Which of the following are considered noncardiogenic causes of increased capillary permeability?

1. Therapeutic lung radiation 2. Cigarette smoke 3. Acute respiratory distress syndrome (ARDS) 4. Inhaled phosgene a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: C Among the many causes of noncardiogenic pulmonary edema are therapeutic lung radiation, ARDS, and inhaled phosgene. Cigarette smoke is associated with lung cancer and chronic obstructive pulmonary disease but does not cause increased capillary permeability.

8. Lymphatic insufficiency could be caused by: 1. lung transplantation.

2. lymphangitic carcinomatosis.

3. removal of pleural fluid.

4. decreased oncotic pressure. a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: A Lymphatic insufficiency could be caused by lung transplantation and lymphangitic carcinomatosis. Although the rapid removal of pleural fluid and decreased oncotic pressure can lead to pulmonary edema, they are not associated with lymphatic insufficiency.

9. Management of cardiogenic pulmonary edema includes giving a patient which of the following types of medications?

1. Reduction of systemic vascular resistance 2. Positive inotropic medication 3. Preload reducing medication 4. Positive chronotropic medication a. 1, 4 b. 2, 3 c. 3, 4 d. 1, 2, 3 ANS: D The therapeutic intervention to address the patient’s circulatory systems has the following three main goals: (1) reduction of pulmonary venous return (preload reduction); (2) reduction of systemic vascular resistance (afterload reduction); and (3) inotropic support (treatment of reduced cardiac contractility). A positive chronotropic medication would N R I G B.C increase heart rate. This is noUt inSdicaNtedTin the trOeatment of cardiogenic pulmonary edema.

10. A patient has a decreased oncotic pressure. What can be done to increase it? a. Implement a high-salt diet. b. Administer albumin. c. Administer milrinone. d. Administer morphine sulfate.

ANS: B Giving albumin will increase oncotic pressure. A low-salt diet will decrease fluid retention to increase hydrostatic pressure. Morphine sulfate acts as a vasodilator. Milrinone is a positive inotropic agent and vasodilator. It reduces afterload and preload and increases cardiac output.

11. A patient with pulmonary edema is cyanotic and complaining of difficulty breathing. What should be recommended by the respiratory therapist? a. Provide supplemental oxygen. b. Begin mechanical ventilation. c. Have the patient use pursed-lip breathing. d. Begin bronchopulmonary hygiene therapy.

ANS: A

Cyanosis indicates hypoxemia. Giving supplemental oxygen will help to correct the hypoxemia and decrease the patient’s work of breathing. Mechanical ventilation is not yet indicated. Pursed-lip breathing may help the breathing of a patient with an obstructive lung problem. Bronchopulmonary hygiene therapy is not indicated because there is no sign of a secretion problem.

12. Mask CPAP is used with pulmonary edema patients because it: 1. decrease vascular congestion.

2. reduce work of breathing.

3. it is less expensive than mechanical ventilation.

4. improves lung compliance. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C While CPAP may be less expensive than mechanical ventilation mask CPAP is used because it decreases vascular congestion, reduces work of breathing, and improves lung compliance. These things improve oxygenation and may preclude the need for mechanical ventilation.

13. A patient with cardiogenic pulmonary edema has had intravascular catheters placed for monitoring purposes. Which of the following values would be expected?

1. Decreased SV 2. Increased PCWP 3. Increased CVP 9TH 4. Decreased RAP a. 2, 3 b. 1, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C A patient with cardiogenic pulmonary edema will have a decreased SV (stroke volume), increased PCWP (pulmonary capillary wedge pressure), and increased CVP (central venous pressure). The RAP (right atrial pressure) is the same as the CVP and will be increased, not decreased.

14. A patient with cardiogenic pulmonary edema would be expected to have which of the following chest radiograph findings?

1. Depressed diaphragms 2. Pleural effusion 3. Cardiomegaly 4. Bilateral “butterfly” pattern fluffy infiltrates a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3

ANS: C The position of the diaphragms will not be changed by pulmonary edema. The chest radiograph will often show pleural effusion, cardiomegaly, and bilateral “butterfly” pattern fluffy infiltrates, among other findings.

15. A patient has noncardiogenic pulmonary edema. What chest radiograph findings would be expected?

1. “Bat’s wings” pattern fluffy infiltrates 2. Normal cardiac silhouette 3. Fluffy densities near the hilum 4. Pleural effusion a. 1 b. 2, 3 c. 3, 4 d. 1, 2, 4 ANS: B A person with noncardiogenic pulmonary edema will have a normal cardiac silhouette and fluffy densities near the hilum. The chest radiograph of a person with cardiogenic pulmonary edema will show “bat’s wings” pattern fluffy infiltrates and pleural effusion.

16. The respiratory therapist is asked to evaluate a patient with suspected congestive heart failure. Which of the following laboratory tests should the respiratory therapist recommend to evaluate the patient for possible congestive heart failure? a. Brain natriuretic peptide (BNP) b. Lactic dehydrogenase (LDH) c. Aspartate aminotransfeN Urase SR(A N ITST)G OB.C M d. Alanine aminotransferase (ALT) ANS: A The brain natriuretic peptide (BNP), also known as B-type natriuretic peptide or ventricular natriuretic peptide (still BNP), is an important biomarker used to help establish the diagnosis of congestive heart failure (CHF). The BNP hormone is produced by the heart and reflects how well the heart is functioning. Normally, only a low amount of BNP (<100 pg/mL) is found in blood. However, when the heart is working harder than normal over a long period of time, it releases more BNP, increasing the blood level of BNP. The other laboratory tests are not used for congestive heart failure.

17. Which of the following may be causes of cardiogenic pulmonary edema?

1. Pulmonary embolism 2. Dysrhythmias 3. Systemic hypertension 4. Excessive fluid administration a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C

Pulmonary embolism may cause noncardiogenic pulmonary edema. All of the other listed options may cause cardiogenic pulmonary edema.

18. The respiratory therapist is asked to recommend a medication to reduce afterload for a patient with cardiogenic pulmonary edema. The therapist could recommend: a. captopril. b. furosemide. c. albumin. d. atropine.

ANS: A Afterload reducers include the following: • Captopril prevents the conversion of angiotensin I to angiotensin II. It is a potent vasodilator. Afterload and cardiac output usually improve in 10 to 15 minutes.

• Enalapril (Vasotec) is a competitive ACE inhibitor and reduces angiotensin II levels.

• Nitroprusside (Nitropress) is a potent, direct smooth muscle-relaxing agent that primarily reduces afterload.

9TH

Chapter 21: Pulmonary Vascular Disease: Pulmonary Embolism and Pulmonary Hypertension Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. The death of lung tissue that may result from an obstruction of the pulmonary artery is called a: a. pulmonary embolism. b. pleural effusion. c. pulmonary infarction. d. pulmonary empyema.

ANS: C A pulmonary infarction causes the death of lung tissue. This can happen when a pulmonary embolism (a clot that moves from another part of the body to the lung) significantly disrupts pulmonary blood flow. A pleural effusion is the leakage of fluid into the pleural space around a lung. An empyema is the accumulation of pus in the pleural space.

2. Bronchospasm may happen after a pulmonary embolism. Which of the following can lead to this bronchospasm?

1. Localized hypoxemia 2. Localized hypercapnia 3. Localized hypocapnia 4. Release of cellular mediaNtoUrRs fSroImNpGlaTteBle.tsCOM a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: D A pulmonary embolism can result in hypocapnia and hypoxemia in the local alveoli. In addition, there is the release of cellular mediators from platelets. All of these can cause bronchospasm.

3. A pulmonary embolism causes which of the following major pathologic and structural changes in the lungs?

1. Alveolar consolidation 2. Mucosal edema 3. Alveolar atelectasis 4. Pleural friction rub a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A

After a pulmonary embolism, alveolar consolidation and atelectasis can occur. Mucosal edema is associated with asthma. Pleural friction rub is associated with an empyema.

4. Which of the following are associated with the formation of a deep vein thrombosis (DVT)?

1. Blood vessel injury 2. Age greater than 40 years 3. Hypercoagulability 4. Venous stasis a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D Age is not directly linked to the development of a DVT. The other three listed options make up Virchow’s triad of the primary factors that lead to a DVT. 5. Predisposing factors of pulmonary emboli include: 1. varicose veins.

2. smoking.

3. obesity.

4. asthma. a. 2, 4 b. 1, 3 c. 1, 2, 4 d. 1, 2, 3 ANS: D

9TH

Asthma does not predispose a person to having pulmonary emboli.

6. The sudden onset of which of the following signs and symptoms indicates a pulmonary embolism?

1. Bradycardia 2. Coughing out blood-streaked sputum 3. Cyanosis 4. Sudden shortness of breath a. 3, 4 b. 1, 2 c. 2, 3, 4 d. 1, 2, 3 ANS: D Bradycardia is not a sign or symptom that could indicate a pulmonary embolism.

7. The best test for diagnosing a suspected pulmonary embolism is a(n): a. spiral volumetric computerized tomography pulmonary angiogram. b. ultrasonography. c. D-dimer blood test. d. chest radiograph.

ANS: A

The spiral (helical) volumetric computed tomography pulmonary angiogram (CTPA) (also called a CT pulmonary angiography) with intravenous contrast is fast becoming the first-line test for diagnosing suspected pulmonary embolism.

8. A pulmonary angiogram is usually ordered: a. as the first test to identify a pulmonary embolism. b. when other tests for a pulmonary embolism are inconclusive. c. in conjunction with a magnetic resonance image to identify a pulmonary embolism. d. in conjunction with an extremity venogram to identify a pulmonary embolism.

ANS: B The CTPA is increasingly being preferred to the previous gold standards for diagnosing a pulmonary embolism—ventilation-perfusion scanning or direct pulmonary angiography—because (1) the scan only requires an intravenous line, (2) the image resolution is very good, (3) the volumetric scanning allows the contrast material to be administered more economically and timed more precisely, and (4) the entire chest can be scanned in a single breath hold, or in several successive short breath holds.

9. A patient’s D-dimer blood test results show a value of 550 ng/mL. How should these results be interpreted? a. The patient does not have a pulmonary embolism. b. The patient’s anticoagulant level is acceptable. c. The patient has increased level of fibrinogen. d. The patient is having a heart attack.

N R I G B.C M The D-dimer blood test (also called theUfibrS inogNen T test) is uO sed to check for an increased level of the ANS: C

protein fibrinogen—an integral component of the blood-clotting process. The test is relatively simple and fast; it entails drawing a blood sample, and the results can be available in less than 1 hour. Ddimer values higher than 500 ng/mL are considered positive—which may suggest the possibility of blood clots. However, it should be emphasized that there are many conditions that can increase an individual’s D-dimer level, including recent surgery.

10. Which of the following conditions is an indication of magnetic resonance imaging (MRI) use in a patient with a suspected pulmonary embolism?

1. Pregnancy 2. Asthma 3. End-stage renal disease 4. Emphysema a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A A magnetic resonance imaging (MRI) scan of the chest may be used for individuals whose kidneys may be harmed by dyes used in x-ray tests and for women who are pregnant.

11. Which of the following are included in the management of pulmonary embolism?

1. Oxygen 2. Vitamin K 3. Heparin 4. Warfarin a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3 ANS: C The treatment of pulmonary embolism usually begins with treating the symptoms. Oxygen is administered per the Oxygen Therapy Protocol. This is typically followed by the administration of slow-acting, oral anticoagulant warfarin (Coumadin, Panwarfarin).

Heparin and warfarin are given together for 5 to 7 days, until blood tests show that the warfarin is effectively preventing clotting.

12. Which of the following are preventive measures taken with patients at high risk for thromboembolic disease?

1. Drink lots of water.

2. Dangle your legs over the edge of the bed before getting up.

3. Walk frequently.

4. Wear compression stockings. a. 1, 3 b. 2, 4 c. 1, 3, 4 d. 1, 2, 3 9TH ANS: C There is no advantage to dangling your legs rather than just getting out of bed. Prolonged bed rest is known to lead to blood clots. All of the other listed options are helpful in preventing blood clots.

13. Which of the following are major mechanisms that contribute to the pulmonary hypertension commonly seen in a patient with a pulmonary embolism?

1. Decreased cross-sectional area of the pulmonary vascular system 2. Vasoconstriction induced by alveolar hypoxia 3. Reflexes from the aortic and carotid sinus baroreceptors 4. Vasoconstriction induced by humoral agents a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: C Three things can lead to pulmonary hypertension after a pulmonary embolism: less area for blood to flow through, alveolar hypoxia, and released humoral agents (serotonin and prostaglandin).

Baroreceptors are stimulated by hypotension and cause the heart rate to increase.

14. The respiratory therapist is listening to the heart sounds of a patient with a suspected pulmonary embolus. The therapist could expect to hear: 1. increased second heart sound (S2).

2. increased splitting of the second heart sound (S2).

3. third heart sound (S3).

4. fourth heart sound (S4). a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D As a result of the pulmonary embolus and the increase in pulmonary vascular resistance, the following heart sounds could be expected: increased second heart sound (S2), increased splitting of the second heart sound (S2), and third heart sound (ventricular gallop). The fourth heart sound would not be an expected finding.

15. In order to prevent pulmonary emboli, a filter may be placed into which of the following vessels to prevent clots from being carried into the pulmonary circulation? a. Subclavian vein b. Pulmonary artery c. Femoral artery d. Inferior vena cava ANS: D An inferior vena cava vein filter may be surgically placed in the inferior vena cava to prevent clots from being carried into the pulmonary circulation. The effectiveness and safety N R I G B.C of these filters are not well esUtabSlisheNd aTnd, in gOeneral, they are only recommended in some high-risk patients. Edema distal to the filters is a complicating factor.

16. Medications may be used to prevent pulmonary emboli include: 1. enoxaparin.

2. dalteparin.

3. tinzaparin.

4. reteplase. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Enoxaparin, dalteparin, and tinzaparin are all low–molecular weight heparins that are anticoagulants used in the prevention of pulmonary emboli. Reteplase is a thrombolytic used in the treatment, not prevention, of pulmonary emboli.

17. A patient is on warfarin therapy for the prevention of deep venous thrombosis (DVT). The respiratory therapist should advise the patient to avoid eating or drinking: a. broccoli and spinach. b. orange juice. c. coffee.

d. peppers and onions.

ANS: A Patients on warfarin should be advised to avoid foods that are high in vitamin K (which affects blood clotting), such as broccoli, spinach and other leafy green vegetables, liver, grapefruit, and grapefruit juice. Green tea may also need to be avoided. Orange juice is high in potassium, but this is unrelated to warfarin therapy.

18. A pulmonary embolus produces which of the following ventilation-perfusion abnormalities? a. True shunting b. Shunt effect c. Dead-space effect d. True dead space ANS: D When an embolus lodges in the pulmonary vascular system, blood flow is reduced or completely absent distal to the obstruction. Consequently the alveolar ventilation beyond the obstruction is wasted, or dead space, ventilation, and no carbon dioxide–oxygen exchange occurs. The ventilation-perfusion distal to the pulmonary embolus is high and may even be infinite if there is no perfusion at all.

19. Therapies used to treat pulmonary hypertension include: 1. albuterol.

2. diuretics.

3. digoxin.

4. reteplase. a. 1 9TH b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B Therapies commonly used to treat all types of PH include the following: • Diuretics—to help decrease fluid buildup—including swelling in ankles and feet.

• Phosphodiesterase inhibitors, especially in group I patients.

• Blood-thinning medications—to help prevent blood clots from forming or getting larger.

• Cardiac glycosides (digoxin, etc.)—to help the heart to pump stronger or to control the heart rate.

• Oxygen therapy—to treat hypoxemia.

• Physical activity—to improve exercise tolerance.

• Inhaled nitric oxide (iNO) therapy—may be helpful in groups I and IV. An oral agent which mimics the effect of the inhaled gas is now available (riociguat).

Chapter 22: Flail Chest Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. While assessing a patient who was involved in a serious car crash and hit his steering wheel, the respiratory therapist observes that a section of his left anterior chest wall sinks inward during inspiration. What is the most likely cause? a. Pulmonary fibrosis b. Flail chest c. Pneumothorax d. Cardiac tamponade ANS: B A flail segment of a flail chest would move inward during inspiration, opposite of normal chest wall movement.

2. What is the most common finding at the site of the flail portion of a flail chest? a. Pulmonary contusion b. Pulmonary abscess c. Pulmonary edema d. Pulmonary fibrosis ANS: A The force of the injury thatNU fracS mGultiBpl.e C ribsM most likely will injure the RturNIesTcontusion. underlying lung resulting in a pulmonary 3. Which of the following accurately describes a flail chest? a. Double fractures of two adjacent ribs b. Double fractures of three adjacent ribs c. Single fracture of three adjacent ribs d. Triple fractures of two adjacent ribs ANS: B A flail chest is defined as double fractures of three or more adjacent ribs.

4. Which of the following are pathologic changes associated with a flail chest?

1. Pneumothorax 2. Secondary pneumonia 3. Pleural effusion 4. Elevated diaphragms a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: A Among the conditions that may result with a flail chest are the development of a pneumothorax and the development of a secondary pneumonia.

5. Which of the following are causes of a flail chest?

1. Blast injury 2. Motor vehicle accident 3. Split sternum for open heart surgery 4. Fall from heights a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B A flail chest can be caused by blunt injury, trauma incurred in an MVA, and falls from heights.

6. Which of the following would be recommended for the management of an adult with a severe flail chest?

1. Continuous positive airway pressure (CPAP) 2. Pain management 3. Mechanical ventilation 4. Positive end-expiratory pressure (PEEP) a. 1, 2 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4

N R I G B.C M Appropriate pain management is needeU d wS ith aNflaiT l chest iO njury. Mechanical ventilation with ANS: C

PEEP will stabilize the chest and provide ventilatory support.

7. How many days of ventilatory support are anticipated for a patient with a flail chest to allow sufficient time for bone healing? a. 3 to 5 days b. 5 to 10 days c. 12 to 15 days d. 18 to 21 days ANS: B Although full bone healing will not be complete, 5 to 10 days of ventilatory support should allow sufficient healing of the flail area.

8. What is the primary cause of hypoxemia in a patient with a severe flail chest? a. Myocardial contusion b. Hemorrhage c. Pulmonary edema d. Alveolar atelectasis ANS: D Compression of the lung tissue occurs beneath the flail section and atelectasis results. The atelectasis then results in a decreased ventilation/perfusion ratio leading to increased venous admixture. Hypoxemia will occur.

9. Which of the following statements is true regarding paradoxical chest movement? a. With inspiration, the flail section moves outward. b. The trachea deviates away from the flail side of the chest. c. During inspiration, the flail section moves inward. d. During exhalation, the flail area moves inward.

ANS: C Paradoxical chest movement means that the flail area moves in the opposite direction from which it normally would. So, with inspiration, the flail area moves inward, and with exhalation, the flail area moves outward. The tracheal position is not affected by broken ribs.

10. When a patient has a flail chest, what happens during the ventilatory cycle? a. The I:E ratio becomes inverse. b. Air leaks out through the flail area. c. Air leaks in through the flail area. d. Air is shunted from one lung to the other.

ANS: D Because of the instability of the flail area, the ribs and lung tissue will move in the opposite direction than normal during a breath. This can cause air to be shunted from one lung to the other during the ventilatory cycle.

11. A patient with a flail chest is experiencing pendelluft. Which of the following would be expected in a patient with a flail chest with pendelluft?

1. Hypoventilation 9TH 2. Hypertension 3. Cyclical deeper and then more shallow breathing 4. Rebreathing dead-space gas a. 1, 4 b. 1, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: A Pendelluft is the movement of air from one lung to the other and results in hypoventilation and the rebreathing of dead-space gas.

12. Which breath sounds would be expected to be heard when auscultating the chest of a patient with a flail chest? a. Diminished over the flail chest section only b. Diminished over both lungs c. Crackles over the flail chest section d. Bilateral wheezing ANS: B With a flail chest, the patient’s breath sounds will be diminished on both the affected and unaffected sides.

13. Which of the following chest radiograph findings would be expected for a patient with a flail chest?

1. Increased opacity 2. Rib fractures 3. Decreased opacity 4. Tracheal deviation a. 1, 2 b. 1, 4 c. 2, 3 d. 2, 4 ANS: C Chest radiograph findings would be expected to include multiple rib fractures and increased opacity of the lung area with compression and atelectasis.

14. What is the term for abnormal gas movement from one lung to the other? a. Paradoxical movement b. Pendelluft c. Palindromic breathing d. Pneumatic shift ANS: B The abnormal movement of gas from one lung to the other is termed pendelluft and may occur with a flail chest.

15. Which of the following can stimulate an increased respiratory rate when a flail chest is present?

NURSINGTB.COM 1. Activation of deflation receptors 2. Activation of irritant receptors 3. Stimulation of J receptors 4. Hypotension a. 1, 3 b. 1, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C When a flail chest is present, pain and anxiety, stimulation of J receptors, and activation of deflation receptors and irritant receptors may all contribute to an increased respiratory rate.

16. Which of the following initial blood gas results would a respiratory therapist expect to find in a patient with a mild flail chest?

Elevated pH and elevated SaO2 a.

Decreased pH and decreased SaO2 b.

Increased pH and decreased SaO2 c.

Decreased pH and increased SaO2 d.

ANS: C With a mild flail chest, an increased pH and a decreased SaO2 would be expected. The patient would be expected to initially have alveolar hyperventilation with hypoxemia.

Chapter 23: Pneumothorax Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are anatomic alterations that occur when a person has a pneumothorax?

1. The lung on the affected side collapses.

2. The visceral and parietal pleura separate.

3. The visceral pleura adheres to the parietal pleura.

4. The chest wall moves outward. a. 1, 3 b. 3, 4 c. 2, 4 d. 1, 2, 4 ANS: D When air is introduced between the visceral and parietal pleura, the pleura will separate, leading to lung collapse and the outward movement of the chest wall.

2. A pneumothorax manifests itself clinically as a primary a. restrictive b. obstructive c. restrictive disorder with a secondary obstructive

disorder.

d. obstructive disorder wiNthUseRcSonIdNarGy TreBst.ricCtiOveM ANS: A A pneumothorax manifests itself clinically as a restrictive pulmonary disorder because air in the pleural space limits inspiration. In a tension pneumothorax, the heart may be pushed away from the affected lung. Although this can decrease cardiac output, a pneumothorax directly affects lung function.

3. What is the primary cause of hypotension in a patient with a large pneumothorax? a. Pain b. Decreased venous return to the heart c. Tracheal compression d. Atelectasis ANS: B A pneumothorax can cause compression of the great vessels and decrease venous return to the heart.

4. According to the way gas enters the pleural space, a pneumothorax will be classified as: 1. intrinsic.

2. extrinsic.

3. open.

4. closed. a. 2, 3

b. 1, 4 c. 3, 4 d. 1, 2 ANS: C No matter how air enters the pleural space, a pneumothorax will be classified as open or closed.

