TEST BANK for Clinical Manifestations and Assessment of Respiratory Disease 8th Edition by Jardins

Test Bank for Clinical Manifestations and Assessment of Respiratory Disease 8th Edition Jardins

Table Of Contents PART 1: Assessment of Cardiopulmonary Disease SECTION I: Bedside Diagnosis 1. The Patient Interview 2. The Physical Examination 3. The Pathophysiologic Basis for Common Clinical Manifestations

SECTION II: CLINICAL DATA OBTAINED FROM LABORATORY TESTS AND SPECIAL PROCEDURES—Objective Findings 4. Pulmonary Function Testing 5. Blood Gas Assessment 6. Assessment of Oxygenation 7. Assessment of the Cardiovascular System 8. Radiologic Examination of the Chest 9. Other Important Tests and Procedures

SECTION III: THE THERAPIST-DRIVEN PROTOCOL PROGRAM—THE ESSENTIALS 10. The Therapist-Driven Protocol Program 11. Respiratory Insufficiency, Respiratory Failure and Ventilatory Management Protocols 12. Recording Skills and Intra-Professional Communication

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

PART III: Loss of Alveolar Volume 17. Atelectasis

PART IV: Infectious Pulmonary Disease 18. Pneumonia, Lung Abscess Formation and Important Fungal Diseases 19. Tuberculosis

PART V: Pulmonary Vascular Disease 20. Pulmonary Edema 21. Pulmonary Vascular Disease: Pulmonary Embolism and Pulmonary Hypertension

PART VI: Chest and Pleural Trauma 22. Flail Chest 23. Pneumothorax

PART VII: Disorders of the Pleura and of the Chest Wall 24. Pleural Effusion and Empyema 25. Kyphoscoliosis

PART VIII: Lung Cancer 26. Cancer of the Lung: Prevention and Palliation

PART IX: Environmental Lung Diseases 27. Interstitial Lung Diseases

PART X: Diffuse Alveolar Disease 28. Acute Respiratory Distress Syndrome

PART XI: Neuro-Respiratory Disorders 29. Guillain-Barre Syndrome 30. Myasthenia Gravis 31. Respiratory Insufficiency in the Patient with Neuro-Respiratory Disease

PART XII: Sleep-Related Breathing Disorders 32. Sleep Apnea

PART XIII: Newborn and Early Childhood Cardiopulmonary Disorders 33. The Newborn Disorders 34. Pediatric Assessment, Protocols, and PALS Management 35. Meconium Aspiration Syndrome 36. Transient Tachypnea of the Newborn 37. Respiratory Distress Syndrome 38. Pulmonary Air Leak Syndrome 39. Respiratory Syncytial Virus Infection (Bronchiolitis) 40. Chronic Lung Disease of Infancy 41. Congenital Diaphragmatic Hernia 42. Congenital Heart Disease 43. Croup and Croup-like Syndromes: Laryngotracheobronchitis, Bacterial Tracheitis and Acute Epiglottitis

PART XIV: Other Important Topics 44. Near Drowning/Wet Drowning Smoke Inhalation, Thermal Injuries, and Carbon Monoxide Intoxication

Chapter 01: The Patient Interview Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. The respiratory therapist is conducting a patient interview. The main purpose of this interview

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

a. b. c. d.

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. 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

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?

To prompt the patient to ask a question After a direct question After an open-ended question To allow the patient to review his or her history

a. b. c. d.

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: confrontation. giving advice. using avoidance language. distancing.

a. b. c. d.

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?

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

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.

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

Chapter 02. The Physical Examination Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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

There are times during brain or cardiac surgery that hypothermia is induced to lower the patient’s metabolism so that less oxygen is needed by the body. If a patient has a high fever, measures are taken to lower it but not to the point of hypothermia. Carbon monoxide poisoning is not treated by hypothermia.

REF: pp. 11-12 2. A 50-year-old patient has a heart rate by palpation of 120 bpm. How should this be

interpreted?

Within the normal range for an adult An error since a stethoscope was not used Bradycardia Tachycardia

a. b. c. d.

ANS: D

In an adult, a heart rate of greater than 100/minute is considered to be tachycardia. A heart rate of less than 60/minute in an adult is considered to be bradycardia. Palpation and auscultation are both acceptable to check heart rate.

REF: p. 14 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, 4 ANS: B

Tachypnea may be the result of hypoxemia, fever, and other causes. Hypothermia and sedation will usually result in bradycardia.

REF: p. 15

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

In an adult, hypotension is defined as a blood pressure of 90/60 mm Hg. A heart rate of 55 bpm would be bradycardia. Pulse pressure is normally about 40 mm Hg. REF: p. 17 5. A dull percussion note would be heard in all of the following situations EXCEPT: a. atelectasis. b. pleural thickening. c. chronic obstructive pulmonary disease (COPD). d. consolidation.

ANS: C

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.

REF: p. 29 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 2. The Physical Examination 3. The Pathophysiologic Basis for Common Clinical Manifestations c. 2, 3, 4 d. 1, 2, 3 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.

REF: p. 30 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 more shallow. 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.

REF: p. 17 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. slows the respiratory rate. a. 1 b. 2, 3 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: D

All of the listed options are benefits of pursed-lip breathing in a patient with an airway obstruction problem such as asthma or COPD. REF: p. 29 9. A patient comes into the emergency department with a complaint of centrally located, constant

chest pain. What is his most likely problem?

Pleurisy Myocardial ischemia Pneumothorax Fractured rib

a. b. c. d.

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.

REF: p. 37 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 2. Odor 3. Amount 4. Consistency a. 3 b. 3, 4 c. 1, 2 d. 1, 2, 3, 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.

REF: p. 42 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.

REF: p. 55 12. The respiratory therapist is examining a patient in the medical ward and notes that the trachea

is deviated to the left. All of the following may be causing the tracheal deviation to the left EXCEPT: 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).

REF: pp. 52-53 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 exam finding? a. Right-sided atelectasis b. Right-sided pneumothorax c. Right-sided pleural effusion 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.

REF: p. 55

Chapter 04. Pulmonary Function Testing Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Pulmonary function studies are done for all of the following measurements EXCEPT: a. the patient’s carbon monoxide level. b. lung volumes and capacities. c. pulmonary diffusion capacity. d. forced expiratory flow rates.

ANS: A

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.

REF: p. 45 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 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.

REF: p. 45 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.

REF: p. 45 4. Which of the following forced vital capacity test times should be interpreted as normal? 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. Patients with restrictive lung diseases may blow out the FVC in less than 4 seconds. Patients with obstructive lung diseases will need more than 6 seconds to blow out the FVC. REF: p. 48 5. Overall characteristics of pulmonary function testing results on a patient with obstructive lung

disease include that the FEV1: is reduced and FEV1% is normal. and FEV1% are both increased. and FEV1% are both reduced. is increased and FEV1% is decreased.

a. b. c. d.

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.

REF: p. 48 6. The FEF25%-75% is used to evaluate: a. flow in large airways. b. restrictive lung disease. c. maximum breathing effort. d. flow in medium-size to small airways.

ANS: D

Expiratory flow in medium-size to small airways is assessed by the FEF25%-75% test. Other tests would be needed to assess the other listed options.

REF: p. 49 7. All of the following are true of the peak expiratory flow rate test EXCEPT it: a. is effort dependent. b. is taken from the FVC test results. c. is taken from the MVV test results. d. assesses large upper airways.

ANS: C

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.

REF: p. 51 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. 3, 4 b. 2, 3 c. 1, 2 d. 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.

REF: p. 45 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.

REF: p. 52 10. Total lung capacity is composed of all of the following EXCEPT: a. IRV. b. IC. c. ERV. d. RV. ANS: A

Total lung capacity (TLC) can be calculated by adding IC, ERV, and RV. Also see Figure 3-1 for other ways to calculate the TLC. REF: p. 46 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. e. The patient has chronic bronchitis.

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.

REF: p. 55 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 respiratory muscle strength? a. Maximum inspiratory pressure (MIP) b. Maximum inspiratory flow rate (MIFR) c. Maximum expiratory flow rate (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).

REF: p. 52 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 normal lung function, measurements of airway responsiveness to inhaled methacholine or a cold air challenge may be useful in confirming a diagnosis of asthma. A warm, humid air challenge would not be effective in producing results consistent with airway reactiveness. Body plethysmography is used to determine functional residual capacity. This would not be helpful in establishing a diagnosis of asthma.

REF: pp. 55-56

Chapter 05. Blood Gas Assessment Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 58 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 oxygen.

REF: p. 58 3. All of the following will be seen in the arterial blood gas values of a patient with acute

ventilatory failure EXCEPT a(n): acidic pH. near-normal bicarbonate level. alkaline pH. high carbon dioxide level.

a. b. c. d.

ANS: C

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.

REF: p. 62 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 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. REF: p. 62 5. A patient has had chronic ventilatory failure for several years. What is the primary factor that

determines her breathing pattern?

Muscle efficiency Ventilatory efficiency Heart function Work efficiency

a. b. c. d.

ANS: D

It is work efficiency (calories consumed) rather than ventilatory efficiency that determines a person’s breathing pattern. Muscle efficiency and heart function do not affect breathing pattern.

REF: p. 63 6. An anion gap of 15 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. REF: p. 66 7. Common causes of metabolic acidosis include all of the following EXCEPT: a. diabetic ketoacidosis. b. shallow breathing from a sedative overdose. c. lactic acidosis. d. renal (kidney) failure.

ANS: B

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

REF: p. 66 8. Which of the following would be found in a stable patient with long-standing obstructive lung

disease?

Low bicarbonate level and low carbon dioxide level Low bicarbonate level and high carbon dioxide level High bicarbonate level and low carbon dioxide level High bicarbonate level and high carbon dioxide level

a. b. c. d.

ANS: D

A high bicarbonate level and high carbon dioxide level are found in a stable patient with longstanding obstructive lung disease. The other options are associated with other acid-base disorders.

REF: p. 66 9. Common causes of metabolic alkalosis include:

1. diuretic therapy.

2. vomiting.

3. excessive sodium bicarbonate administration.

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

All of the listed options can cause metabolic alkalosis.

