Chapter 27: Asthma Test Bank

Multiple Choice

1. Which of the following types of cells play a role in the pathophysiology of asthma?

I. Mast cells

II. Eosinophils

III. Neutrophils

IV. Basophils a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only

ANS: C

Many cells and cellular elements play a role in the disease in particular, mast cells, eosinophils, T lymphocytes, IgE, macrophages, neutrophils, and epithelial cells.

REF: p. 533

2. Which of the following pathophysiologic events are responsible for airway obstruction?

I. Airway remodeling

II. Airway edema

III. Gas velocity

IV. Mucous plugginga. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: C

Airway obstruction is the consequence of six significant components. These include inflammation, acute bronchoconstriction, airway edema, mucous plugging, airway hyperresponsiveness, and airway remodeling.

REF: p. 534 a. IgA b. IgE c. IgM d. IgD

3. Which of the following immunoglobulins has been identified as a key molecule in mediating allergic asthma and should be measured in serum?

ANS: B

Asthma has been shown to be predominately allergic in nature with 80% of children and more than 50% of adults with asthma. IgE has been identified as a key molecule in mediating allergic asthma. Total serum IgE levels have been shown to have a close association with selfreported asthma.

REF: p. 533 a. Release of preformed mediators b. Antigen–antibody reactions on the surface of mast cells c. Inhalation of offending antigen d. Bronchial mucosal edema

4. Which of the following events occurs during the first phase of airway inflammation?

ANS: A

The first phase involves the preformed mediators that are released with degranulation: histamine, heparin, tryptase.

REF: p. 534

5. Persistent inflammation in asthma leads to a remodeling phase that is characterized by which of the following processes? a. Bronchoconstriction b. Mucous hyporsecretion c. Airway smooth muscle hypertrophy d. Ciliary paralysis

ANS: C

Features of airway remodeling include inflammation, mucous hypersecretion, subepithelial fibrosis, airway smooth muscle hypertrophy, and angiogenesis.

REF: p. 534

6. What appears to be the strongest identifiable predisposing factor for developing asthma? a. Atopy b. Genetics c. Socioeconomic status d. Race

ANS: A

Atopy seems to be the strongest identifiable predisposing factor for developing asthma, with atopic dermatitis often preceding its onset.

REF: p. 535

7. A 2-year-old child diagnosed with asthma has a family history of frequent respiratory infections. What is the most common respiratory virus isolated from infants who wheeze? a. Adenovirus b. Parainfluenza virus c. Respiratory syncytial virus (RSV) d. Coxsackievirus

ANS: C

RSV is the most common viral respiratory tract pathogen isolated from infants who wheeze. Many of these infants with severe infection with respiratory syncytial virus develop recurrent wheezing and asthma later in life.

REF: p. 535

8. On the basis of the National Asthma Education and Prevention Program (NAEPP) guidelines, when a diagnosis of asthma is being made, which of the following criteria are recommended?

I. That the patient be free of any comorbidity

II. That a physical examination be performed

III. That spirometry is conducted to determine the presence of reversible diseaseIV. That a detailed medical history be conducted a. I and III only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only

ANS: D

The NAEPP guidelines recommend a detailed medical history, physical examination, and spirometry to determine reversible disease. It is also important to determine the severity, control, and responsiveness to therapy to determine the patient's current asthma status. Once a diagnosis has been made, it is important that the clinician use methods (e.g., testing for allergies and determining IgE levels) to identify precipitating factors.

REF: p. 536

9. Which of the following spirometric measurements is sensitive to small changes in airway caliber and decreases in value with increasing obstructive disease? a. Forced vital capacity (FVC) b. Forced expiratory flow between 200 and 1200 mL of the FVC (FEF200-1200) c. Mean forced expiratory flow during the middle half of the FVC (FEF25-75) d. Forced expiratory volume in 1 second (FEV1)

ANS: C

The FEF25-75 is also known as the maximum midexpiratory flow. It is sensitive to small changes in airway caliber and also decreases with increasing obstructive disease; however, it is highly variable.

REF: p. 536 a. FEV1 less than 80% of predicted and FEV1/FVC less than 80% b. FEV1 less than 60% of predicted and FEV1/FVC less than 60% c. FEV1 less than 80% of predicted and FEV1/FVC less than 65% d. FEV1 less than 65% of predicted and FEV1/FVC less than 80%

10. Which of the following spirometric criteria are used to determine the presence of airway obstruction?

ANS: C

Airway obstruction is indicated when the FEV1 is less than 80% of the predicted value and FEV1/FVC values are less than 65% (or below the lower limit of normal).

REF: p. 536 a. When the patient’s FEF25-7% increases by 12% and 200 mL/second b. When the patient’s FEV1 increases by 12% and 200 mL c. When the FVC increases by 20% and 200 mL d. When the FEV1/FVC ratio increases by 25%

11. How is significant clinical airflow limitation determined from pre- and postbronchodilator spirometry?

ANS: B

Significant reversibility is established when there is a greater than 12% increase in the postbronchodilator FEV1 measurement.

REF: p. 536 b. The patient is less likely to respond to corticosteroids. c. The patient is likely to require immunotherapy. d. The patient has a neutrophilic phenotype of asthma.

12. The therapist has been asked to check the FENO on a patient with asthma. The level is < 15 ppb. How should the therapist interpret this data? a. The asthma is well controlled.

ANS: B

Many clinicians today use FENO to determine the eosinophilic response to corticosteroids, unmasking of otherwise unsuspected nonadherence to therapy, and routine monitoring. According to the ATS Clinical Practice Guidelines, a patient with a low FENO level of less than 25 parts per billion (ppb) is considered less likely to respond to corticosteroids than one with a high FENO level of > 50 ppb who is symptomatic. An intermediate is considered to be between 25-50 ppb.

REF: p. 537 a. Albuterol b. Ipratropium bromide c. Heparin d. Histamine

13. Which of the following pharmacologic agents may be used for bronchoprovocation challenge testing?

ANS: D

Airway responsiveness can be assessed using pharmacologic (e.g., histamine, methacholine) and nonpharmacologic (e.g., exercise, cold air hyperventilation) challenges.

REF: p. 537 a. Stop the challenge because a drop in the FEV1 is consistent with a positive test b. Stop the challenge because only four concentrations are delivered c. Administer one more concentration to confirm that FEV1 drop is in fact 12% d. Continue administering methacholine until FEV1 decreases 20%

14. The respiratory therapist is assisting the pulmonologist on a methacholine challenge. After inhalation of the fourth concentration of methacholine, the FEV1 decreases 12%. What should the therapist suggest at this time?

ANS: D

The patient's FEV1 is measured after inhalation of each concentration until there is a 20% decrease in the FEV1 or until all nine concentrations have been delivered. A 20% decrease in the FEV1 is considered a positive challenge.

REF: p. 537 b. The challenge is consistent with a positive test for asthma. c. The challenge test is inconclusive for EIB. d. The therapist needs to wait 30 more minutes before interpreting the results.

15. The respiratory therapist is performing an exercise challenge for a child suspected of having exercise-induced bronchospasm. After 30 minutes of stopping exercise, the FEV1 has decreased 15% from baseline. How should the therapist interpret this information? a. The challenge is consistent with a positive test for EIB.

ANS: A

Most children are exercised until their heart rate reaches at least 170 beats per minute or more than 85% of the predicted maximum heart rate for their sex and age for 5 to 8 minutes. The FEV1 is measured immediately and at 5-minute intervals for 20 to 30 minutes after exercise has stopped. A decrease in the FEV1 of 15% or more from the pretest baseline indicates a positive response and exercise-induced bronchospasm (EIB).

REF: p. 537 a. Short-acting beta-2 adrenergic agonists b. Leukotriene modifiers c. Methylxanthines d. Inhaled corticosteroids

16. Which of the following medications are considered the first line of chronic treatment for patients with asthma?

ANS: D

Inhaled corticosteroids are the most consistently effective controller medication for asthma and are considered first-line therapy for its chronic treatment.

REF: p. 538 a. Headache b. Blurred vision c. Changes in pupillary size d. Oral candidiasis

17. The therapist is asked to explain to a 10-year-old how to use a corticosteroid inhaler. Which of the following side effects should the therapist mention to the patient and caregiver?

ANS: D

Although there is much less risk of developing adverse events with inhaled compared with systemic corticosteroids, the potential for side effects remains. Dysphonia, voice change, reflex cough, and oral candidiasis occur most often with higher doses, although these manifestations can occur at any dose.

REF: p. 538 a. Formoterol b. Salmeterol c. Tiotropium bromide d. Albuterol

18. The therapist is asked to recommend a quick-onset, long-acting beta-2 agonist to be added to the inhaled corticosteroid for a patient with asthma. Which of the following medications should the therapist recommend?

ANS: A

Salmeterol and formoterol are long-acting inhaled beta-2 agonists (LABAs) available in the United States. Formoterol is available in a dry powder inhaler device alone and as combination therapy and most recently in a liquid form for nebulization. The biggest difference between the two long-acting bronchodilators is their onset of action. Salmeterol can take from 30 minutes to 90 minutes to have peak effect while formoterol begins to work in 3 to 5 minutes.

REF: p. 538 a. Zileuton b. Salmeterol c. Xopenex d. Omalizumab

19. Which of the following medications is indicated for a 15-year-old patient with moderate asthma who is not controlled with inhaled corticosteroids and exhibits the following signs: (1) a positive skin test or positive in vitro test for aeroallergens and (2) an IgE level of 500 IU/L?

ANS: D

Omalizumab, the only drug that specifically binds circulating IgE, is indicated for the moderate to severe asthmatic over 12 years of age with a positive skin test or positive in vitro test for aeroallergens, a quantitative IgE level between 30 and 700 IU/L, and who is not controlled on ICS therapy.