5. A patient had a penetrating knife wound to her chest wall that resulted in a valvular pneumothorax. What is another term for this condition? a. Spontaneous pneumothorax b. Tension pneumothorax c. Iatrogenic pneumothorax d. Benign pneumothorax ANS: B A valvular pneumothorax is also called a tension pneumothorax. Gas enters the pleural space on inspiration but cannot exit due to the valvelike action of the pleura or chest wall itself.

6. A 17-year-old male has been brought to the hospital because he felt short of breath after being tackled in a football game. A chest radiograph shows a broken rib and a pneumothorax in the right lung with pleural space not in direct contact with the atmosphere. Which of the following conditions would be present? a. Closed pneumothorax b. Pleural effusion c. Iatrogenic pneumothoraNx I G B.C M

R

d. Sucking chest wound

U S N T

O

ANS: A If the pneumothorax is the result of an internal lung injury (in this case probably from the sharp edge of the broken rib), it is called a closed pneumothorax. In a closed pneumothorax, gas in the pleural space is not in direct contact with the atmosphere.

7. A 6-foot-tall, 140-pound, 28-year-old female patient has come to the emergency department with a complaint of a sudden sharp pain in the right upper chest followed by shortness of breath. The pain originated while she participated in deep breathing exercises in a yoga class. The physician has determined that she has a 15% pneumothorax. How should the pneumothorax be classified? a. Open b. Exercise related c. Spontaneous d. Traumatic ANS: C When a pneumothorax occurs suddenly and without any obvious underlying cause, it is referred to as a spontaneous pneumothorax. A spontaneous pneumothorax is secondary to certain underlying pathologic processes such as pneumonia, tuberculosis, and chronic obstructive pulmonary disease (COPD). A spontaneous pneumothorax is sometimes caused by the rupture of a small bleb or bulla on the surface of the lung.

8. An iatrogenic pneumothorax may be caused by: 1. positive-pressure mechanical ventilation.

2. pleural biopsy 3. subclavian vein cannulation.

4. endotracheal intubation. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D Endotracheal intubation does not pose a risk for pneumothorax. All of the other listed options can lead to medical procedure–related pneumothorax.

9. A 40-year-old patient requires placement of a thoracostomy chest tube. Which of the following are recommended for the procedure?

1. Application of –5 cm H2O pressure to the chest tube 2. Use of a No. 28 to 36 French gauge tube 3. Placement of the tube at the apex of the lung 4. Clamping and removing the tube within 24 hours of insertion a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D Thoracostomy tubes are clamped only after bubbling from the tube has ceased and then are left in N R I G B.C place without suction fUor aSnotNher T24 to 48Ohours.

10. After a patient experienced four pneumothoraces of her right lung over a 24-month period, the physician recommended a procedure to reduce the occurrence of future pneumothoraces. Which procedure would the physician have recommended? a. Pleurodesis b. Right pneumonectomy c. Permanent right-sided thoracostomy tube d. Right upper lobectomy ANS: A A pleurodesis involves placement of chemical or pharmacologic agents into the chest cavity to cause an inflammatory reaction to increase the adherence of the pleural surface to the inside of the chest wall. The procedure reduces the occurrence of future pneumothoraces.

11. A patient has a pneumothorax with a sucking chest wound resulting in the movement of gas from one lung to another. This is called: a. panting. b. paradoxical movement. c. bidirectional flow. d. pendelluft.

ANS: D Pendelluft is the movement of gas from one lung to another.

12. Which of the following chest assessment findings would be expected in a patient with a tension pneumothorax? a. Decreased thoracic volume on the affected side b. Dull percussion note c. Tracheal shift away from the affected side d. Wheezes ANS: C With a tension pneumothorax, the buildup of air pressure on the affected side of the chest pushes the trachea, lung, and heart to the opposite (unaffected) side.

13. Which of the following hemodynamic indices will be found in a patient with a large hemothorax? a. Decreased QS/QT b. Decreased CO c. Increased CI d. Increased SV ANS: B Because a large pneumothorax can impede venous blood return to the heart, the cardiac output (CO) will be decreased.

14. If the patient has a tension pneumothorax, which of the following chest radiograph findings would be expected?

1. Elevated diaphragm 2. Mediastinal shift to the uNnafRfectIed sGide B.C M 3. Increased translucency on Uthe SsideNof Tthe pneuOmothorax 4. Atelecta sis a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C The buildup of air in the pleural space will depress rather than elevate the diaphragm.

15. A sucking chest wound would be classified as a(n) a. open b. closed c. iatrogenic d. valvular

pneumothorax.

ANS: A A sucking chest wound is an example of an open pneumothorax.

16. Which type of pneumothorax would result from the rupture of bulla on the surface of a lung? a. Spontaneous pneumothorax b. Iatrogenic pneumothorax c. Open pneumothorax

d. Visceral pneumothorax ANS: A When blebs or bulla on the surface of the lung suddenly rupture, the pneumothorax that results is termed a spontaneous pneumothorax.

17. Which type of untreated pneumothorax is considered to be the most serious? a. Spontaneous b. Tension c. Malignant d. Iatrogenic ANS: B An untreated tension pneumothorax is considered the most serious type of pneumothorax due to the compression of the affected lung and mediastinum.

18. Gas can gain entrance to the pleural space: 1. via the lungs through a perforation of the visceral pleura.

2. via the surrounding atmosphere through a perforation of the chest wall and parietal pleura.

3. from gas-forming microorganisms in an empyema in the pleural space.

4. from a pulmonary embolism in the pulmonary artery. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D

N R I G B.C M

S space N Tin the following O Gas can gain entrance to the U pleural three ways: 1. From the lungs through a perforation of the visceral pleura.

2. From the surrounding atmosphere through a perforation of the chest wall and parietal pleura or, rarely, through an esophageal fistula or a perforated abdominal viscus.

3. From gas-forming microorganisms in an empyema in the pleural space (rare).

Chapter 24: Pleural Effusion and Empyema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. The anatomic alteration caused by a pleural effusion is: a. pulmonary fibrosis. b. separation of the visceral and parietal pleura. c. adhesion of the visceral and parietal pleura. d. pulmonary edema.

ANS: B A number of pleural diseases can cause fluid to accumulate in the pleural space; this fluid is called a pleural effusion. Similar to free air in the pleural space, fluid accumulation separates the visceral and parietal pleura and compresses the lungs.

2. The major pathologic and structural changes associated with a significant pleural effusion include which of the following?

1. Diaphragm elevation 2. Atelectasis 3. Compression of the great vessels 4. Lung compression a. 1, 4 b. 2, 3 c. 2, 3, 4 9TH d. 1, 3, 4 ANS: C A large effusion could cause the diaphragm to be depressed, not elevated.

3. Which of the following are associated with a transudative pleural effusion?

1. Thin and watery fluid 2. Fluid has a lot of cellular debris 3. Fluid has high protein count 4. Few blood cells a. 2, 3 b. 1, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: B A transudative pleural effusion is thin and watery with few blood cells, little cellular debris, and a low protein count.

4. A patient has malignant mesothelioma related to chronic asbestos exposure. What would his pleural effusion fluid likely show on laboratory analysis?

1. Erythrocytes 2. Lymphocytes

3. Normal mesothelial cells 4. Malignant mesothelial cells a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 4 ANS: C Asbestos is known to cause mesothelioma, a cancer of the mesothelial cells lining the lungs and chest wall (the visceral and parietal pleura). The pleural effusion fluid, in this case, will show a mix of normal and abnormal mesothelial cells and lymphocytes.

5. An adult patient with a large pleural effusion requires placement of a thoracostomy tube.

Which of the following statements are true regarding thoracostomy tube placement?

1. The tube is placed in the second to third intercostal space.

2. The tube is placed in the fourth to fifth intercostal space.

3. The tube is placed in the midclavicular line.

4. The tube is placed in the midaxillary line. a. 1, 4 b. 2, 3 c. 1, 3 d. 2, 4 ANS: D Because fluid pools at the base of the lung, the chest tube is placed in the fourth to fifth intercostal space in the midaxillary line.

6. a. b. c. d.

N

R

I

G

B . COM

Treatment of an empyema tyUpi caSll y Nin clTud e s: pleurodesis. thoracostomy tube insertion. lobectomy. pneumonectomy.

ANS: B The treatment of an empyema may require placement of a thoracostomy tube.

7. A patient has a pleural effusion from an unknown cause. A fluid sample has been taken for analysis. To help identify the cause of the effusion, which of the following tests should be performed?

1. Specific gravity 2. Biochemical makeup 3. Cytologic examination 4. Bacterial culture a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Specific gravity is a measurement of the density of fluids and would not be indicated in evaluating the cause of a pleural effusion.

8. A respiratory therapist is assisting a physician who is performing a thoracentesis. It is suspected that the patient has a chylothorax. How would the pleural effusion be described? a. Milky white b. Straw colored c. Red d. Green ANS: C In a chylothorax, the fluid in the pleural cavity would appear to be milky white.

9. During a chest assessment on a patient with a large pleural effusion, which of the following would be expected?

1. Increased tactile and vocal fremitus 2. Hyperresonant percussion note 3. Diminished breath sounds 4. Tracheal shift a. 1, 4 b. 1, 2 c. 3, 4 d. 1, 3, 4 ANS: C A tracheal shift and diminished breath sounds are findings consistent with a large pleural effusion.

10. While reviewing an upright chest radiograph of a patient with a pleural effusion, the N R I G B.C respiratory therapist observesUa fSluidNdenTsity in Othe right lung area that extends upward around the anterior, lateral, and posterior thoracic walls. What is this characteristic sign called? a. Meniscus sign b. Scarf sign c. Transudate sign d. Kerley B lines ANS: A In a moderate pleural effusion (>1000 mL) in the upright position, an increased density usually appears at the costophrenic angle. The fluid first accumulates posteriorly in the most dependent part of the thoracic cavity between the inferior surface of the lower lobe and the diaphragm. As the fluid volume increases, it extends upward around the anterior, lateral, and posterior thoracic walls in the socalled meniscus sign.

11. Which of the following are chest radiograph findings associated with a large pleural effusion?

1. Blunting of the costophrenic angle 2. Fluid level on the affected side 3. Mediastinal shift toward the unaffected side 4. Elevated hemidiaphragm on the affected side a. 1, 3 b. 2, 4

c. 1, 2, 4 d. 1, 2, 3 ANS: D Typical radiographic findings in a large pleural effusion include blunting of the costophrenic angle, fluid level on the affected side, and mediastinal shift to the unaffected side.

12. What percentage of patients with bacterial pneumonia are likely to develop pleural effusion? a. Up to 10% b. Up to 20% c. Up to 30% d. Up to 40% ANS: D As many as 40% of patients with bacterial pneumonia have an accompanying pleural effusion.

13. In the absence of surgery or trauma, what does the presence of blood in the pleural fluid most likely signify? a. Malignant disease b. Fungal disease c. Chylothorax d. Tuberculosis ANS: A In the absence of trauma or surgery, blood in the pleural fluid most likely results from malignant disease. A pulmonary embolization and infarction may also cause blood in the pleural fluid.

9TH 14. What is the most common cause of a chylothorax? a. Thoracic duct trauma b. Abdominal tumor c. GERD d. Pyloric stenosis ANS: A When the thoracic duct is damaged by trauma, a chylothorax can result. Thoracic duct trauma is the most common cause of a chylothorax.

15. Pulmonary function testing on a patient with atelectasis associated with pleural effusion would likely reveal: 1. increased VC. 2. decreased ERV. 3. decreased FRC. 4. normal RV/TLC ratio. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: C

Pulmonary Function Test Findings (Restrictive Lung Pathology) Lung Volume and Capacity Findings on a patient with atelectasis associated with pleural effusion VT IRV ERV RV N or VC IC FRC TLC RV/TLC ratio N

9TH

Chapter 25: Kyphoscoliosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Posterior curvature of the spine best describes: a. kyphoscoliosis. b. spina bifida. c. scoliosis. d. kyphosis.

ANS: D Kyphosis is a posterior curve of the spine (humpback).

2. Which of the following would be expected to appear on the chest radiograph of a patient with scoliosis? a. Increased lung translucency b. An S or C shape to the spine c. Bullae d. Pectus excavatum ANS: B The lateral curve of the spine found with scoliosis results in the spine having an S or C shape.

N R I G B.C M

U S changes N T ofOthe lungs found with kyphoscoliosis include: 3. The major pathologic and structural 1. mediastinal shift.

2. elevated diaphragms.

3. lung compression.

4. mucus accumulation. a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C Pulmonary changes found in a patient with kyphoscoliosis include mediastinal shift, lung compression, mucus accumulation (and atelectasis).

4. Which age group is most likely to develop idiopathic scoliosis? a. Infants b. Juveniles c. Adolescents d. Adults ANS: C Scoliosis is most likely to develop after the age of 10 years in the adolescent age group.

5. Positive risk factors for the development of kyphoscoliosis include:

1. male gender.

2. female gender.

3. taller person.

4. shorter person. a. 1, 3 b. 2, 4 c. 2, 3 d. 1, 4 ANS: C Height and gender are contributing factors for developing kyphoscoliosis. It is more prevalent among females and taller individuals.

6. Scoliosis is defined as a spinal curvature of a. >10 b. >20 c. >30 d. >40

degrees.

ANS: A Scoliosis is defined as a spinal curvature of greater than 10 degrees 7. In which of the following is bracing the primary form of treatment? a. Adolescents with idiopathic scoliosis (AIS) b. Patients with congenital scoliosis c. Patients with neuromuscular scoliosis d. Infants with idiopathic G B.C M scol iosi s N R I ANS: A

U S N T O

Bracing is the primary treatment for adolescent idiopathic scoliosis (AIS).

8. The Charleston bending brace is preferred over other braces because it: 1. is worn only 23 hours a day.

2. is worn for 8 to 10 hours at night.

3. is worn at night, when human growth hormone level is highest.

4. corrects any associated upper airway obstruction. a. 1, 4 b. 1, 2 c. 2, 3 d. 1, 3, 4 ANS: C The Charleston bending brace is worn for 8 to 10 hours at night, when a child’s human growth hormone level is highest.

9. A patient has a 45-degree curvature of her spine. The physician is most likely to recommend which of the following treatments? a. Surgical intervention b. Observation checkup in about 3 months c. Milwaukee brace d. Boston brace

ANS: A Surgical correction is usually recommended for a patient with curvature of 40 to 50 degrees.

10. Which of the following chest assessment findings are associated with kyphoscoliosis?

1. Crackles or wheezing 2. Hyperresonant percussion note 3. Whispered pectoriloquy 4. Tracheal shift a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C A patient with kyphoscoliosis will have crackles or wheezing for breath sounds, whispered pectoriloquy due to atelectasis, and a tracheal shift in the direction of the lateral curve of the spine.

11. Which of the following pulmonary function results are likely to be found in a patient with kyphoscoliosis?

1. Increased VT 2. Normal or increased PEFR 3. Decreased VC 4. Decreased FVC a. 1, 2 b. 3, 4 9TH c. 1, 3, 4 d. 2, 3, 4 ANS: B A patient with kyphoscoliosis may have a decreased vital capacity (VC) and decreased forced vital capacity (FVC).

12. A patient with severe kyphoscoliosis and chronic ventilatory failure with hypoxemia may have: 1. increased PaCO2.

2. increased hematocrit.

3. normal pH. 4. increased pH. a. 1, 3 b. 1, 3, 4 c. 1, 2, 4 d. 1, 2, 3 ANS: D In a patient with chronic ventilatory failure with hypoxemia, the PaCO2 will be increased with a normal pH because of metabolic compensation. Because of the chronic hypoxemia, the body compensates by increasing the hematocrit (and hemoglobin).

13. In a case of severe kyphoscoliosis, which of the following chest radiograph findings would be expected?

1. Normal size heart 2. Areas of atelectasis 3. Increased lung opacity 4. Thoracic deformity a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: D With severe kyphoscoliosis, the thoracic deformity, an enlarged heart, atelectasis, and increased lung opacity would appear on a chest radiograph.

14. What is the name for the degree of lateral spinal curvature calculated from a radiograph? a. Carr angle b. Sheumann angle c. Cobb angle d. Sands angle ANS: C The degree of lateral spinal curvature calculated from a radiograph is called the Cobb angle.

15. Which of the following are orthotic braces used in the management of scoliosis?

1. Boston 2. Milwaukee 9TH 3. Chicago 4. Charleston bending a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B The Boston brace, Milwaukee brace, and Charleston bending brace are orthotic options in the management of scoliosis.

16. For best results, how many hours per day should a SpineCor brace be worn? a. 8 b. 10 c. 16 d. 20 ANS: D For optimal results, the SpineCor brace should be worn 20 hours a day for the correction of scoliosis.

Chapter 26: Cancer of the Lung, Prevention and Palliation Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Benign tumors: 1. are metastatic.

2. grow slowly.

3. are usually encapsulated.

4. grow in a disordered manner. a. 1, 4 b. 2, 4 c. 2, 3 d. 1, 3, 4 ANS: C Benign tumors grow slowly and are encapsulated. Because of this, they are less harmful than malignant tumors, which are metastatic and grow in a disordered manner.

2. Malignant tumors: 1. invade surrounding tissues.

2. grow slowly.

3. cause necrosis.

4. may be metastatic. a. 1, 4 9TH b. 2, 3 c. 1, 2, 4 d. 1, 3, 4 ANS: D Malignant tumors invade surrounding tissues, cause necrosis of the tissue, and may be metastatic.

3. Which of the following are pathologic or structural changes associated with bronchogenic carcinoma?

1. Excessive mucous production 2. Inflammation of the airways 3. Alveolar consolidation 4. Fibrocalcific pleural plaques a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D Fibrocalcific pleural plaques are associated with asbestosis, not bronchogenic carcinoma.

4. The most common cause of lung cancer is:

a. b. c. d.

cigarette smoking. air pollution. exposure to asbestos. exposure to radon gas.

ANS: A Cigarette smoking far exceeds all other causes combined as the most common cause of lung cancer. According to the American Cancer Society, about 80% of lung cancer deaths are thought to be caused by smoking.

5. Which of the following is considered a small cell lung cancer? a. Oat cell carcinoma b. Undifferentiated carcinoma c. Squamous carcinoma d. Adenocarcinoma ANS: A Small cell lung cancer is also known as oat cell carcinoma because the cancer cells have a compressed, oval shape.

6. Which of the following are non–small cell lung cancers?

1. Large cell carcinoma 2. Squamous carcinoma 3. Adenocarcinoma 4. Oat cell carcinoma a. 1, 3 b. 2, 4 9TH c. 1, 2, 3 d. 2, 3, 4 ANS: C The non–small cell types are large cell (undifferentiated), squamous cell, and adenocarcinoma. Oat cell carcinoma is a small cell cancer.

7. Staging of a lung cancer is based on which of these criteria?

1. L, for location of the tumor 2. M, for extent of metastasis 3. N, for lymph node involvement 4. T, for extent of the primary tumor a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: C Staging is based on three factors: extent of the primary tumor, extent of metastasis, and lymph node involvement.

8. What is the preferred surgical treatment for a large, single tumor located in the right lower lobe? a. Lobectomy

b. Wedge resection c. Segmentectomy d. Pneumonectomy ANS: A A lobectomy is preferred to reduce the chance of local recurrence.

9. A patient with lung cancer has learned the cancer has metastasized to three other locations.

What is the recommended treatment option? a. Radiation therapy to all known tumors b. Surgical removal of all known tumors c. Chemotherapy d. Needle aspiration of the tumors ANS: C Chemotherapy is a systemic treatment and would be the recommended treatment for metastatic tumors.

10. During bronchoscopy, a tumor was found in the right mainstem bronchus. What is the recommended treatment? a. Pneumonectomy b. Brachytherapy c. Cryotherapy d. Photodynamic therapy ANS: B Brachytherapy involves the placement of small radioactive rods into or near the tumor to kill the cancerous cells.

9TH 11. Chest radiograph findings associated with lung cancer include a(n): 1. large irregular mass.

2. enlarged heart.

3. coin lesion.

4. pleural effusion. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D The patient’s heart size should not be affected by a lung tumor.

12. Signs and symptoms associated with metastatic lung cancer include: 1. fatigue.

2. bone pain.

3. seizures.

4. weight gain. a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3

ANS: D The symptoms from metastatic lung cancer vary depending on where the other tumors are growing but may include fatigue, bone pain, seizures, and weight loss.

13. Which of the following is the most common form of lung cancer among those who have never smoked cigarettes or other tobacco products? a. Squamous cell carcinoma b. Adenocarcinoma c. Large cell carcinoma d. Small cell carcinoma ANS: B Of the lung cancers, adenocarcinoma has the weakest association to smoking. It is the most common form of lung cancer among those individuals who have never smoked.

14. Which form of lung cancer has the poorest prognosis? a. Large cell carcinoma b. Adenocarcinoma c. Small cell carcinoma d. Squamous cell carcinoma ANS: C Untreated small cell carcinoma has a survival rate of 1 to 3 months, thus making it the lung cancer with the poorest prognosis.

15.

When a patient develops drooping eyelid and small pupil in the same eye, which of the following syndromes is preNseUnRt?SINGTB.COM a. Superior vena cava syndrome b. Paraneoplastic syndrome c. Horner’s syndrome d. Cushing’s syndrome

ANS: C Horner’s syndrome is caused by a tumor near the lung apex that damages the nerve passing from the upper chest to the neck, resulting in eyelid droop, a small pupil, and minimal or absent perspiration on the affected side of the face.

16. A patient presents in the emergency department complaining of fatigue, headaches, and mouth sores. His CBC indicates a low while blood cell count. Current medications include Cyramza and Combivent. Which of the medications are likely causing his symptoms? a. Cyramza b. Combivent c. The combination of these medications is contributing to his complaints. d. None of these medications are contributing to his complaints.

ANS: A Some targeted drugs, called angiogenesis inhibitors, are used to obstruct the new vessels supplying blood to the tumors. These agents include bevacizumab (Avastin) and ramucirumab (Cyramza).

Common side effects of these agents include: • Hypertension

• Fatigue • Bleeding • Low white blood cell count • Headaches • Mouth sores • Loss of appetite • Diarrhea

9TH

Chapter 27: Interstitial Lung Diseases Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are anatomic alterations of the lungs that may be found with the chronic stage of interstitial lung disease (ILD)?

1. Honeycombing 2. Edema 3. Interstitial thickening 4. Granulo mas a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 3, 4 ANS: D Honeycombing, interstitial thickening, and granulomas are associated with the chronic stages of interstitial lung disease.

2. What major pathologic and structural changes are associated with asbestosis?

1. Fibrocalcific pleural plaques 2. Excessive bronchial secretions 3. Bronchospasm 4. Mediastinal 9TH shift a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C Fibrocalcific pleural plaques, bronchospasm, and excessive bronchial secretions are among the pathologic and structural changes associated with asbestosis.