REF: p. 66 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 ventilationperfusion 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 causes the ventilatory rate to increase.

The increased ventilatory response in turn causes the PaCO2 to decrease and the pH to increase.

REF: p. 62 11. Mechanical ventilation is indicated for which of the following ABG results? a. pH 7.56; PaCO2 27; HCO3 23; PaO2 63 b. pH 7.23; PaCO2 63; HCO3 26; PaO2 52 c. pH 7.36; PaCO2 79; HCO3 43; PaO2 61 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.

REF: p. 62

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.

REF: p. 67 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. Partially compensated respiratory acidosis with hypoxemia e. Acute alveolar hyperventilation superimposed on chronic ventilatory failure ANS: E

An end-stage COPD patient would be expected to have chronic ventilatory failure for baseline ABG results. During an exacerbation, he or 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 or she might initially interpret the ABG values as signifying partially compensated metabolic alkalosis with severe hypoxemia. However, the clinical situation that offsets 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.

REF: p. 64

Chapter 06. Assessment of Oxygenation Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. When a sample of arterial blood is analyzed for the pressure of oxygen (PaO2), the value

comes from the: blood plasma. leukocytes. hemoglobin. erythrocytes.

a. b. c. d.

ANS: A

A blood gas analyzer measures the pressure of oxygen and carbon dioxide in the blood plasma. 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.

REF: p. 70 2. Oxygen consumption:

1. increases with exercise.

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

3. is inversely related to carbon dioxide production.

4. is about 250 mL/min 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/min. Oxygen use is not inversely related to carbon dioxide production.

REF: p. 74 3. A patient has been exposed to carbon monoxide during a house fire. An ABG result shows a

normal PaO2. How should the patient’s PaO2 value be interpreted?

The PaO2 is being falsely elevated by the carbon monoxide.

The PaO2 is being falsely decreased by the carbon monoxide.

The PaO2 is accurate.

The PaO2 is a false measurement because the presence of carbon monoxide makes the analyzer unable to determine the PaO2.

a. b. c. d.

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.

REF: p. 78 4. A person’s C(a-v)O2 increases in all of the following situations EXCEPT: a. seizures. b. peripheral shunting. c. hyperthermia. d. exercise.

ANS: B

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.

REF: p. 76 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?

40 mm Hg 95 mm Hg 75% 97%

a. b. c. d.

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. REF: p. 74 6. Polycythemia is:

a. b. c. d.

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.

1, 2 2, 3 1, 4 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.

REF: pp. 77-78 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 Low PaO2 High PaCO2 High pH

a. b. c. d.

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.

REF: pp. 77-78 8. An increased cardiac output causes the:

a. b. c. d.

1. C(a-v)O2 to decrease.

2. SvO2 to increase.

3. total O2 delivery to decrease.

4. O2ER to increase.

1 2, 3 3, 4 1, 2

ANS: D

As cardiac output increases, less oxygen is extracted from the blood. Because of this, the C(av)O2 decreases and SvO2 increases. Increased cardiac output would also increase total oxygen delivery and decrease the oxygen extraction ratio.

REF: p. 76 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 poisoning will cause anemic hypoxia because the hemoglobin cannot carry oxygen.

REF: pp. 77-78 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.

REF: pp. 77-78 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.

REF: pp. 77-78 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.

REF: p. 77 13. A patient is mildly hypoxemic. Which of the following signs would the respiratory therapist

expect to find in this patient?

An increase in the patient’s breathing rate and heart rate A decrease in systemic blood pressure Cardiac dysrhythmias on an EKG Anemia

a. b. c. d.

ANS: A

Clinically, the presence of mild hypoxemia generally stimulates the oxygen peripheral chemoreceptors to increase the patient’s breathing 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.

REF: p. 77

Chapter 07. Assessment of the Cardiovascular System Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: pp. 81-82 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?

60 75 100 150

a. b. c. d.

ANS: C

Approximate heart rate can be determined by dividing the number of large boxes between QRS complexes on the rhythm strip into 300. Therefore, 300 divided by 3 = 100 bpm for a heart rate.

REF: pp. 81-82 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.

REF: pp. 82-83 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.

REF: pp. 83-84 5. A premature ventricular contraction (PVC) can be caused by:

1. hypokalemia.

2. intrinsic myocardial disease.

3. hypoxemia.

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

All of the listed options can cause PVCs. REF: pp. 83-84 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 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.

REF: pp. 82-83 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.

REF: pp. 83-84 8. A pulmonary artery (Swan-Ganz) catheter can be used for all of the following EXCEPT: a. measuring cardiac output. b. arterial blood sampling. c. measuring left atrial pressure. d. measuring pulmonary artery pressure.

ANS: B

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.

REF: pp. 85-86 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.

REF: pp. 85-86 10. Which of the following hemodynamic changes are commonly seen in a patient with

cardiogenic pulmonary edema?

1. Increased pulmonary capillary wedge pressure (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. 1, 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.

REF: pp. 86-87 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? hypoxemia severe anemia hyperthermia massive hemorrhage beta blocker medications

a. b. c. d. e.

ANS: E

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.

REF: pp. 81-82 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. REF: pp. 83-84 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 NOT be indicated at this time? a. Call a code. b. Begin CPR. c. Defibrillate the patient. d. Administer ACLS medications.

ANS: C

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.

REF: pp. 83-84

Chapter 08. Radiologic Examination of the Chest Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: pp. 91-92 2. Which of the following are evaluated on a chest radiograph?

1. The bony structures 2. Exposure quality 3. The heart shadow 4. The tracheobronchial tree a. 4 b. 1, 4 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

All of the listed options, and others, are evaluated on a chest radiograph.

REF: pp. 92-95 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.

REF: p. 90 4. The heart shadow on a chest radiograph will show up larger than normal on a(n):

a. b. c. d.

AP film.

PA film. left lateral film. 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 (see Fig. 7-3). A PA and left lateral film will show the heart at the correct size. The same is true of a CT scan.

REF: p. 90 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. 1, 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.

REF: pp. 92-95 6. The chest radiograph shows blunting of the patient’s costophrenic angles. What does this

suggest?

The patient did not take a deep enough breath.

Lung cancer Pleural fluid Underpenetrated exposure on the film

a. b. c. d.

ANS: C

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.

REF: pp. 94-95 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 all of the following advantages EXCEPT: a. bronchial tumors can be seen. b. lung tumors as small as 0.4 cm can be seen. c. a tumor’s metabolism can be identified. d. a mediastinal mass can be seen.

ANS: C

Only a PET scan can identify a tumor by its metabolic activity. A CT scan can offer the other listed advantages.

REF: pp. 94-95 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, 3 d. 1, 2, 3, 4 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.

REF: pp. 96-101 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, 4 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 of hemoptysis.

REF: pp. 100-101 10. A patient has had a ventilation-perfusion scan. What would be identified from the ventilation

scan?

Location of a lung abscess Alveolar consolidation Location of a pulmonary embolism Location of an airway obstruction

a. b. c. d.

ANS: B

A ventilation scan can identify the location of an airway obstruction. A perfusion scan can identify the other listed problems.

REF: pp. 100-102

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 lordotic film e. A lateral decubitus film ANS: E

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.

REF: pp. 91-92 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 e. CT 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 first-line 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.

REF: pp. 100-101 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. b. This is a decreased cardiothoracic ratio. 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.

REF: pp. 92-94

Chapter 09. Other Important Tests and Procedures Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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 used to actively grow bacteria to determine the antibiotic(s) best suited for combating an infection. 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.

REF: p. 105 2. Therapeutic bronchoscopy is used for all of the following EXCEPT: a. to remove a foreign body. b. in selective lavage. c. in bronchiectasis evaluation. d. to manage life-threatening hemoptysis.

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.

REF: p. 106 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, 3, 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.

REF: p. 105

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.

REF: pp. 107-108 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. 1, 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.

REF: pp. 107-108 6. After a thoracentesis procedure, it is important to monitor the patient for: a. bronchospasm. b. hemoptysis. c. increased blood urea nitrogen (BUN). d. pneumothorax.

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.

REF: pp. 107-108 7. In a normal differential white blood cell (WBC) count, which of the following would have the

highest number?

Neutrophils Basophils Eosinophils Lymphocytes

a. b. c. d.

ANS: A

Normally, there are 60% to 70% neutrophils in a WBC count. Fewer basophils, lymphocytes, eosinophils, and other WBC types will be seen.

REF: pp. 108-110 8. A 14-year-old patient has had a serious asthma attack. Her white blood cell count can be

expected to show: decreased neutrophils. decreased erythrocytes. increased eosinophils. increased monocytes.

a. b. c. d.

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.

REF: pp. 108-110 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.

REF: pp. 108-110 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

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

REF: p. 112 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 of bleeding, the therapist should establish that the patient has a platelet count of at least /mm3 before recommending placement of the arterial line. a. 1,000 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.

REF: pp. 110-111 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. Suspect that the patient has Mycoplasma pneumoniae pneumonia. b. Suspect that the patient has Rickettsiae pneumonia. c. Suspect that the patient has Pneumocystis jiroveci (carinii) pneumonia. d. 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.

REF: p. 105 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.

REF: p. 112

Chapter 10. The Therapist-Driven Protocol Program Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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 downregulated.

REF: p. 119 2. A TDP can be started after: a. the nurse finishes his or 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.

REF: p. 122 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.

REF: p. 123 4. When a patient has 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.

REF: p. 122 5. According to the aerosolized medication therapy protocol, the respiratory therapist may select

medications from all of the following categories EXCEPT antiinflammatory sympathomimetic parasympatholytic antimicrobial

agents.

a. b. c. d.

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.

REF: p. 126 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 protocol(s) should be implemented?

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

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.

REF: p. 125 7. Which of the following is (are) associated with the bronchospasm clinical scenario?

1. Increased airway resistance 2. Decreased FRC 3. Bronchial breath sounds 4. Hyperresonant percussion note a. 3 b. 1, 4 c. 2, 3 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.

REF: p. 133 8. Which of the following is (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. 3 b. 2, 4 c. 1, 2, 3 d. 1, 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.

REF: p. 132 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.

REF: p. 133 10. Which of the following would be associated with 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.

REF: p. 134 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.