REF: p. 539

20. In order to establish the personal best peak flow, which instructions should the asthma educator give the patient?

I. Record peak flows when free of symptoms

II. Record peak flows once a week for 2 to 3 weeks

III. Record peak flows preferably in early afternoon

IV. Maintain peak flow values within 80% of the best peak flowa. I, III, and IV only b. II and IV only c. I, II, and III only d. I, III, and IV only

ANS: D

There are predicted "normal" peak flow values that are determined by height, age, gender, and race. However, it is necessary to determine a child's "personal best" peak flow reading. This is defined as simply the highest or best measurement obtained when the patient is free of symptoms and asthma is under control. To determine the personal best reading, the patient records peak flow readings at least once a day for 2 to 3 weeks. The best peak flow reading will usually occur in the early afternoon. Once a patient's personal best peak flow has been established, every effort is made to maintain the peak flow values within 80% of this number.

REF: p. 542 a. Three 20-minute administrations of salmeterol via a small-volume nebulizer in the first hour b. Three treatments with albuterol given every 20 to 30 minutes by nebulization c. Intravenous administration of corticosteroids d. Combination therapy with a short-acting agonist and an anticholinergic bronchodilator via a metered dose inhaler (MDI)

21. What is typically the first pharmacologic intervention instituted by the therapist to treat a patient who enters the emergency room with an asthmatic episode?

ANS: B

One of the first lines of therapy is with beta-2 agonist agents, such as albuterol or levalbuterol. The EPR-3 recommends that the patient receive three treatments given every 20 to 30 minutes by either nebulization or MDI. If there is an inadequate response to this, continuous nebulization of albuterol may be initiated. In severe exacerbation the addition of ipratropium bromide to beta-2 agonists should be considered.

REF: p. 545 a. 25% inspiratory pause b. Tidal volume 10 mL/kg c. Low to moderate positive end-expiratory pressure (PEEP) d. Low FiO2

22. When endotracheal intubation and mechanical ventilation are indicated for a pediatric patient with asthma, which of the following ventilator setting adjustments should the therapist consider making?

ANS: C

After intubation, the child is mechanically ventilated with 6-8 mL per kg IBW with low to moderate positive end-expiratory pressure (PEEP) to assist with distal airway collapse and degree of auto-PEEP present. Larger tidal volumes may be required if prolonged expiratory times and low rates are utilized. The mode of ventilation and set respiratory rate is determined according to the patient's degree of sedation, peak inspiratory pressures generated, oxygenation, and acceptable levels of PaCO2. Initially the FiO2 is 1.0, with the goal to decrease the level to 0.5 or less when able.

REF: p. 545

Chapter 28: Cystic Fibrosis Test Bank

Multiple Choice

1. What are the primary characteristics of cystic fibrosis?

I. Chronic obstruction and inflammation of the airways

II. Exocrine pancreatic insufficiency

III. Malabsorption and small bowel obstructionIV. Decreased sweat chloride concentration a. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: B

The signs and symptoms of classic CF are related to the overproduction of thick, viscous secretions in multiple organ systems:

Chronic obstruction, infection, and inflammation of the airways; Exocrine pancreatic insufficiency with malabsorption and small bowel obstruction; Infertility in males;

Elevated sweat chloride levels.

REF: p. 549 a. 100% b. 75% c. 50% d. 25%

2. What are the chances of two CFTR gene carriers having a normal child?

ANS: D

An individual with CF is a homozygote, or an individual possessing two abnormal CFTR alleles. Each parent of a child with CF is an obligate carrier (or heterozygote), possessing one normal CFTR allele and one mutated allele. Each child of two carriers has a 1 in 4 chance of having CF, a 2 in 4 chance of being a carrier, and a 1 in 4 chance of having two normal alleles.

REF: p. 551

3. Which of the following respiratory signs and symptoms should prompt the therapist for evaluation of cystic fibrosis in a child?

I. Recurrent wheezing

II. Frequent thick sputum production

III. Chronic coughIV. Nasal polyps a. I and II only b. III and IV only c. I, II, and III only d. I, II, III, and IV

ANS: D

Box 28-1 Signs and Symptoms That May Prompt Evaluation for Cystic Fibrosis

Recurrent wheezing

Chronic cough

Frequent thick sputum production

Severe, prolonged, or recurrent sinopulmonary infections

Respiratory infections with pathogens associated with cystic fibrosis

Persistently abnormal chest radiograph

Nasal polyps

Clubbing of the nail beds

REF: p. 550 b. The child has CF. c. The child is likely to develop CF. d. The child does not have CF.

4. A 10-year-old child has had two sweat tests, each indicating a sweat chloride concentration of 30 mEq/L. How should the therapist interpret these data? a. The child is a carrier of CF.

ANS: D

The gold standard for the diagnosis of CF is the sweat chloride test. Normal secretion and resorption of chloride in the sweat glands are dependent on adequate CFTR function. A sweat chloride concentration 60 mmol/L confirms the diagnosis. A concentration between 40 and 59 mmol/L in infants older than 6 months is considered intermediate and should be repeated along with CFTR mutation analysis. Normal individuals can occasionally have elevated sweat chloride concentrations not related to CFTR dysfunction.

REF: p. 550 b. It can generate a false-negative sweat test. c. Adrenal insufficiency can cause either a false-positive or a false-negative result. d. Adrenal insufficiency has no known effect on the result of a sweat test.

5. A sweat chloride test is performed in a 14-year-old child who has adrenal insufficiency. What effect can this condition have on the results of this diagnostic test? a. It can produce a false-positive sweat test.

ANS: A

The sweat is obtained by stimulating the skin on the forearm with pilocarpine iontophoresis (see Figure 28-1 in the textbook). Technical error can result in false-negative and falsepositive results. In addition to inadequate sweat collection, malnutrition, edema, and hypoalbuminemia can also give false-negative results. Therefore, patients with clinical features suggestive of CF but normal or borderline sweat test results should have the test repeated. Conditions that can produce false-positive results include malnutrition, eczema, adrenal insufficiency, pseudohypoaldosteronism, and hypothyroidism.

REF: p. 552

6. A sweat chloride test and CFTR mutation analysis performed in a 10-year-old child with signs and symptoms consistent with CF are inconclusive. Which of the following tests should the therapist suggest at this time? a. Sodium in urine b. Nasal potential difference c. CT scan of the chest with contrast d. Immunoreactive trypsinogen

ANS: B

Measuring the difference in voltage potentials across the nasal epithelium is another method used in the diagnosis of CF, particularly when sweat chloride and/or CFTR mutation analysis results are inconclusive.

REF: p. 551 a. Sodium in urine b. Nasal potential difference c. CT scan of the chest with contrast d. Immunoreactive trypsinogen

7. Which of the following methods is the most commonly recommended for newborn screening?

ANS: D

As of January 2010, all 50 states and the District of Columbia included CF in standard newborn screening. The most common method is measurement of serum immunoreactive trypsinogen (IRT) obtained from a dried heel-stick blood sample.

REF: p. 551

8. Which of the following is the earliest pathologic change that causes airway dysfunction? a. Infection b. Inflammation c. Bronchospasm d. Plugging of the submucosal glands

ANS: D

Airway dysfunction begins during the first year of life, with the earliest pathologic change being thickened mucus and plugging of the submucosal gland ducts in the large airways. These changes appear to precede infection and inflammation.

REF: p. 553

9. Which of the following microorganisms commonly colonize the airways of patients with cystic fibrosis?

I. Actinomyces israelii

II. Haemophilus influenzae

III. Pseudomonas aeruginosa IV. Staphylococcus aureus a. III only b. I and II only c. II and IV only d. II, III, and IV only

ANS: D

The presence of endobronchial pathogens changes with age. Staphylococcus aureus and Haemophilus influenzae typically appear early in life, with S. aureus reaching maximum prevalence at ages 6 to 17 years and H. influenzae peaking at 2 to 5 years of age.

REF: p. 552 a. More than 5% b. More than 20% c. More than 50% d. More than 70%

10. What percentage of patients with adult cystic fibrosis are chronically infected with Pseudomonas?

ANS: D

More than 73% of adults with CF in the United States are chronically infected with Pseudomonas. It is strongly associated with accelerated lung function decline and survival.

REF: p. 552

11. Approximately what percentage of patients with cystic fibrosis present with pulmonary symptoms? a. 100% b. 80% c. 50% d. 30%

ANS: C

Nearly half of all patients with CF are diagnosed as a result of pulmonary symptoms. The diagnosis of CF should be considered in every patient who presents with chronic or recurrent lower respiratory tract disorders, including bronchitis, bronchiectasis, pneumonia, and refractory asthma. Children with CF have frequent pulmonary exacerbations, with the most consistent feature being a chronic cough.

REF: p. 553 a. Air bronchograms b. Dome-shaped diaphragms c. Bronchiectatic changes d. Meniscus sign

12. Which of the following radiographic features is consistent with CF?

ANS: C

The chest radiograph initially shows hyperinflation with flattened diaphragms secondary to air trapping (see Figure 28-2 in the textbook). Mucus plugging and patchy atelectasis can also be seen. Diffuse fibrosis, bronchial wall thickening, and bronchiectasis are found predominantly in the upper lobes. However, over time all lung fields are involved.

REF: p. 553

13. On pulmonary function testing, which of the following lung abnormalities is/are common in patients with severe cystic fibrosis?

I. Obstructive pattern

II. Restrictive pattern

III. Airway hyperreactivity

IV. Normal pattern when asymptomatica. I only b. I and IV only c. II and III only d. I, II, and III only

ANS: D

Pulmonary function testing initially demonstrates air flow obstruction. As the disease progresses, both a restrictive and an obstructive pattern can be seen, along with a decrease in air flow. About 50% of patients with CF have a positive methacholine challenge test, which indicates airway hyperreactivity.

REF: p. 553 a. Airway clearance techniques b. Bronchodilators c. Antihistamines d. PEP therapy

14. Which of the following therapeutic interventions should be the focus of the treatment of patients with cystic fibrosis?