3. Which of the following is not considered an interstitial lung disease? a. Asbestosis b. Sarcoidosis c. Staphylococcus d. Silicosis ANS: C Staphylococcus is a bacteria and is not an example of an ILD. 4. Which of the following is the largest group of agents associated with drug-induced interstitial lung disease? a. Anticancer agents b. Cardiovascular agents c. Antibiotics agents

d. Antiinflammatory agents ANS: A Anticancer (chemotherapeutic) agents exceed the other categories in contributing to druginduced ILD. 5. Which of the following organs can be affected by systemic scleroderma?

1. Skin 2. Reproductive organs 3. Lungs 4. Br ain a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: A Systemic scleroderma causes fibrous degeneration of the connective tissue of the skin and lungs (and esophagus, digestive tract, and kidneys).

6. What is the most common pulmonary complication associated with systemic lupus erythematosus (SLE)? a. Bronchospasm b. Pleurisy c. Atelectasis d. Diaphragmatic dysfunction

NURSING TB.COM Pleurisy, with or without effusion, is the most common pulmonary complication associated ANS: B

with SLE. 7. Which of the following Americans would be the most likely to get sarcoidosis? a. A 27-year-old African-American female b. A 60-year-old African-American male c. A 45-year-old Caucasian female d. A 60-year-old Hispanic male ANS: A African-American women in the 20- to 30-year age group are the most likely people to get sarcoidosis.

8. Cryptogenic organizing pneumonia (COP) is associated with: 1. COPD. 2. connective tissue disease.

3. infection.

4. toxic gas inhalation. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3

ANS: C COP has been associated with infection, connective tissue disease, and toxic gas inhalation.

9. A patient has just been diagnosed with Wegener’s granulomatosis. Her long-term prognosis is: a. excellent, with full recovery expected. b. fair, with recovery expected after proper treatment. c. guarded; recovery is possible after proper treatment. d. poor; it is considered a fatal disease.

ANS: D Wegener’s granulomatosis is considered an aggressive and fatal disorder, although the prognosis has significantly improved with the use of cytotoxic agents.

10. What category of medications is commonly prescribed to manage interstitial lung disease? a. Antibiotics b. Mucolytics c. Corticosteroids d. Diuretics ANS: C In general, corticosteroids are commonly administered in this group of illnesses with reasonably good results, but the benefit varies remarkably from one patient and condition (cause) to another.

11. Chest assessment findings in a patient with ILD would include: 1. pleural friction 9TH rub.

2. increased vocal fremitus.

3. vesicular breath sounds.

4. hyperresonant percussion note. a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: A A patient with ILD would have a pleural friction rub and increased vocal (and tactile) fremitus.

12. The diffusing capacity of a patient with coal worker’s pneumoconiosis or silicosis would be expected to be: a. normal. b. increased. c. decreased. d. variable based on the age of the patient.

ANS: C In almost all cases of ILD, the diffusing capacity will be decreased because of pulmonary fibrosis and related problems.

13. Which of the following chest radiograph findings would be associated in a patient with ILD? 1. Pleural effusion 2. Honeycombing 3. Cavity formation 4. Increased translucency a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 1, 2, 3 ANS: D On the chest radiograph of a patient with ILD, pleural effusion, honeycombing, and cavity formation may be seen depending on the specific disorder.

14. Which of the following are associated with an increased DLCO? a. Goodpasture’s syndrome and idiopathic pulmonary hemosiderosis b. Goodpasture’s syndrome and Churg-Strauss syndrome c. Churg-Strauss syndrome and LAM d. Idiopathic pulmonary hemosiderosis and COP ANS: A An increased DLCO is associated with Goodpasture’s syndrome and idiopathic pulmonary hemosiderosis.

15. Which of the following are associated with lymphangioleiomyomatosis (LAM)?

1. Recurrent chylothoracesNandRrecIurreGnt pBn.euCmoMthoraces.

2.

Increased airway obstructiUon. S

N T

O

3. Postmenopausal women are primarily affected.

4. Airway smooth muscle is affected. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B With LAM, women of childbearing age, not postmenopausal women, are primarily affected. Airway smooth muscle is affected and proliferates. Both chylothoraces and pneumothoraces are recurrent with LAM. 16. Which ILD is a smoking-related condition characterized by star-shaped nodules in the midlung? a. PLCH b. LIP c. BOOP d. CWP ANS: A PLCH is a smoking-related ILD characterized by midlung-zone, star-shaped nodules with adjacent thin-walled cysts.

17. What is another name for rheumatoid pneumoconiosis? a. Goodpasture’s syndrome b. Caplan’s syndrome c. Churg-Strauss syndrome d. Sjögren’s syndrome ANS: B Caplan’s syndrome (also called rheumatoid pneumoconiosis) is a progressive pulmonary fibrosis of the lung commonly seen in coal miners.

9TH

Chapter 28: Acute Respiratory Distress Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following materials will be found in the intraalveolar walls of a patient with ARDS? 1. Leukocytes 2. Cellular debris 3. Fibrin 4. Hyaline membrane a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B As the disease progresses, the intraalveolar walls become lined with a thick, rippled hyaline membrane similar to the hyaline membrane seen in newborns with respiratory distress syndrome (hyaline membrane disease). The membrane contains fibrin and cellular debris.

2. A patient has a prolonged case of ARDS. What changes would be expected in the patient’s alveolar cells? a. Multiplication of the type I cells b. Influx of macrophages 9TH c. Hyperplasia and swelling of the type II cells d. Development of emphysema ANS: C With a prolonged case of ARDS, the patient’s alveoli show hyperplasia and swelling of the type II cells.

3. Which of the following pulmonary changes are associated with ARDS? 1. Abnormal surfactant 2. Interstitial edema 3. Decreased shunt 4. Narrowing of the alveolar-capillary membrane a. 1, 2 b. 3, 4 c. 1, 3 d. 1, 2, 3 ANS: A A patient with ARDS will have abnormal pulmonary surfactant and interstitial edema.

4. What is the reason for the elevated risk for developing ARDS associated with massive blood transfusions? a. Shock (hypovolemia)

b. Receiving the wrong blood type c. Fat emboli d. Blockages in pulmonary blood vessels ANS: D With massive transfusions, aggregated cells in stored blood can occlude or damage the small pulmonary blood vessels.

5. ARDS can result from the inhalation of all of: 1. FIO2 >0.60 for prolonged exposure.

2. nitrogen dioxide.

3. very dry air.

4. chlorine gas. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Inhaling very dry air may be irritating to the upper airway but will not cause ARDS. 6. Which of the following are causes of ARDS? 1. Liver failure 2. Drug abuse 3. Septicemia 4. Goodpasture’s syndrome a. 1, 4 9TH b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: C Heroin abuse, septicemia, and Goodpasture’s syndrome are among the causes that can lead to ARDS. 7. Which of the following are recommended to treat alveolar consolidation and atelectasis associated with ARDS? 1. Aerosolized bronchodilator medications 2. Continuous positive airway pressure (CPAP) 3. Chest percussion and postural drainage 4. Positive end-expiratory pressure (PEEP) a. 4 b. 1, 2 c. 1, 3 d. 2, 4 ANS: D Lung expansion measures, including CPAP and PEEP, will help offset alveolar consolidation and atelectasis associated with ARDS. 8. Which of the following are current ventilatory strategies in the treatment of ARDS?

1. Large tidal volume 2. Small tidal volume 3. Rapid respiratory rates 4. Slow respiratory rates a. 2 b. 3 c. 1, 4 d. 2, 3 ANS: D Currently, small tidal volumes and high respiratory rates are recommended ventilatory strategies in ARDS treatment.

9. What initial tidal volume setting on the ventilator would be recommended for a 70-kg adult male with ARDS? a. 350 mL b. 420 mL c. 560 mL d. 700 mL ANS: C The initial tidal volume is usually set at 8 mL/kg PBW—with the ability to drop down, at 1 mL/kg intervals, to 6 mL/kg PBW, if needed to maintain a low plateau pressure [Pplat].

10. Which of the following would be low tidal volume ventilation goals in a patient with ARDS? 1. Decrease 9TH barotrauma.

2. Maintain plateau pressure >30 cm H2O. 3. Decrease high transpulmonary pressures.

4. Reduce overdistention of the lungs. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D With the low tidal volume strategy, the Pplat should be maintained between 25 and 30 cm H2O. 11. Breath sounds associated with ARDS include: 1. vesicular.

2. bronchovesicular.

3. crackles.

4. bronchial. a. 4 b. 1, 2 c. 3, 4 d. 2, 3, 4 ANS: C

Bronchial breath sounds and crackles are commonly heard during the chest assessment of a patient with ARDS. 12. Which of the following clinical manifestations are associated with ARDS? 1. Increased pulmonary capillary wedge pressure (PCWP) 2. Increased CVP 3. Intercostal retractions 4. Cyanosis a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 3, 4 ANS: C Clinical manifestations of ARDS may include low or normal PCWP, increased CVP, intercostal retractions, and cyanosis.

13. The chest radiograph finding indicative of severe ARDS is: a. “ground-glass” appearance of the lungs. b. pleural effusion. c. bilateral hyperinflation of the lungs. d. tracheal deviation.

ANS: A A “ground-glass” appearance is seen on the chest radiograph when severe ARDS is present.

14. According to the Berlin definition of ARDS, what does a PaO 2/FIO ratio of 150 mm Hg N URaniScal NvenTtilation Owith a PEEP of 10 cm H2O? indicate for a patient on mech 2 IG a. Normal lungs b. Mild ARDS B.C M c. Moderate ARDS d. Severe ARDS ANS: C Moderate ARDS is present when the PaO2/FIO2 ratio falls between 100 and 199 mm Hg. 15. What is the most common cause of ARDS? a. Sepsis b. Fat embolism c. Inhalation of irritants d. Aspiration of gastric contents ANS: A Sepsis is the most common cause of ARDS. 16. When would symptoms of ARDS associated with a fat embolism from a long bone fracture be most likely to develop? a. 2 to 4 hours following the fracture b. 4 to 12 hours following the fracture c. 12 to 48 hours following the fracture d. 48 to 96 hours following the fracture

ANS: C ARDS symptoms typically appear 12 to 48 hours after the trauma.

17. The clinical manifestations associated with ARDS usually appear: a. 2 to 4 hours following the inciting event. b. 4 to 12 hours following the inciting event. c. 6 to 72 hours following the inciting event. d. 72 to 96 hours following the inciting event.

ANS: C The clinical manifestations associated with ARDS usually appear within 6 to 72 hours of an inciting event and worsen rapidly.

18. Permissive hypercapnia is typically allowed to: a. protect the lungs from high airway pressures. b. protect the lungs from high PaO2 levels. c. protect the lungs from high tidal volumes. d. protect the lungs from fluid accumulation.

ANS: A Finally, the patient’s PaCO2 is often allowed to increase (permissive hypercapnia) as a trade-off to protect the lungs from high airway pressures. In most cases, an increased ventilatory rate adequately offsets the decreased tidal volume used in the management of ARDS. The PaCO2, however, should not be permitted to increase to the point of severe acidosis (e.g., a pH below 7.2).

BH.leCve l MOdoes the 19. During permissive hypercaNpnUiaR, SatIwN hGat pT increasing PaCO2 become a concern? a. 7.2 b. 7.3 c. 7.5 d. 7.6 ANS: A Finally, the patient’s PaCO2 is often allowed to increase (permissive hypercapnia) as a trade-off to protect the lungs from high airway pressures. In most cases, an increased ventilatory rate adequately offsets the decreased tidal volume used in the management of ARDS. The PaCO2, however, should not be permitted to increase to the point of severe acidosis (e.g., a pH below 7.2).

Chapter 29: Guillain-Barré Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. The peripheral nervous system problems found with Guillain-Barré syndrome (GBS) include: 1. loss of reflexes.

2. increased reflex reactions.

3. flaccid paralysis of skeletal muscles.

4. tetany of skeletal muscles. a. 2, 3 b. 1, 4 c. 1, 3 d. 2, 4 ANS: C Peripheral nervous system problems in GBS include loss of reflexes and flaccid paralysis of the skeletal muscles.

2. Under microscopic inspection, the skeletal muscle nerves of a Guillain-Barré patient show which of the following?

1. Hypertrophy 2. Edema 3. Inflammation 9TH 4. Demyelination a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C In GBS, the skeletal muscle nerves show edema, inflammation, and demyelination.

3. The major pathologic or structural changes of the lungs associated with ventilator failure accompanying Guillain-Barré syndrome include: 1. alveolar consolidation.

2. airway distortion and dilation.

3. mucosal edema.

4. atelectasis. a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: A Alveolar consolidation and atelectasis are structural changes in the lungs of the GuillainBarré patient with ventilatory failure.

4. In which of the following persons would Guillain-Barré syndrome most likely occur? a. African-American female—22 years of age b. Hispanic male—31 years of age c. Asian female—17 years of age d. Caucasian male—53 years of age ANS: D GBS occurs worldwide with an overall incidence of 1 to 2 per 100,000 people. The incidence GBS is slightly more frequent in males than in females. The incidence is greater in people over 50 years of age.

5. When a person has Guillain-Barré syndrome, how are peripheral nerves affected? a. They hypertrophy. b. They fail to reproduce. c. The myelin sheath is removed. d. Schwann cells attack the peripheral nerves.

ANS: C Lymphocytes and macrophages appear to attack and strip off the myelin sheath of the peripheral nerves and leave swelling and fragmentation of the neural axon.

6. Common noncardiopulmonary manifestations associated with Guillain-Barré are: 1. asymmetric muscle weakness in distal extremities.

2. leg pain.

3. distal paresthesia.

4. muscle paralysis that mo st o ften spr ead s d o wnw ard from the face to the N R I G B .C M arms and trunk. a. 1 U S N T O b. 2, 3 c. 1, 2, 4 d. 2, 3, 4 ANS: B The general clinical history of patients with GBS is (1) symmetric muscle weakness in the distal extremities accompanied by paresthesia (tingling, burning, shock-like sensations) or dysesthesias (unpleasant, abnormal sense of touch), (2) pain (throbbing, aching, especially in the lower back, buttocks, and leg), and (3) numbness. The muscle paralysis then spreads upward (ascending paralysis) to the arms, trunk, and face. Although GBS is typically an ascending paralysis—that is, moving from the lower portions of the legs and body upward—in about 10% of cases, muscle paralysis affects the facial and arm muscles first and then moves downward.

7. The diagnosis of Guillain-Barré syndrome is based on: 1. urinalysis, which shows elevated blood urea nitrogen.

2. abnormal electromyography results.

3. cerebrospinal fluid, which shows elevated protein level.

4. clinical history. a. 4 b. 1, 2, 4 c. 2, 3, 4

d. 1, 2, 3 ANS: C Urinalysis and BUN levels are not used to diagnose Guillain-Barré syndrome.

8. Clinical indications that a patient has impending acute ventilatory failure include: 1. pH < 7.35.

2. FVC < 20 mL/kg.

3. PaCO2 > 45 mm Hg. 4. MEP > 40 cm H2O. a. 1, 3 b. 1, 2, 3 c. 2, 4 d. 2, 3, 4 ANS: B Good clinical indicators of impending acute ventilatory failure include which of the following: • FVC < 20 mL/kg.

• MIP < –30 cm H2O—In other words, the patient is unable to generate a maximum inspiratory pressure of –30 cm H2O or more. For example, an MIP of only –15 cm H2O would confirm severe muscle weakness and, importantly, that acute ventilatory failure is likely.

• MEP < 40 cm H2O. • PaCO2 > 45 mm Hg. • pH < 7.35.

N UR SI NG TB.CO M

9. A patient with Guillain-Barré is paralyzed and on mechanical ventilatory support. Which of the following pulmonary complications is most likely to occur as the result of prolonged immobilization? a. Pneumonia b. Pressure sores c. Thromboembolism d. Atelectasis ANS: C Any patient who must remain in bed for a prolonged time is at risk for developing a thromboembolism.

10. Which of the following has been shown to shorten the course of a severe case of Guillain-Barré syndrome? a. Renal dialysis b. Plasmapheresis c. Blood transfusion d. NSAIDs ANS: B Plasmapheresis can shorten a severe case of Guillain-Barré by removing the antibodies that attack the peripheral nerves.

11. A 75-kg, 50-year-old male patient has Guillain-Barré syndrome. His most recent assessment indicates his VC is 900 mL and NIF is –16 cm H2O. What plan should the respiratory therapist recommend? a. Initiate EMG monitoring. b. Initiate continuous positive airway pressure (CPAP). c. Initiate mechanical ventilation. d. Reassess the patient each hour.

ANS: C Mechanical ventilation should be initiated because the patient’s VC and NIF indicate impending ventilatory failure.

12. Typical chest assessment findings in a patient with Guillain-Barré syndrome include: 1. diminished breath sounds.

2. crackles.

3. tracheal deviation.

4. depressed diaphragms. a. 1, 3, 4 b. 1, 2 c. 3, 4 d. 2, 3, 4 ANS: B Diminished breath sounds and crackles are associated with GBS. 13. A Guillain-Barré syndrome patient has autonomic nervous system dysfunction which can result in which of the G B.C M followNingR? I 1. Tachycardia U S N T O 2. Hypotension 3. Urinary retention 4. Fever a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D

Among the symptoms resulting from dysautonomia are tachycardia, hypotension that often alternates with hypertension, and urinary retention.

14. A patient with Guillain-Barré syndrome developed atelectasis. His chest radiograph findings would be expected to show: a. “ground-glass” appearance. b. “honeycombing.” c. increased opacity. d. blunted costophrenic angles.

ANS: C When atelectasis occurs, the chest radiograph will show increased opacity.

15. Approximately what percentage of patients with GBS develop respiratory muscle paralysis?

a. <5% b. 6% to 9% c. 10% to 30% d. 31% to 50% ANS: C In 10% to 30% of cases, respiratory muscle paralysis—followed by acute ventilatory failure (hypercapnic respiratory failure)—develops. Although GBS is typically an ascending paralysis—that is, moving from the lower portions of the legs and body upward—in about 10% of cases, muscle paralysis affects the facial and arm muscles first and then moves downward.

16. Which of the following are identified as the causative organisms of the respiratory or gastrointestinal infections that precede the onset of most cases of GBS? a. Chlamydia psittaci and Campylobacter jejuni b. Cytomegalovirus and mononucleosis c. Campylobacter jejuni and cytomegalovirus d. Mononucleosis and parainfluenza 2 ANS: C In about two-thirds of the cases, the onset of GBS occurs 1 to 4 weeks after a febrile episode caused by a mild respiratory or gastrointestinal viral or bacterial infection. Although the precise infection cause of GBS is not fully understood, it is known that many GBS patients have had a Campylobacter jejuni or cytomegalovirus (CMV) infections prior to developing GBS. 17. In the United States and EuNropRe, wIhatGis thBe.mCostMcommon subtype of GBS? a.

Miller Fisher syndrome (UMF SS) N T

O

b. Acute motor axonal neuropathy (AMAN) c. Acute pandysautonomic neuropathy (APN) d. Acute inflammatory demyelinating polyneuropathy (AIDP) ANS: D 80% or 90% of patients with GBS in North America and Europe, particularly those with the AIDP form of GBS.

Chapter 30: Myasthenia Gravis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are associated with myasthenia gravis?

1. It interferes with acetylcholine transmission.

2. It causes weakness of voluntary muscles.

3. It is usually an ascending paralysis starting in the legs.

4. It is usually preceded by a viral infection. a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A Myasthenia gravis is a condition where there is interference with acetylcholine transmission. This causes weakness of voluntary muscles.

2. What clinical change would be expected following a rest period for a patient with myasthenia gravis? a. There is no clinical change. b. Strength decreases. c. Muscle strength improves.

d. Ascending paralysis deNscUenRdSs.INGTB.COM ANS: C A common finding in myasthenia gravis patients is the return of muscle strength after a rest period.

3. The major pathologic or structural changes of the lungs associated with myasthenic crisis include: 1. alveolar consolidation.

2. airway obstruction.

3. mucus accumulation.

4. hyperinflation. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Alveolar consolidation, airway obstruction, mucus accumulation, and atelectasis are structural changes in the lungs associated with a myasthenia crisis.

4. Which demographic groups are most likely to develop myasthenia gravis?

1. Females >40 years of age 2. Males <35 years of age

3. Females 15 to 35 years of age 4. Males 40 to 70 years of age a. 1, 2 b. 3, 4 c. 2, 3 d. 1, 4 ANS: B According to the Myasthenia Gravis Foundation of America, there are about 36,000 to 60,000 cases of myasthenia gravis in the United States (20 per 100,000 population). The disease usually has a peak age of onset in females of 15 to 35 years, compared with 40 to 70 years in males.

5. Which of the following are signs and symptoms associated with myasthenia gravis?

1. Double vision 2. Weakness of neck muscles 3. Drooping of eyelids 4. Temporary muscle fatigue a. 1, 2 b. 1, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The hallmark of myasthenia gravis is chronic muscle fatigue. The muscles become progressively weaker during periods of activity and improve after periods of rest. Signs and symptoms include facial muscle weakness; ptosis (drooping of one or both eyelids); diplopia N R I G B.C (double vision); ophthalmoplUegiaS(paNralyTsis or wOeakness of one or more of the muscles that control eye movement); difficulty in breathing, speaking, chewing, and swallowing; unstable gait; and weakness in arms, hands, fingers, legs, and neck brought on by repetitive motions.

6. What test is usually performed to confirm the diagnosis of myasthenia gravis? a. RNS b. PFT c. CBC d. EEG ANS: A The repetitive nerve stimulation (RNS) and single-fiber electromyography (SFEMG) tests are important diagnostic supplements to the immunologic studies. The RNS study is the most frequently used electrodiagnostic test for myasthenia gravis.

7. If a patient with myasthenia gravis is given edrophonium, what response would be expected? a. Diaphragmatic strength will increase for 12 to 24 hours. b. Strength will temporarily improve for 10 minutes. c. Muscle strength will increase for 48 to 72 hours. d. Muscle strength will decrease for 10 minutes.

ANS: B

The edrophonium (Tensilon) test is used in patients with obvious ptosis or ophthalmoparesis.

Edrophonium, a short-acting drug, blocks cholinesterase from breaking down ACh after it has been released from the terminal axon. This action increases the myoneural concentration of ACh, which in turn offsets the influx of antibodies at the neuromuscular junction. When muscular weakness is caused by myasthenia gravis, a dramatic transitory improvement in muscle function (lasting about 10 minutes) is seen after the administration of edrophonium.

8. Which of the following values would be associated with impending ventilatory failure in a patient with myasthenia gravis?

1. NIF –15 cm H2O 2. VC 10 mL/kg 3. PaCO2 44 mm Hg 4. pH 7.36 a. 1, 4 b. 1, 2 c. 2, 4 d. 1, 2, 3 ANS: B A VC of 10 mL/kg and an NIF of –15 cm H2O indicate loss of muscle strength and impending ventilatory failure.