REF: p. 132

Chapter 11. Respiratory Insufficiency, Respiratory Failure and Ventilatory Management Protocols Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: pp. 143-144 2. All of the following are contraindications for noninvasive ventilation (NIV) EXCEPT: a. facial and head trauma. b. community-acquired pneumonia. c. copious, viscous sputum. d. severe upper GI bleeding.

ANS: B

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.

REF: pp. 146-147 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 S/ T a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 1, 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.

REF: pp. 139-140 4. Which of the following is a critical value for the key clinical indicators in hypercapnic

respiratory failure in an adult?

1. pH 7.25 2. Ventilatory rate 35 breaths/min 3. MIP -25 cm H2O 4. VD/VT 40% a. 1 b. 2 c. 1, 2 d. 3, 4 ANS: C

In an adult, a respiration of more than 30 or fewer than 10 breaths per minute may be a key clinical indicator of hypercapnic ventilatory failure.

REF: pp. 146-147 5. What effect would a pulmonary embolism have on the VD/VT and the a. The VD/VT would increase and the / would decrease.

/ ratios?

b. The VD/VT would decrease and the / would increase. c. The V /V and the / ratios would both increase.

D

T

d. The VD/VT and the /

ratios would both decrease.

ANS: D

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

/

REF: pp. 141-142 6. All of the following are causes of hypercapnic respiratory failure EXCEPT: a. impending ventilatory failure. b. apnea. c. severe refractory hypoxemia. d. acute ventilatory failure.

ANS: C

Hypoxemic respiratory failure results when severe refractory hypoxemia is present. Invasive ventilatory support may be required to treat profound refractory hypoxemia.

REF: p. 145

Chapter 12. Recording Skills and Intra-Professional Communication Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Which of the following are basic methods to record assessment data?

1. Computer documentation 2. Block chart 3. Source-oriented record 4. Problem-oriented medical record a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: C

Widely accepted methods to record patient data include computer documentation, sourceoriented record (also called a traditional chart), block chart, and problem-oriented medical record.

REF: p. 163 2. A problem-oriented medical record is used by health-care practitioners to:

1. systemically gather the patient’s data.

2. communicate with the patient’s family.

3. develop an assessment.

4. formulate a treatment plan. a. 1, 2 b. 3, 4 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: C

A problem-oriented medical record is used to systemically gather the patient’s data, develop an assessment, and formulate a treatment plan.

REF: p. 163 3. When reviewing a SOAPIER progress note, all of the following would be found in the O area

EXCEPT: hemodynamic data. patient’s admission complaint. blood pressure. sputum production.

a. b. c. d.

ANS: B

The O in SOAPIER stands for objective information and would include hemodynamic data, vital signs, and sputum production. 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.

REF: p. 163 4. When the respiratory therapist is entering a SOAPIER progress note in a patient’s chart, the A

stands for: application of the data. acceptance of the treatment options by the patient. affect of the patient. assessment of the data by the respiratory therapist.

a. b. c. d.

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.

REF: p. 163 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 downregulated.

REF: p. 163 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 supplies a. 3, 4 b. 1, 2 c. 1, 2, 3 d. 1, 2, 3, 4 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.

REF: p. 166 7. Which of the following statements is TRUE regarding Health Insurance Portability and

Accountability Act (HIPAA) regulations?

a. b. c. d.

A bank can check for a preexisting condition.

The patient controls access to his or her medical records.

Psychotherapy and medical records are treated equally.

An employer can check for a preexisting condition.

ANS: B

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

Psychotherapy records are given extra protection.

REF: p. 167 8. In which section of the SOAPIER format should the patient’s response to a specific treatment

modality be recorded?

Assessment Implementation Observation Evaluation

a. b. c. d.

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.

REF: p. 163 9. Which agency should be notified if violations of HIPAA regulations have occurred? a. HHS b. FDA c. CDC d. Joint Commission ANS: A

Alleged breaches of HIPAA regulations should be reported to the U.S. 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.

REF: p. 167 10. All of the following statements are true regarding a patient’s chart EXCEPT: a. the patient’s chart is a legal record and can be used in court. b. accreditation agencies may access a patient’s chart to assess appropriateness of

care. c. the patient’s insurance company may review the patient’s chart before providing

reimbursement. d. the patient’s spouse may access the patient’s chart without authorization by the

patient.

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 or her privacy, and unless a documented release has been granted, a spouse would be denied access to information in the chart.

REF: p. 162

Chapter 13. Chronic Obstructive Pulmonary Disease, Chronic Bronchitis and Emphysema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Which of the following statements accurately describe(s) emphysema?

1. It is characterized by alveolar wall destruction.

2. It is most closely associated with cystic fibrosis.

3. It is reversible and preventable.

4. It is characterized by thick secretions and mucus plugging. a. 1 b. 3 c. 1, 3 d. 1, 2, 4 ANS: A

Emphysema is defined pathologically as the presence of permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar walls.

REF: p. 171 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. Exposure to environmental tobacco smoke ANS: D

Exposure to tobacco smoke remains the greatest cause of COPD in the United States and the rest of the world.

REF: p. 171 3. A genetically linked cause of panlobular emphysema is: a. bronchiectasis. b.  1-antitrypsin deficiency. c. cystic fibrosis. d. bronchial asthma.

ANS: B

Patients with  1-antitrypsin deficiency are at risk of developing panlobular emphysema, which primarily affects the lower portions of the lungs.

REF: pp. 171-174 4. Emphysema may be caused by all of the following EXCEPT: a. inhaling asbestos fibers.

b.  1-antitrypsin deficiency. c. secondhand cigarette smoke. d. air pollution.

ANS: A

Exposure to airborne asbestos fibers is associated with asbestosis and mesothelioma but not emphysema.

REF: pp. 173-175 5. The genetic reference to a person with a normal level of  1-antitrypsin is a. Z b. MZ c. MM d. ZZ

phenotype.

ANS: C

Individuals who have the genetic phenotype MM (or M phenotype) have normal levels  1antitrypsin.

REF: pp. 174-175 6. Which of the following are anatomic alterations found with chronic bronchitis?

1. Increased size of submucosal bronchial glands 2. Destruction of pulmonary capillaries 3. Chronic bronchial wall inflammation and thickening 4. Bronchospasm 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.

REF: p. 171 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. 1, 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.

REF: p. 171 8. The management of COPD may include:

1. annual influenza immunization.

2. bronchopulmonary hygiene procedures.

3. bronchodilators.

4. smoking cessation. a. 1, 2 b. 2, 3 c. 2, 3, 4 d. 1, 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.

REF: pp. 186-188 9. Which of the following terms 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 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.

REF: pp. 177-179 10. Which of the following clinical manifestations are associated with late-stage chronic

bronchitis?

1. Rhonchi 2. Cor pulmonale 3. Digital clubbing 4. Stocky, overweight build a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3, 4

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.

REF: pp. 177-179 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, 4 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.

REF: p. 180 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.

REF: p. 179 13. Which of the following are clinical findings associated with chronic bronchitis?

1. Cyanosis 2. Purulent sputum 3. Right heart failure 4. Elevated CO2 level a. 1, 2 b. 3, 4 c. 1, 3 d. 1, 2, 3, 4 ANS: D

Patients with chronic bronchitis may demonstrate cyanosis, purulent sputum, right heart failure, and hypercarbia.

REF: p. 179

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 history of environmental risk factors.

REF: p. 179 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, 3 d. 1, 3, 4 ANS: C

A chronic cough, chronic exposure to environmental smoke, and FEV1 below 80% are constant with COPD. REF: pp. 174-175 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.

REF: pp. 174-176 17. In the United States, the primary factor leading to the development of COPD is: a.  1-antitrypsin deficiency. b. recurrent respiratory infections. c. socioeconomic status. d. tobacco smoking.

ANS: D

Tobacco smoking is the leading cause of COPD. The majority of cases of COPD simply could have been prevented in the absence of tobacco smoking.

REF: p. 180

Chapter 14. Asthma Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Which of the following are associated with extrinsic asthma?

1. 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

Extrinsic asthma, also called allergic asthma, is triggered by exposure to a specific allergen.

Environmental factors, including exposure to mold and pet dander, can trigger asthmatic reactions.

REF: pp. 204-205 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?

Deferred dyspneic response Asynchronous activation response Biphasic response Bipolar response

a. b. c. d.

ANS: C

In extrinsic asthma, individuals may experience an early asthmatic response that may then be followed hours later by a late asthmatic response. This is termed a biphasic response.

REF: pp. 204-205 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. 2, 3, 4 d. 1, 2, 3, 4 ANS: B

Emotional stress and gastroesophageal reflux disease (GERD) are associated with intrinsic asthma.

REF: pp. 203-205 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?

Bronchial smooth muscle contraction will occur.

Airway edema will increase.

The medications oppose each other, resulting in no airway changes.

Bronchial smooth muscle relaxation will occur.

a. b. c. d.

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.

REF: pp. 206-207 5. After the inhalation of a bronchodilator, what percentage change in peak expiratory flow

(PEFR) would be required to demonstrate reversible airflow limitation consistent with asthma? a. –20% b. –10% c. +10% 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.

REF: pp. 206-207 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 2. Decreased vocal fremitus 3. Increased vesicular breath sounds 4. Hyperresonant percussion note a. 1, 4 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3, 4 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.

REF: p. 209 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 to taken to aggressively treat the patient.

REF: p. 210 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?

Increased IgE level Increased erythrocyte count Colonization of P. aeruginosa Decreased IgE level

a. b. c. d.

ANS: A

Patients with extrinsic asthma will demonstrate increased immunoglobulin E (IgE) levels.

REF: p. 210 9. What findings on a chest radiograph would be expected during a prolonged asthma episode?

1. Depressed diaphragm 2. Increased anterior-posterior diameter 3. Asymmetrical lung inflation 4. Translucent lung fields a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3, 4 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 increased. A more subtle change would be darkened lung fields caused by the increased air within the alveoli.

REF: p. 211 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.

REF: pp. 201-202 11. At what age does asthma severity peak in males? a. 1 and 3 years b. 5 and 7 years c. 18 and 20 years d. 30 and 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.