ANS: D

Treatment of the pulmonary manifestations of CF focuses on routine therapy aimed at physically removing thickened mucus from the airways. Pharmacologic control of infection with the aggressive use of antibiotics is crucial.

REF: p. 554

15. Which of the following medications should the therapist routinely administer during the management of hospitalized patients with cystic fibrosis?

I. Albuterol

II. Hypertonic saline

III. DNAseIV. Salmeterol a. I and II only b. II and III only c. I and IV only d. I, II, and III only

ANS: D

Aerosol therapy is an important aspect of CF respiratory care in the hospital and in the home. A number of medications are designed to address specific aspects of CF pulmonary disease. Put together, a commonly utilized sequence is as follows: bronchodilator, hypertonic saline, recombinant human DNAse, airway clearance therapy, maintenance medication (inhaled corticosteroid and/or antibiotic).

REF: p. 554 a. rhDNase b. N-Acetylcysteine c. Albuterol d. Amiloride

16. Which of the following drugs should the therapist give before administering nebulized 7% saline to a patient with CF?

ANS: C

Because hypertonic saline causes bronchospasm in some patients, it is generally recommended to premedicate with a beta-2 agonist.

REF: p. 554

17. Which of the following aerosolized antibiotics is nebulized to treat infections caused by Pseudomonas aeruginosa in patients with CF? a. Gentamycin b. Tobramycin c. Amiloride d. Ibuprofen

ANS: B

Aerosolized antibiotics such as tobramycin are frequently used as chronic suppressive therapy to treat patients infected with P. aeruginosa to prolong the time between pulmonary exacerbations and to slow the progression of lung function decline. A Cochrane review of inhaled tobramycin for CF concluded that aerosolized antipseudomonal antibiotics improved lung function. A unit dose of 300 mg/5 mL is considered standard. It is given twice a day for 28-day cycles every other month.

REF: p. 554

18. Which of the following antiinflammatory agents should be considered in patients with CF to slow the progression of the lung disease? a. Prednisone b. Any inhaled corticosteroid c. Aspirin d. Ibuprofen

ANS: D

Ibuprofen has been demonstrated to slow the progression of lung disease over a 2-year period. However, specific dosing and close pharmacokinetic monitoring is required when using this medication.

REF: p. 555

Chapter 29: Acute Respiratory Distress Syndrome Test Bank

Multiple Choice

1. On the basis of the Berlin definition of Acute Respiratory Distress Syndrome (ARDS), the definition of moderate acute respiratory distress syndrome comprises which of the following components?

I. PaO2/FiO2 200 mm Hg

II. Onset of respiratory symptoms within 1 week of clinical insult

III. Pulmonary capillary wedge pressure greater than 18 mm Hg

IV. Chest radiograph with bilateral infiltrates not fully explained by effusions or collapse a. I and II only b. I and III only c. II and IV only d. I, II, and IV only

ANS: C

Within 1 week of known clinical insult or new/worsening respiratory symptoms; Bilateral opacities that are not fully explained by effusions, lobar/lung collapse, or nodules. Can be either on CXR or CT scan; With PEEP 5, mild ARDS: PaO2/FiO2 201-300, moderate ARDS:

PaO2/FiO2 200, severe ARDS: PaO2/FiO2 00; Risk factors for ARDS must be present. Respiratory failure that is not fully explained by cardiac failure or fluid overload. If no risk factors are present, objective assessment (e.g., echocardiography) is required to exclude hydrostatic edema.

REF: p. 562 a. 20.7 b. 13.1 c. 1.31 d. 200

2. A therapist is evaluating the progress of a patient with ARDS. The arterial blood gas reveals a PaO2 of 55 mm Hg and a PaCO2 of 65 mm Hg. The PEEP is set at 12 cm H2O, and the mean airway pressure is 18 on an FiO2 of 0.60. What is the OI in this patient?

ANS: A

OI = ( FiO2)/PaO2 100

REF: p. 562 a. Pneumonia b. Chest trauma c. Closed head injury d. Cor pulmonale

3. Which of the following indirect insults can cause ARDS?

ANS: C

ARDS can be caused by numerous insults (risk factors) that both directly and indirectly affect the lung via the generation of inflammatory mediators. Direct pulmonary insults include pneumonia, aspiration, chest trauma, and smoke inhalation. Indirect lung injury may be the result of generalized systemic conditions, such as sepsis, closed head injury, multiple trauma, transfusion reactions, and hemorrhagic shock.

REF: p. 563 a. Mixed acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic acidosis

4. What acid-base abnormality does a patient generally display when experiencing stage 2 of ARDS?

ANS: B

The clinical course of ARDS is characterized by distinct clinical, radiographic, and pathologic manifestations. The first stage consists of direct or indirect acute injury to the lung tissue. Clinically, patients may display mild tachypnea and dyspnea and tend to have normal radiographic findings. The second stage, or latent period, lasts a variable period of time after the onset of acute injury. During this time the patient may appear clinically stable but begins to develop early signs of pulmonary injury or insufficiency manifested by hyperventilation with hypocarbia and a respiratory alkalosis.

REF: p. 563 a. Refractory hypoxemia b. Hypocarbia c. Increased anatomic dead space d. Decreased cardiac output

5. Which of the following clinical signs characterizes the onset of the third stage of ARDS?

ANS: A

The third stage, acute respiratory failure, is heralded by the rapid onset of respiratory failure with hypoxemia refractory to supplemental oxygen. Diffuse pulmonary edema and worsening compliance cause significant atelectasis and intrapulmonary shunting. Clinically, patients develop rapid, shallow tachypnea with increased work of breathing.

REF: p. 563

6. What are some of the physical signs of respiratory failure among children?

I. Head bobbing

II. Nasal flaring

III. CryingIV. Grunting a. I and II only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only

ANS: B

The physical signs of respiratory failure will vary with age and include subcostal and supraclavicular retractions, grunting (i.e., an attempt to generate increased intrinsic positive end-expiratory pressure, PEEP), nasal flaring, and head bobbing.

REF: p. 563

7. The therapist is auscultating a 2-year-old patient with ARDS. Which of the following is a common auscultatory finding in ARDS? a. Wheezing b. Stridor c. Crackles d. Pleural rub

ANS: C

Lung examination usually reveals diffuse crackles on auscultation.

REF: p. 563 a. Horizontal ribs b. Bilateral consolidations c. Flattened diaphragms d. Pleural effusions

8. Radiographically, what features are typically seen in ARDS?

ANS: C

Radiographically, there are bilateral areas of consolidation with air bronchograms that reflect alveolar filling and atelectasis.

REF: p. 564

9. Which of the following interventions should the therapist implement to decrease mortality in patients with ARDS? a. High PEEP b. Alveolar recruitment maneuvers c. Low tidal volume d. High respiratory rate

ANS: D

Except for low tidal volume ventilation, no single intervention for adult ARDS has been clearly shown to decrease mortality. This highlights the pressing need for development of effective management strategies for ARDS.

REF: p. 565 a. Destruction of alveolar type II cells b. Inactivation of pulmonary surfactant c. Fluid accumulation in the pleural spaces d. Rapid removal of fluid by the pulmonary lymphatics

10. Which of the following pathophysiologic conditions contribute to the decreased pulmonary compliance associated with ARDS?

ANS: B

Pulmonary compliance is significantly worsened by the presence of edema and can result in widespread atelectasis. Pulmonary compliance is further impacted by the inactivation of surfactant that results from the presence of plasma protein, such as fibrin, and inflammatory mediators, such as proteinases, in the alveolar space.

REF: p. 564

11. Which of the following pathophysiologic changes seen in ARDS is responsible for the decrease in available surface area for gas exchange? a. Hyperinflation of the lungs b. Decreased right ventricular cardiac output c. Pulmonary hypertension d. Obliteration of small precapillary vessels

ANS: D

Vascular changes occur throughout the later stages of ARDS with obliteration of small precapillary vessels and an increase in the medial thickness of intra-acinar pulmonary arteries. Overall, these changes markedly decrease the available surface area for gas exchange and result in intractable respiratory failure or chronic lung disease, potentially requiring prolonged ventilator support.

REF: pp. 564-565 a. High transpulmonary pressures b. High transairway pressures c. Hyperinflated lungs d. Refractory hypoxemia

12. What pathophysiologic change accounts for the alteration of the hysteresis curve during ARDS?

ANS: A

During ARDS, marked hysteresis of the pressure–volume loop occurs, making significantly higher transpulmonary pressures during inspiration than during expiration necessary to achieve a given lung volume.

REF: p. 565

13. How should the therapist use the point on the pressure–volume loop where the shape changes from concave to exponential? a. To set PEEP b. To set VT c. To set Ti d. To set PIP

ANS: A

The point on the pressure–volume loop where the shape changes from concave to exponential is known as the lower inflection point. It reflects the pressure point at which alveoli begin to open and is located above functional residual capacity (see Figure 35-2 in the textbook). This suggests that many gas exchange units will collapse at normal transpulmonary pressures in acutely injured lungs and may need significant PEEP to maintain patency during expiration.

REF: p. 565

14. Which of the following regions of the lungs is most likely to be unaffected by pathophysiology associated with ARDS? a. The dependent regions of the lung b. The nondependent regions of the lung c. The middle zone of the lung d. Depends on the etiology

ANS: B

Lung injury and areas of involvement in ARDS are heterogeneous and not uniform through all lung units. Some areas of the lung, typically in the dependent regions, are grossly affected. Other regions of the lung, typically in the nondependent regions, may be relatively unaffected. This creates varying areas of compliance within the lung itself. Dependent regions are generally fluid filled, atelectatic, and noncompliant. Nondependent areas are relatively normal and, thus, at risk for overdistention (i.e., volutrauma) and/or barotrauma during mechanical ventilation.