9. Which of the following are among the therapy modalities for the patient with myasthenia gravis?

1. Acetylcholinesterase inhibitors 2. Chronic immunotherapieUNsSR NI TG B.C O M 3. Rapid immunotherapies 4. Monoamine oxidase inhibitors a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C There are four basic therapy modalities used to treat myasthenia gravis. They are: (1) symptomatic treatment (acetylcholinesterase inhibitors), (2) chronic immunotherapies (e.g., glucocorticoids and other immunosuppressive drugs), (3) rapid immunotherapies (plasma exchange and intravenous immune globulins [IVIG]), and (4) thymectomy.

10. Complications commonly associated with long-term use of steroids in the management of myasthenia gravis include: 1. infections.

2. cataracts.

3. pulmonary edema.

4. osteoporos is. a. 1, 3 b. 1, 2 c. 2, 3, 4 d. 1, 2, 4

ANS: D Pulmonary edema is not a common complication associated with the long-term use of corticosteroids in myasthenia gravis.

11. A 50-kg (110-pound) 30-year-old female patient has myasthenia gravis. Bedside spirometry has found her VC to be 700 mL and NIF –14 cm H2O. Vital signs show a respiratory rate of 38 breaths/min, a heart rate of 140/minute, and blood pressure of 130/90 mm Hg. What should the respiratory therapist recommend? a. Check the vital signs every hour. b. Encourage airway clearance per protocol. c. Administer supplemental oxygen per protocol. d. Initiate mechanical ventilation per protocol.

ANS: D Based on the VC and NIF results, ventilatory failure is impending. Mechanical ventilation should be initiated.

12. A physician recommended a thymectomy for a patient with generalized myasthenia gravis.

The primary benefit of this procedure is to: a. eliminate the source of AChR antibodies. b. block the antigen-antibody reactions. c. remove the source of cholinesterase. d. cure the ocular myasthenia gravis.

ANS: A A thymectomy has been shown to reduce the symptoms in about 70% of the patients with myasthenia gravis. This haNppUenRsSbIecNauGsTe Bth.e tChOymMus is the source of the AChR antibodies that lead to the muscle weakness.

13. A patient has a severe case of generalized myasthenia gravis. It is most important that the patient be monitored for: a. urine output. b. atrial fibrillation. c. hypotension. d. apnea.

ANS: D A patient with a severe case of myasthenia gravis can develop weakness to paralysis of the diaphragm and other breathing muscles, resulting in apnea.

14. A patient with myasthenia gravis will have lung volume and capacity findings that indicate a(n): a. upper airway obstruction. b. obstructive pulmonary disorder. c. restrictive pulmonary disorder. d. combined obstructive and restrictive disorder.

ANS: C Myasthenia gravis results in a restrictive pulmonary disorder.

15. During a myasthenia crisis, a patient was placed on mechanical ventilation but is now stable.

What will the chest radiograph most likely show? a. Normal lungs b. Mediastinal shift c. Pericardial tamponade d. Ground-glass appearance ANS: A With an uncomplicated case of myasthenia gravis, the patient’s chest radiograph should show normal lung fields.

16. Which of the following disrupts the nerve impulse transmission in myasthenia gravis? a. MuSK b. Edrophonium c. IgG antibodies d. RNS ANS: C The IgG antibodies disrupt the transmission of ACh at the neuromuscular junction.

17. What percentage of patients with only ocular myasthenia gravis are seropositive? a. <10% b. 25% c. 50% d. 90% ANS: C Patients who have detectabNleU aRnt ib SIod ieG Ns toBTt.heCA CMhR, O or to the musclespecific receptor tyrosine kinase (MuSK), are said to have seropositive myasthenia gravis, whereas those lacking both AChR and MuSK antibodies on standard assays are said to have seronegative myasthenia gravis. About 50% of patients with only ocular myasthenia gravis are seropositive.

About 90% of generalized cases of myasthenia gravis are seropositive.

18. What is the most sensitive diagnostic test for myasthenia gravis? a. Ice pack test b. SFEMG c. Edrophonium test d. PEFR ANS: B SFEMG is considered to be the most sensitive diagnostic test for myasthenia gravis.

19. In which clinical classification of myasthenia gravis is intubation indicated? a. Class I b. Class 1IIb c. Class V d. Class II ANS: C Intubation, with or without mechanical ventilation, is recommended at Class V myasthenia gravis.

20. Which of the following is considered a disadvantage of the edrophonium test? a. It is associated with false-negative and false-positive results about 50% of the time. b. It should not be given to you patients with a history of asthma. c. It can be complicated by cholinergic side effects. d. Initiate mechanical ventilation per protocol is likely following the test.

ANS: C A disadvantage of the edrophonium test is that it can be complicated by cholinergic side effects that include cardiac arrhythmias and cardiopulmonary arrest. Cardiac monitoring, or avoiding this test altogether, is suggested in the elderly or those with a history of arrhythmia or heart disease. Although the sensitivity of the Tensilon test for the diagnosis of myasthenia gravis is in the 80% to 90% range, it is associated with many false-negative and false-positive results.

9TH

Chapter 31: Cardiopulmonary Assessment and Care of Patients With Neuromuscular Disease Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following is the leading cause of death in a patient with neuromuscular disease (NMD)? a. Infections b. Breathing disorders c. Cardiac disorders d. Suicide ANS: B Neuromuscular disease (NMD) is a generalized term used to describe disorders of the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. These disorders are associated with a wide range of motor and sensory deficits; however, patients with neuromuscular disease may develop significant cardiopulmonary issues. In fact, breathing disorders are the leading cause of death in patients with neuromuscular disease.

2. Cervical nerves a. C1; C7 b. C1; C2 c. C3; C5 d. C5; C7

through

innervate the diaphragm.

9TH

ANS: C Damage to the lumbosacral spinal cord results in lower extremity weakness/paralysis, spasticity, and dysfunction of the bowel and bladder. Cervical nerves C3 through C5 innervate the diaphragm via the phrenic nerve.

3. Management of a traumatic spinal cord injury below the level of C5 involves: 1. prompt assessment to prevent addition injury.

2. immediate intubation.

3. anticoagulation therapy.

4. intravenous fluid resuscitation. a. 1, 3 b. 2, 4 c. 1, 3, 4 d. 1, 2, 3 ANS: C

The treatment of spinal cord injuries involves a multidisciplinary approach. Prompt assessment is important to prevent additional injury and to initiate the appropriate treatment in a timely fashion.

Autonomic dysfunction may require intravenous fluid resuscitation and possibly vasoactive medications to maintain adequate tissue perfusion. Anticoagulation should be initiated to prevent venous thromboembolism. Patients with injuries below the level of C5 generally do not require any ventilatory support; however, significant injuries at the C5 level and above will have diaphragmatic impairment (as well as impairment of other respiratory muscles) necessitating additional respiratory support. The risk for intubation of patients with cervical spinal cord injuries is significant.

4. Which of the following is a progressive neurologic disorder characterized by degeneration of upper and lower motor neurons? a. Amyotrophic lateral sclerosis b. Duchenne muscular dystrophy c. Myotonic dystrophy d. Emery-Dreifuss muscular dystrophy ANS: A Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disorder characterized by degeneration of upper and lower motor neurons. Duchenne muscular dystrophy is inherited as an Xlinked recessive trait, which means it is much more likely to occur in males than in females. Muscular dystrophy is a term that represents several genetic disorders characterized by pathologic changes within muscles affecting the limbs, face, and sometimes respiratory and cardiac muscles as well. They are distinguished from other neuromuscular disorders in that they are primary myopathies, progressive, manifest degeneration of muscle fibers pathologically, and have a genetic origin.

Myotonic dystrophy manifests at any age. Patients may have facial wasting, hyNpotRoniU Ia,SanGNarcTBh.edCpaMlate (secondary to weakness of the temporal and pterygoid muscles), and progressive weakness that begins in the distal muscles. Emery-Dreifuss muscular dystrophy, also known as scapuloperoneal or scapulohumeral muscular dystrophy, is transmitted in X-linked, autosomal recessive, and autosomal dominant fashions. Patients typically exhibit muscle weakness and wasting in a scapulohumeroperoneal distribution.

5. Which of the following is disease in which patients may have facial wasting, hypotonia, an arched palate with progressive weakness that begins in the distal muscles? a. Amyotrophic lateral sclerosis b. Duchenne muscular dystrophy c. Myotonic dystrophy d. Emery-Dreifuss muscular dystrophy ANS: C

Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disorder characterized by degeneration of upper and lower motor neurons. Duchenne muscular dystrophy is inherited as an Xlinked recessive trait, which means it is much more likely to occur in males than in females. Muscular dystrophy is a term that represents several genetic disorders characterized by pathologic changes within muscles affecting the limbs, face, and sometimes respiratory and cardiac muscles as well. They are distinguished from other neuromuscular disorders in that they are primary myopathies, progressive, manifest degeneration of muscle fibers pathologically, and have a genetic origin.

Myotonic dystrophy manifests at any age. Patients may have facial wasting, hypotonia, an arched palate (secondary to weakness of the temporal and pterygoid muscles), and progressive weakness that begins in the distal muscles. Emery-Dreifuss muscular dystrophy, also known as scapuloperoneal or scapulohumeral muscular dystrophy, is transmitted in X-linked, autosomal recessive, and autosomal dominant fashions. Patients typically exhibit muscle weakness and wasting in a scapulohumeroperoneal distribution.

6. Which of the following is transmitted in X-linked, autosomal recessive, and autosomal dominant fashions in which patients typically exhibit muscle weakness and wasting in a scapulohumeroperoneal distribution? a. Amyotrophic lateral sclerosis b. Duchenne muscular dystrophy c. Myotonic dystrophy d. Emery-Dreifuss muscular dystrophy ANS: D Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disorder characterized by degeneration of upper and lower motor neurons. Duchenne muscular dystrophy is inherited as an Xlinked recessive traNit, wRhicIh mGeanBs .itCis mMuch more likely to occur in males than in U S N T females. Muscular dystrophy is a term that represents several genetic disorders characterized by pathologic changes within muscles affecting the limbs, face, and sometimes respiratory and cardiac muscles as well. They are distinguished from other neuromuscular disorders in that they are primary myopathies, progressive, manifest degeneration of muscle fibers pathologically, and have a genetic origin. Myotonic dystrophy manifests at any age. Patients may have facial wasting, hypotonia, an arched palate (secondary to weakness of the temporal and pterygoid muscles), and progressive weakness that begins in the distal muscles. Emery-Dreifuss muscular dystrophy, also known as scapuloperoneal or scapulohumeral muscular dystrophy, is transmitted in X-linked, autosomal recessive, and autosomal dominant fashions. Patients typically exhibit muscle weakness and wasting in a scapulohumeroperoneal distribution.

7. You are treating a patient with a proximal distribution of weakness. Which of the following NMD is most likely? a. Amyotrophic lateral sclerosis b. Facioscapulohumeral dystrophy c. Limb girdle muscular dystrophy d. Emery-Dreifuss muscular dystrophy ANS: C

Limb girdle muscular dystrophy (LGMD) is a heterogenous group of disorders characterized by a proximal distribution of weakness. There are many forms of the disease that can be inherited in autosomal recessive or autosomal dominant fashion. Multiple genetic mutations can occur on different chromosomes and lead to the various disease states.

8. Diagnosis of muscular dystrophy combines: 1. physical examination.

2. laboratory testing.

3. muscle biopsy findings.

4. pulmonary function testing. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The diagnosis of muscular dystrophy combines physical examination, laboratory testing, and muscle biopsy findings. Clinical findings of muscular weakness, fatigue, muscle wasting, or dysphagia should prompt evaluation for a myopathic disorder. A thorough family history should be obtained when muscular dystrophy is suspected. In circumstances where the clinical presentation and inheritance pattern are consistent with a diagnosis, additional testing may not be necessary.

9. Which of the following NMD can be diagnosed with genetic testing of the dystrophin gene?

1. Duchenne muscular dystrophy 2. Facioscapulohumeral dystrophy 3. Becker muscular dystropUNhy B.C M S RN IT G O 4. Limb girdle muscular dystrophy a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A Many, but not all, muscular dystrophies are associated with elevations in CK and aldolase. In Duchenne and Becker muscular dystrophies, genetic testing of the dystrophin gene can be diagnostic and obviate the need for muscle biopsy.

10. Elevation of what laboratory values suggest muscle damage?

1. Albumin 2. Aldolase 3. Immunoglobulin 4. Creatine kinase a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Creatine kinase (CK) and aldolase are proteins that if elevated may suggest muscle damage.

11. The use of hands and arms to “walk up” their own body from a squatting position is referred to as: a. limb-girdle’s sign. b. Gower’s sign. c. Lou Gehrig’s sign. d. leg amyotrophic diplegia.

ANS: B Children with DMD, as well as those with other forms of muscular dystrophy, exhibit the Gower’s sign at approximately 3 years of age (use of hands and arms to “walk up” their own body from a squatting position). This is indicative of proximal muscle weakness, particularly of the hips and thighs.

12. Which of the following is early sign of disease seen in an infant with Duchenne muscular dystrophy? a. Pseudohypertrophy b. Hypotonia c. Muscle wasting of the thighs d. Gower’s sign ANS: B Infants born with DMD are generally asymptomatic but may have hypotonia. Poor head control in infancy may be an early sign of disease. Pseudohypertrophy of the calf muscles occurs due to fatty infiltration of the muscle. This is typically accompanied by muscle wasting of the thighs. Children with DMD, as well as those with other forms of muscular dystrophy, exhibit the GowNer’sRsigIn at app ro x ima tely 3 years of age.

G

B .C

M

U S N T

O

13. Which of the following are the two main categories of stroke? a. Cellular damage or cellular death b. Transient or permanent c. Sensory or motor d. Hemorrhagic and ischemic ANS: D Stroke, also known as acute brain attack or cerebrovascular accident, is a condition characterized by decreased perfusion to the brain resulting in cellular damage or cellular death. The two main categories of stroke are hemorrhagic and ischemic.

14. Which of the following areas involved in a stroke will cause sensory and motor impairment of the lower extremities? a. Strokes of the anterior circulation b. Strokes of the midbrain c. Strokes of the posterior cerebral artery d. Strokes of the pons ANS: A

Strokes of the anterior circulation will cause sensory and motor impairment of the lower extremities, akinetic mutism, and incontinence. Posterior cerebral artery (PCA) strokes may result in contralateral hemiplegia (paralysis), chorea, hemiballismus, visual field deficits, memory deficits, and visual hallucinations. Strokes impairing the midbrain generally cause cranial nerve deficits (e.g., double vision, taste disturbances, hearing loss, dizziness, and difficulty swallowing).

15. You are assisting the physician with the assessment of a patient that is thought to have ALS. What clinical cues should you be most aware of?

1. Sialorrhea 2. Muscle biopsy results 3. Tongue fasciculations 4. Nerve conduction study results a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A As a respiratory therapist, sialorrhea (drooling) and tongue fasciculations are two important clinical cues which should prompt one to consider a diagnosis of ALS. Electromyography will find signs of acute and chronic denervation. Nerve conduction studies are often normal, but compound motor action potential amplitudes may be reduced in more severe disease.

16. Tissue plasminogen activator (TPa) should be administered within stroke symptoms. a. 4.5 hours 9TH b. 5.5 hours c. 6.5 hours d. 7.5 hours

of the onset of

ANS: A Patients with ischemic strokes may require tissue plasminogen activator (TPa) to lyse clots and to reestablish cerebral perfusion. TPa should be administered within 4.5 hours of the onset of stroke symptoms provided there are no contraindications.

17. You are assessing the patient-ventilator system of a patient being treated for stroke. What parameters are you most concerned with during the assessment?

1. PEEP level of 20 cm H2O 2. Frequency of 18 breaths/min 3. MAP level of 30 mm Hg 4. Peak inspiratory pressure of 21 cm H2O a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: A

When utilizing mechanical ventilation, it is important to be mindful that high levels of PEEP may reduce mean arterial pressure (MAP) and ultimately decrease cerebral perfusion pressure (CPP).

18. The respiratory therapist can prevent increases in intracranial pressure (ICP) by: a. the administration of albuterol q4h. b. placing the patient in the Trendelenburg position. c. elevating the head of the bed at least 30 degrees. d. hypoventilating the patient.

ANS: A Prevention of increases in intracranial pressure (ICP) is important. Head of bed elevation at least 30 degrees minimizes venous outflow resistance and promotes CSF displacement into the spinal compartment, reducing ICP in the process.

19. General management and care of a patient with neuromuscular disease includes: 1. nutritional assessment.

2. gastrostomy tube placement.

3. mechanical ventilation.

4. weekly nerve conduction studies. a. 1, 3 b. 1, 2 c. 2, 3, 4 d. 1, 2, 3 ANS: D Nutrition is a vital, and often underestimated, aspect in the care of patients with N R I G B.C neuromuscular diseases (NMUD).SGasNtrosTtomy tuObe placement may be required to supplement nutritional needs and provide enteral access for medication administration. Mechanical ventilation is an important part of the care for NMD patients with respiratory insufficiency. Weekly nerve conduction studies are not done.

Chapter 32: Sleep Apnea Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following are found during rapid eye movement sleep?

1. The diaphragm functions normally.

2. The person is easy to awaken.

3. Dreaming occurs.

4. Skeletal muscles are paralyzed. a. 1, 2 b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B During rapid eye movement (REM) sleep, a person is difficult to awaken. Dreaming occurs during REM sleep and the skeletal muscles are paralyzed. Breathing is maintained by the diaphragm.

2. Signs and symptoms associated with obstructive sleep apnea include: 1. insomnia.

2. excessive daytime sleepiness.

3. hypothyroidism.

4. metabolic alkalosis.

9TH a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: A Obstructive sleep apnea is associated with insomnia, excessive daytime sleepiness, and other signs and symptoms. Hypothyroidism and other clinical disorders are associated with central sleep apnea.

Metabolic alkalosis is not associated with obstructive sleep apnea.

3. Clinical disorders associated with central sleep apnea include: 1. Pickwickian syndrome.

2. depression.

3. encephalitis.

4. brain stem infarction. a. 1, 2 b. 3, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: B

Clinical disorders associated with central sleep apnea include, but are not limited to, encephalitis and brain stem infarction. Obstructive sleep apnea is associated with Pickwickian syndrome, depression, and other signs and symptoms.

4. Sleep apnea would be diagnosed in a patient who has which of these findings?

1. More than 15 apnea episodes per hour of sleep.

2. More than 5 apnea episodes per hour over an 8-hour period.

3. More than 75% of the apneas are obstructive.

4. More than 75% of the apneas and hypopneas are obstructive. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: D During a sleep study, obstructive sleep apnea (OSA) is confirmed when either of the following two conditions exists: 15 or more apneas, hypopneas, or RERAs per hour of sleep (i.e., the AHI or RDI >15 events/hour) in an asymptomatic patient. More than 75% of the apneas and hypopneas must be obstructive. Or, 5 or more apneas, hypopneas, or RERAs per hour of sleep (i.e., the AHI or RDI >5/hour events/hour) in patients with symptoms (e.g., sleepiness, fatigue, and inattention) or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). More than 75% of the apneas and hypopneas must be obstructive.

5. Which of the following is typically not evaluated during a polysomnographic sleep study? a. Breath sounds. b. Chest and/or abdominal movement c. Electro-oculogram (EON UG)SR NI TG B.C O M d. Nasal and oral air flow ANS: A Breath sounds are not part of a polysomnographic sleep study. All of the other listed physiologic parameters, and others, are measured during the study.

6. Mixed sleep apnea has which of these traits?

1. Obstructive apnea traits 2. Central apnea traits 3. Usually begins as central apnea 4. Usually ends as central apnea a. 2, 4 b. 1, 3 c. 1, 2, 3 d. 1, 2, 4 ANS: C A person with mixed sleep apnea usually begins with central apnea (no breathing effort) that is followed by obstructive apnea (breathing effort without air flow).

7. Continuous positive airway pressure (CPAP) is useful in the management of the patient with obstructive sleep apnea because it: a. pushes air into and out of the lungs like a mechanical ventilator.

b. prevents airway collapse. c. stretches the J receptors in the chest wall to stimulate breathing. d. delivers a tidal volume breath to the patient.

ANS: B CPAP prevents the collapse of the hypotonic upper airway tissues. It is standard treatment in a patient with obstructive sleep apnea. The CPAP is delivered to the patient through a nasal (or full-face) mask.

CPAP does not breathe for a patient like a mechanical ventilator does.

8. A CPAP titration polysomnogram is performed to: a. find the maximum CPAP level for the functional residual capacity. b. determine the lowest possible CPAP level. c. find the CPAP level to maintain an open airway. d. determine the pressure needed for negative-pressure ventilation.

ANS: C A CPAP titration polysomnogram is performed to find the CPAP level to maintain an open airway.

The CPAP is delivered to the patient through a nasal (or full-face) mask. If the CPAP level is too low, the airway will tend to still collapse. Too high a CPAP level puts unnecessary pressure on the lungs and heart. The CPAP level is not used to set the pressure for negative-pressure ventilation.

9. First-line treatment for the management of hyperventilation-related central sleep apnea includes: a. CPAP. b. adaptive servo-ventilation (VPAP). c. mechanical ventilation.N R I G B.C d. palatopharyngoplasty. U S N T ANS: A Similar to OSA, continuous positive airway pressure (CPAP) has customarily been the first-line therapy for patients with hyperventilation-related CSA. Patients who do not respond well to CPAP should receive a trial of adaptive servo-ventilation (ASV) with the variable positive airway pressure adapt (VPAP Adapt).

10. Which of the following may be used in the management of a patient with central sleep apnea?

1. Acetazolamide 2. Oxygen therapy 3. Inhaled bronchodilator medications 4. Adaptive servo-ventilation (VPAP) a. 1, 3 b. 2, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: C Respiratory stimulants (like acetazolamide), supplemental oxygen, and adaptive servo-ventilation may be used in the management of a patient with central sleep apnea. Inhaled bronchodilator medications are not helpful because the patient’s problem is not caused by bronchospasm.

11. During a pulmonary function study, it was found that a patient has a sawtooth pattern on his flow-volume loop. What is this finding associated with? a. Central sleep apnea b. COPD c. Obstructive sleep apnea d. Laryngeal edema (epiglottitis) ANS: C An inspiratory sawtooth pattern on the flow-volume loop is associated with obstructive sleep apnea.

The sawtooth pattern is caused by loose tissues in the throat moving during the rapid inspiration.

Patients with COPD have a distinctively slow expiratory flow pattern. A patient with laryngeal edema (epiglottitis) will often have a distinctive inspiratory stridor sound.

12. Sleep apnea is associated with: 1. increased SVR. 2. decreased SVR. 3. increased PVR. 4. decreased PVR. a. 1, 3 b. 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: A Sleep apnea is associated wNith Ran iIncreGaseBin.bCothMSVR and PVR.