REF: pp. 202-203 12. All of the following symptoms are commonly associated with asthma EXCEPT recurrent: a. cough. b. chest tightness. c. fever. d. wheeze.

ANS: C

A recurrent cough, recurrent chest tightness, and recurrent wheeze are symptoms associated with asthma.

REF: pp. 206-207 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 an inspiratory fall in systolic blood pressure greater than 10 mm Hg. It can occur with the large intrapleural pressure swings than may happen during a severe asthmatic episode and is associated with a life-threatening situation.

REF: p. 209 14. How many components of care are included in the NAEPP-EPR-3 asthma management

guidelines?

3 4 5 6

a. b. c. d.

ANS: B

According to the NAEPP-EPR-3, there are four components of care: assessment and monitoring, patient education, control of triggers/factors impacting asthma control, and pharmacologic treatments.

REF: pp. 200-201 15. Which of the following is the acronym for the bronchospasm and airway inflammation

resulting from the aspergillus fungus?

ABPA AGA ACOS AEC

a. b. c. d.

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.

REF: pp. 206-207

Chapter 15: Cystic Fibrosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. During the advanced stages of cystic fibrosis, the anatomic alterations cause the patient to

have: a primarily restrictive lung disease. a primarily obstructive lung disease. equal parts restrictive and obstructive lung disease. normal airways with emphysema.

a. b. c. d.

ANS: B

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

Restrictive changes play a minor role.

REF: p. 236 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 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.

REF: p. 236 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. 1, 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.

REF: pp. 236-237 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.

REF: pp. 237-238 5. Cystic fibrosis patients can have all of the following EXCEPT: a. malnutrition. b. meconium ileus (bowel obstruction). c. excessive, viscous pulmonary secretions. d. tendency for status asthmaticus.

ANS: D

Asthma is a separate condition that is not associated with cystic fibrosis. All of the other listed options can be found in patients with cystic fibrosis.

REF: p. 237 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.

REF: p. 237 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 Figure 15-2, if this couple had four children, the odds are that one would have cystic fibrosis (1 in 4 chance, 25%), two would be carriers (2 in 4 chance, 50%), and one would not be a carrier (1 in 4 chance, 25%).

REF: p. 238 8. Which ethnic group has the greatest number of people with cystic fibrosis? a. African-Americans b. Asians c. Hispanics d. Caucasians ANS: D

Although cystic fibrosis is a rare disease in all ethnic groups, Caucasians have the greatest risk of having cystic fibrosis.

REF: p. 238 9. All of the following can be used in the diagnosis of cystic fibrosis EXCEPT: a. an elevated potassium level in the sweat. b. an elevated chloride level in the sweat. c. genetic testing of the patient and/or parents. d. chronic lung infections from an early age.

ANS: A

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.

REF: pp. 238-240 10. Which of the following are commonly used in the management of cystic fibrosis?

1. Pancreatic enzymes and vitamins 2. Antibiotics 3. Postural drainage 4. Expectorants a. 1, 4 b. 2, 3 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: D

All of the listed options are used in the treatment of cystic fibrosis.

REF: pp. 244-246 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.

REF: pp. 245-246 12. A cystic fibrosis patient in generally good condition may be a candidate for which of the

following?

Cryosurgery Total DNA replacement Diaphragmatic pacemaker Lung transplant

a. b. c. d.

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.

REF: pp. 245-246 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.

REF: p. 241 14. What complicating pulmonary problem is likely to happen to a patient with cystic fibrosis? a. Pulmonary edema b. Pleural effusion c. Spontaneous pneumothorax d. Cardiac tamponade 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.

REF: p. 241

15. All of the following pulmonary function findings would be expected in a patient with

moderate to severe cystic fibrosis EXCEPT: increased FVC. increased RV. decreased PEFR. decreased FEF50%.

a. b. c. d.

ANS: A

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.

REF: p. 241 16. Which of the following may be recommended to reduce bronchial inflammation in a 12-year-

old child with cystic fibrosis? a. High-dose ibuprofen b. High-dose acetaminophen c. High-dose naproxen d. 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.

REF: pp. 245-246 17. Which of the following is NOT recommended in children with cystic fibrosis? a. Systemic corticosteroids b. High-dose ibuprofen c. Inhaled antibiotics d. Inhaled DNase (Dornase alpha) (Pulmozyme®) ANS: A

Systemic glucocorticoids are not recommended in children and adolescents with CF. The benefits of systemic glucocorticoids are outweighed by the adverse effects on growth retardation, glucose metabolism, development of CF-related diabetes, and cataract risks. Highdose 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.

REF: pp. 245-246 18. All of the following chest assessment findings may be seen in a patient with cystic fibrosis

EXCEPT: decreased tactile and vocal fremitus. dull percussion note. diminished breath sounds. decreased heart sounds.

a. b. c. d.

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.

REF: p. 241 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.

REF: p. 244

Chapter 16: Bronchiectasis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 223 2. Rigid and dilated bronchi are the key anatomic alterations found in which type of

bronchiectasis?

Varicose Cystic Emphysematous Cylindrical

a. b. c. d.

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.

REF: pp. 222-223 3. Irregularly dilated and constricted bronchi are the key anatomic alterations found in which

type of bronchiectasis?

Cystic Varicose Tubular Saccular

a. b. c. d.

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.

REF: p. 222 4. Which form of bronchiectasis causes the greatest amount of damage to the tracheobronchial

tree?

Triphasic Varicose Cystic Fusiform

a. b. c. d.

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.

REF: p. 223 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.

REF: pp. 224-225 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 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.

REF: p. 224 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 of 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.

REF: pp. 223-224 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. 1, 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.

REF: p. 232 9. Which of the following should a patient with bronchiectasis do to reduce the risk of 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, 4 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 should only be taken against a specific infectious organism for a set time period.

REF: p. 232 10. Severe bronchiectasis is associated with all of the following EXCEPT: a. vesicular breath sounds. b. cor pulmonale. c. distended neck veins. d. polycythemia.

ANS: A

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.

REF: p. 226 11. Which of the following pulmonary function testing values would be found in a patient with

severe, obstructive bronchiectasis?

Decreased RV/TLC ratio Increased PEFR Increased FEF25%-75% Decreased FEF25%-75%

a. b. c. d.

ANS: D

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.

REF: p. 226 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.

REF: p. 227 13. The preferred radiographic method to evaluate a patient’s bronchiectasis is: a. posterior-anterior radiograph (x-ray). b. anterior-posterior radiograph (x-ray). c. computed tomography (CT). d. bronchogram.

ANS: C

A CT scan of the lungs will provide very detailed images of the damaged areas. Although a radiograph of the chest or bronchogram will provide valuable information, the CT scan is the best method available.

REF: p. 228 14. One of the main challenges in caring for a patient with bronchiectasis is:

a. b. c. d. e.

contending with bronchospasm. removing excessive bronchopulmonary secretions. returning the FRC to within normal limits. maximizing gas exchange across the alveolar-capillary membrane. 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.

REF: p. 234 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.

REF: p. 223 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 flow rates 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.

REF: p. 226 17. Which of the following is the usual characteristic of the sputum of a patient with

bronchiectasis?

It is usually sweet or musky smelling.

When examined microscopically there are Kirshman’s spirals.

It contains eosinophils.

It is usually voluminous and tends to settle into several different layers.

a. b. c. d.

ANS: D

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

REF: p. 226 18. A patient with severe bronchiectasis may show all of the following signs EXCEPT: a. distended neck veins. b. pitting edema.

c. enlarged and tender liver. d. S3 heart sound.

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.

REF: p. 226

Chapter 18: Fungal Diseases of the Lung Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. 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.

REF: pp. 283-284 2. Fungal infection of the lungs is closest in similarity to: a. pleural disease. b. interstitial lung disease. c. tuberculosis. d. bronchiectasis.

ANS: C

Because of the fibrosis and scarring that can occur with a fungal lung infection, it resembles tuberculosis more closely than the other listed options.

REF: p. 284 3. What 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.

REF: p. 284 4. Fungal lung infections are usually spread by: a. inhaling spores. 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.

REF: pp. 284-285 5. A patient lives in Chicago and has HIV and a weakened immune system. What fungal

infection is the patient at risk of developing?

Mycoplasma infection Blastomycosis Streptococcal infection Disseminated histoplasmosis

a. b. c. d.

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.

REF: pp. 284-285 6. Which type of fungal lung infection frequently results in productive cough with purulent

sputum?

Staphylococcal infection Blastomycosis Klebsiella infection Histoplasmosis

a. b. c. d.

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.

REF: pp. 285-286 7. 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.

REF: pp. 285-286 8. 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 d. Cryptococcal infection ANS: C

Histoplasma capsulatum is found in chicken (and other bird) excreta as well as soil.

REF: pp. 284-285 9. All of the following are identified as opportunistic yeast pathogens EXCEPT: a. Candida albicans. b. Cryptococcus neoformans. c. Aspergillus. d. Mycoplasma.

ANS: D

Mycoplasma is an organism that has traits of both bacteria and viruses. The other listed options are yeasts.

REF: p. 286 10. In the Midwestern part of the United States, what is the most common fungal infection of the

lungs?

Cryptococcosis Histoplasmosis Blastomycosis Coccidioidomycosis

a. b. c. d.

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.

REF: pp. 284-285 11. The drug of choice for the treatment of fungal lung diseases is: a. penicillin (penicillin G). b. tetracycline. c. amphotericin B (Fungizone). d. ketoconazole (Nizoral).

ANS: C

Amphotericin B (Fungizone) is very effective against a variety of fungal infections. The other listed options are used against other fungi or bacteria.

REF: p. 289 12. A patient has an Aspergillus niger infection. What should be used to treat it? a. Fluconazole (Diflucan) b. Ribavirin (Virazole) c. Metronidazole (Flagyl) d. Ketoconazole (Nizoral) ANS: A

An A. niger infection is best treated with fluconazole (Diflucan). The other listed options are used against other fungi, viruses, or bacteria.

REF: p. 289 13. A patient with an advanced pulmonary fungal infection has cor pulmonale. How will this

manifest itself?

Distended neck veins Poor skin turgor Wheezy breath sounds Asymmetrical chest movement when breathing

a. b. c. d.