REF: p. 565 a. 40% b. 50% c. 60% d. Any level above 30%

15. What level of FiO2 should the therapist avoid using long term in patients with ARDS?

ANS: C

Every patient with ARDS is hypoxemic by definition. Prolonged administration of high concentrations of oxygen can damage the lungs, owing to the formation of highly reactive oxygen free radicals. Human and animal studies suggest that a prolonged FiO2 greater than 0.60 should be avoided to prevent oxygen-induced pulmonary damage.

REF: p. 566 a. Risk of pneumothorax b. Decreased cardiac output c. Auto-PEEP d. Overdistention

16. The therapist was titrating PEEP levels to maintain an SaO2 of 85% and found that 13 cm H2O were required to achieve this goal. What should the most important concern with this level of PEEP?

ANS: B

PEEP is typically increased to a level that allows adequate oxygenation as defined by an arterial oxygen saturation (SaO2) of 85% or greater at an acceptable FiO2 of 0.60 or less. It should be noted that the minimal acceptable arterial oxygen saturation remains very controversial. A PEEP level of 10 to 15 cm H2O, or even higher, may be required to achieve adequate oxygenation. However, as PEEP levels exceed 12 to 15 cm H2O, the increase in intrathoracic pressure may adversely affect cardiac output, primarily by decreasing systemic venous return. As PEEP is increased, the ARDS patient should be monitored for a decrease in cardiac output with a decrease in peripheral perfusion.

REF: p. 566 a. PEEP less than 15 cm H2O and tidal volume (VT) between 8 and 10 mL/kg b. Peak inspiratory pressure (PIP) less than 40 cm H2O and Pplateau less than 30 cm H2O c. VT less than 6 mL/kg and Pplateau less than 30 cm H2O d. A high or low level of PEEP and a VT between 8 and 10 mL/kg

17. Which of the following ventilatory strategies is appropriate when mechanically ventilating a patient with ARDS?

ANS: C

The ARDS Network investigated the optimal PEEP-FiO2 strategy for adults with ARDS. The results of this prospective, randomized, multicenter study indicate that in adult ARDS patients who are ventilated with 6 mL/kg tidal volumes and an end-inspiratory plateau pressure of less than 30 cm H2O, a "moderately high" or "very high" PEEP strategy produced similar survival rates. It must be noted that this study investigated two relatively aggressive PEEP strategies. Subsequent studies performed outside the United States also showed similar results. In a study involving 30 ICUs and 983 adult patients with ARDS, there was no difference in hospital mortality despite the reduction in the need of rescue therapies in the “high” PEEP group. A recent systematic review on the effect of PEEP in ARDS showed that the subgroup of ARDS patients who may stand to benefit most from a “high” PEEP strategy are those with the worst degree of hypoxemia.

REF: p. 566 a. 35 cm H2O b. 32 cm H2O c. 25 cm H2O d. 20 cm H2O

18. What level of Pplateau should the therapist target to improve outcomes in patients with ARDS?

ANS: B

The data support the conclusion that for adult patients with ARDS, the Pplateau should be limited to < approximately 32 cm H2O to improve outcome. The applicability of this conclusion to pediatric ARDS patients requires investigation. It is very possible that the "critical" limit on plateau pressure for infants and children will be < 32 cm H2O and may vary with patient age and size.

REF: p. 567 b. The pH should never remain below 7.30. c. The rate at which the CO2 rises may be more important than the actual PaCO2. d. The target PaCO2 should be reached in 48 hours.

19. During the implementation of permissive hypercapnia, which of the following concepts is the most critical to prevent complications of this strategy? a. The PaCO2 should never reach 100 mm Hg.

ANS: B

Recent data from a laboratory model of ischemia-reperfusion acute lung injury indicate that hypercapnic acidosis is protective and that buffering of the hypercapnic acidosis attenuates its protective effects. In allowing permissive hypercapnia, the rate at which carbon dioxide rises may be more important than the actual value itself. A rapid regression to normocapnia may be more deleterious to the cardiac system than hypercapnia itself.

REF: p. 569

Chapter 30: Shock, Sepsis and Anaphylaxis Test Bank

Multiple Choice

1. A 7-year-old patient with insulin-dependent diabetes is evaluated in the emergency department due to ketoacidosis. What type of shock is most commonly associated with diabetic ketoacidosis?

a. Hypovolemic b. Cardiogenic c. Obstructive d. Distributive

ANS: A

In hypovolemic shock, rapid restoration of the vascular volume is paramount. For hemorrhagic shock, a subtype of hypovolemic shock, blood loss causes shock and thus treatment requires replacement of the lost blood volume. Other potential causes of hypovolemic shock include osmolar diuresis such as from diabetic ketoacidosis or from infectious enteritis.

REF: p. 573 a. Hypovolemic b. Cardiogenic c. Obstructive d. Distributive

2. Which of the following types of shock is the most common among children?

ANS: A

Typically, shock can be classified in four general states: hypovolemic, cardiogenic, obstructive, and distributive. The first, hypovolemic shock, is most common worldwide among children, most often resulting from severe dehydration.

REF: p. 573 a. Administration of the wrong fluid b. Inadequate dose of vasopressors c. Hypoxia d. Adrenal insufficiency

3. A respiratory therapist has intubated a child with septic shock who has also received intravenous fluids and vasopressors. What condition could explain a lack of response to therapy?

ANS: D

When septic shock is refractory to fluid and/or catecholamines, consideration must also be given to adrenal insufficiency as a component of the shock state, particularly in patients who are at risk for impairment in their hypothalamic-pituitary-adrenal axis or who have had a history of steroid exposure. In such patients, the clinical status may not improve unless the patient receives “stress-dose” steroids with hydrocortisone.

REF: p. 575

4. A respiratory therapist is gathering equipment to intubate a patient with anaphylactic shock who has severe bronchospasm. What is one of the most prominent inflammatory mediators responsible for the increase in airway resistance and fall in the PaO2? a. Epinephrine b. Histamine c. Interleukin d. IgE

ANS: B

Histamine is one of the most prominent mediators and is believed to be responsible for the increase in airway resistance and the fall in partial pressure of oxygen due to its contractile action on the smooth muscle of the lung.

REF: p. 576 a. Vasopressin b. Dopamine c. Epinephrine d. IV fluids

5. What is the mainstay of therapy for patients with anaphylactic shock?

ANS: C

Providing oxygen will help ensure adequate oxygenation, and the wheezing often abates with the administration of epinephrine for circulatory support. Epinephrine is the mainstay of therapy. Circulatory dysfunction and shock are the next most pressing issues. For circulatory collapse, large volume infusions, as in other types of shock, help to restore the circulating blood volume. Hypotension can be severe and resistant to therapy. Circulatory support with repeated doses of epinephrine and a continuous epinephrine infusion help support the patient until the directed therapy can begin.

REF: p. 577 a. This cardiac index is associated with an increased risk of mortality. b. This cardiac index is in the high range of normal, and it is an indication to wean vasopressors and fluids. c. This cardiac index is within normal limits but still requires close monitoring because it is in the low range of normal. d. This cardiac index is normal and no action is required.

6. A child admitted to the emergency department with a diagnosis of shock has a cardiac index is 3.5 L/min/m2. How should the therapist interpret this value?

ANS: C

In children, normal values for the cardiac index are in the range of 3.3 to 6.0 L/min/m2 A cardiac index of < 2.0 L/min/m2 has been associated with an increase in mortality.

REF: p. 576 a. Preload b. Afterload c. Inotropy d. Chronotropy

7. A measure of the resistance or force against which the heart must pump defines which of the following terms?

ANS: B

Afterload is a measure of the resistance or force against which the heart must pump.

REF: p. 577 a. Tachycardia b. Bradycardia c. Hypotension d. Dyspnea

8. Which of the following signs is one of the first to indicate decreased peripheral perfusion in children?

ANS: A

Infants and children have a limited ability to increase stroke volume. As a result, they will attempt to compensate for a reduction in cardiac output by increasing their heart rate.

Tachycardia is one of the first signs of decreased peripheral perfusion in children.

Hypotension is an unreliable and late finding of shock in children occurring when the child's compensatory mechanisms have already failed.

REF: p. 578

9. A therapist is calculating oxygen delivery for a patient admitted with a diagnosis of shock. Which of the following parameters should the therapist measure?

I. Hemoglobin

II. Oxygen bound to hemoglobin

III. Dissolved oxygen

IV. Cardiac output a. I, II, and IV only b. II, III, and IV only c. I, II, III, and IV d. I, II, and III only

ANS: C

Oxygen delivery depends on oxygen-carrying capacity (% hemoglobin), oxygen provided (oxygen bound to hemoglobin plus dissolved oxygen), and cardiac output.

REF: p. 578 a. Adequate cardiac output b. Increased afterload c. Inadequate cardiac output d. Decreased preload

10. How should the therapist interpret a capillary refill time of approximately 1 second in a pediatric patient?

ANS: A

Capillary refill (the process of blanching the skin for several seconds and timing the return of blood flow to the blanched skin) is a quick, useful, and noninvasive test that provides important information regarding perfusion in the acute setting. The normal capillary refill time should be less than 2 seconds and correlates with a cardiac index of > 2.0 L/min/m2

REF: p. 579 b. The infant has late cardiogenic shock. c. The patient has decreased cardiac output. d. The patient may have early septic shock.

11. Assessment of an infant suspected of having shock reveals skin that is warm, pink, and well perfused. How should the therapist interpret these findings? a. The infant has hypovolemic shock.

ANS: D

Evaluation of skin color and temperature is easily performed. The skin of children in shock may be pale, cyanotic, or mottled because of poor perfusion. Traditionally, practitioners have described two phases of septic shock. In early septic shock the skin appears well perfused, warm, and pink. These signs are caused by vasodilation and increased cardiac output. Later in the course of shock, the cardiac output begins to fall. Skin examined during this period is likely to be cool, cyanotic, or mottled, representing a decrease in the amount of substrate reaching the skin.