U S N T

O

13. Which of the following cardiac dysrhythmias is life threatening? a. Atrioventricular block b. Sinus bradycardia c. Ventricular tachycardia d. Premature ventricular contraction ANS: C Ventricular tachycardia is potentially life threatening because there is very little cardiac output and the patient’s blood pressure will drop drastically. The other dysrhythmias are still a concern.

14. The respiratory therapist is evaluating a patient for risk for obstructive sleep apnea.

Which of the following are risk factors for obstructive sleep apnea?

1. Excess weight 2. Large neck size 3. Hypertension 4. Hypoglycemia a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D

More than 50% of the patients diagnosed with obstructive sleep apnea are overweight. It is suggested that fat deposits around the upper airway may obstruct breathing. Obstructive sleep apnea is often seen in the patients with large neck size. A neck circumference greater than 17 inches in males and greater than 16 inches in females increases the risk for obstructive sleep apnea. Obstructive sleep apnea is commonly seen in patients with high blood pressure. Obstructive sleep apnea occurs twice as often in patients with chronic nasal congestion from any cause. Patients with diabetes, not hypoglycemia, are three times more likely to have obstructive sleep apnea than healthy individuals.

15. Which of the following may be a disadvantage of in-home portable sleep testing? a. Convenience b. Patient acceptance c. Performed over multiple nights d. Published standards for scoring or interpretation ANS: D Advantages of in-home portable monitoring include: it can be done in the patient’s home and/or in areas without ready access to sleep centers, convenience, patient acceptance, and decreased cost. A disadvantage is that there are no published standards for scoring or interpretation.

16. The rationale behind the use of supplemental oxygen in the treatment of sleep apnea is to: a. preoxygenate the airway prior to the apneic episodes. b. stimulate the central chemoreceptors and prevent apneic episodes. c. increase the respiratory drive in the medulla. d. blow off carbon dioxide in the alveolus.

ANS: A

9TH

Because of the hypoxemia-related cardiopulmonary complications of sleep apnea (arrhythmias and pulmonary hypertension), nocturnal low-flow oxygen therapy is sometimes used alone to offset or minimize the oxygen desaturation. The reasoning behind the use of nasal oxygen therapy’s effectiveness is that the airway is continually “flooded” with oxygen, which will be inspired during the nonapneic episodes—in effect, “preoxygenating” the patient in anticipation of the apnea events.

Usually, no improvement in sleep fragmentation or hypersomnolence occurs with the use of supplemental oxygen.

17. Scales used in the diagnosis of obstructive sleep apnea include: 1. Glasgow Coma Scale.

2. Epworth Sleepiness scale.

3. Fatigue Severity Scale.

4. Visual Analogue Fatigue Scale. a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: D

The Epworth Sleepiness scale is routinely used as a validated measure of daytime sleepiness.

Sleepiness must be differentiated from fatigue, which can be semi-quantitated with the use of the Fatigue Severity Scale (FSS) or the Visual Analogue Fatigue Scale (VAFS). This is followed by a careful examination of the upper airway and perhaps by pulmonary function studies (especially by analysis of the flow-volume loop) to determine whether upper airway obstruction is present.

9TH

Chapter 33: Newborn Assessment and Management Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Early clinical manifestations of an infant with respiratory distress include: 1. cyanosis.

2. substernal retractions.

3. expiratory grunting.

4. apn ea. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D Early on, when an infant is having respiratory distress, he/she will show cyanosis, sternal retractions, expiratory grunting, and other signs. He/she will have apnea and other signs later on.

2. Late clinical manifestations of an infant with respiratory distress include: 1. elevated diaphragm.

2. decreased respiratory rate.

3. CO2 retention.

4. lethar 9TH gy. a. 2, 3 b. 1, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: A Late clinical manifestations that an infant is having respiratory distress include decreased respiratory rate, CO2 retention, and other signs. He/she will have lethargy and other signs early on. Elevated diaphragm is not an early or late sign of respiratory distress.

3. An infant in respiratory distress will often generate a high negative intrapleural pressure during inspiration. In comparison to an adult, this will result in: 1. cyanosis of dependent thoracic areas.

2. “seesaw” breathing pattern.

3. alveolar hyperinflation.

4. intercostal retractions. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B

Alveolar hyperinflation is associated with air trapping. A high negative intrapleural pressure can result in cyanosis of dependent thoracic areas, “seesaw” breathing pattern, and intercostal retractions.

4. A neonate in respiratory distress will often dilate his/her nostrils to: a. facilitate inspiration. b. nurse more easily. c. sneeze out amniotic fluid. d. raise the intrapleural pressure.

ANS: A Dilation of the nostrils will make inspiration easier in the premature neonate. None of the other listed options are affected by dilated nostrils.

5. A neonatal patient is found to have grunting on expiration. What physiologic effect does this produce? a. Increased vital capacity Increased PaO2 b.

Decreased PaCO2 c. d. Closes the ductus arteriosus ANS: B An expiratory grunt is the sound generated when expired air is moving through a partially closed glottis. This partial closing of the glottis applies positive pressure against the alveoli. An increased PAO2 should result. Glottis closure will not increase vital capacity, decrease PaCO2, or close the ductus arteriosus.

N

R

I

G

B.C M

O Apnea of prematurity can b eUde fSin edNa s:T 1. respiratory pause causing bradycardia.

2. cycles of short breathing pauses followed by faster breathing.

3. no breathing for >20 seconds.

4. sudden apnea and death (crib death). a. 1, 4 b. 2, 3 c. 1, 3 d. 3, 4

6.

ANS: C Apnea has two possible definitions: (1) respiratory pause causing bradycardia (or cyanosis or both) and (2) no breathing for less than 20 seconds. Apnea is usually found in a baby of less than 37 weeks’ gestation. Period breathing is described as cycles of short breathing pauses followed by faster breathing. Sudden apnea and death (crib death) cases are usually associated with upper airway obstruction in an infant lying on its stomach or entangled with bed linens.

7. Apneic episodes in a premature neonate can be caused by which of the following?

1. Epiglottitis 2. Immature central nervous system 3. Immature airway receptors 4. Immature chemoreceptors

a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Epiglottitis is an inflammation of the epiglottis caused by an infection. In severe cases, it can close off the upper airway. However, it is not associated with apnea of prematurity. All of the other listed options can lead to apnea of prematurity.

8. Which of the following can trigger apnea in the premature infant?

1. Micrognathia 2. Intracranial hemorrhage 3. REM sleep 4. Hyperthermia a. 2 b. 3, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C See Box 33.3 for the full list of possible triggering events or conditions.

9. Respiratory causes of persistent pulmonary hypertension of the newborn (PPHN) include: 1. congenital heart disease.

2. hypoxia.

3. meconium aspiration synNdroRme I(MAGS).B.C M U S N T

4.

O

respiratory distress syndro me

(RD S).

a. 2 b. 3, 4 c. 1, 3 d. 2, 3, 4 ANS: B Respiratory factors associated with PPHN include MAS and RDS. Congenital heart disease is a cardiovascular factor associated with PPHN. Hypoxia is a fetal factor associated with PPHN. See Box 33.4 for the complete list.

10. When a neonate has PPHN, what structures does the blood flow through to bypass the lungs?

1. Ductus venosus 2. Foramen ovale 3. Hypogastric arteries 4. Ductus arteriosus a. 3, 4 b. 1, 3 c. 2, 4 d. 1, 2, 4 ANS: C

During PPHN, blood will flow through the foramen ovale and ductus arteriosus to bypass the lungs. Fetal circulation involves blood passing through the foramen ovale, ductus arteriosus, ductus venosus, and hypogastric arteries. See Fig. 33.4.

11. PPHN usually appears: a. in utero during the last trimester. b. within 1 hour of birth. c. within the first 12 hours of birth. d. between the first and sixth days of life.

ANS: C PPHN usually appears within the first 12 hours of birth. It cannot be detected in utero. Other conditions will appear quickly after birth or several days later.

12. A neonatal patient has PPHN. What may develop as a consequence of this? a. Cardiomegaly b. Pulmonary embolism c. Mucosal edema d. Cardiac tamponade ANS: A PPHN results in increased pulmonary vascular resistance. This will increase right ventricular afterload and can result in cardiomegaly.

13. A newborn is flaccid and apneic, has a cyanotic body and a heart rate of 85/min, and shows no reaction to stimulation. Her Apgar score would be: a. 8.

9TH b. 5. c. 2. d. 1.

ANS: D The neonate’s Apgar score of 1 is found by adding these points: heart rate of 85 = 1 point, cyanotic body = 0 points, apnea = 0 points, flaccid muscle tone = 0 points, no reaction to stimulation = 0 points.

14. A newborn’s 5-minute Apgar score is 7. How should this be interpreted? a. Normal adjustment to being born b. Moderate distress; intubate the airway and suction the lungs c. Moderate distress; administer supplemental oxygen d. Severe distress; begin bag-mask resuscitation ANS: A A 5-minute Apgar score of 7 to 10 indicates no difficulty in adjusting to extrauterine life. A score of less than 7 indicates some difficulty. Additional steps will need to be taken to resuscitate the neonate depending on the severity of the situation.

15. A premature infant is found to be “bobbing” her head. This is important because it can be a sign of which of the following? a. Hypoxemia b. Renal failure

c. Intracranial hemorrhage d. Respiratory distress ANS: D Head bobbing is a sign of respiratory distress in an infant. When in respiratory distress, the infant often uses the scalene and sternocleidomastoid accessory muscles of inspiration to assist in ventilation. When these muscles contract, the infant’s head moves (“bobs”) back and forth because the neck extensor muscles are not strong enough to stabilize the head.

16. A premature infant has two pulse oximeters placed: one on the right hand and one on the left foot. The respiratory therapist notes that the reading on the right hand is consistently 12% greater than the reading on the left foot. Which of the following is the best interpretation of this finding? a. The infant has left-sided intrapulmonary shunting. b. The infant likely has pneumonia. c. The infant is in septic shock with systemic capillary shunting. d. The infant has persistent pulmonary hypertension of the newborn.

ANS: D For the newborn in respiratory distress, pulse oximetry is often used to monitor both the preductal SpO2 and the postductal SpO2. To measure the preductal SpO2, the oximeter probe is placed on the right hand or wrist; to measure the postductal SpO2, the probe is placed on either foot. A large difference between the two readings (>10%) indicates a right-to-left shunt, and persistent pulmonary hypertension of the newborn (PPHN) is likely.

17. A premature infant is suspected of having persistent pulmonary hypertension of the newborn. How is this diagnNosisRcoInfirGmedB?.C M S N T O a. Arterial blood gas analysUis b. Chest radiography c. Pulmonary angiography d. Echocardiography ANS: D The diagnosis of PPHN should always be suspected in any infant with nonresponsive or ongoing hypoxemia and cyanosis that is out of proportion to the degree of pulmonary disease, oxygen requirement, and mean airway pressure support. The diagnosis of PPHN is confirmed by echocardiography. When PPHN is present, echocardiography demonstrates normal structural cardiac anatomy with evidence of pulmonary hypertension (e.g., flattened or displaced ventricular septum).

Doppler studies show right-to-left shunting through the patent ductus arteriosus and/or foramen ovale.

Chapter 34: Pediatric Assessment, Protocols, and PALS Management Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. A popular communication tool utilized in the clinical setting is which of the following? a. The SOAP format b. The SBAR technique c. PEWS d. Glasgow Coma Score ANS: B A popular communication tool utilized in the clinical setting is the Situation, Background, Assessment, and Recommendation approach—the SBAR technique. The benefit of the SBAR format is that it quickly and succinctly communicates the assessments, concerns, and recommendations to appropriate members of the health care team, particularly the physicians/providers who are responsibility and have the authority for directing care.

2. Which of the following is a common cause of respiratory failure in children? a. Fatigue caused by the increased work of breathing b. Undiagnosed cardiac defects A decreased PaCO2 c. d. Metabolic disorders ANS: A

NURSING TB.COM

Since the common cause of respiratory failure in children is fatigue caused by the increased work of breathing (WOB), a diminished level of consciousness (LOC) is a key indicator of impending acute ventilatory failure. Infants and pediatric patients who are alert and anxious are of concern, but they are of less concern than those who are somnolent and difficult to arouse while still struggling to breathe.

3. Which of the following is used as an early indicator of those hospitalized children at risk for deterioration? a. The SOAP format b. The SBAR technique c. PEWS d. Glasgow Coma Score ANS: C Some hospitals use the Pediatric Early Warning Score (PEWS) as an early indicator of those hospitalized children at risk for deterioration. The PEWS system objectively uses the patient’s vital signs, level of consciousness, oxygen saturation, glucose level, white blood count (WBC), and urine output. The PEWS helps to heighten awareness for patients who may have issues that can complicate their care—for example, family concerns, high-risk patients, behavioral and communication concerns.

4. While suctioning an infant the RT notices a significant drop in the patient’s heart rate. What is a possible cause?

a. b. c. d.

Undiagnosed cardiac abnormality Asthma Vagal stimulation Croup

ANS: C The infant and young child both have narrowed airways which predispose them to significant upper or lower airway obstruction from viral illnesses such as croup or bronchiolitis. Infants with congenital or acquired airway stenosis or malacia will likely become less symptomatic as their airways grow in diameter. Because infants are very sensitive to vagal stimulation—which, for example, can cause bradycardia and a drop-in blood pressure—the respiratory therapist should avoid any contact with the infant’s vocal cords when suctioning.

5. How can an infant increase his/her minute ventilation? a. Increase the volume of their breath. b. Decrease the depth of their breath. c. Increase their respiratory rate. d. Decrease their respiratory rate.

ANS: C Without the rigidity of the chest wall, the “bucket handle effect” limits the volume and depth of each breath. Thus the infant is only able to increase his/her respiratory rate to generate a greater minute ventilation.

6.

is/are a color-coded grouping of appropriate sized equipment based on the child’s length?

9TH a. Broselow tape b. PEWS c. Glasgow Coma Score d. Pediatric treatment protocols

ANS: A In pediatric respiratory emergencies, the Broselow tape and Broselow Cart commonly uses a colorcoded grouping of appropriate sized equipment based on the child’s length.

7. You are assisting in the intubation of a newborn patient who weighs 4 kg. What size endotracheal tube should you have available? a. 2.5. b. 3.0. c. 3.5. d. 4.

ANS: B See Table 34.6.

8. Early signs of pertussis include which of the following?

1. Runny nose 2. High fever 3. Mild cough 4. Tachycardia

a. b. c. d.

1, 2 1, 3 2, 3, 4 1, 2, 3

ANS: A Pertussis, also known as whooping cough, is a very contagious respiratory illness caused by a type of bacteria called Bordetella pertussis, which spreads from person to person by coughing or sneezing or sharing the same breathing space. Early symptoms can last for 1 to 2 weeks and include: • Runny nose • Low-grade fever • Mild, occasional cough • Apnea (in babies) 9. Your patient has suspected carbon monoxide poisoning. Which of the following statement is true regarding the SpO2 goals? a. The SpO2 should be kept between 88% and 92% until measured carboxyhemoglobin level drops to desired normal range (<15%). b. The SpO2 should be kept between 88% and 92%. c. Mechanical ventilation should be immediately administered to obtain a SpO2 between 92% and 94% d. Ignore SpO2 and deliver 100% oxygen until measured carboxyhemoglobin level drops to desired normal range (<5%).

ANS: D SpO2 Goals: Generally SpeNU cifiS Rc toNIUni Gt PoBli.cyCor MRespiratory Care Protocol T • CHD: to be determined by managing physician based on patient history • CLDI: 93% to 97%; may need to keep toward the higher range to prevent BPD “fits” with transient hypoxia.

• Bronchiolitis: 91% to 94% or higher.

• Asthma: 92% to 94% or higher.

• Pneumonia: 92% to 94% or higher.

• Chronic CF: 88% to 92% or higher.

• Carbon monoxide poisoning: ignore SpO2 and deliver 100% oxygen until measured carboxyhemoglobin level drops to desired normal range (<5%).

Chapter 35: Meconium Aspiration Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. How may a fetus respond when he/she becomes hypoxemic? a. The fetus stops making breathing efforts. b. The fetus makes rapid, shallow chest movements. c. The fetus makes very deep, gasping inspiratory movements. d. The fetus shows Kussmaul respirations.

ANS: C When a fetus is experiencing hypoxemia, he/she will make very deep, gasping inspiratory movements. As a result, the fetus will inhale amniotic fluid or meconium. Kussmaul respirations are related to diabetic ketoacidosis.

2. What is the consequence of meconium aspiration if there is a “ball-valve” effect in the small airways? a. Air trapping on exhalation b. Apnea of prematurity c. Air trapping on inhalation d. Bronchiectasis ANS: A A “ball-valve” effect in the Nsm Rall a I seMair trapping on exhalation. In Gays .ill cau C Apnea UirwS N BTw other words, air will be inhaled but cannot be fully exhaled. of prematurity and bronchiectasis are not related to the “ball-valve” effect.

3. A patient has meconium aspiration syndrome (MAS) and a chemical pneumonitis as a result. What effects can this have?

1. Increased surfactant production 2. Increased bacterial growth 3. Edema of bronchial mucosa 4. Excessive bronchial secretions a. 2, 3 b. 1, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: D A chemical pneumonitis caused by MAS can result in a decreased surfactant production.

4. A neonate with MAS has hypoxemia. Which of the following can be a pulmonary effect of this? a. Status asthmaticus b. Persistent pulmonary hypertension of the newborn (PPHN) c. Bronchopulmonary dysplasia (BPD) d. Pulmonary fibrosis

ANS: B MAS can cause hypoxemia, which, in turn, can lead to PPHN. Hypoxemia will not cause status asthmaticus, BPD, or pulmonary fibrosis.

5. About how many neonatal patients with MAS will require mechanical ventilation or CPAP? a. 50% to 70% b. 30% to 50% c. 10% to 15% d. Less than 10% ANS: B About 30% to 50% of infants with severe MAS will require mechanical ventilation or CPAP. About 10% to 15% may develop a pneumothorax. MAS has about a 4% mortality rate.

6. Infants who are older than 42 weeks’ gestation are at greater risk for MAS because they have: 1. a full bowel.

2. strong peristalsis.

3. amniotic fluid in their stomach.

4. sphincter tone. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 4

N R I G B.C M Infants who are older than 42 weeks’ gU estaS tion N are T at greateO r risk for MAS because they have strong ANS: B

peristalsis and sphincter tone. It does not matter how full the infant’s bowel is or that there is amniotic fluid in his/her stomach.

7. Risk factors for the development of MAS include: 1. being postterm.

2. a mother who is hypertensive.

3. a mother who is toxemic.

4. being the first twin born. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: D Risk factors for the development of MAS include, but are not limited to, the fetus being postterm (or full-term) and the mother being hypertensive or toxemic. MAS is not directly related to the first twin (or second twin) born.

8. Indications that a newborn has aspirated meconium include: 1. a high Apgar score.

2. meconium in amniotic fluid.

3. newborn is not actively breathing.

4. meconium staining on skin. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C A high Apgar score indicates that the infant is adapting well to being born. A low Apgar score indicates the infant is having difficulty without being specific about the cause. An apneic newborn with obvious signs of meconium would give a strong indication of meconium aspiration.

9. It is highly suspected that a newborn has aspirated meconium. What actions should be immediately undertaken?

1. Instill exogenous surfactant 2. PRN suctioning of the airways 3. Gentle oral suctioning 4. Elective intubation for the clearance of meconium stained fluid a. 2, 3 b. 1, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The Neonatal Resuscitation Program (NRP) Guidelines recommend using gentle oral suctioning for babies with meconium stained fluids, who are having difficulty clearing their airway, and who are not breathing or crying. After the infant has been stabilized and N R I G B.C transported to the neonatal inUtensSiveNcarTe unit, PORN suctioning of the airways should be performed. Elective intubation for the clearance of meconium stained fluid is no longer recommended. During a resuscitation, if adequate chest rise is not able to be obtained, intubation and suctioning through the endotracheal tube may be required. Because meconium aspiration disrupts normal surfactant production, exogenous pulmonary surfactant is often administered to infants with MAS. 10. What risks are there in positive-pressure ventilation before all meconium has been removed from the airways?

1. Forcing meconium into the lower airways 2. Pneumothorax 3. Triggering persistent pulmonary hypertension of the neonate (PPHN) 4. Triggering an asthma attack a. 1, 4 b. 3, 4 c. 1, 2 d. 2, 3, 4 ANS: C Positive-pressure ventilation can force any meconium from the upper airway down into the smaller airways. This can result in a “ball-valve” type of obstruction to exhalation. The trapped air can cause hyperinflation that can lead to a pneumothorax. PPHN and asthma are not linked to positive-pressure ventilation.

11. If mechanical ventilation is needed to support a neonate with MAS, which of the following settings is especially important? a. High positive end-expiratory pressure (PEEP) level. b. Long exhalation time. c. High humidity level. d. Give no more than 50% oxygen.

ANS: B Because of the risk for incomplete exhalation with MAS, the infant receiving mechanical ventilation must have a long exhalation time. It is important to confirm that there is complete exhalation of the delivered tidal volume. PEEP is not usually needed with the MAS patient. All patients receiving mechanical ventilation should be given a fully humidified tidal volume. Follow the oxygen therapy protocol to guide delivery of the necessary oxygen percentage. More than 50% oxygen may be needed until the infant’s airways are open.

12. A common finding in a neonate with MAS is a respiratory rate that is: a. under 40/min. b. between 40 and 60/min. c. well over 60/min. d. cyclical with faster and then slower breaths.

ANS: C It is common to find an infant with MAS to have a respiratory rate of well over 60/min. A normal infant will have a respiratory rate between 40 and 60/min. A cyclical breathing pattern would be seen in anNinfRant IwithGpeBrio.dCic bMreathing.

U S N T

O

13. An infant with MAS will show what clinical manifestations associated with the more negative intrapleural pressures needed during inspiration?

1. Seesaw breathing movement.

2. Breath sounds reveal rhonchi and crackles.

3. Expiratory grunting.

4. Cyanosis of the dependent thoracic areas. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: A Clinical manifestations associated with the more negative intrapleural pressures needed during inspiration include, but are not limited to, seesaw breathing movement and cyanosis of the dependent thoracic areas. Chest assessment findings may include rhonchi and crackles for breath sounds because of meconium in the airways. If the neonate is hypoxic, he/she may display expiratory grunting. However, these last two findings are not directly associated with the more negative intrapleural pressures needed during inspiration.

14. A patient with MAS has had a chest radiograph taken. What findings can be expected? a. Elevated diaphragms b. Mediastinal shift

c. Irregular densities throughout the lungs d. Air bronchograms ANS: C Meconium in the airways will be seen on the chest radiograph as irregular densities throughout the lungs. An infant with MAS is more likely to have depressed diaphragms due to air trapping. There should not be any mediastinal shift with MAS. Air bronchograms are associated with diffuse atelectasis, not MAS. 15. Hyperinflation is noted on the chest radiograph of a patient with MAS. What sudden developments must be watched for?