ANS: A

Cor pulmonale is right-sided heart failure. Patients with this problem will have distended neck veins and other findings associated with fluid overload. Often they will have peripheral edema rather than poor skin turgor. Breath sounds may reveal crackles but not wheezes. Chest movement is not affected.

REF: p. 287 14. Pulmonary function testing results on a patient with advanced fungal pneumonia will display

all of the following EXCEPT: increased ERV. decreased IRV. decreased IC. decreased TLC.

a. b. c. d.

ANS: A

RV will be decreased rather than increased. Because advanced fungal pneumonia causes a restrictive lung disease pattern, volumes and capacities will be decreased.

REF: p. 287 15. During the advanced stages of a fungal lung infection, which of the following is commonly

seen on the chest radiograph?

Hyperinflation Spherical nodules Right shift of the heart Cavities

a. b. c. d.

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.

REF: p. 288 16. What is considered to be the gold standard for the diagnosis of histoplasmosis? a. Fungal stain b. Blood serum antigen levels c. Chest x-ray d. Fungal culture e. Skin test

ANS: D

The fungal culture test is considered the gold standard for detecting histoplasmosis. Although fungal stains and blood serology may be used, they are not considered to be the gold standard for diagnosis. Skin testing only confirms exposure, not necessarily infection. Chest x-rays are helpful, but not diagnostic.

REF: pp. 284-285 17. Fungal diseases 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

Fungal diseases of the lung cause a chronic restrictive pulmonary disorder.

REF: p. 284 18. Which of the following is NOT considered to cause an opportunistic fungal infection? a. Candida albicans b. Aspergillus c. Coccidioides immitis d. Cryptococcus neoformans ANS: C

Opportunistic yeast pathogens such as Candida albicans, Cryptococcus neoformans, and Aspergillus also are associated with lung infections in certain patients.

REF: p. 286

Chapter 18: Pneumonia Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. When a patient has pneumonia, which of the following would be found in the alveolar

effusion fluids?

1. Mucus 2. Serum fluid 3. Saliva 4. Red blood cells a. 1, 3 b. 2, 4 c. 2, 3 d. 1, 2, 3, 4 ANS: B

During the inflammatory processes found with pneumonia, the effusion fluids in the alveoli will contain serum fluid, red blood cells, and polymorphonuclear leukocytes and macrophages. Saliva is found in the mouth, and mucus is found in the airways. Neither will be found in the alveoli.

REF: pp. 252-254 2. A patient has a bacterial pneumonia. What kills the invading bacteria? a. Macrophages 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.

REF: pp. 252-254 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. 1, 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.

REF: pp. 252-254 4. If a patient has pneumonia, which of the following can increase the risk of 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 (chronic obstructive pulmonary disease [emphysema and chronic bronchitis]) 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.

REF: pp. 252-254 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.

REF: pp. 256-257 6. Which of the following pulmonary infections is most commonly seen in patients with AIDS? a. Anaerobic b. Pneumocystis jiroveci c. Streptococcus pneumoniae (Diplococcus pneumoniae) d. Legionella pneumophila 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.

REF: pp. 256-257 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. b. c. d.

Bacteroides melaninogenicus Staphylococcus aureus Chlamydia psittaci 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.

REF: pp. 256-257 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 48 to 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 or 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.

REF: pp. 257-258 9. A patient has a pleural effusion related to her pneumonia. Which of the following should the

respiratory therapist recommend to treat the pleural effusion?

Hyperinflation therapy Supplemental oxygen Thoracentesis Percussion and postural drainage

a. b. c. d.

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.

REF: pp. 263-264 10. Physical assessment findings on a patient with pneumonia would include all of the following

EXCEPT: bradycardia. whispered pectoriloquy. dull percussion note. increased vocal fremitus.

a. b. c. d.

ANS: A

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

REF: pp. 252-254

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, 4 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.

REF: p. 252 | p. 255 12. All of the following are considered to be normal causative agents for community-acquired

pneumonia (CAP) EXCEPT: staphylococcal pneumonia.

Haemophilus influenza.

Legionella pneumophila.

Candida albicans.

a. b. c. d.

ANS: D

Staphylococcal pneumonia, Haemophilus influenza, and Legionella pneumophila are all causes of community-acquired pneumonia. Candida albicans is an opportunistic yeast infection.

REF: pp. 253-254

Chapter 18. Pneumonia, Lung Abscess Formation and Important Fungal Diseases Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. During the early stages of a lung abscess, the pathologic process is identical to that of: a. pulmonary edema. b. bronchopulmonary dysplasia. c. acute pneumonia. 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.

REF: p. 267 2. 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.

REF: p. 267 3. 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.

REF: p. 267 4. 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. 1, 2, 3, 4 ANS: B

Peptococci and B. fragilis are anaerobic microorganisms and may be present in the lower respiratory tract following aspiration.

REF: p. 268 5. 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. Head trauma 3. Seizure disorder 4. Alcohol abuse a. 1, 2 b. 1, 3, 4 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: D

General anesthesia, head trauma, seizure disorders, and alcohol abuse are among the factors that can predispose a patient to aspiration of oropharyngeal secretions and/or gastric contents into the lower airway.

REF: p. 267 6. Which of the following conditions can result in a lung abscess?

1. Penetrating chest wound 2. Septic embolism 3. Aspirated foreign body 4. Bronchogenic cyst a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

All of the listed conditions are among the causes that can lead to the development of a lung abscess.

REF: p. 268 7. 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.

REF: p. 268 8. A patient with an abscess has produced a large volume of brown-colored, putrid sputum. What

type of microorganism would most likely result in brown, putrid sputum production? a. Fungi b. Viruses c. Aerobic bacteria d. Anaerobic bacteria ANS: D

Anaerobic bacteria are responsible for foul-smelling, brown or grey secretions associated with a lung abscess.

REF: p. 269 9. 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?

The lungs are hyperinflated.

Hemoptysis has developed.

The abscess is located near the pleural surface.

A pneumothorax has developed.

a. b. c. d.

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.

REF: p. 269 10. What is the standard treatment for a lung abscess caused by an anaerobic pathogen? a. Clindamycin b. Linezolid c. Neomycin d. Omalizumab ANS: A

When a lung abscess is caused by an anaerobic pathogen, clindamycin is prescribed as the standard treatment.

REF: p. 270

11. What is the recommended treatment for a lung abscess caused by methicillin-resistant

Staphylococcus aureus (MRSA)?

Neomycin Linezolid Penicillin Clindamycin

a. b. c. d.

ANS: B

Linezolid is the recommended treatment for a lung abscess caused by MRSA. REF: p. 270 12. In the early stages of a lung abscess, a patient would most likely have a: a. nonproductive, hacking cough. b. productive cough with foul-smelling, grey sputum. c. productive cough with hemoptysis. d. productive cough with copious white sputum.

ANS: A

In the early stages of the development of a lung abscess, a nonproductive barking or hacking cough would be present.

REF: p. 269 13. All of the following are parasites associated with lung abscesses EXCEPT: a. Paragonimus westermani. b. Echinococcus. c. Streptococcus pyogenes. d. Entamoeba histolytica.

ANS: C

Streptococcus pyogenes is a gram-positive bacteria, not a parasite. S. pyogenes is not associated with the development of lung abscess.

REF: p. 268

Chapter 19. Tuberculosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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?

Primary TB Postprimary TB Disseminated TB Multiorgan TB

a. b. c. d.

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.

REF: p. 275 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.

ANS: A

As the lung undergoes the healing process, tissue fibrosis and calcification occur in each of the tubercle sites. This results in lung retraction and scarring and the distortion of bronchi.

REF: p. 275 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.

REF: p. 275

4. A patient who has an uncontrolled tuberculosis infection will show all of the following signs

EXCEPT: weight loss. high fever. bloody sputum. night sweats.

a. b. c. d.

ANS: B

Patients typically will have a low-grade fever with this infection. All of the other listed items, and others, will be found.

REF: p. 275 5. A negative tuberculin test would be demonstrated by an induration (wheal) of what size? a. 4 mm or less b. 6 mm or less c. 8 mm or greater d. 10 mm or greater ANS: A

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.

REF: pp. 276-277 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

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.

REF: p. 276 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.

REF: p. 276

8. When a person has TB spread throughout the body, it is found in all of the following

EXCEPT: upper lobes. kidneys. brain. lower lobes.

a. b. c. d.

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.

REF: p. 275 9. Nontuberculous mycobacteria such as Mycobacterium avium and Mycobacterium kansasii are

associated with which one of the following diseases?

COPD Bronchiectasis Status asthmaticus Cystic fibrosis

a. b. c. d.

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.

REF: pp. 276-277 10. What medication is used to treat a person who has converted to a positive TB skin test but

does not have active disease?

Virazole Isoniazid Rifampin Tetracycline

a. b. c. d.

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.

REF: p. 280 11. A first-line agent used to treat a TB infection is: a. gentamycin. b. penicillin. c. streptomycin. d. isoniazid.

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.

REF: p. 280 12. Risk factors predisposing a person to TB include all of the following EXCEPT:

a. b. c. d.

having HIV/AIDS. being immunosuppressed.

African American or Hispanic heritage. malnutrition.

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 of getting TB when exposed to it.

REF: p. 275 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.

REF: p. 278 14. Pulmonary function testing results on a patient with an advanced case of TB will display all of

the following EXCEPT: increased RV. decreased IRV. decreased VC. decreased TLC.

a. b. c. d.

ANS: A

RV will be decreased rather than increased. Because TB causes a restrictive lung disease pattern, volumes and capacities will be decreased.

REF: p. 279 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.

REF: p. 279 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.

REF: p. 280 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 flulike 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.

REF: p. 280 18. In which of the following ways is tuberculosis generally NOT spread? a. Inhaling droplets of aerosol from an infected person b. Drinking unpasteurized milk from cattle infected with the pathogen c. Laceration with contact of infected secretions during postmortem autopsy d. Sharing utensils and glassware with an infected person 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.

REF: p. 276

Chapter 20: Pulmonary Edema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. As pulmonary edema progressively worsens, the fluid moves in which of the following

sequences?