REF: p. 580

12. Which vascular site would provide the most reliable measurement of the beat-to-beat monitoring of the blood pressure in an infant who is suspected of having shock? a. Any vessel b. Any peripheral vein c. A peripheral or central artery d. A central vein

ANS: C

The placement of a catheter in a peripheral or central artery can be performed for the monitoring of blood pressure on a continuous basis in the intensive care unit. Arterial catheterization can provide beat-to-beat monitoring of the blood pressure.

REF: p. 581

13. Which of the following can be obtained from a central venous pressure measurement? a. Stroke volume b. Afterload c. Preload d. Myocardial contractility

ANS: C

The placement of a catheter in the central venous system allows for an assessment of the volume status of the child with shock. The catheter, when attached to a continuous column of fluid and a pressure transducer, measures the downstream intravascular pressure, or CVP, in the right atrium. This intravascular pressure represents preload, one of the contributors to the stroke volume, which contributes to the cardiac output.

REF: p. 580

14. Which of the following hemodynamic assessments can be obtained from a pulmonary capillary wedge pressure measurement? a. Central venous pressure b. Right ventricular preload c. Left ventricular afterload d. Left ventricular preload

ANS: D

The use of PA catheters in children is supported by the American College of Critical Care Medicine for circumstances in which irreversible shock manifesting as poor perfusion, acidosis, and hypotension persists despite the use of therapies directed at the arterial blood pressure, CVP pressure, and oxygen saturation indices. In addition to the measurements obtained directly from the catheter, a number of derived values provide information regarding the homeostatic function of the child, including systemic vascular resistance as a measure of afterload and oxygen consumption and oxygen extraction.

REF: p. 581 a. Administer an additional 20 mL/kg bolus of fluids b. Switch to lactated Ringer’s solution c. Start vasopressors d. Alternate normal saline and Ringer’s solution

15. A child has been treated for shock with 60 mL/kg of normal saline. What should be considered at this time?

ANS: C

Large fluid deficits typically exist and initial volume resuscitation usually requires 40 to 60 mL/kg but can require as much as 200 mL/kg in some cases of septic shock. Continued fluid losses and persistent hypovolemia due to capillary leak can persist despite fluid resuscitation. Ongoing fluid replacement is necessary to maintain adequate tissue perfusion, and large volumes may be required as vascular permeability results in peripheral and third space losses. When total administered volumes of 60 mL/kg are reached, intravascular monitoring and initiation of vasoactive support should be considered.

REF: p. 581 a. When a patient demonstrates leukopenia b. When a patient shows evidence of anemia c. When the risk of sepsis is present d. When a patient shows evidence of hypovolemic shock

16. In which of the following clinical situations may the administration of packed red blood cells be indicated?

ANS: B

If there is evidence of anemia or suspected losses of blood, repletion of the intravascular volume with packed red blood cells should be performed.

REF: p. 582 a. In synchrony with the QRS complex b. Synchronously with the appearance of the P wave c. Immediately before the ST segment d. At any point during the cardiac cycle

17. When cardioversion is indicated, at what point during the cardiac cycle must it be applied?

ANS: A

An unstable tachycardia manifested with hypotension or signs of shock should be treated with electrical therapy in the form of synchronized cardioversion or defibrillation. Cardioversion synchronizes the delivery of the shock with the QRS complex to prevent deterioration to a more lethal arrhythmia and should be used in patients who have a palpable pulse.

REF: p. 581

18. A child is receiving aggressive therapy for shock. Cardiac failure has developed. Which of the following inotropes is the most frequently used under these circumstances? a.

Epinephrine b. Dopamine c. Norepinephrine d. Digitalis

ANS: B

Inotropic agents are used to increase contractility and cardiac output. Dobutamine is a beta-1 adrenergic agonist with chronotropic and inotropic actions, as well as afterload reduction. Dopamine, the most frequently used inotrope, increases renal blood flow but also has vasoconstrictive properties at high doses due to release of norepinephrine. Epinephrine is a naturally circulating neurohormone that increases contractility during stress and shock. At low dose it provides inotropy but at higher doses increases peripheral vascular tone and acts as a vasopressor. Patients with heart failure and increased systemic vascular resistance may be harmed by these higher doses unless epinephrine is combined with an inodilator or vasodilator.

REF: p. 582

19. During the treatment of sepsis, what intervention may be needed if hypotension persists despite the maximal application of inotropic and vasomotor support? a. Endotracheal intubation and mechanical ventilation b. High-frequency oscillatory ventilation c. Extracorporeal membrane oxygenation d. Hyperbaric oxygenation

ANS: C

Patients remaining in shock despite the supportive therapies may benefit from mechanical cardiac support, such as extracorporeal membranous oxygenation (ECMO). ECMO is highly effective for cardiogenic shock because it helps support the ailing heart, but it is less successful in septic shock, except possibly in treating refractory low–cardiac output septic shock.

REF: p. 583

20. Which of the following microorganisms are likely responsible for neonatal meningitis?

I. Klebsiella species

II. Neisseria meningitidis

III. Escherichia coli IV. Listeria monocytogenes a. I and IV only b. II and III only c. III and IV only d. I, III, and IV only

ANS: D

The common causative agents for meningitis are age specific. For neonates, the primary bacterial agents include Streptococcus agalactiae, Klebsiella species, Escherichia coli, and uniquely Listeria monocytogenes

REF: p. 583

21. Which of the following microorganisms are currently the leading causes of childhood meningitis?

I. Group B Streptococcus

II. Streptococcus pneumoniae

III. Methicillin-resistant Staphylococcus aureus IV. Neisseria meningitides a. I and IV only b. II and IV only c. I, II, and III only d. II, III, and IV only

ANS: B

In older infants through the early toddler years, Streptococcus pneumoniae, Neisseria meningitides, and Haemophilus influenzae are most likely.

REF: p. 584

Chapter 31: Pediatric Trauma Test Bank

Multiple Choice

1. Which of the following anatomic considerations in children are important to better understand trauma in this age group?

I. Children have less body fat.

II. Children have a small surface area relative to volume.

III. Children’s skeletons are more pliable.

IV. Children have a greater distribution of force per unit body area of smaller body mass.a. I and III only b. II and IV only c. I, II, and III only d. I, III, and IV only

ANS: D

Children are not just small adults. It is important to understand the fundamental differences between adults and children. Notable are the size and shape differences. There is a greater distribution of force per unit body area because of smaller body mass resulting in greater acceleration. The child’s body has less fat, elastic connective tissue, and close proximity of multiple organs. This can place the child with a penetrating injury at risk of multiple organ involvement. Children also have a large surface area relative to volume, predisposing them to thermal evaporative loss resulting in hypothermia. A child’s skeleton is more pliable due to incomplete calcification. Trauma can result in serious organ injury without overlying skeletal fracture.

REF: p. 588 a. Head injury b. Pulmonary contusion c. Cervical spine injury d. Leg fracture

2. What should be always assumed in the case of traumatic injury regardless of the mechanism?

ANS: C

The initial assessment is the same for all pediatric patients who have sustained a traumatic injury regardless of mechanism. Always assume cervical spine injury and take necessary precautions during the assessment. The head and neck should be held in line with the body by placing a cervical collar or by assigning an individual to hold the patient in C-spine precautions.

REF: p. 588

3. A respiratory therapist arrives at the scene of an accident to assist a victim of a motor vehicle accident. What would the best method to open the airway until a full assessment is completed? a. Jaw thrust b. Head tilt c. Sniff position d. Chin lift

ANS: A

A patent airway can be initiated by means of a jaw thrust maneuver to open the airway. Maintain the airway with orotracheal intubation, nasotracheal intubation, cricothyrotomy, or tracheostomy. In order to maintain cervical spine stabilizations, do not use the head tilt, sniff position, or chin lift maneuvers because these procedures change the orientation of the spinal column and increase the risk of additional spinal injury. The jaw thrust technique may be used in these children unless otherwise contraindicated.

REF: p. 588

4. A respiratory therapist is asked to rapidly assess adequacy of peripheral circulation while an intravenous line is placed. Which of the following methods should the therapist use? a. Measure blood pressure b. Measure pulse pressure c. Assess pulse intensity d. Assess capillary refill

ANS: D

Assessing capillary refill is a quick and specific method of checking the adequacy of peripheral circulation. One method of determining capillary refill is to depress the patient's thumb nail with moderate force. This will cause the underlying tissue to blanch (turn white or pale pink) by forcing blood from the tissue. Releasing the pressure allows blood to refill the tissue's capillaries. Normal capillary refill time is less than 2 seconds. Inadequate capillary refill on initial assessment may be caused by regional perfusion problems. To rule out this possibility, repeat the capillary refill test on the opposite hand.

REF: p. 589

5. Which of the following areas is evaluated on the Glasgow Coma Scale, used for the neurologic assessment of adults, older children, and adolescents? a. Respiratory b. Verbal c. Circulatory d. Olfactory

ANS: B

Immediate assessment of neurologic status is beneficial in acute trauma management. The most common way to perform this assessment is with the Glasgow Coma Score (GCS). Patients are scored in three areas: eye opening, verbal response, and motor response. Although the standard GCS is accurate for use in adults, older children, and adolescents, the agespecific GCS combines adult and child forms so it is applicable to all ages. The age-specific GCS is particularly useful in nonverbal children.

REF: p. 589

6. A respiratory therapist working in the emergency department has received report of a patient who suffered a traumatic brain injury and whose Glasgow Coma Scale score is 8. What should the therapist anticipate doing when the patient arrives? a. Place a cervical collar b. Place an intravenous catheter c. Obtain a head CT scan d. Intubate

ANS: D

If the GCS is less than or equal to 8, the patient likely does not have the ability to protect his/her airway and a more definitive airway should be established. Intubation is the most common option for a definitive airway, with cricothyroidotomy being a secondary option.