1. PPHN 2. Pneumothorax 3. Cardiomegaly 4. Pneumomediastinum a. 2, 3 b. 2, 4 c. 1, 2, 3 d. 1, 3, 4 ANS: B If an infant with MAS has air trapping, he/she can suddenly develop a pneumothorax (about 10% to 15% of the time) or pneumomediastinum. PPHN and cardiomegaly are slow to develop.

16. The major pathologic or structural changes associated with the physical presence of meconium in MAS include: NURairSI NGTB.C 1. partially obstructed airways, trapping, and O alveolar hyperinflation.

2. pulmonary air leak syndromes (pneumomediastinum or pneumothorax).

3. totally obstructed airways and absorption atelectasis.

4. pulmonary edema and alveolar flooding. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The major pathologic or structural changes associated with MAS due to the physical presence of the meconium include partially obstructed airways, air trapping, alveolar hyperinflation, pulmonary air leak syndromes (pneumomediastinum or pneumothorax), and totally obstructed airways and absorption atelectasis. They do not include pulmonary edema and alveolar flooding.

Chapter 36: Transient Tachypnea of the Newborn Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Initially, TTN will have a clinical presentation similar to: a. the early stage of respiratory distress syndrome (RDS). b. the late stage of respiratory distress syndrome (RDS). c. bronchial pneumonia. d. meconium aspiration syndrome (MAS).

ANS: A TTN and the early stage of respiratory distress syndrome (RDS) have an initially similar clinical presentation.

2. The causes of TTN include: 1. mother’s diagnosis of cystic fibrosis.

2. infant’s hypoxemia.

3. mother’s hypoxemia.

4. infant’s inadequate inspiratory effort. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3

9TH

ANS: B If the newborn infant is hypoxemic and has an inadequate inspiratory effort, there is a delay in the clearance of pulmonary fluid. This leads to TTN. 3. How soon will TTN begin to resolve after birth? a. 4 to 6 hours after birth b. 12 to 24 hours after birth c. 48 to 72 hours after birth d. 72 to 96 hours after birth ANS: C Usually TTN will begin to resolve within 48 to 72 hours after birth as the pulmonary fluid is absorbed by the lymphatic system and pulmonary capillaries.

4. The major pathologic and structural changes associated with TTN include: 1. decreased removal of fluid by pulmonary lymphatics.

2. air trapping.

3. pleural effusion.

4. atelectasis. a. 1, 2 b. 3, 4 c. 1, 2, 3 d. 2, 3, 4

ANS: A The major pathologic and structural changes associated with TTN include, but are not limited to, decreased removal of fluid by the pulmonary lymphatics and air trapping caused by the compromised clearance of bronchial secretions.

5. Risk factors for the development of TTN include: 1. maternal diabetes.

2. male gender.

3. maternal bleeding.

4. breech delivery. a. 1, 3 b. 2, 4 c. 1, 3, 4 d. 1, 2, 3 ANS: D Risk factors for the development of TTN include, but are not limited to, maternal diabetes, male gender infant, and maternal bleeding.

6. What respiratory rate would be expected during the physical examination of a patient with TTN? a. 60 to 100 breaths/min b. 40 to 60 breaths/min c. 20 to 40 breaths/min d. Less than 20 breaths/min

N R I G B.C M Normally, a newborn infant’s respiratorUy raS te isNaboTut 40 toO60 breaths/min. During the early stages of ANS: A

TTN, the respiratory rate is often 60 to 100 breaths/min.

7. In reviewing the chart of a neonate who has developed TTN, what is a likely finding related to the Apgar score? a. The 1- and 5-minute scores are good. b. The 1-minute score is good and 5-minute score is bad. c. The 1-minute score is bad and 5-minute score is good. d. Both scores are bad.

ANS: A A typical infant with TTN has good Apgar scores at 1 and 5 minutes.

8. Which of the following is not typically performed in the general management of a patient with TTN? a. Oxygen therapy administration b. Administration of diuretics c. Proper stabilization d. Ruling out other serious conditions ANS: B General care includes proper stabilization, administration of oxygen therapy, and ruling out other serious conditions.

9. Which of the following breathing patterns are associated with TTN? 1. Normal rate 2. Rapid rate 3. Higher than normal tidal volume 4. Shallow tidal volume a. 1, 3 b. 2, 3 c. 1, 4 d. 2, 4 ANS: D The hallmark clinical manifestations of an infant with TTN are a rapid respiratory rate and shallow tidal volume.

10. Which of the following clinical manifestations are associated with the more negative intrapleural pressures needed during inspiration?

1. Thick, tenacious secretions 2. Intercostal retractions 3. Nasal flaring 4. Mediastinal shift a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 4 ANS: B Clinical manifestations associated with the more negative intrapleural pressures needed during N R I G B.C inspiration include, buUt arSe noNt limTited toO, intercostal retractions and nasal flaring.

11. Initially, a mild case of TTN manifests itself clinically as a(n) a. restrictive pulmonary b. obstructive pulmonary c. equally restrictive and obstructive d. initially obstructive and then a progressively restrictive

disorder.

ANS: A TTN manifests itself clinically as a restrictive pulmonary disorder because excess fluid in the lungs limits inspiration.

12. An infant with a mild case of TTN will show which of the following arterial blood gas values?

1. Increased pH 2. Decreased pH 3. Low PaO2 4. Low PaCO2 a. 1, 4 b. 3, 4 c. 2, 3 d. 1, 3, 4 ANS: D

In mild to moderate cases of TTN, the PaO2 will be low, the PaCO2 will be low, and the pH will be increased.

13. What are the radiologic findings anticipated on a chest radiograph taken 2 hours after delivery in a newborn suspected of having TTN? a. Normal lung fields b. Hyperlucency c. Flattened diaphragms d. Bulging intercostal spaces ANS: A The initial chest radiograph of an infant with TTN will appear normal. Changes usually occur on the chest radiograph between 4 and 6 hours after birth.

14. Which of the following radiologic findings would not be expected in a 12-hour-old neonate with TTN? a. Air bronchograms b. Fluid in the interlobular fissures c. Elevated diaphragms d. Prominent perihilar streaking ANS: C Elevated diaphragms are not consistent with the clinical picture associated with TTN and thus would be not be found on a chest radiograph.

15. On a chest radiograph, starbursts are indicative of: a. bacterial 9TH pneumonia. b. carinal carcinoma. c. pulmonary vascular congestion. d. foreign body aspiration.

ANS: C Starbursts, also called perihilar streaking, are indicative of pulmonary vascular congestion.

16. Which of the following oxygenation indices would be elevated in TTN? a. Arterial-venous oxygen content difference b. Oxygen consumption c. Mixed venous oxygen saturation d. Pulmonary shunt fraction ANS: D In TTN, the pulmonary shunt fraction would be expected to be elevated.

17. At what gestational age is TTN most common? a. 26 to 28 weeks’ gestational age b. 28 to 30 weeks’ gestational age c. 34 to 36 weeks’ gestational age d. 38 to 40 weeks’ gestational age ANS: D TTN appears most commonly in full-term infants.

Chapter 37: Respiratory Distress Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Respiratory distress syndrome (RDS) primarily affects infants who are: a. preterm with insufficient surfactant. b. full-term. c. postterm with too much surfactant. d. preterm with too much surfactant.

ANS: A RDS is found in preterm neonates with insufficient surfactant. Surfactant is produced by the alveolar type II cells in the lungs of a full-term (or near-term) neonate.

2. Which of the following is usually seen in the lungs of a neonate with RDS? a. Alveolar collapse (atelectasis) b. Segmental atelectasis c. Lobar atelectasis d. Pulmonary fibrosis ANS: A RDS is caused by the lack of surfactant within the alveoli of the neonate. This leads to alveolar collapse (atelectasis). Segmental or lobar atelectasis is associated with a bronchial obstruction by a foreign boNdy . RPu lmIo nGar yBfi.brCos isMis not associated with RDS.

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S

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3. The hyaline membrane seen in the alveoli of a neonate with RDS is similar to the anatomic alteration found in what other pulmonary disease? a. Bacterial pneumonia b. Pulmonary fibrosis c. Acute respiratory distress syndrome (ARDS) d. Meconium aspiration syndrome (MAS) ANS: C The hyaline membrane containing fibrin and cellular debris is the same in RDS and ARDS. Bacterial pneumonia, pulmonary fibrosis, and MAS will have other types of pulmonary changes.

4. What vascular anatomic alteration could occur as a consequence of hypoxia in a patient with RDS? a. Closure of the ductus arteriosus b. Transient pulmonary hypertension c. Increased flow through the ductus venosus d. Airway mucosal edema ANS: B

Hypoxia can induce arterial vasoconstriction leading to transient pulmonary hypertension. This can lead to blood shunting through an open ductus arteriosus. Because the neonate has been born, the ductus venosus will remain closed. Hypoxia will not cause airway mucosal edema.

5. What is the primary cause of RDS in the newborn? a. Underdevelopment of alveolar type I cells b. Deficiency or abnormality of pulmonary surfactant c. Hypoxia causing pulmonary hypoperfusion d. Excessive amniotic fluid in the lungs ANS: B RDS is caused by the abnormality or deficiency of pulmonary surfactant from the alveolar type II cells. It is most likely that pulmonary hypoperfusion is a secondary response to the surfactant abnormality and related hypoxia. Alveolar type I cells allow for easy gas exchange and do not produce surfactant. Transient tachypnea of the newborn (TTN) is caused by the delayed absorption of fetal amniotic lung fluid.

6. A patient with RDS has alveolar hypoxia and pulmonary vasoconstriction. How will this affect his blood flow?

1. Blood shunts through the foramen ovale 2. Increased systemic blood flow 3. Blood shunts through the ductus arteriosus 4. Decreased blood flow to the gut a. 2, 4 b. 1, 3 c. 1, 2, 3 9TH d. 2, 3, 4 ANS: B As a consequence of alveolar hypoxia, the neonate can develop pulmonary vasoconstriction and transient pulmonary hypertension. This will lead to a right-to-left shunt as blood flows through the foramen ovale and ductus arteriosus. This results in a partial return to fetal circulation. There is no change in systemic blood flow and flow to the gut.

7. Which of the following are associated with an increased risk for developing RDS? 1. Low–birth weight infant 2. Prenatal asphyxia 3. Maternal bleeding 4. First-born twin a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The second-born twin has an increased risk for the neonate developing RDS. 8. Which of the following amniotic fluid lab findings would indicate mature fetal lungs? a. S:A ratio is <55.

b. PG is absent. c. L:S ratio is 2:1. d. L:S ratio is 1:2.

ANS: C Mature fetal lungs are indicated by an S:A ratio of >55, the presence of PG, and an L:S ratio of 2:1 or greater. An L:S ratio of 1:2 (anything less than a 2:1 ratio) would indicate immature lungs and increased risk for RDS. 9. The neonate with RDS would have a phosphatidylglycerol (PG) level that is: a. present. b. absent. c. above normal. d. below normal.

ANS: B PG is the second most abundant phospholipid in surfactant. The absence of PG in amniotic fluid would indicate immature lungs, as would be the case in a neonate with RDS. The presence of PG would indicate mature lungs with surfactant.

10. What special environmental concerns are there with a neonate with RDS in order to avoid compromising his/her oxygenation? a. Keeping a normal body temperature b. Placing a bilirubin light on the neonate c. Keeping the infant cool d. Humidifying the inhaled oxygen ANS: A

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Maintain the neonate’s normal body temperature to avoid compromising its oxygenation.

Avoid having the neonate either too cool or too warm. Bilirubin lights have no effect on oxygenation. Inhaled oxygen should be humidified to avoid the drying of secretions.

11. A mother is about to deliver a 25 weeks’ gestation infant. What therapeutic intervention should the respiratory therapist be prepared to give to minimize the risk for RDS? a. Mask CPAP b. Airway suctioning c. Exogenous surfactant d. Mechanical ventilation ANS: C It is very likely that a 25 weeks’ gestation age infant will develop RDS. In this situation, exogenous surfactant should be given as soon as possible to prevent pulmonary complications. Airway suctioning will be performed to remove airway fluids but will not prevent RDS. Giving exogenous surfactant should help to minimize the need for CPAP or mechanical ventilation.

12. Management of a neonate with RDS may include: 1. emergency tracheostomy.

2. instilling surfactant into the lungs.

3. mechanical ventilation.

4. supplemental oxygen.

a. b. c. d.

3, 4 2, 3 2, 3, 4 1, 3, 4

ANS: C Emergency tracheostomy is typically not needed to support a neonate with RDS. 13. The respiratory pattern of a neonate with RDS will have which of these characteristics?

1. Respiratory rate of about 50/min 2. Respiratory rate of >60/min 3. Cyclical breathing pattern 4. Hard and deep breaths a. 1, 3 b. 2, 3 c. 1, 4 d. 2, 4 ANS: D Because of the stiff lungs associated with RDS, the neonate will typically have a respiratory rate of >60/min and hard and deep breaths.

14. A patient has RDS. What clinical manifestations are associated with the more negative intrapleural pressures needed during inspiration?

1. Seesaw breathing movement 2. Vesicular breath sounds 3. Pulmonary edema NURSINGTB.COM 4. Dependent thoracic areas are cyanotic a. 1, 4 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: A Clinical manifestations associated with the more negative intrapleural pressures needed during inspiration include, but are not limited to, seesaw breathing movement and cyanosis of the dependent thoracic areas. It is unlikely that your patient will have normal, vesicular breath sounds. Pulmonary edema is not associated with RDS. 15. It is likely that a neonate with RDS will have which of the following chest radiograph findings? a. Airway dilation and distortion b. Fluffy infiltrates in the bases of the lungs c. Ground-glass appearance d. Cardiomegaly ANS: C

RDS causes alveolar atelectasis. This will be seen on the chest radiograph as a white density of the lung fields that will appear as a fine ground-glass appearance. Airway dilation and distortion are associated with bronchiectasis. Fluffy infiltrates in the bases of the lungs are commonly seen in a patient with pulmonary edema. Cardiomegaly is an enlarged heart and is associated with right- or leftsided heart failure.

16. A premature infant with RDS is receiving mechanical ventilation. In managing the patient’s oxygenation, the respiratory therapist should strive to keep the PaO2 at: a. between 25 and 50. b. between 40 and 70. c. between 80 and 100. d. 95 or greater.

ANS: B A PaO2 of 40 to 70 mm Hg is normal for newborn infants. No effort should be made to get an infant’s PaO2 within the normal adult range (80 to 100 mm Hg).

17. In assessing a patient with RDS, the respiratory therapist would expect to find: 1. intercostal retractions.

2. acrocyanosis.

3. flaring nostrils.

4. wheezing. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D

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The following signs may be found in an infant with RDS: intercostal retractions, substernal retraction and abdominal distention (seesaw movement), acrocyanosis mottling and cyanosis of the dependent portions of the thoracic and abdominal areas, flaring nostrils, bronchial (or harsh) breath sounds, fine crackles, and cyanosis. Wheezing would not be expected because bronchospasm is not part of the pathophysiology of RDS. 18. The standard of care to evaluate the oxygenation status of a premature infant with RDS is by: a. capillary blood gas (CBG). b. arterial blood gas (ABG). c. capnography. d. pulse oximetry.

ANS: D Because of the difficulty of obtaining arterial blood gas (ABG) samples from newborn and pediatric patients, capillary blood gas (CBG) samples are usually used to determine the pH, PaCO2, and HCO3– (i.e., the acid-base and ventilation status only). Capillary PO2 values are unreliable and should not be used for clinical analysis. The standard practice of care to evaluate the oxygenation status in these young patients is pulse oximetry (SpO2).

19. The INSURE method of surfactant administration includes: 1. respiratory support.

2. insertion of a feeding tube.

3. extubation.

4. intubation. a. 1, 3 b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B The INSURE method (INtubate-SURfactant-Extubate) has been used with great success on many preterm infants. With this method, an infant is intubated, given surfactant, then extubated and placed on nasal or bubble CPAP for continued respiratory support. Surfactant therapy occasionally may need to be repeated when there is a persistent or recurrent oxygen requirement of 30% or more 2 to 6 hours after the initial dose. The protocol includes safeguards, such as confirming endotracheal tube position before surfactant administration, the method of administration, and dosing specifics for the type of surfactant used.

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Chapter 38: Pulmonary Air Leak Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Prior to the introduction of exogenous surfactant, with which condition were preterm neonates most likely to develop pulmonary air leak syndrome? a. Meconium aspiration syndrome (MAS) b. Respiratory distress syndrome (RDS) c. Transient tachypnea of the newborn (TTN) d. Apnea of prematurity ANS: B Prior to the introduction of exogenous surfactant, pulmonary air leak syndromes commonly occurred in preterm neonates with RDS on mechanical ventilation.

2. How does pulmonary interstitial emphysema (PIE) affect lung function?

1. Increased airway resistance 2. Decreased lung compliance 3. Increased lung compliance 4. Decreased airway resistance a. 1, 3 b. 1, 2 c. 3, 4 d. 2, 4 9TH ANS: D PIE primarily causes decreased lung compliance by hyperinflating the lungs. Additionally, gas trapped within the interstitial cuffs compresses the airways and increases airway resistance.

3. Which of the following are associated with a pneumopericardium?

1. Systemic hypotension 2. Reduced cardiac output 3. Decreased stroke volume 4. Increased cardiac index a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D A pneumopericardium will cause reduced cardiac output, decreased stroke volume, and systemic hypotension.

4. What clinical presentation would be seen in a patient with a pneumoperitoneum? a. Mediastinal shift toward affected area b. Change in point of maximum impulse

c. Sudden onset of abdominal distention d. Pleural effusion ANS: C With a pneumoperitoneum, sudden abdominal distention occurs.

5. Following delivery, when do pulmonary air leak syndromes commonly occur in preterm neonates? a. 1 to 4 hours after delivery b. 5 to 8 hours after delivery c. 12 to 24 hours after delivery d. 24 to 48 hours after delivery ANS: D Air leak syndrome occurs in 1% to 2% of all newborns; the highest incidence is among infants with meconium aspiration syndrome. Preterm infants who weigh less than 1000 g at birth have an increased risk for the early occurrence of pulmonary air leak syndromes (often within the first 24 to 48 hours of life), especially because of the weak noncartilaginous structures of their distal airways.

6. During mechanical ventilation of a preterm neonate, which of the following are considered to be important etiologic factors for the development of pulmonary air leak syndromes?

1. High levels of PEEP 2. High oxygen concentration 3. Prolonged inspiratory time 4. High PIP a. 2, 3 9TH b. 3, 4 c. 1, 3, 4 d. 1, 2, 4 ANS: C A prolonged inspiratory time, high PIP, and high levels of PEEP during mechanical ventilation increase the risk for pulmonary air leak syndromes in a preterm neonate.

7. An intubated, mechanically ventilated neonate developed a pneumothorax of the right lung.

What could the respiratory therapist recommend to help the injured lung to heal? a. Selectively place the endotracheal tube into the left mainstem bronchus. b. Selectively place the endotracheal tube into the right mainstem bronchus. c. Replace the endotracheal tube with a tracheostomy tube. d. Change to continuous positive airway pressure (CPAP).

ANS: A Selectively intubating the left mainstem bronchus and ventilating just the left lung may allow the right lung to heal.

8. A neonate on mechanical ventilation developed pulmonary air leak syndrome. What change should the respiratory therapist now recommend? a. Initiate the bronchopulmonary hygiene therapy protocol. b. Decrease the oxygen percentage. c. Initiate high-frequency ventilation.

d. Insert bilateral pleural chest tubes.

ANS: C The respiratory therapist could recommend high-frequency ventilation, which has been effective in treating infants with pulmonary air leak syndromes.

9. During the physical examination of a neonate with early pulmonary air leak syndromes, what respiratory rate would be expected? a. <20 breaths/min b. 20 to 30 breaths/min c. 40 to 60 breaths/min d. >60 breaths/min ANS: D Normally, a newborn’s respiratory rate is about 40 to 60 breaths/min. During the early stages of pulmonary air leak syndromes, the respiratory rate is generally well over 60 breaths/min.

10. What clinical manifestations are associated with the more negative intrapleural pressures generated during inspiration by a patient with pulmonary air leak syndrome?

1. Cyanosis of dependent thorax and abdomen 2. Intercostal and substernal retractions 3. Flaring nostrils 4. Inspiratory stridor a. 1, 3 b. 2, 4 c. 1, 2, 3 9TH d. 2, 3, 4 ANS: C When more negative intrapleural pressures are needed during inspiration, the associated clinical manifestations include cyanosis of the dependent thoracic and abdominal areas, intercostal and substernal retractions, and flaring nostrils.

11. A neonate with pulmonary interstitial emphysema has developed a pneumothorax. In the early stages, a pneumothorax will manifest itself clinically as disorder. a. an equally restrictive and obstructive b. an obstructive pulmonary c. a restrictive pulmonary d. neither a restrictive nor an obstructive ANS: C In the early stages, a pneumothorax will manifest itself clinically as a restrictive pulmonary disorder.

12. A physician is performing transillumination to determine whether a neonate has a pneumothorax. What finding would confirm the presence of a pneumothorax? a. The trachea will be illuminated. b. Light will shine through the hole in the lung. c. There will be increased illumination on the unaffected side. d. There will be increased illumination on the affected side.

ANS: D When free air is in the pleural space, transillumination will result in increased illumination on the affected side. This would confirm a pneumothorax.

13. Which of the following chest radiograph findings would confirm the presence of PIE? 1. Mediastinal shift to the unaffected side 2. Air below the diaphragms 3. Lung hyperinflation 4. Fine, bubbly appearance of the lungs a. 2, 3 b. 1, 4 c. 2, 3, 4 d. 1, 3, 4 ANS: C PIE is identified on the chest radiograph film by lung hyperinflation and the fine, bubbly appearance of the lungs.

14. Which of the following conditions is described as dissection of gas into the fascial planes of the skin and neck? a. SIAHD b. Intravascular air embolism c. PIE d. Subcutaneous emphysema ANS: D Iiss eG Subcutaneous emphysema NisU thRe dS Ncti oBTn .ofCg asMOinto the fascial planes of the neck and skin.

15. Which of the following medications would be recommended for the treatment of SIAHD? a. Beta2-agonists b. NSAIDs c. Diuretics d. Corticosteroids ANS: C The reason for this is that babies who have iatrogenic tension pneumothoraces often develop what is called a transient syndrome of inappropriate antidiuretic hormone (SIADH). In other words, the pneumothorax causes the release of antidiuretic hormone, which inhibits urination. Some of the retained fluid accumulates in the baby’s lungs. Often, a diuretic (such as furosemide), a little more airway pressure, an increased FIO2, or an increased ventilator rate may need to be administered to offset this transient problem.