Peribronchial interstitial spaces, bronchi, trachea Alveoli , bronchioles, bronchi Bronchioles, bronchi, trachea Pulmonary capillaries, alveoli, bronchioles

a. b. c. d.

ANS: B

With severe pulmonary edema, the fluid would move progressively from the pulmonary vascular system (pulmonary capillaries), to the perivascular and peribronchial interstitial spaces, to the alveoli and bronchi, where the patient may cough it out.

REF: p. 293 2. Pulmonary edema manifests itself clinically as a(n) a. restrictive pulmonary b. obstructive pulmonary c. equally restrictive and obstructive d. obstructive cardiac

disorder.

ANS: A

Pulmonary edema manifests itself clinically as a restrictive pulmonary disorder because fluid in the lungs limits inspiration. Even if the heart is the cause of the pulmonary edema, the problem is not obstructive.

REF: p. 294 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.

REF: p. 294

4. All of the following are causes of cardiogenic pulmonary edema EXCEPT: a. myocardial infarction. b. mitral valve disease. c. allergic reaction to drugs. d. congenital heart defects.

ANS: C

Allergic reaction to drugs can cause noncardiogenic pulmonary edema. The other listed options, and others, can cause cardiogenic pulmonary edema.

REF: p. 295 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

Normal hydrostatic pressure in the pulmonary capillaries is 10 to 15 mm Hg. REF: p. 295 6. All of the following are positive risk factors for coronary heart disease (CHD) EXCEPT: a. elevated homocysteine level. b. elevated vitamin E level. c. hypertension. d. diabetes mellitus.

ANS: B

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

REF: p. 295 7. Which of the following is/are considered noncardiogenic cause(s) of increased capillary

permeability?

1. Therapeutic lung radiation 2. Cigarette smoke 3. Acute respiratory distress syndrome (ARDS) 4. Inhaled phosgene a. 1 b. 2, 3 c. 1, 3, 4 d. 1, 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.

REF: p. 295

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. 1, 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 not associated with lymphatic insufficiency.

REF: pp. 295-296 9. Management of cardiogenic pulmonary edema includes giving a patient which of the

following types of medications?

1. Afterload reducer 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. A positive chronotropic medication would increase heart rate. This is not indicated in the treatment of cardiogenic pulmonary edema.

REF: pp. 298-300 10. A patient has a decreased oncotic pressure. What can be done to increase it? a. High-salt diet b. Mannitol c. Albumin withheld d. Morphine sulfate ANS: B

Giving mannitol (and albumin) will increase oncotic pressure. A low-salt diet will decrease fluid retention to increase hydrostatic pressure. Morphine sulfate acts as a vasodilator.

REF: p. 299

11. A patient with pulmonary edema is cyanotic and complaining of difficulty breathing. What

should be recommended by the respiratory therapist?

Provide supplemental oxygen.

Begin mechanical ventilation.

Have the patient use pursed-lip breathing.

Begin bronchopulmonary hygiene therapy.

a. b. c. d.

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.

REF: p. 299 12. Mask CPAP is used with pulmonary edema patients because it does all of the following

EXCEPT: a. decrease vascular congestion. b. reduce work of breathing. c. it is less expensive than mechanical ventilation. d. improve lung compliance.

ANS: C

Although CPAP may be less expensive than mechanical ventilation, that is not why it is used.

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.

REF: p. 299 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 4. Decreased RAP a. 2, 3 b. 1, 4 c. 1, 2, 3 d. 1, 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.

REF: p. 297

14. A patient with cardiogenic pulmonary edema would be expected to have all of the following

chest radiograph findings EXCEPT: depressed diaphragms. pleural effusion. cardiomegaly. bilateral “butterfly” pattern fluffy infiltrates.

a. b. c. d.

ANS: A

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.

REF: p. 297 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.

REF: p. 297 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 aminotransferase (AST) 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.

REF: p. 297

17. All of the following may be causes of cardiogenic pulmonary edema EXCEPT: a. dysrhythmias. b. systemic hypertension. c. congenital heart defects. d. excessive fluid administration. e. pulmonary embolism.

ANS: E

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

REF: p. 295 18. The respiratory therapist is asked to recommend a medication to reduce afterload for a patient

with cardiogenic pulmonary edema. The therapist could recommend all of the following EXCEPT: a. captopril. b. norepinephrine (Levophed). c. enalapril (Vasotec). d. nitroprusside (Nitropress).

ANS: B

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.

Norepinephrine (Levophed) may be used in the management of cardiogenic pulmonary edema; however, it is a positive inotropic agent, not an afterload reducer.

REF: p. 299

Chapter 21: Pulmonary Vascular Disease: Pulmonary Embolism and Pulmonary Hypertension Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. The death of lung tissue that may result from an obstruction of the pulmonary artery is called

a: a. b. c. d.

pulmonary embolism. pleural effusion. pulmonary infarction. 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.

REF: p. 303 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 mediators from platelets a. 1, 2 b. 2, 4 c. 1, 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.

REF: p. 303 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, 4 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.

REF: p. 303 4. All of the following are associated with the formation of a deep vein thrombosis (DVT)

EXCEPT: blood vessel injury. age greater than 40 years. hypercoagulability. venous stasis.

a. b. c. d.

ANS: B

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. REF: p. 304 5. Predisposing factors of pulmonary emboli include:

1. varicose veins.

2. smoking.

3. obesity.

4. congestive heart failure. a. 2, 4 b. 1, 3 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

All of the listed options, and other factors, can predispose a person to having pulmonary emboli.

REF: p. 304 6. The sudden onset of which of the following signs and symptoms indicates a pulmonary

embolism?

1. Wheezing 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, 4 ANS: D

All of the listed options, and others, are signs and symptoms that could indicate a pulmonary embolism.

REF: p. 304 7. The best test for diagnosing a suspected pulmonary embolism is a(n): a. spiral computerized tomography scan. b. pulmonary function test. c. electrocardiogram. d. chest radiograph.

ANS: A

A spiral computerized tomography scan can quickly identify a pulmonary embolism because it makes a three-dimensional image of the lungs and pulmonary circulation. Pulmonary function testing, electrocardiogram, and chest radiograph are not helpful because they do not provide specific indicators of a pulmonary embolism.

REF: p. 305 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

If other, simpler tests are inconclusive, a pulmonary angiogram is usually ordered to accurately identify a pulmonary embolism. It is not combined with any other testing.

REF: p. 306 9. A patient’s D-dimer blood test results show a value of 250 ng/mL. How should these results

be interpreted?

The patient does not have a pulmonary embolism.

The patient’s anticoagulant level is acceptable.

The patient has a pulmonary embolism.

The patient has a deep vein thrombosis.

a. b. c. d.

ANS: A

With this low D-dimer value, a pulmonary embolism can be ruled out. A D-dimer value of greater than 500 ng/mL is considered positive for a pulmonary embolism.

REF: p. 305 10. The duplex venous ultrasonography test is used to: a. diagnose a blood clot below the knee. b. identify a saddle embolism. c. diagnose a blood clot behind the knee or thigh. d. identify a pulmonary infarction.

ANS: C

The duplex venous ultrasonography test is very accurate for diagnosing a blood clot behind the knee or thigh. It is not useful for any of the other listed options. Other tests would be needed.

REF: p. 305 11. Which of the following fibrinolytic agents are used to treat a pulmonary embolism?

1. Urokinase 2. Vitamin K 3. Heparin 4. Streptokinase a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: A

Fibrinolytic agents such as streptokinase (Streptase), urokinase (Abbokinase), alteplase (Activase), and reteplase (Retavase) actually dissolve blood clots. These agents (commonly referred to as “clot-busters”) have proved beneficial in treating acute pulmonary embolism.

Heparin is an anticoagulant, not a fibrinolytic. Vitamin K does affect clotting time but is not given therapeutically to break up an existing blood clot.

REF: p. 311 12. All of the following are preventive measures taken with patients at high risk for

thromboembolic disease EXCEPT: Drink lots of water.

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

Walk frequently.

Wear compression stockings.

a. b. c. d.

ANS: B

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.

REF: p. 311 13. Which of the following is/are major mechanism(s) that contribute to the pulmonary

hypertension commonly seen in a patient with a pulmonary embolism?

1. Decreased cross-section 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 b. 2, 3 c. 1, 2, 4 d. 1, 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.

REF: pp. 309-310 14. The respiratory therapist is listening to the heart sounds of a patient with a suspected

pulmonary embolus. The therapist could expect to hear all of the following EXCEPT: increased second heart Sound (S2). increased splitting of the second heart sound (S2). third heart sound (S3). fourth heart sound (S4).

a. b. c. d.

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.

REF: pp. 308-309 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?

Subclavian vein Pulmonary artery Thoracic duct Inferior vena cava Femoral artery

a. b. c. d. e.

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 of these filters are not well established and, in general, they are only recommended in some high-risk patients. Edema distal to the filters is a complicating factor.

REF: p. 311 16. All of the following medications may be used to prevent pulmonary emboli EXCEPT: a. enoxaparin. b. dalteparin. c. tinzaparin. d. reteplase.

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.

REF: p. 311

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 all of the following EXCEPT: broccoli. spinach. liver. grapefruit. orange juice.

a. b. c. d. e.

ANS: E

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.

REF: p. 311 18. A pulmonary embolus produces which of the following a. True shunting b. Shunt effect c. Dead space effect d. True dead space

/ abnormalities?

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.

REF: p. 306

Chapter 22: Flail Chest Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 320 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 that fractures multiple ribs most likely will injure the underlying lung resulting in a pulmonary contusion.

REF: p. 320 3. Which of the following accurately describes a flail chest? a. Double fractures of 2 adjacent ribs b. Double fractures of 3 adjacent ribs c. Single fracture of 3 adjacent ribs d. Triple fractures of 2 adjacent ribs ANS: B

A flail chest is defined as double fractures of three or more adjacent ribs.

REF: p. 320 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. 1, 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.

REF: p. 320 5. All of the following are causes of a flail chest EXCEPT: a. blast injury. b. motor vehicle accident. c. split sternum for open heart surgery. d. fall from heights.

ANS: C

A flail chest can be caused by blunt injury, trauma incurred in an MVA, and falls from heights.