REF: p. 589

7. Why are infants and children highly vulnerable to head injury?

I. Their head is large and heavy compared with the rest of the body.

II. They lack mature judgment.III. They are uncoordinated. IV. They tend to move too fast. a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only

ANS: C

A child's head is large and heavy in relation to the body. Therefore, the center of gravity shifts toward the head. In addition, a child’s balance, coordination, gait, and judgment are immature, which results in children being especially vulnerable to falls with head injury.

REF: p. 589 a. The infant’s brain has the ability to absorb more energy per square centimeter than the adult brain. b. The infant’s brain is more rigid than the adult brain up to 2 years of age. c. The infant’s brain is capable of transferring functions from damaged to undamaged regions. d. The brain of an infant has the ability to completely replace damaged neurons with new neurons.

8. What is the meaning of the word plasticity when used to describe brain damage in infants?

ANS: C

The brains of infants and children apparently have a large degree of plasticity (i.e., adaptability) in redistributing function from a damaged area to an undamaged area. In adults the ability of brain segments to adapt to new functions seems to be rarely, if ever, present.

REF: p. 591

9. Which of the following factors provide infants and young children protection against head trauma by allowing a degree of expansion of the cranial volume?

I. Reduced cranial weight

II. Less cranial ossification

III. Presence of fontanels

IV. Presence of flat bonesa. I and III only b. II and III only c. I, II, and IV only d. II, III, and IV only

ANS: D

Infants and young children also have malleable skulls because of the large fontanels (“soft spots”) and the flat bones of the skull, which have not yet fused and still may be cartilaginous before ossification. These factors allow for elasticity of the cranial vault and lessen or prevent both fractures and pressure-related brain injuries during passage through the birth canal. Skull malleability also protects against damage from other sources, such as trauma or illness, causing increased pressures in the cranial vault. This protection occurs by allowing a degree of expansion of the cranial volume.

REF: p. 591

10. Which of the following respiratory procedures must be avoided in a patient suspected of having direct cranial trauma?

I. Oral airway insertion

II. Nasotracheal suctioning

III. Nasotracheal intubationIV. Nasogastric tube insertion a. I only b. I and III only c. II and III only d. II, III, and IV only

ANS: D

In patients with direct cranial trauma, avoid nasotracheal intubation, nasotracheal suctioning, or inserting nasogastric tubes because inadvertent cranial intubation may result through open fractures of the cranial vault, especially in patients who may have basilar skull injuries or paranasal fractures. In addition, irritating procedures such as nasopharyngeal or nasotracheal suctioning, insertion of a nasogastric tube, or intubation may result in an exacerbation of an already increased intracranial pressure.

REF: p. 592

11. The respiratory therapist has intubated a patient with a traumatic brain injury whose respiration has deteriorated. Which of the following ventilatory strategies should the therapist try to minimize the effects on intracranial pressures? a. Minimize peak inspiratory pressure b. Increase mean airway pressure c. Prolong inspiratory time d. Decrease respiratory rate

ANS: A

If respirations deteriorate or the patient's state of consciousness declines, mechanical ventilation should be instituted immediately. Minimize peak inflation pressure (PIP) and mean airway pressure (), and select inspiratory and expiratory times that favor prolonged expiration if possible. Decreasing minimizes outflow tract resistance from the cerebral vasculature, enhancing cerebral perfusion by minimizing effects on intracranial pressure (ICP). Remember to minimize suctioning to prevent coughing and gagging on the tracheal tube or suction catheter, which may increase ICP.

REF: p. 589

12. A child with a head injury displays bruising discolorations around the orbits, or “raccoon eyes.” What does this indicate? a. Direct trauma to the eyes b. Frontal trauma c. Basilar skull fracture d. Brain herniation

ANS: C

Some classic "signs" are associated with certain head injuries. These signs indicate fractures of the basilar skull. Traumatic head injury may be highlighted by the presence of Battle's sign or "raccoon eyes." Battle's sign represents ecchymosis, or bruised areas behind the ear that indicate basilar skull fractures. The self-explanatory term raccoon eyes represents bruising discolorations around the orbits. Both Battle's sign and raccoon eyes are the body's attempts to show internal injury with as simple a sign as a small bruise.

REF: p. 593 a. 10 mm Hg b. 20 mm Hg c. 30 mm Hg d. 40 mm Hg

13. What is the normal value for intracranial pressure?

ANS: A

Normal intracranial pressure is 130 mm H2O (10 mm Hg).

REF: p. 593 a. 90 mm Hg b. 70 mm Hg c. 50 mm Hg d. 40 mm Hg

14. Intracranial pressure (ICP) monitoring has been initiated for a patient with brain injury. The child’s ICP is 10 mm Hg, and mean blood pressure is 80 mm Hg. What is this child’s CPP?

ANS: B

Compression of the brain tissue inhibits blood flow by reducing cerebral perfusion pressure (CPP) and causes cerebral tissue hypoxia, ischemia, and coma. CPP = mean BP - ICP and averages 85 ± 15 mm Hg.

REF: p. 593 a. Diplopia b. Bulging fontanels c. Seizures d. Miosis

15. A 3-month-old baby suspected of having a life-threatening encephalopathy is being transported from a rural area. Which of the following signs may assist in the confirmation of intracranial hypertension?

ANS: B

Increased ICP can be a life-threatening feature of an encephalopathy. CSF and blood acting on the brain and bony structures of the skull generate ICP. In the newborn and infant, measuring the head circumference and palpating the anterior fontanel allow rapid assessment of ICP. Bulging of the fontanels may be a key sign of increased ICP that requires a response by caregivers.

REF: p. 593 a. 50 mm Hg b. 40 mm Hg c. 35 mm Hg d. 25 mm Hg

16. The therapist is instituting hyperventilation to a child with intracranial hypertension. What should be the lowest PaCO2 before brain ischemia can occur?

ANS: D

ICP declines within seconds of beginning hyperventilation. The mechanism is vasoconstriction resulting from hypocarbia. The goal is to lower the partial pressure of arterial carbon dioxide (PaCO2) from 40 to 25 mm Hg. Further reduction can result in cerebral ischemia and is contraindicated.

REF: p. 594 a. Mannitol crosses the blood–brain barrier and removes water from the cerebral vascular spaces. b. Mannitol increases the permeability of the loop of Henle, causing water to leave the nephrons. c. Mannitol enters the ventricles of the brain, causing fluid to leave the choroid plexus and enter the circulation for delivery to the kidneys. d. Mannitol remains in the plasma, creating an osmotic gradient that draws water from the brain into the cerebral capillaries.

17. What is the mechanism of action of the osmotic diuretic mannitol in the setting of increased ICP?

ANS: D

Mannitol is given intravenously as a 20% solution. It does not cross the blood–brain barrier and remains in the plasma, creating an osmotic gradient that draws water from the brain into the capillaries, reducing cerebral fluid volume and therefore ICP. The effect is short term, and infusions must be given 3 to 6 times each day.

REF: p. 594 a. Place the patient on an oxygen cannula prior to the administration of pentobarbital b. Place an oropharyngeal airway to avoid patient’s biting the tongue c. Prepare to intubate and start mechanical ventilation d. Place the patient on noninvasive mechanical ventilation

18. A patient with status epilepticus has been treated with benzodiazepines and phenobarbital without success. Now a pentobarbital coma is indicated. What should the therapist do at this time?

ANS: D

If none of the medications administered are effective in stopping the seizure, a pentobarbital coma may be necessary. For this, the patient should be intubated and mechanically ventilated, and vital signs need to be monitored closely.

REF: p. 596

19. A child is admitted to the emergency department displaying an abnormal breathing pattern consisting of random, ineffective, haphazard breaths and pauses. What is the name of this breathing pattern? a. Apneustic b. Ataxic c. Cheyne Stokes d. Primary alveolar hypoventilation

ANS: B

Hypothalamic and midbrain damage results in rapid, sustained, deep hyperventilation (central neurogenic hyperventilation). Injury to the medulla and the pons affects the respiratory centers and produces several different patterns: apneustic breathing, with a prolonged pause at full inspiration; ataxic breathing, which consists of random, ineffective, haphazard breaths and pauses without a predictable pattern; and primary alveolar hypoventilation (Ondine's curse), a failure to breathe while sleeping, which is the failure of automatic breathing centers when asleep.

REF: p. 597

20. Which of the following conditions results from the fracture of adjacent ribs in at least two places along the same ribs? a. Pneumothorax b. Respiratory alternans c. Flail chest d. Condochondritis

ANS: C

When several adjacent ribs are fractured in two areas, a flail segment of the chest wall may be produced. This segment of the chest moves in paradoxical fashion with respiratory effort, collapsing with inspiratory effort and expanding with expiration. This paradoxical motion interferes with tidal ventilation of the ipsilateral lung and, in conjunction with pulmonary parenchymal contusion, may cause serious respiratory embarrassment.

REF: p. 599 a. Pulmonary contusion b. Hemothorax c. Empyema d. Pleural effusion

21. Which of the following conditions is the most commonly associated with penetrating chest trauma?

ANS: B

The most common injury sustained with penetrating thoracic trauma is a pneumothorax or hemothorax with accumulation of air or blood within the pleural space.

REF: p. 599 a. 40 to 60 mm Hg b. 60 to 80 mm Hg c. 80 to 100 mm Hg d. 100 to 120 mm Hg

22. What range of systolic pressure should be sufficient to maintain adequate tissue perfusion during fluid resuscitation of a victim of a penetrating chest injury before controlling the source of bleeding?

ANS: C

For most pediatric patients, systolic blood pressures of 80 to 100 mm Hg should be sufficient to maintain adequate tissue perfusion during this interval.