16. Which of the following might be used to relieve a tension pneumothorax in a neonate? a. Transillumination b. Needle thoracentesis c. Lung expansion therapy protocol d. Surfactant replacement therapy ANS: B

To relieve a tension pneumothorax in a neonate, a needle thoracentesis would be recommended to release the trapped air prior to placement of a chest tube.

17. Common strategies used to reduce the risk for mechanical ventilation include: 1. low tidal volume ventilation.

2. normalization of blood gases.

3. minimize intrinsic positive end-expiratory pressure.

4. increase the respiratory rate. a. 1, 3 b. 1, 2, 3 c. 1, 3, 4 d. 2, 3, 4 ANS: A Permissive hypercapnia defined: Mechanical ventilation was traditionally applied with the goal of normalizing arterial blood gas values, particularly the arterial carbon dioxide tension (PaCO2).

However, this is no longer the primary objective of mechanical ventilation. Today, the emphasis is on maintaining adequate gas exchange while—and, importantly—minimizing the risks of mechanical ventilation. Common strategies used to reduce the risk for mechanical ventilation include (1) low tidal volume ventilation—to protect the lung from ventilator-associated lung injury in patients with acute lung injury (e.g., ARDS)—and (2) reduction of the tidal volume, respiratory rate, or both—to minimize intrinsic positive end-expiratory pressure (i.e., auto-PEEP) in patients with obstructive lung disease (e.g., COPD). Although these mechanical ventilation strategies may result in an increased PaCO2 level (hypercapnia), they do help to protect the lung from barotrauma (i.e., physical damage to lung tissues caused by excessive gas pressures).

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Chapter 39: Respiratory Syncytial Virus Infection (Bronchiolitis) Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. A respiratory syncytial virus (RSV) infection will cause which of the following anatomic alterations of the lungs?

1. Chemical pneumonitis of the small airways 2. Peribronchiolar mononuclear infiltration 3. Small airway epithelial necrosis 4. Edema of the epiglottis and upper airway a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: B Peribronchiolar mononuclear infiltration and small airway epithelial necrosis are anatomic alterations of the lungs found with RSV. Meconium aspiration syndrome can cause a chemical pneumonitis of the small airways. Croup syndrome is associated with edema of the epiglottis and upper airway.

2. Anatomic alterations related to an RSV infection can lead to: 1. pneumomediastinum.

2. partial airway obstructioNn.URSINGTB.COM 3. decreased airway lumen.

4. complete airway obstruction. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Pneumomediastinum is associated with a pulmonary air leak syndrome. RSV can lead to a decreased airway lumen or partial or complete airway obstruction.

3. Which of the following are major pathologic or structural changes associated with RSV? 1. Dilation and distortion of the airways 2. Inflammation of the peripheral airways 3. Alveolar hyperinflation 4. Pulmonary edema a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3 ANS: B

Major anatomic alterations associated with RSV include, but are not limited to, inflammation of the peripheral airways and alveolar hyperinflation. RSV does not alter airway structure or cause pulmonary edema.

4. Which of the following patients is least likely to experience a severe RSV infection? a. A 6-month-old recently diagnosed with cystic fibrosis b. A 3-month-old who was born prematurely c. A 2-year-old undergoing chemotherapy for leukemia d. A 3-year-old with no siblings ANS: D Of the situations listed, a normal 3-year-old child is the least likely to have a severe RSV infection. All of the other situations involve a child with a preexisting medical condition that could result in a severe case of RSV. 5. Which of the following characteristics would put an adult at increased risk for a severe case of RSV? 1. Compromised immune system 2. History of asthma 3. Under 30 years of age 4. More than 65 years of age a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 1, 2, 4

N R I G B.C M An adult with a compromised immune U systS em N whoTis over O age 65 is at increased risk for a severe ANS: A

case of RSV. A history of asthma or being under age 30 is not an increased risk factor for RSV. 6. Several small children who attend the same day care facility have become sick with RSV. The owner of the day care can expect them to recover within: a. 4 to 6 days. b. 3 to 8 days. c. 1 to 2 weeks. d. greater than 3 weeks.

ANS: C For those who seek medical attention early in the course of the disease, their mild symptoms may worsen over 3 to 5 days, resulting in repeated office or emergency department visits and readmission.

Most patients will recover in 1 to 2 weeks, but about 25% will have symptoms after 21 days.

7. Outbreaks of RSV are usually found in which of the following seasons of the year?

1. Spring 2. Summer 3. Fall 4. Win ter a. 3, 4

b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B RSV outbreaks are unusual in the summer months. The cold and flu season months have outbreaks of RSV. 8. A patient with an RSV is hypoxemic. What could cause this?

1. Atelectasis 2. Excessive airway fluid 3. Persistent pulmonary hypertension of the newborn (PPHN) 4. Consolidati on a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: C Atelectasis, excessive airway fluid, and consolidation seen in an RSV patient can cause hypoxemia.

Persistent pulmonary hypertension of the newborn (PPHN) is not associated with RSV. 9. What can be given to a premature baby in order to prevent an RSV infection? a. An inhaled corticosteroid agent b. Ribavirin (Virazole) c. Palivizumab (Synagis) N R I G B.C d. A sympathomimetic agentU S N T ANS: C The injectable drug palivizumab is given to high-risk babies to help prevent an RSV infection.

Ribavirin is only given if the patient has an RSV infection. Corticosteroid and sympathomimetic drugs do not prevent an RSV infection.

10. An infant with RSV will show what clinical manifestations associated with the more negative intrapleural pressures needed during inspiration?

1. Seesaw breathing movement 2. Breath sounds reveal pleural friction rub 3. Inspiratory stridor 4. Cyanosis of the dependent abdominal areas a. 2, 4 b. 1, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: B Clinical manifestations associated with the more negative intrapleural pressures needed during inspiration include, but are not limited to, seesaw breathing movement and cyanosis of the dependent thoracic areas. Pleural friction rub and inspiratory stridor are not associated with an infant with RSV.

11. The physical examination of a neonate with RSV will often reveal: 1. a change in point of maximum impulse (PMI).

2. excessive secretions.

3. expiratory grunting.

4. cyano sis. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C The PMI would only change if the heart’s position changed. This is not likely to happen in an infant with RSV. The neonate with RSV will often have many secretions and will show cyanosis and expiratory grunting because of hypoxemia.

12. A chest radiograph was taken of a patient with RSV. What finding can be expected? a. Elevated diaphragms b. “Steeple point” sign c. Lobar atelectasis d. Pneumothorax ANS: C Secretions may completely occlude a lobar bronchus leading to lobar atelectasis. An infant with RSV is more likely to have depressed diaphragms due to air trapping. The “steeple point” sign is associated with croup. Pneumothorax is not a common finding in a neonate with RSV.

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13. Infants with RSV benefit fr omU wShi chNo fTth e fo llOow ing?

1. Chest percussion and drainage 2. High-flow nasal cannula therapy 3. Bulb suctioning of the nares 4. Nebulized hypertonic saline a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Infants with RSV bronchiolitis do not benefit from chest percussion and drainage—in fact, its use is discouraged. Patient agitation associated with percussion therapy may exacerbate small airway obstruction.

14. Which of the following is no longer recommended in the management of a patient with RSV infection? a. Palivizumab (Synagis) b. Bulb suctioning of the nares c. Nebulized hypertonic saline d. Ribavirin (Virazole) ANS: D

Although ribavirin was widely used when it was first introduced, the routine use of nebulized ribavirin (Virazole) in infants and children with RSV is no longer recommended. The efficacy of ribavirin in this population has not been proven. In addition, ribavirin is expensive, requires special equipment, adds technical risk to ventilator care when used in line, and is associated with occupational exposure concerns.

15. The diagnosis of RSV is most often confirmed with a sample obtained by: a. tracheal suctioning. b. venipuncture. c. arterial blood sampling. d. nasopharyngeal aspirate.

ANS: D RSV infection should be suspected when the clinical manifestations correlate to the time of year, the presence of a local outbreak, the age of the patient, and the history of the illness and recent exposure.

RSV can be diagnosed with commercially available antigen assay tests, typically ordered as an RSV enzyme immunoassay (RSV-EIA). This test requires a nasopharyngeal aspirate or lavage sample, often obtained in the physician’s office or emergency department (ED). It is a rapid and usually reliable screen—but a negative RSV-EIA does not rule out RSV.

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Chapter 40: Chronic Lung Disease of Infancy Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. What is the single most important causative factor associated with the development of chronic lung disease of infancy (CLDI)? a. Prematurity b. Transient tachypnea of the newborn (TTN) c. Asthma d. Laryngotracheobronchitis ANS: A The single most important causative factor associated with the development of CLDI is prematurity.

In addition, the retardation or restriction of intrauterine growth and a family history of respiratory distress syndrome and asthma put the infant at a higher risk for CLDI. 2. Which of the following is consistent with stage II of CLDI? 1. Occurs 4 to 10 days after birth.

2. Occurs 11 to 30 days after birth.

3. Extensive atelectasis.

4. Alternating areas of atelectasis and emphysema. a. 2, 3 b. 1, 4 c. 2, 3, 4 9TH d. 1, 3, 4 ANS: D Stage II CLDI was said to occur 4 to 10 days after birth. Atelectasis was more extensive during this period. In addition, metaplasia of the normal lung tissue cells caused bronchial necrosis, cellular debris, partial airway obstruction, air trapping, and alveolar hyperinflation. The pathologic findings during stage II were commonly described as alternating areas of atelectasis and emphysema. These changes appeared on the chest radiograph as patchy opaque areas of atelectasis next to areas of dark translucency.

3. Which of the following is the major anatomic pathology associated with CLDI? a. Extensive pulmonary fibrosis b. Extensive airway injury c. Alveolar hypoplasia d. Dextrocardia ANS: C Today, the pathologic findings of CLDI are described as “more uniformly inflated with minimal airway injury or fibrosis.” The major anatomic pathology is a decrease in alveolar number, called alveolar hypoplasia. In the very preterm infant with the new CLDI, the lung is just completing the canalicular stage of development at the time of birth. Interruption of the canalicular stage is thought to significantly disrupt the progress of alveolar growth and likely contributes to the development of the new CLDI.

4. Which of the following can increase an infant’s likelihood of developing CLDI? a. Birth weight >3000 g b. Overfeeding c. Use of beta2-agonists d. Postnatal bacterial sepsis ANS: D The development of postnatal bacterial sepsis or pneumonia puts the infant at risk for CLDI. See Table 40.3.

5. Which of the following ventilator parameters have been linked to the development of CLDI? 1. High peak inspiratory pressure 2. Overdistention of the lungs 3. Tidal volumes <5 mL/kg 4. High mean airway pressure a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B The development of CLDI is strongly associated with mechanical ventilation. The major causative factors linked to mechanical ventilation are (1) high peak inspiratory pressures, (2) high mean airway pressures, and (3) overdistention of the lungs.

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6. What changes result when strUe ssSfr acNtu reTs o f t heOc apillary endothelium and basement membranes develop during mechanical ventilation? a. Fluid leakage into alveolar spaces b. Bronchospasm c. Pulmonary embolism d. TTN ANS: A Overinflation of the lungs causes stress fractures of the capillary endothelium, epithelium, and basement membranes. This mechanical injury in turn causes leakage of fluid into the alveolar spaces, with additional inflammation.

7. Diagnostic criteria for the diagnosis of mild CLDI in an infant less than 32 weeks includes: a. need for <30% oxygen at 36 weeks’ PMA or discharge, whichever comes first. b. breathing room air at 36 weeks’ PMA or discharge, whichever comes first. c. need for 30% oxygen and/or PPV or NCPAP at 36 weeks’ PMA or discharge, whichever comes first. d. breathing room air by 56 days’ postnatal age or discharge, whichever comes first.

ANS: B See Table 40.2.

8. Which nutrient is essential for maintaining the epithelial cells of the tracheobronchial tree? a. Vitamin A

b. Vitamin C c. Carbohydrates d. Proteins ANS: A Vitamin A is an essential nutrient in maintaining the epithelial cells of the tracheobronchial tree.

9. What agent can be administered postnatally to a preterm infant to help reduce lung inflammation and the incidence of CLDI? a. Vitamin D b. Bronchodilators c. Ribavirin (Virazole) d. Corticosteroids ANS: D The administration of postnatal corticosteroids to preterm infants has been shown to reduce lung inflammation and the incidence of CLDI. 10. An infant with severe CLDI has developed cor pulmonale. What can be given to promote pulmonary vasodilation? a. Furosemide (Lasix) b. Inhaled nitric oxide (iNO) c. Inhaled albuterol d. FIO2 >50% ANS: B Infants with severe CLDI mNaUyRal so or.pCul mMonale SIh aGNve cBT O (pulmonary hypertension), requiring treatment with pulmonary vasodilators, such as sildenafil, or inhaled nitric oxide for acute respiratory failure.

11. Which of the following clinical manifestations are associated with CLDI? 1. Hyperresonant lungs 2. Wheezes and crackles 3. Nasal flaring 4. Intercostal retractions a. 1, 3 b. 2, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: D Clinical Manifestations Associated with CDLI include: • Intercostal retractions • Substernal retraction and abdominal distention (seesaw movement) • Cyanosis of the dependent portions of the thoracic and abdominal areas • Nasal flaring • Diminished breath sounds • Wheezes • Crackles

• Expiratory grunting • Cyanosis 12. A neonate is reported to have classic stage IV CLDI with emphysematous lung changes.

What pulmonary function test finding(s) would confirm this?

1. Increased RV/TLC ratio 2. Increased FRC 3. Decreased VC 4. Increased RV a. 3, 4 b. 1, 2 c. 2, 3, 4 d. 1, 2, 4 ANS: D Emphysematous lung changes would cause overinflation and be identified by an increased RV/TLC ratio, an increased functional residual capacity (FRC), and increased residual volume (RV).

13. A patient with classic stage II CLDI will have which of the following chest radiograph findings? a. Ground-glass granular pattern b. Emphysematous bullae c. Honeycomb appearance d. Patchy opaque areas of atelectasis next to areas of dark translucency

N R I G B.C M U S N T O The pathologic findings during stage II were commonly described as alternating areas of atelectasis ANS: D

and emphysema. These changes appeared on the chest radiograph as patchy opaque areas of atelectasis next to areas of dark translucency.

14. If a patient has severe CLDI, what cardiac problem may be identified on the chest radiograph? a. Pneumomediastinum b. Cardiac tamponade c. Change in point of maximum impulse d. Cor pulmonale ANS: D Infants with severe CLDI may also have cor pulmonale (pulmonary hypertension), requiring treatment with pulmonary vasodilators, such as sildenafil, or inhaled nitric oxide for acute respiratory failure.

15. What is the most common chronic lung disease of premature infants? a. CLDI b. Asthma c. Cystic fibrosis d. TTN ANS: A CLDI is the most common chronic lung disease of premature infants.

16. What is the most significant treatment of the neonate for the prevention of CLDI? a. Corticosteroids b. Diuretic therapy c. Vitamin E therapy d. Exogenous surfactant ANS: D The administration of exogenous surfactant is the most significant treatment for prevention of CLDI.

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Clinical Manifestations and Assessment of Respiratory Disease 9th Edition Jardins Test Bank

Chapter 41: Congenital Diaphragmatic Hernia Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Which of the following anatomic alterations is not typically found in a patient with a congenital diaphragmatic hernia? a. Lungs are compressed. b. Atelectasis. c. Hyperinflation. d. Complete lung collapse.

ANS: C The lungs of a patient with a CDH are compressed rather than hyperinflated. This can lead to atelectasis or complete lung collapse.

2. What pulmonary change is associated with a Bochdalek’s hernia? a. Pulmonary hypoplasia b. Respiratory distress syndrome (RDS) c. Pulmonary edema d. Meconium aspiration ANS: A If, however, the bowels reach this area before Bochdalek’s foramen closes, a hernia results—a congenital diaphNrag R mat I called Bochdalek’s hernia Ba ( .C CDHhernia M Uic heThus S GrniBochdalek’s N) (also or posterior-lateral diaphragmatic hernia). is an abnormal hole in the posterolateral corner of the T left diaphragm that allows the intestines—and in some cases the stomach —to move directly into the chest cavity and compress the developing lungs.

3. When does respiratory distress normally develop in a newborn with a CDH? a. Shortly after delivery b. 6 to 12 hours after delivery c. 12 to 24 hours after delivery d. 24 to 48 hours after delivery ANS: A A newborn infant with a CDH will have respiratory distress soon after being born. As the infant begins to breathe, air will enter the stomach or intestine within the chest and compress the lungs.

4. What happens as an infant with a CDH creates an increased negative inspiratory pressure in order to breathe? a. Meconium is drawn deeper into the airways. b. Lung compliance is improved. c. More of the gastrointestinal structures are sucked into the thorax. d. Lungs fill and expand to full capacity.

ANS: C

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As the infant with a CDH and respiratory distress generates a more negative inspiratory pressure to breathe, more of the gastrointestinal structures are sucked into the thorax. This worsens the existing problem.

5. Which of the following are major pathologic and structural changes associated with a CDH? 1. Increased numbers of bronchial generations and alveoli 2. Complete lung collapse 3. Atelectasis 4. Mediastinal shift a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: D The number of bronchial generations and alveoli is decreased.

6. The prognosis of an infant with a diaphragmatic hernia depends on which of the following factors?

1. Spontaneous closure without the need for surgery 2. Size of the diaphragmatic defect 3. Condition of the lung on the unaffected side 4. Degree of hypoplasia a. 1 b. 1, 2 c. 1, 3, 4 d. 2, 3, 4 9TH ANS: D The mortality rate for infants with CDH, including spontaneous abortions, stillbirths, and prehospital deaths, is about 50% to 60%. The prognosis depends on (1) the size of the defect, (2) the degree of hypoplasia, (3) the condition of the lung on the unaffected side, and (4) the success of the surgical diaphragmatic closure. Most cases of CDH are now diagnosed by prenatal ultrasound, allowing the infant to be delivered at a hospital where surgical repair of the diaphragmatic hernia can occur very shortly after birth. A few pediatric centers are performing high-risk prenatal surgery to repair the diaphragm.

7. In the delivery room, which of the following are recommended to manage a newborn with a CDH? 1. Administer oxygen.

2. Begin bag and mask manual ventilation.

3. Intubate and ventilate the neonate.

4. Place the newborn in the Trendelenburg position. a. 1, 2 b. 3, 4 c. 1, 3 d. 1, 3, 4

Clinical Manifestations and Assessment of Respiratory Disease 9th Edition Jardins Test Bank Immediately administer supplemental oxygen. The newborn should then have an endotracheal tube inserted and mechanical ventilation should be initiated.

8. What initial ventilator setting(s) would be recommended for a newborn with a CDH? 1. PEEP of 5 to 8 cm H2O 2. FIO2 of 1.0 3. Peak inspiratory pressure of <30 cm H2O 4. Respiratory rate of 40 to 50 breaths/min a. 2 b. 3, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C Mechanical ventilation should be applied with low peak airway pressures (<30 cm H 2O) and rapid respiratory rates. A typical set of ventilator parameters would be peak inspiratory pressure (PIP) +18 to +26 cm H2O, respiratory rate (RR) 20 to 40, FIO2 1.0, positive end-expiratory pressure (PEEP) +5 to +8 cm H2O, and inspiratory time (Ti) 0.4.

High-frequency oscillatory ventilation and high-frequency jet ventilation are other successful ventilation techniques to achieve adequate oxygenation and CO2 elimination while keeping airway pressures lower.

9. If inhaled nitric oxide (iNO) does not work, what treatment might be required for a patient with a CDH and significant pulmonary hypoplasia? a. Plasmapheresis b. ECMO c. Cardiac pacemaker 9TH d. Bronchoscopy ANS: B Occasionally, certain pharmacologic agents may be administered to offset the infant’s pulmonary hypertension. Such drugs include tolazoline, prostacyclin, prostaglandin 1E, sildenafil, and inhaled nitric oxide (iNO), in combination with different inotropes, such as dopamine and dobutamine. The physiologic action of iNO is believed to be similar to that of the vasoactive substance, endotheliumderived relaxing factor. The use of iNO has significantly reduced the need for extracorporeal membrane oxygenation (ECMO) therapy.

10. An infant with a CDH also has pulmonary hypertension. Which of the following can be administered to relieve this problem? a. Inhaled nitric oxide (iNO) b. Inhaled parasympatholytic agent c. 80% helium–20% oxygen d. Corticosteroids ANS: A It has been shown that iNO causes vasodilation and is used to treat pulmonary hypertension.

11. Which of the following auscultation findings would be associated with a CDH? 1. Bilateral bruits 2. Apical heartbeat heard over the unaffected side

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3. Absent breath sounds over the affected area 4. Bowel sounds over the affected area a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C Auscultation in a CDH patient will reveal an apical heartbeat heard over the unaffected side, absent breath sounds over the affected area, and bowel sounds over the affected area.

12. A newborn infant shows respiratory distress upon delivery. He is observed to have a scaphoid abdomen. Auscultation reveals diminished breath sounds with heart sounds on the right side of the chest. What is the infant’s most likely diagnosis? a. Tension pneumothorax b. CDH c. Pneumoperitoneum d. Abdominal aortic aneurysm ANS: B A newborn with a CDH will have diminished breath sounds and heart sounds on the right side of the chest. A scaphoid abdomen is seen when the stomach and intestines have moved into the thoracic cavity.

13. What effect would a substantial left-sided CDH have on pulmonary function test findings? a. A restrictive pulmonary disorder b. An obstructive pulmonNary B.C M U S N T O RdisoIrderG c. An equally restrictive and ob stru ctiv e disord er d. A restrictive disorder with increased DLCO ANS: A A CDH manifests itself clinically as a restrictive pulmonary disorder because the displaced abdominal organs limit lung expansion and result in reduced lung volumes.

14. Which of the following chest radiograph findings is typically not associated with a CDH? a. Steeple point sign. b. Complete lung collapse. c. Lungs do not meet the chest wall. d. Heart is shifted to the unaffected side.

ANS: A The steeple point sign is associated with laryngotracheobronchitis rather than CDH. 15. What is the medical term for the condition associated with some cases of CDH in which the heart is pushed to the right side of the chest? a. Morgagni’s movement b. Dextrocardia c. Ambidextrocardia d. Bochdalek’s shift ANS: B

When the heart is pushed toward the right side of the chest, the condition is termed dextrocardia.

16. Which of the following is described as abnormal elevation of an intact diaphragm into the chest cavity? a. Diaphragmatic eventration b. Morgagni’s hernia c. Bochdalek’s hernia d. Diaphragmatic altimetry ANS: A An abnormal elevation of an intact diaphragm is called diaphragmatic eventration.