REF: p. 320 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, 2, 3, 4 ANS: C

Appropriate pain management is needed with a flail chest injury. Mechanical ventilation with PEEP will stabilize the chest and provide ventilatory support.

REF: p. 324 7. How many days of ventilatory support are anticipated for a patient with a flail chest to allow

sufficient time for bone healing?

3 to 5 days 5 to 10 days 12 to 15 days 18 to 21 days

a. b. c. d.

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.

REF: p. 324 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.

REF: p. 324 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.

REF: p. 322 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.

REF: p. 322 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 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, 2, 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.

REF: p. 322 12. Which breath sounds would be expected to be heard when auscultating the chest of a patient

with a flail chest?

Diminished over the flail chest section only Diminished over both lungs Crackles over the flail chest section Bilateral wheezing

a. b. c. d.

ANS: B

With a flail chest, the patient’s breath sounds will be diminished on both the affected and unaffected sides.

REF: p. 323 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.

REF: p. 323 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.

REF: p. 322 15. Which of the following can stimulate an increased respiratory rate when a flail chest is

present?

1. Activation of deflation receptors 2. Activation of irritant receptors 3. Stimulation of J receptors 4. Pain and anxiety a. 1, 3

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

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.

REF: p. 322 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 Decreased pH and decreased SaO2 Increased pH and decreased SaO2 Decreased pH and increased SaO2

a. b. c. 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.

REF: p. 323

Chapter 23: Pneumothorax Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 327 2. A pneumothorax manifests itself clinically as a primary a. restrictive b. obstructive c. restrictive disorder with a secondary obstructive d. obstructive disorder with secondary restrictive

disorder.

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.

REF: p. 327 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.

REF: p. 331 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.

REF: p. 327 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?

Spontaneous pneumothorax Tension pneumothorax Iatrogenic pneumothorax Benign pneumothorax

a. b. c. d.

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.

REF: p. 328 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 20% pneumothorax in the right lung. Which of the following conditions would be present? a. Closed pneumothorax b. Pleural effusion c. Iatrogenic pneumothorax d. Sucking chest wound 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.

REF: p. 328 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

A spontaneous pneumothorax is one that occurs suddenly and without any obvious underlying cause. Frequently, it happens in tall, thin young adults when a high lung pressure causes a surface bleb or bulla to rupture.

REF: p. 329 8. An iatrogenic pneumothorax may be caused by all of the following EXCEPT: a. positive-pressure mechanical ventilation. b. pleural biopsy. c. subclavian vein cannulation. d. endotracheal intubation.

ANS: D

Endotracheal intubation does not pose a risk of pneumothorax. All of the other listed options can lead to medical procedure–related pneumothorax.

REF: p. 330 9. A 40-year-old patient requires placement of a thoracostomy chest tube. All of the following

are recommended for the procedure EXCEPT: application of –5-cm H2O pressure to the chest tube. use of a No. 28 to 36 French gauge tube. placement of the tube at the apex of the lung. clamping and removing the tube within 24 hours of insertion.

a. b. c. d.

ANS: D

Thoracostomy tubes are clamped only after bubbling from the tube has ceased and then are left in place without suction for another 24 to 48 hours.

REF: p. 333 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.

REF: p. 333 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.

REF: p. 330 12. Which of the following chest assessment findings would be expected in a patient with a

tension pneumothorax?

Decreased thoracic volume on the affected side Dull percussion note Tracheal shift away from the affected side Wheezes

a. b. c. d.

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.

REF: p. 330 13. Which of the following hemodynamic indices will be found in a patient with a large

hemothorax?

Decreased QS/QT Decreased CO Increased CI Increased SV

a. b. c. d.

ANS: B

Because a large pneumothorax can impede venous blood return to the heart, the cardiac output (CO) will be decreased.

REF: p. 331 14. If the patient has a tension pneumothorax, all of the following chest radiograph findings

would be expected EXCEPT: elevated diaphragm. mediastinal shift to the unaffected side. increased translucency on the side of the pneumothorax. atelectasis.

a. b. c. d.

ANS: A

The buildup of air in the pleural space will depress rather than elevate the diaphragm.

REF: p. 332 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.

REF: p. 328 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.

REF: p. 329 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.

REF: p. 328

Chapter 24: Pleural Effusion and Empyema Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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 pleural effusion causes the separation (not adhesion) of the visceral and parietal pleura.

REF: p. 336 2. The major pathologic and structural changes associated with a significant pleural effusion

include all of the following EXCEPT: diaphragm elevation. atelectasis. compression of the great vessels. lung compression.

a. b. c. d.

ANS: A

A large effusion could cause the diaphragm to be depressed, not elevated.

REF: p. 336 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.

REF: p. 336 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, 3, 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.

REF: p. 338 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 2nd to 3rd intercostal space.

2. The tube is placed in the 4th to 5th 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 4th to 5th intercostal space in the midaxillary line.

REF: p. 340 6. Treatment of an empyema usually includes: a. pleurodesis. b. thoracostomy tube insertion. c. lobectomy. d. pneumonectomy.

ANS: B

The treatment of an empyema may require placement of a thoracostomy tube.

REF: p. 338 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, all of the following tests should be performed EXCEPT: a. specific gravity. b. biochemical makeup. c. cytologic examination. d. bacterial culture.

ANS: A

Specific gravity is a measurement of the density of fluids and would not be indicated in evaluating the cause of a pleural effusion.

REF: pp. 340-341 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?

Milky white Straw colored Red Green

a. b. c. d.

ANS: C

In a chylothorax, the fluid in the pleural cavity would appear to be milky white.

REF: p. 338 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 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.

REF: p. 339 10. While reviewing an upright chest radiograph of a patient with a pleural effusion, the

respiratory therapist observes a fluid density in the 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

A meniscus sign is seen in a pleural effusion when fluid extends upward around the anterior, lateral, and posterior thoracic walls.

REF: p. 339 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.

REF: p. 339 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

It is estimated that up to 40% of patents with bacterial pneumonia have an accompanying pleural effusion.

REF: p. 338 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.

REF: p. 341 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.

REF: p. 338

Chapter 25: Kyphoscoliosis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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).

REF: p. 345 2. Which of the following would be expected to appear on the chest radiograph of a patient with

scoliosis?

Increased lung translucency An S or C shape to the spine Bullae Pectus excavatum

a. b. c. d.

ANS: B

The lateral curve of the spine found with scoliosis results in the spine having an S or C shape.

REF: p. 345 3. The major pathologic and structural changes of the lungs found with kyphoscoliosis include:

1. mediastinal shift.

2. elevated diaphragms.

3. lung compression.

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

Pulmonary changes found in a patient with kyphoscoliosis include mediastinal shift, lung compression, mucus accumulation (and atelectasis).

REF: pp. 345-346 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.

REF: p. 347 5. Positive risk factor(s) for the development of kyphoscoliosis include:

1. male gender.

2. female gender.

3. taller person.

4. shorter person. a. 1 b. 2 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.

REF: p. 347 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 REF: p. 347 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 scoliosis ANS: A

Bracing is the primary treatment for adolescent idiopathic scoliosis (AIS).

REF: pp. 349-350 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 b. 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.

REF: pp. 349-350 9. A patient has a 45-degree curvature of her spine. The physician is most likely to recommend

which of the following treatments?

Surgical intervention Observation checkup in about 3 months Milwaukee brace Boston brace

a. b. c. d.

ANS: A

Surgical correction is usually recommended for a patient with curvature of 40 to 50 degrees.

REF: pp. 350-351 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. 1, 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.

REF: p. 348 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 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: B

A patient with kyphoscoliosis may have a decreased vital capacity (VC) and decreased forced vital capacity (FVC).

REF: p. 348

12. A patient with severe kyphoscoliosis and chronic ventilatory failure with hypoxemia will have

all of the following laboratory findings, EXCEPT: increased PaCO2. increased hematocrit. normal pH. increased pH.

a. b. c. d.

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).

REF: pp. 348-349 13. In a case of severe kyphoscoliosis, which of the following chest radiograph findings would be

expected?

1. Enlarged heart 2. Areas of atelectasis 3. Increased lung opacity 4. Thoracic deformity a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 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.

REF: p. 349 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.

REF: p. 347 15. All of the following are orthotic braces used in the management of scoliosis EXCEPT

brace.

Boston Milwaukee Chicago Charleston bending

a. b. c. d.

ANS: C

The Boston brace, Milwaukee brace, and Charleston bending brace are orthotic options in the management of scoliosis.

REF: pp. 349-350 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.

REF: pp. 349-350

Chapter 26. Cancer of the Lung: Prevention and Palliation Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Benign tumors:

1. are metastatic.

2. grow slowly.

3. are usually encapsulated.

4. grow in a disordered manner. a. 1 b. 2 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.

REF: p. 374 2. Malignant tumors:

1. invade surrounding tissues.

2. grow slowly.

3. cause necrosis.

4. may be metastatic. a. 1 b. 4 c. 2, 4 d. 1, 3, 4 ANS: D

Malignant tumors invade surrounding tissues, cause necrosis of the tissue, and may be metastatic.

REF: p. 374 3. All of the following are pathologic or structural changes associated with bronchogenic

carcinoma EXCEPT: excessive mucous production. inflammation of the airways. alveolar consolidation. fibrocalcific pleural plaques.

a. b. c. d.

ANS: D

Fibrocalcific pleural plaques are associated with asbestosis, not bronchogenic carcinoma.

REF: p. 375

4. The most common cause of lung cancer is: a. cigarette smoking. b. air pollution. c. exposure to asbestos. d. exposure to radon gas.

ANS: A

Cigarette smoking far exceeds all other causes combined as the most common cause of lung cancer.

REF: p. 375 5. Which of the following is (are) small cell lung cancer(s)?

1. Undifferentiated carcinoma 2. Squamous carcinoma 3. Adenocarcinoma 4. Oat cell carcinoma a. 4 b. 1, 3 c. 2, 4 d. 1, 2, 3 ANS: A

Small cell lung cancer is also known as oat cell carcinoma because the cancer cells have a compressed, oval shape.

REF: p. 375 6. Which of the following is (are) non–small cell lung cancer(s)?