REF: p. 600

23. For victims of penetrating chest wall trauma demonstrating respiratory distress, which of the following therapeutic interventions generally need to be administered before radiologic studies are obtained to ascertain the status of intrathoracic organ injuries? a. Arterial puncture procedure b. Noninvasive ventilation c. Neurological assessment d. Ipsilateral tube thoracotomy

ANS: D

Although the diagnosis of penetrating thoracic trauma is usually rapidly evident from the history of the mechanism of injury and the physical examination, specific information regarding injuries to intrathoracic organs will require radiologic and interventional procedures. Patients presenting with severe respiratory distress should be treated immediately by intubation and ipsilateral tube thoracotomy, before any radiologic studies are obtained. Patients with less severe symptoms and those who have been stabilized are initially investigated with an anteroposterior chest radiograph.

REF: p. 600 a. Evacuation of 200 mL of blood from the pleural space after placing the chest tube b. Continuous bleeding through the chest tube c. Presence of pneumothorax d. Presence of respiratory distress

24. Which of the following signs indicate injury of a major thoracic vessel?

ANS: B

The evacuation of more than 300 mL of blood from the pleural space after placement of a chest tube, or continuous bleeding through the chest tube, should prompt evaluation for a major vessel injury.

REF: p. 600 a. Spinal cord injury b. Thoracic cage damage c. Esophageal injury d. Intra-abdominal injury

25. The presence of entrance wounds below the level of the nipples suggests which of the following types of injury?

ANS: D

Patients with penetrating injury in whom either entrance wounds or exit wounds are below the level of the nipples should be suspected of having diaphragmatic and intra-abdominal injuries. These patients should undergo an abdominal computed tomography (CT) scan to assess for that possibility.

REF: p. 600 a. Empyema b. Hydrothorax c. Flail chest d. Tension pneumothorax

26. A penetrating chest wall trauma that produces a ball–valve type injury of the visceral pleura frequently produces which type of condition?

ANS: D

The injuries associated with penetrating thoracic trauma include pneumothorax, hemothorax, pulmonary parenchymal injuries, major airway injuries, great vessel injuries, esophageal injuries, and diaphragmatic injuries. Pneumothorax is seen as a consequence of virtually all penetrating thoracic trauma because the pleural space is opened to atmospheric pressure even if the visceral pleura is not violated. The presence of both blood and air in the pleural space is referred to as hemopneumothorax. Air under pressure in the pleural space, as might occur with a ball–valve type injury of the visceral pleura, is termed a tension pneumothorax

REF: p. 600 a. Decreased pulmonary compliance b. Aspiration of stomach contents c. Gastric inflation d. Major airway injuries

27. Patients experiencing penetrating thoracic trauma presenting with a significant pneumothorax with a continuous air leak through the chest tube should be suspected of having what type of problem?

ANS: D

Patients with penetrating thoracic trauma presenting with a significant pneumothorax with a continuous air leak through the chest tube should be suspected of having major airway injuries. The majority of these patients will be found to have a pneumomediastinum on plain chest radiographs or chest CT scans. Airway penetration should be confirmed by bronchoscopy.

REF: p. 601 a. Diaphragm b. Esophagus c. Trachea d. Vertebrae

28. Injury to which of the following structures should be suspected in a young child who has a penetrating chest wound located at the 5th intercostal space?

ANS: A

Some patients with penetrating thoracic trauma may also have sustained significant intraabdominal injury. In most of the respiratory cycle the apex of the diaphragm is as high as the fourth intercostal space. This is because intraabdominal pressure exceeds intrapleural pressure throughout all phases of ventilation. Penetrating injuries at or below this level, the level of the nipples, must be suspected of having diaphragm penetration and potential intraabdominal injuries. These patients should be evaluated with a chest-abdomen CT scan. In otherwise stable individuals, thoracoscopy has been reported to be helpful in diagnosing traumatic diaphragm lacerations.

REF: p. 601 a. Sedation and paralysis along with patient-triggered, volume-controlled ventilation b. Sedation and paralysis along with inverse ratio ventilation c. Noninvasive positive pressure ventilation d. Ventilation to achieve reduced mean airway pressures

29. What type of ventilation strategy is often employed when a patient with a penetrating chest wall injury has a massive air leak while receiving mechanical ventilation?

ANS: D

Children with penetrating thoracic injuries who require intubation may present significant ventilatory difficulties because of a massive air leak. Ventilator strategies in these patients generally include reducing peak inspiratory pressures and mean airway pressures to minimize the air leak. Lowering these pressures can often be accomplished by reducing the tidal volume and using minimal positive end-expiratory pressure (PEEP), with an increase in respiratory rate.

REF: p. 601 a. Volume-controlled ventilation b. Inverse ratio ventilation c. High-frequency ventilation d. Airway pressure release ventilation

30. Which ventilation strategy should the therapist suggest for patients with very large leaks?

ANS: C

Patients with very large air leaks may benefit from the use of high-frequency or oscillating ventilators.

REF: p. 601 a. Oropharyngeal suctioning b. Central venous catheter placement c. Orogastric tube placement d. Nasogastric tube placement

31. Which of the following procedures can cause an iatrogenic pneumothorax?

ANS: B

A variety of procedures can produce an iatrogenic pneumothorax. These may include endotracheal suctioning, laceration of the trachea during endotracheal intubation, penetration of the airway during endoscopy, high-pressure mechanical ventilation, central venous catheter placement, or thoracentesis.

REF: p. 601 a. The posterior basilar segment of the right lower lobe b. The inferior segment of the right middle lobe c. The medial basilar segment of the right lower lobe d. Either lingular segment of the left upper lobe

32. When a suction catheter is inserted beyond the distal tip of an endotracheal tube, which of the following segmental bronchi is prone to injury?

ANS: C

Iatrogenic airway injuries are known to occur as a consequence of overzealous endotracheal suctioning in young infants. The suction catheter should be carefully measured and passed down only to the level of the end of the endotracheal tube in order to avoid direct tracheal or bronchial injury. The most common site of injury is in the medial-basal segment of the right lower lobe. This segmental bronchus is on a straight line beyond the end of the endotracheal tube, and catheters that are passed without attention to the depth will puncture the visceral pleura in this segment.

REF: p. 602 a. To categorize the degree of burn injury b. To triage the body to determine which area demands immediate attention c. To estimate the percent body surface area burned d. To ascertain the percent of skin grafting needed

33. What is the purpose of the “rule of nines”?

ANS: C

The “rule of nines” is the method most frequently used to estimate percent body surface area burned. This estimate is based on various anatomic regions representing 9% of body surface area, or a multiple of nine. However, because infants and younger children have body proportions different from those of an adult, a modified “rule of nines” may be used for them. Figure 31-7 in the textbook describes the percentages of various anatomic regions as the child ages.

REF: p. 605

34. Which of the following medications should be considered during the hypermetabolic state of a patient who has a burn injury? a. Catabolic agents b. Antiadrenergics c. Diuretics d. Inotropes

ANS: B

The metabolic rate can increase as much as two to three times normal after burn injury and is generally related to the size of the burn. This is accompanied by constant hyperthermia. Nutritional support is extremely important and is best accomplished by calculating caloric needs and correcting electrolyte disturbances that are common to burn patients.

Pharmacologic support of the hypermetabolic response consists of using anabolic agents to alleviate muscle wasting and preserve lean body mass and antiadrenergic drugs to decrease myocardial oxygen consumption and cardiac work.

REF: p. 605 a. Systemically administered antibiotics b. Aggressive wound excision c. Aggressive application of topical corticosteroids d. Aggressive administration of topical antibiotics

35. What management practice has accounted for the drop in mortality from burn injuries over the decades?

ANS: B

Aggressive wound excision and grafting, along with the use of topical antibiotics, have dramatically decreased the incidence of burn wound sepsis. Inhalation injury has now emerged as the most frequent cause of death in patients with severe burns.

REF: p. 606

36. What are characteristics of direct thermal burns to the upper airway?

I. Edema

II. Hemorrhage

III. Ulceration

IV. Pseudomembranous castsa. IV only b. I and II only c. I, II, and III only d. II, III, and IV only

ANS: C

Direct thermal trauma is limited to the upper airway and results in obstruction from edema, hemorrhage, and ulceration of the mucosa. In only a few hours, mild pharyngeal edema can rapidly progress to complete upper airway obstruction with asphyxia. The worsening of upper airway edema is most prominent in supraglottic structures. Serial nasopharyngoscopic evaluations demonstrate obliteration of the aryepiglottic folds, arytenoid eminences, and interarytenoid areas by edematous tissue that prolapses and occludes the airway.

REF: p. 606

37. A smoke inhalation victim is having his oxygenation status evaluated in the emergency room by a therapist using a pulse oximeter, which indicates an SpO2 (oxygen saturation as determined by pulse oximetry) of 87%. How should the therapist interpret this value? a. As accurate b. Falsely high c. Falsely low d. Inconsistent

ANS: B

Pulse oximetry measurement does not accurately reflect oxygen saturation in the presence of carboxyhemoglobin (COHb). The pulse oximeter equates COHb with oxygenated hemoglobin and measures the percentage of saturation of available binding sites, regardless of whether the sites are occupied by CO or oxygen. This causes the pulse oximeter to read falsely elevated oxygen saturation values in the presence of COHb. Direct measurement of COHb by cooximetry is recommended.

REF: p. 607 a. Chest radiograph demonstrating focal infiltrates b. Singed nasal vibrissae c. Inspiratory and expiratory stridor d. Mucoid sputum

38. In the emergency room, a patient with smoke inhalation injury will tend to display which of the following clinical signs?

ANS: B

The clinical diagnosis of inhalation injury has traditionally rested on various unreliable observations. Smoke inhalation injury is more likely to be present in those with a history of burn injury in an enclosed space, the appearance of facial burns, singed nasal vibrissae and facial hair, erythema of the oropharynx, and the presence of carbonaceous sputum and debris around the nose, mouth, and pharynx. Rhonchi, crackles, wheezes, stridor, dyspnea, cough, and hoarse voice are seldom present on admission, occurring only in persons with the most severe injury and implying an extremely poor prognosis. The admission chest radiograph is often normal and is a poor indicator of severity of acute lung injury. However, two thirds of patients develop changes, including diffuse or focal infiltrates or pulmonary edema, within 5 to 10 days of injury.