17. Why would bag and mask ventilation be contraindicated in resuscitation of a neonate with CDH? a. It results in air swallowing, which enlarges the stomach and compresses lung tissue. b. It requires too much effort for the respiratory therapist to manually squeeze the bag. c. The FIO2 delivered by the device can cause oxygen toxicity and ROP. d. The high tidal volumes may result in pulmonary interstitial emphysema.

ANS: A The infant must not be manually ventilated with a bag and mask, because of the danger of air swallowing.

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Chapter 42: Congenital Heart Disease Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. According to the NHLBI, what is the most common type of birth defect? a. Cerebral palsy b. Congenital heart defects c. Congenital diaphragmatic hernia d. Cleft palate ANS: B According to the NHLBI, congenital heart defects are the most common type of birth defects.

2. Which of the following are considered to be noncyanotic defects?

1. PDA 2. ASD 3. TOF 4. VSD a. 1, 2 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4

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ANS: C PDA, ASD, and VSD are examples of defects with left-to-right shunts and therefore are noncyanotic defects.

3. Which cardiac anomaly is associated with coeur-en-sabot on a chest radiograph? a. TOF b. ASD c. VSD d. PDA ANS: A Coeur-en-sabot is the typical radiologic appearance of well-developed tetralogy of Fallot— i.e., infundibular pulmonary valve stenosis, ventricular septal defect, right ventricular hypertrophy, and dextroposition of the aorta.

4. Which congenital cardiac abnormality results from “the arrested development of the secundum septum”? a. Ostium secundum VSD b. Ostium secundum ASD c. Ostium secundum TGA d. Ostium secundum TOF ANS: B

An ostium secundum atrial septal defect (ASD) results from the arrested development of the secundum septum.

5. Which of the following is used to confirm the diagnosis of ASD? a. Electromyogram b. Electrocardiogram c. Echocardiogram d. Electrophoresis ANS: C An echocardiogram is used to confirm the diagnosis of ASD. 6. What is the most common type of VSD? a. Inlet ventricular septal defect b. Perimembranous ventricular septal defect c. Muscular ventricular septal defect d. Conoventricular ventricular septal defect ANS: C The most common type of VSD is the muscular ventricular septal defect.

7. What is the most common congenital heart disorder? a. ASD b. VSD c. TGA d. TOF ANS: B

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Ventricular septal defects are the most common of the congenital disorders and account for almost half of all congenital heart disease.

8. Which of the following are associated with tetralogy of Fallot?

1. Pulmonary artery stenosis.

2. Dextroposition of the aorta.

3. Right ventricular hypertrophy.

4. Atrial septal defect. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D An atrial septal defect is not associated with tetralogy of Fallot.

9. What is the most common form of TGA? a. a-TGA b. b-TGA c. c-TGA d. d-TGA ANS: D

Dextrotransposition or d-TGA is the most common form of transposition of the great vessels.

10. What is the most common cyanotic congenital cardiac defect in neonates? a. ASD b. VSD c. TGA d. TOF ANS: C Transposition of the great vessels (TGA) is the most common cyanotic congenital cardiac defect of neonates.

11. What is the term used to a describe a sudden, marked increase in cyanosis, followed by syncope? a. Vagal response b. A tet spell c. A hypocapnic spell d. A systolic thrill ANS: B A typical tet spell is characterized by a sudden, marked increase in cyanosis, followed by syncope.

Older children will often squat during a tet spell in an effort to increase systemic vascular resistance to help generate a temporary reversal of the right-to-left shunt.

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Chapter 43: Croup and Croup-like Syndromes: Laryngotracheobronchitis, Bacterial Tracheitis, and Acute Epiglottitis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. When a patient has laryngotracheobronchitis (LTB), which of the following is the primary anatomic alteration that is found? a. Edema of the mucous membranes b. Airway smooth muscle contraction c. Excessive alveolar fluid d. Epiglottitis ANS: A LTB is an inflammatory process that causes edema and swelling of the mucous membranes. Airway smooth muscle contraction is found in asthma. Pulmonary edema is excessive alveolar fluid.

Epiglottitis is a swollen epiglottis.

2. Which of the following anatomic alterations may be found in a patient with LTB? 1. Increased secretions 2. Ineffective cilia 3. Narrowed airway lumen 4. Excessive surfactant production a. 1, 3 b. 1, 2, 4 9TH c. 2, 3, 4 d. 1, 2, 3 ANS: C A patient with LTB should have normal alveoli and surfactant production. All of the other listed options may be found in a patient with LTB. 3. A patient has epiglottitis. This condition will affect which of the following?

1. Pharynx 2. Aryepiglottic folds 3. False vocal cords 4. Trachea a. 1, 2 b. 2, 3 c. 1, 2, 3 d. 2, 3, 4 ANS: B Epiglottitis affects the epiglottis, aryepiglottic folds, and false vocal cords.

4. What is the main clinical risk facing a patient with epiglottitis? a. Secretions will block the trachea. b. The epiglottis will bleed.

c. The laryngeal inlet may become covered by the epiglottis. d. The vocal cords will spasm and close the laryngeal inlet.

ANS: C If the patient’s swollen epiglottis covers the laryngeal inlet, the airway will be completely obstructed. Epiglottitis does not cause the other listed problems.

5. Most cases of LTB occur during which seasons of the year?

1. Spring 2. Summer 3. Fall 4. Winter a. 1, 2 b. 2, 4 c. 3, 4 d. 1, 2, 3 ANS: C LTB cases occur primarily during the fall and winter months.

6. The diagnosis of LTB typically does not include the child: a. having inspiratory stridor and barking cough. b. having a normal temperature or low fever. c. having a significant fever. d. Being able to drink without difficulty.

ANS: C A high fever is associated wNiU thRe pi SIgl otNGtit isB Tr.athCe r MOthan LTB. A patient with LTB may show the other listed findings.

7. Childhood vaccination is done to prevent which of the following possible causes of epiglottitis? a. Haemophilus influenza type B b. Streptococcus pneumoniae c. Diphtheria d. Parainfluenza viruses ANS: A There is a vaccination against Haemophilus influenza type B that can prevent a child from developing epiglottitis. Although there is a vaccination against diphtheria, this infection does not cause epiglottitis.

8. The diagnosis of epiglottitis is aided by: 1. laying the patient down and observing the throat with a tongue blade.

2. visualization of the throat during tracheal intubation.

3. observing if the patient can swallow.

4. observing how the patient holds his/her tongue. a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 3, 4

ANS: C All of the following may be used to help in the diagnosis of a patient with epiglottitis: visualization of the throat during tracheal intubation, observing if the patient can swallow, and observing how the patient holds his/her tongue. A patient who is suspected of having epiglottitis should not lie flat to have the throat visualized unless an endotracheal tube is being inserted.

9. The barking sound heard in a patient with LTB is caused by which of the following? a. Partial lower airway obstruction b. Partial upper airway obstruction c. Expiration against a partially closed glottis d. Pharyngeal edema ANS: B Clinically, the inspiratory barking sound heard in a patient with a partial upper airway obstruction is called inspiratory stridor.

10. The medication racemic epinephrine is given to a patient with LTB because it: a. is an effective bronchodilator. b. causes mucosal vasoconstriction. c. causes bradycardia. d. has an appealing taste and smell.

ANS: B Racemic epinephrine constricts the blood vessels in the mucous membrane of the airway. This helps to counteract the airway inflammation found in a patient with LTB. Although the drug is also a bronchodilatoNr,UiRt iSs nIoNt gGiTveBn.foCr OthMis effect. The drug may cause tachycardia as a side effect. There should not be any particular taste to the drug because it is nebulized.

11. The treatment of epiglottitis includes: 1. antibiotics specific to the virus causing the illness.

2. antibiotics specific to the bacteria causing the illness.

3. supplemental oxygen by face mask.

4. endotracheal intubation. a. 1, 3 b. 2, 4 c. 1, 2, 4 d. 2, 3, 4 ANS: B A patient with epiglottitis will be given an antibiotic for the bacterial infection and be intubated to ensure a secure airway. Oxygen may be given through the endotracheal tube.

12. The following would not be expected during the assessment of a young child with LTB? a. Decreased respiratory rate. b. Diminished breath sounds. c. Use of accessory muscles. d. Hypoxemia.

ANS: A

Assessment findings will likely include increased respiratory rate, diminished breath sounds, the use of accessory muscles, and hypoxemia.

13. The respiratory therapist is assigned to the pediatric unit of the hospital. The physician who is caring for a 3-year-old boy with LTB asks what respiratory therapy treatments should be given. The respiratory therapist should suggest which of the following?

1. Racemic epinephrine 2. Cool mist 3. Antibiotics 4. Endotracheal or tracheostomy tube a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: A Treatment for LTB can include, but is not limited to, inhaled nebulized racemic epinephrine and a cool mist. Epiglottitis treatment often includes antibiotics and intubation.

14. Which of the following is/are commonly seen on the lateral neck x-ray of a patient with LTB? 1. “Pencil point” narrowing of the upper airway 2. Haziness in the subglottic area 3. Classic “thumb sign” 4. “Steeple point” narrowing of the upper airway a. 1, 3 b. 2, 4 9TH c. 1, 2, 4 d. 2, 3, 4 ANS: C Lateral neck x-ray findings of a patient with LTB can include the “pencil point” or “steeple point” sign indicating narrowing of the upper airway. Haziness in the subglottic area may also be seen. The “thumb sign” is an indication of a swollen epiglottis.

15. In evaluating a 16-month-old boy, the respiratory therapist finds him to be in mild respiratory distress, without a fever, but with a barking-type cough. A lateral neck x-ray taken in the emergency department shows a “steeple point” narrowing of the trachea. Based on this information, which of the following would the respiratory therapist conclude is the most probable diagnosis? a. Acute bronchitis b. Epiglottitis c. Bronchiolitis d. LTB ANS: D All of the listed clinical signs indicate a diagnosis of LTB. The other conditions would have a different mix of signs.

16. A patient has been diagnosed with bacterial tracheitis. Which of the following antibiotics should the respiratory therapist most likely recommend? a. Cloxacillin b. Nebcin c. Keflex d. Unasyn ANS: D When bacterial tracheitis is suspected (or confirmed) a third generation cephalosporin combined with a beta-lacta-mate resistant penicillin (e.g., cloxacillin) is an appropriate first-line therapy.

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Chapter 44: Near Drowning/Wet Drowning Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. A 10-year-old girl was rescued from a school swimming pool, where she was found unconscious, and transported to a nearby hospital, where her lungs were discovered to be dry. What could cause dry lungs in this near drowning? a. Her glottis spasmed and prevented pool water from entering her lungs. b. Chlorinated pool water is quickly absorbed across the alveolar-capillary membrane. c. Her young age and the cool pool water prevented serious pulmonary injury. d. She swallowed the water.

ANS: A Glottic spasms will prevent water from entering the trachea and lungs.

2. What are complications associated with a near drowning in unclean, swampy water?

1. Pneumonia 2. Acute respiratory distress syndrome (ARDS) 3. Pulmonary fibrosis 4. Pulmonary hypertension a. 1 b. 3, 4 c. 1, 2 9TH d. 1, 2, 3 ANS: C Because of bacteria and debris inhaled with unclean, swampy water, the victim is at risk for pneumonia or ARDS. 3. In comparing the pathologic changes to the lungs caused by freshwater versus saltwater, which of the following can be stated? a. Saltwater causes more damage. b. Freshwater causes more damage. c. Both cause identical pathologic changes. d. Cold water of either type causes more damage than warm water of either type.

ANS: C The pathologic changes and injury to the lungs from freshwater and saltwater near drownings are identical.

4. The effects of a near-drowning victim inhaling water into the lungs include: 1. alveolar consolidation.

2. bronchospasm.

3. production of frothy, white secretions.

4. pleural effusion. a. 2, 3

b. 1, 2, 3 c. 2, 3, 4 d. 1, 3, 4 ANS: B The pulmonary effects of a near-drowning victim inhaling water include, but are not limited to, alveolar consolidation, bronchospasm, and increased production of frothy, white secretions.

5. Favorable prognostic factors in clean water near drowning include: 1. greater effort to reach the surface.

2. alcohol in the victim.

3. colder water.

4. younger age. a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 3, 4 ANS: B A younger age and colder water temperature increase the likelihood of surviving a neardrowning incident.

6. What water temperature has been shown to be a favorable prognostic factor in near drowning? a. Higher than 104°F b. Between 98.6°F and I G B.C M 10N4°FR c. Between 70°F and 98°F S N T O

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d. Between 27°F and 70°F ANS: D The water temperature needs to range between 27°F and 70°F to increase the chance of surviving a near drowning.

7. A near-drowning victim in cardiac arrest has been placed in an ambulance. During transport, the goals of the paramedics should be to: 1. contact the victim’s insurance carrier.

2. perform high-quality CPR. 3. conserve the victim’s body heat.

4. administer FIO2 1.0. a. 2 b. 2, 3 c. 2, 3, 4 d. 1, 2, 4 ANS: B It is critically important to provide high-quality CPR efforts, administer 100% oxygen, and conserve the victim’s body heat during transport.

8. Hospital management of near-drowning victims includes: 1. measurement of arterial blood gas values.

2. rewarming if the patient is hypothermic.

3. measurement of venous blood gas values.

4. chest radiography. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Venous blood gas values are not typically needed in the management of a near-drowning victim.

9. Which of the following would be routinely ordered for the majority of wet-drowning victims?

1. Positive end-expiratory pressure (PEEP) 2. Hemodialysis 3. Extracorporeal membrane oxygenation (ECMO) 4. Mechanical ventilation a. 1, 4 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3 ANS: A Because of the lung changes that occur when water is inhaled, mechanical ventilation with PEEP will be needed by most patients.

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10. Warming techniques for a c oUld -wSa teNr n eTar -d ro wOn ing victim include: 1. cooling the extremities and warming the body core.

2. warming the inspired oxygen.

3. heated intravenous solutions.

4. heated lavage of the pericardial space. a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: C It would be counterproductive to cool the extremities while warming the core of the coldwater near-drowning victim.

11. After an extended time underwater, a near-drowning victim will most likely have: a. tachypnea. b. a normal respiratory rate. c. bradypnea. d. apnea.

ANS: D The longer a victim is submerged, the more likely it is that he/she will be apneic.

12. Which of the following breath sounds would be expected during auscultation of a wet-drowning victim?

1. Bronchovesicular 2. Vesicular 3. Crackles 4. Friction rub a. 1 b. 3 c. 2, 4 d. 1, 2, 3 ANS: B Crackles are likely to be heard over the lung fields of a wet-drowning victim because of the water within the airways and lungs.

13. The pulmonary function findings for a wet-drowning victim would reveal: a. increased IRV. b. increased DLCO. c. decreased VC. d. increased TLC. ANS: C The VC (vital capacity) will be reduced due to atelectasis. Near drowning results in restrictive pulmonary function test findings.

14. The initial chest radiograph appearance of a near-drowning victim may include: 1. normal lung fields.

9TH 2. atelectasis.

3. pulmonary edema.

4. pencil point sign. a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: C It is possible for the initial chest radiograph to show normal lung fields. But if significant amounts of water were inhaled, the radiograph may show areas of atelectasis or pulmonary edema. These later changes may occur within the first 48 to 72 hours after the incident.

15. In the United States, approximately how many unintentional drownings occur annually? a. 1500 b. 2500 c. 3500 d. 4500 ANS: C According to the Center for Disease Control and Prevention’s most recent data, there is an average of 3536 fatal unintentional drownings (nonboating related) annually in the United States—about 10 deaths per day. About one in five people who die from drowning are children 14 and younger.

16. According to the World Health Organization, where does drowning rank worldwide as a cause of unintentional death? a. It is the leading cause of unintentional death. b. It is the second leading cause of unintentional death. c. It is the third leading cause of unintentional death. d. It ranks 23rd among the causes of unintentional death.

ANS: C According to the WHO, drowning ranks third among the causes of unintentional deaths worldwide.

17. What is the upper time limit that a cold-water near-drowning victim can be submerged and survive? a. 10 minutes b. 20 minutes c. 40 minutes d. 60 minutes ANS: D Sixty minutes appears to be the limit that a near-drowning victim can remain submerged in cold water and survive.

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Chapter 45: Smoke Inhalation, Thermal Injuries, and Carbon Monoxide Intoxication Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 9th Edition MULTIPLE CHOICE 1. Clinical signs of an upper airway thermal injury include: 1. facial burns.

2. atelectasis.

3. mucosal edema.

4. epithelial sloughing. a. 3 b. 1, 4 c. 1, 3, 4 d. 2, 3, 4 ANS: C Clinical signs of an upper airway thermal injury include, but are not limited to, facial burns, mucosal edema, and epithelial sloughing of the upper airway tissues.

2. A patient has been brought to the emergency department after inhaling superheated steam.

Pulmonary injuries unique to this situation include: 1. atelectasis.

2. pulmonary edema.

3. thick secretions.

4. pharyngeal edema.

9TH a. 3 b. 1, 2 c. 2, 3, 4 d. 1, 2, 3 ANS: B Inhaled superheated steam will burn all the way to the small airways and lungs. Injuries unique to a steam inhalation include pulmonary edema and atelectasis.

3. Which of the following conditions occurs in 20% to 30% of hospitalized fire victims with facial burns? a. Acute respiratory distress syndrome (ARDS) b. Upper airway obstruction c. Pneumonia d. Pulmonary embolism ANS: B Even though thermal injury may occur with or without surface burns, the presence of facial burns is a classic predictor of thermal injury. Thermal injury to the upper airway results in blistering, mucosal edema, vascular congestion, epithelial sloughing, and accumulation of thick secretions. Acute upper airway obstruction (UAO) occurs in about 20% to 30% of hospitalized patients with thermal injury and is usually most marked in the supraglottic structures.

4. Late-stage complications of extensive body surface burns include: 1. sepsis.

2. upper airway obstruction.

3. pneumonia.

4. pulmonary embolism. a. 1, 2 b. 3, 4 c. 2, 3 d. 1, 3, 4 ANS: D Late-stage complications are those that occur 5 days or longer after the initial injury occurred. During the late stage following burns, a patient with extensive body surface burns (and prolonged immobility) is at risk for sepsis, pneumonia, and a pulmonary embolism.

5. A 65-year-old patient has third-degree skin burns over 30% of his body and a smoke inhalation injury. How does the combination of skin burns and smoke inhalation affect his prognosis? a. It quadruples the mortality rate. b. It more than triples the mortality rate. c. It almost doubles the mortality rate. d. There is no mortality change between having one or two concurrent problems.

ANS: C The mortality rate almost doubles when a patient has third-degree burns and a smoke inhalation injury comparedNwitRh haIvinGg a Bsin.gCle pMroblem.

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6. Which portion of the pulmonary system will be affected by the inhalation of low–water solubility gases such as hydrogen chloride and phosgene? a. Distal airways and alveoli b. Pulmonary vascular bed c. Upper airway d. Pulmonary lymphatic system ANS: A Low–water solubility gases will penetrate and damage the distal airways and alveoli.

7. Which of the following will be typically found in the air of an enclosed house fire?

1. Steam 2. Carbon monoxide 3. Hydrogen cyanide 4. Hydrogen chloride a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D The burning of typical household materials will result in the release of carbon monoxide, hydrogen cyanide, and hydrogen chloride.

8. A 10-year-old patient has inhaled hot gases, and an inspection of her mouth shows edema and blisters. What should the respiratory therapist recommend? a. Perform a bronchoscopy to evaluate the trachea. b. Perform endotracheal intubation. c. Monitor her SpO2 once per shift. d. Administer an aerosol treatment with racemic epinephrine.

ANS: B Endotracheal intubation should be performed as soon as possible because the patient is at a high risk for airway obstruction.

9. A patient with carbon monoxide poisoning has a COHb level of 20%. If the patient is given 100% oxygen, what will the approximate COHb level be in 1 hour? a. 15% b. 10% c. 5% d. 2.5% ANS: B Breathing 100% oxygen at one atmosphere pressure will reduce the COHb by half in l hour. A 20% COHb level will be reduced to about 10% after 1 hour of breathing FIO2 1.0.

10. Which of the following classes of medications are commonly used in the care of patients with smoke inhalation injury?

1. Parasympatholytics 2. Mucolytics 9TH 3. Sympathomimetics 4. Monoclonal antibody a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: D A monoclonal antibody, such as omalizumab, would not be indicated in the treatment of a smoke inhalation injury.

11. Clinical signs associated with acute upper airway obstruction due to thermal injury include: 1. pleural friction rub.

2. inspiratory stridor.

3. pulmonary edema.

4. painful swallowing. a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3 ANS: B Inspiratory stridor and painful swallowing are two of the clinical signs associated with acute upper airway obstruction due to thermal injury.

12. The long-term effects of a smoke inhalation injury are: a. obstructive lung disorders. b. restrictive lung disorders. c. obstructive and restrictive lung disorders. d. neither obstructive nor restrictive lung disorders, since there is normally complete recovery.

ANS: C A smoke inhalation injury can cause both obstructive and restrictive lung disorders.

13. What COHb level is associated with a throbbing headache, nausea, vomiting, and impaired judgment? a. 1% to 10% b. 10% to 20% c. 20% to 30% d. 30% to 50% ANS: C With COHb levels between 20% and 30%, throbbing headaches, nausea and vomiting, and impaired judgment would be expected.

14. Which of the following radiographic findings would be associated with the intermediate stage of recovery from a serious smoke inhalation injury? a. Pulmonary edema/ARDS b. Patchy or segmental infiltrates c. Empyema 9TH d. Normal/full recovery ANS: A During the intermediate stage (2 to 5 days after inhalation), signs of pulmonary edema and ARDS may appear on the chest radiograph.

15. According to the Parkland formula, what is the recommended volume of fluid that should be infused over a 24-hour period for each percent of body surface burned? a. 1 mL/kg of body weight b. 4 mL/kg of body weight c. 6 mL/kg of body weight d. 10 mL/kg of body weight ANS: B The Parkland formula recommends 4 mL/kg of body weight for each percent of body surface area burned to be infused over a 24-hour period.

16. Which of the following would be recommended for the treatment of cyanide poisoning? a. Aztreonam b. Albuterol sulfate c. Amyl nitrate d. Aclidinium bromide ANS: C

The treatment for cyanide poisoning includes amyl nitrite inhalation and intravenous sodium thiosulfate.

17. What level of carbon monoxide toxicity is associated with coma, convulsions, and Cheyne-Stokes respiration? a. 10% to 20% COHb b. 20% to 30% COHb c. 30% to 50% COHb d. 50% to 60% COHb ANS: D At carboxyhemoglobin levels of 50% to 60%, coma, convulsions, and Cheyne-Stokes respiration would be likely to occur.

18. In an industrial accident, an adult incurred burns over his head and neck, both arms, and his anterior trunk. What percent of his BSA was burned? a. 27% b. 36% c. 45% d. 54% ANS: C Approximately 45% of the patient’s BSA was burned: head and neck (9%), both arms (9% × 2 = 18%), and anterior trunk (18%).

9TH