REF: p. 607 a. As soon as possible b. Only if the patient demonstrates inspiratory and expiratory stridor c. When the airway appears to be narrowing as determined by bronchoscopy d. When the signs and symptoms of respiratory failure are present

39. When should endotracheal intubation be performed on a smoke inhalation victim?

ANS: A

Whenever airway obstruction is suspected, the most experienced clinician should perform endotracheal intubation. It is better to intubate early than to wait and find that the obstruction has progressed to where visualization of the larynx is reduced.

REF: p. 608

40. Which of the following medications is/are used to treat patients who have inhalation injury?

I. Beta-2 agonists

II. Inhaled corticosteroids

III. Racemic epinephrineIV. N-Acetylcysteine a. I only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only

ANS: C

Inhalation injury is best managed with beta-2 agonists, especially in patients who also have preexisting asthma or reactive airway disease. Aerosolized bronchodilators are effective by providing bronchial smooth muscle relaxation and stimulating mucociliary clearance. However, when using these agents, it is important to remember they also increase overall metabolic rates in a patient who is already hypermetabolic secondary to thermal injuries. Racemic epinephrine may be used as an aerosolized vasoconstrictor, bronchodilator, and secretion bond breaker. The vasoconstrictive action of racemic epinephrine is useful in reducing mucosal and submucosal edema within the walls of the pulmonary airways. A secondary bronchodilator action serves to reduce potential spasm of the smooth muscle of the terminal bronchioles. Racemic epinephrine has also been used in the treatment of postextubation stridor. N-Acetylcysteine is a powerful mucolytic agent used in respiratory care. It contains a thiol group, the free sulfhydryl radical of which is a strong reducing agent that ruptures the disulfide bonds that stabilize the mucoprotein network of molecules in mucus. Agents that break down these disulfide bonds produce the most effective mucolysis. N-Acetylcysteine has been proven effective in combination with aerosolized heparin for the treatment of inhalation injury in animal studies. Heparin and N-acetylcysteine combinations have been used as scavengers for the oxygen-free radicals produced when alveolar macrophages are activated, either directly by chemicals in smoke or by one or more compounds in the arachidonic cascade. Animal studies have shown an increased ratio of PaO2 to FiO2, decreased peak inspiratory pressures, and a decreased amount of fibrin cast formation with heparin/N-acetylcysteine combinations. Pediatric patients treated with aerosolized heparin/N-acetylcysteine combinations showed a reduction in the incidence of atelectasis, number of ventilator days, incidence of reintubation for progressive respiratory failure, and mortality.

REF: p. 608 a. Less than 6 mL/kg b. 6 to 8 mL/kg c. 8 to 10 mL/kg d. 10 to 12 mL/kg

41. When mechanically ventilating a victim of inhalation injury, what tidal volume should the therapist initially recommend?

ANS: B

Conventional mechanical ventilation does not reverse the pathologic process, is not characterized by improved clearance of secretions, and may actually compound the existing injury. Conventional volume-limited ventilation in patients with inhalation injury is usually instituted at a tidal volume of 6 to 8 mL/kg. Numerous factors, such as lung/thorax compliance, system resistance, compressive volume loss, oxygenation, ventilation, and barotrauma, must be considered when tidal volumes are selected.

REF: p. 610

42. What appears to be the advantage of using high-frequency percussive ventilation instead of conventional mechanical ventilation?

I. Less barotrauma

II. Lower oxygen concentrations

III. Lower tidal volumes (VTs) IV. Lower inspiratory pressures a. I and IV only b. II and III only c. I, II, and IV only d. II, III, and IV only

ANS: C

High-frequency ventilation has also been employed after inhalation injury. This mode provides oxygenation at lower inspired oxygen concentrations and adequate ventilation at lower peak and mean airway pressures. In addition, a few reports have indicated increased secretion clearance with some forms of high-frequency ventilation.

REF: p. 609 a. Tracheomalacia b. Atelectasis c. Stridor d. Infection

43. Which of the following conditions is considered a late mechanical complication of inhalation injuries?

ANS: A

Late complications of inhalation injury may be related to mechanical damage or to the consequences of an inflammatory response. Mechanical complications occur most often as a result of iatrogenic injury from endotracheal or tracheostomy tube cuffs. This damage may cause erosion of the tracheal cartilage and result in tracheomalacia. Injuries to the tracheal epithelium may result in fibrosis and stenosis of the trachea, which lead to subglottic stenosis. Cuff erosion into adjacent structures (e.g., innominate artery) may result in exsanguinating hemorrhage. The injuries are difficult to diagnose and often develop slowly.

REF: p. 611 a. Voluntary breath holding b. Laryngospasm c. Hypercarbia and hypoxemia d. Aspiration

44. When a victim’s airway moves below the surface of a liquid, what is that person’s first physiologic response?

ANS: A

The drowning process begins when the victim’s airway moves below the surface of the liquid, at which time the victim has a period of voluntary apnea or breath holding.

REF: p. 611 a. Laryngospasm stops, and the victim actively inspires water. b. The victim begins to vomit. c. Laryngospasm continues and the hypercarbia, hypoxemia, and acidemia worsen. d. The victim stops breathing, and water flows into the lungs, causing asphyxia.

45. What occurs to the victim during drowning after the victim has been immersed in water to the point of becoming hypercarbic, hypoxemic, and acidemic?

ANS: A

Breath holding is usually followed by an involuntary period of laryngospasm secondary to the presence of liquid in the oropharynx or larynx. If immersion continues, the victim becomes hypercarbic, hypoxemic, and acidotic and begins to swallow large amounts of water. As the victim becomes more hypoxic, the laryngospasm relaxes, and the victim actively breathes in liquid.

REF: p. 611

46. What form of injury is the major determinant of subsequent survival and long-term morbidity in cases of near drowning? a. Pulmonary injury b. Cardiovascular injury c. Renal injury d. Neurologic injury

ANS: D

CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of near drowning. Primary CNS (neurologic) injury is initially associated with tissue hypoxia and ischemia.

REF: p. 611

47. Which of the following conditions often results as a complication among survivors of submersion injury? a. Pneumonia b. Acute respiratory distress syndrome c. Empyema d. Hypersensitivity pneumonitis

ANS: B

Acute respiratory distress syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common complication in survivors of submersion injury.

REF: p. 612

48. During resuscitation after cold water submersion, which of the following cardiovascular responses tends to occur when the patient is rewarmed? a. Cardiac dysrhythmia b. Pulmonary hypertension c. Hypotension d. Myocardial infarction

ANS: C

Profound hypotension may occur during and after the initial resuscitation period, especially when vasodilation occurs as the patient is rewarmed.

REF: p. 612 a. As soon as the victim is removed from the water b. Once water is removed from the victim’s lungs after the victim is removed from the water c. By the emergency medical crew after the victim is removed from the water d. If possible, before the victim is out of the water

49. When should a rescuer begin applying airway management and rescue breathing at the scene of a drowning event?

ANS: D

The most important point in treatment is the quality of resuscitation at the scene of a drowning event. Airway management and rescue breathing should begin before the victim is out of the water, if possible, and CPR should be started as soon as an adequate surface is available.

REF: p. 613

50. Which of the following conditions should be anticipated in a near-drowning victim brought to the emergency department?

I. Cardiac dysrhythmia

II. Hypoxia

III. Acidosis

IV. Hypothermiaa. I only b. II and III only c. I, II, and III only d. II, III, and IV only

ANS: D

In the emergency department (ED), stability of the airway and adequacy of ventilation should be assessed. The first priority for managing drowning victims is to reverse hypoxemia by restoring adequate oxygenation and ventilation. All victims should be assumed to be hypoxic, acidotic, and hypothermic.

REF: p. 613

51. What should be the least amount of time required to rewarm a hypothermic near-drowning victim who has a core temperature of 29° C in the emergency department? a. 1 hour b. 2 hours c. 3 hours d. 4 hours

ANS: B

Some degree of hypothermia (core temperature less than 35° C) is almost always present after significant submersion, and severe hypothermia is associated with characteristic physical examination findings. The goals of management are to prevent a further fall in core temperature and to establish a safe and steady rewarming rate while maintaining cardiovascular stability. The health care team should attempt to rewarm the patient 1° C to 2° C per hour to a range of 33° C to 36° C. Aggressive rewarming above this range should be avoided because hyperthermia has been shown to worsen underlying cerebral injury in post–cardiac arrest patients.

REF: p. 614

52. What is the most effective means of rewarming a near-drowning victim whose core temperature in the emergency room is 27° C? a. Radiant warmers b. Heated aerosol therapy c. Extracorporeal membrane oxygenation (ECMO) d. Mechanical ventilation with heated humidity

ANS: C

Extracorporeal bypass is the most effective means of increasing body temperature for patients presenting with temperature less than 28° C. In some cases this technique should be considered early in the course of management, although evidence of success in the pediatric population has not been thoroughly studied to date.

REF: p. 613

53. Which of the following types of victims should be admitted to the hospital despite being stable in the emergency room after a submersion injury?

I. Patients with any degree of respiratory compromise

II. Victims who needed rescue breathing

III. Patients who experienced a loss of consciousnessIV. Victims who were combatant at the scene a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only

ANS: C

Victims evaluated in the ED who are minimally affected with no history of loss of consciousness, no altered mental status, and no respiratory signs and symptoms may be observed for a period of hours in the ED and discharged home if no complications arise. Patients with any degree of respiratory compromise, history of need for rescue breathing, or loss of consciousness should be admitted to the hospital even if stable in the ED, because both neurologic injury and lung injury may progress over the first hours to days.

REF: p. 615