1. Large cell carcinoma 2. Squamous carcinoma 3. Adenocarcinoma 4. Oat cell carcinoma a. 1 b. 4 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.

REF: p. 375 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, 4 ANS: C

Staging is based on three factors: extent of the primary tumor, extent of metastasis, and lymph node involvement.

REF: pp. 377-378 8. What is the preferred surgical treatment for a large, single tumor located in the right lower

lobe?

Lobectomy Wedge resection Segmentectomy Pneumonectomy

a. b. c. d.

ANS: A

A lobectomy is preferred to reduce the chance of local recurrence.

REF: p. 391 9. A patient with lung cancer has learned the cancer has metastasized to three other locations.

What is the recommended treatment option?

Radiation therapy to all known tumors Surgical removal of all known tumors Chemotherapy Needle aspiration of the tumors

a. b. c. d.

ANS: C

Chemotherapy is a systemic treatment and would be the recommended treatment for metastatic tumors.

REF: p. 390 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.

REF: p. 390 11. Chest radiograph findings associated with lung cancer include all of the following EXCEPT

a(n): a. large irregular mass. b. enlarged heart. c. coin lesion.

d. pleural effusion.

ANS: B

The patient’s heart size should not be affected by a lung tumor.

REF: p. 384 12. Signs and symptoms associated with metastatic lung cancer include:

1. fatigue.

2. bone pain.

3. seizures.

4. weight loss. a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3, 4 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.

REF: pp. 377-378 13. Which of the following is the most common form of lung cancer among those who have never

smoked cigarettes or other tobacco products?

Squamous cell carcinoma Adenocarcinoma Large cell carcinoma Small cell carcinoma

a. b. c. d.

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.

REF: p. 377 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.

REF: p. 377 15. When a patient develops drooping eyelid and small pupil in the same eye, which of the

following syndromes is present? 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.

REF: pp. 377-378

Chapter 27. Interstitial Lung Diseases Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. All of the following are anatomic alterations of the lungs that may be found with the chronic

stage of interstitial lung disease (ILD) EXCEPT: honeycombing. edema. interstitial thickening. granulomas.

a. b. c. d.

ANS: B

Honeycombing, interstitial thickening, and granulomas are associated with the chronic stages of interstitial lung disease.

REF: p. 357 2. What major pathologic and structural changes are associated with asbestosis?

1. Fibrocalcific pleural plaques 2. Excessive bronchial secretions 3. Bronchospasm 4. Mediastinal shift a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: C

Fibrocalcific pleural plaques, bronchospasm, and excessive bronchial secretions are among the pathologic and structural changes associated with asbestosis.

REF: p. 358 3. All of the following are interstitial lung diseases EXCEPT: a. asbestosis. b. sarcoidosis. c. Staphylococcus. d. silicosis.

ANS: C

Staphylococcus is a bacteria and is NOT an example of an ILD. REF: p. 359 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. REF: p. 361 5. Which of the following organs are affected by systemic scleroderma?

1. Skin 2. Reproductive organs 3. Lungs 4. Brain a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 1, 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).

REF: p. 362 6. What is the most common pulmonary complication associated with systemic lupus

erythematosus (SLE)?

Bronchospasm Pleurisy Atelectasis Diaphragmatic dysfunction

a. b. c. d.

ANS: B

Pleurisy, with or without effusion, is the most common pulmonary complication associated with SLE. REF: pp. 363-364 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.

REF: pp. 363-364 8. Cryptogenic organizing pneumonia (COP) is associated with all of the following EXCEPT: a. COPD.

b. connective tissue disease. c. infection. d. toxic gas inhalation.

ANS: A

COP has been associated with infection, connective tissue disease, and toxic gas inhalation.

REF: pp. 363-364 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

Unfortunately, Wegener’s granulomatosis is considered an aggressive and fatal disorder.

REF: pp. 364-365 10. What category of medications is commonly prescribed to manage interstitial lung disease? a. Antibiotics b. Mucolytics c. Corticosteroids d. Diuretics ANS: C

Corticosteroids are prescribed to slow down or stop the progressive inflammation found with many interstitial lung diseases.

REF: p. 369 11. Chest assessment findings in a patient with ILD would include:

1. pleural friction rub.

2. increased vocal fremitus.

3. vesicular breath sounds.

4. hyperresonant percussion note. a. 1, 2 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: A

A patient with ILD would have a pleural friction rub and increased vocal (and tactile) fremitus.

REF: p. 366 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.

REF: p. 366 13. Which of the following chest radiograph findings would be associated in a patient with ILD?

a. b. c. d.

1. Pleural effusion 2. Honeycombing 3. Cavity formation 4. Increased translucency 1, 4 2, 3 1, 2, 4 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.

REF: p. 367 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.

REF: p. 366 15. All of the following are associated with lymphangioleiomyomatosis (LAM) EXCEPT: a. recurrent chylothoraces and recurrent pneumothoraces. b. increased airway obstruction. c. postmenopausal women are primarily affected. d. airway smooth muscle is affected.

ANS: C

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. REF: pp. 363-364 16. Which ILD is a smoking-related condition characterized by star-shaped nodules in the

midlung?

a. b. c. d.

PLCH LIP BOOP CWP

ANS: A

PLCH is a smoking-related ILD characterized by midlung-zone, star-shaped nodules with adjacent thin-walled cysts.

REF: pp. 364-365 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

Rheumatoid pneumoconiosis is also known as Caplan’s syndrome and is most often seen in coalminers.

REF: pp. 362-363

Chapter 28: Acute Respiratory Distress Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. All of the following materials will be found in the alveoli of a patient with ARDS EXCEPT: a. leukocytes. b. cellular debris. c. fibrin. d. hyaline membrane.

ANS: A

The presence of leukocytes in the alveoli is not associated with ARDS. REF: p. 395 2. A patient has a prolonged case of ARDS. What changes would be expected in the patient’s

alveolar cells?

Multiplication of the type I cells Influx of macrophages Hyperplasia and swelling of the type II cells Development of emphysema

a. b. c. d.

ANS: C

With a prolonged case of ARDS, the patient’s alveoli show hyperplasia and swelling of the type II cells.

REF: p. 395 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.

REF: p. 395 4. What is the reason for the elevated risk of 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.

REF: p. 397 5. ARDS can result from the inhalation of all of the following EXCEPT: a. FIO2 >0.60 for prolonged exposure. b. nitrogen dioxide. c. very dry air. d. chlorine gas.

ANS: C

Inhaling very dry air may be irritating to the upper airway but will not cause ARDS. REF: p. 397 6. Which of the following are causes of ARDS?

1. Liver failure 2. Heroin abuse 3. Septicemia 4. Goodpasture’s syndrome a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: C

Heroin abuse, septicemia, and Goodpasture’s syndrome are among the causes that can lead to ARDS. REF: p. 397 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. REF: p. 399

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.

REF: p. 400 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 suggested guideline for calculating the patient’s tidal volume is to start at 8 mL/kg of ideal body weight (8 mL/kg × 70 kg = 560 mL).

REF: p. 400 10. All of the following would be low–tidal volume ventilation goals in a patient with ARDS,

EXCEPT: decrease barotrauma. maintain plateau pressure >30 cm H2O. decrease high transpulmonary pressures. reduce overdistention of the lungs.

a. b. c. d.

ANS: B

With the low tidal volume strategy, the plateau pressure should be <30 cm H2O, not maintained at levels exceeding 30 cm H2O. REF: p. 400 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. REF: p. 398 12. Which of the following clinical manifestations are associated with ARDS?

1. Normal or decreased 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, 2, 3, 4 ANS: D

Clinical manifestations of ARDS may include low or normal PCWP, increased CVP, intercostal retractions, and cyanosis.

REF: p. 398 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.

REF: p. 399 14. According to the Berlin definition of ARDS, what does a PaO2/FIO2 ratio of 150 mm Hg

indicate for a patient on mechanical ventilation with a PEEP of 10 cm H2O? Normal lungs Mild ARDS Moderate ARDS Severe ARDS

a. b. c. d.

ANS: C

Moderate ARDS is present when the PaO2/FIO2 ratio falls between 100 and 199 mm Hg. REF: p. 397 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. REF: p. 397 16. When would symptoms of ARDS associated with a fat embolism from a long bone fracture be

most likely to develop?

2 to 4 hours following the fracture 4 to 12 hours following the fracture 12 to 48 hours following the fracture 48 to 96 hours following the fracture

a. b. c. d.

ANS: C

Between 12 and 48 hours after the fracture of a long bone, the symptoms of ARDS related to a fat embolism from the fracture would begin to appear.

REF: p. 397

Chapter 29: Guillain-Barré Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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. 3 b. 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.

REF: p. 403 2. Under microscopic inspection, the skeletal muscle nerves of a Guillain-Barré patient show all

of the following EXCEPT: a. hypertrophy. b. edema. c. inflammation. d. demyelination.

ANS: A

In GBS, the skeletal muscle nerves show edema, inflammation, and demyelination.

REF: p. 404 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. 1, 2, 3, 4 ANS: A

Alveolar consolidation and atelectasis are structural changes in the lungs of the Guillain-Barré patient with ventilatory failure.

REF: p. 404

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

While Guillain-Barré syndrome can be found in males and females of any age and ethnicity, individuals over 45 year of age are most frequently affected.

REF: p. 404 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

The autoimmune disorder found with Guillain-Barré syndrome results in the removal of the myelin sheath from around the peripheral nerve.

REF: p. 404 6. Common noncardiopulmonary manifestations associated with Guillain-Barré is (are):

1. difficulty swallowing.

2. leg pain.

3. distal paresthesia.

4. absent deep tendon reflexes. a. 1 b. 2, 3 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

The peripheral nerve problems associated with Guillain-Barré can cause difficulty swallowing, leg pain, distal paresthesia, and absent deep tendon reflexes.

REF: p. 405 7. The diagnosis of Guillain-Barré syndrome is based on all of the following EXCEPT: a. urinalysis shows elevated blood urea nitrogen. b. abnormal electromyography results. c. cerebrospinal fluid shows elevated protein level. d. clinical history.

ANS: A

Urinalysis and BUN levels are not used to diagnose Guillain-Barré syndrome.

REF: pp. 405-406

8. Clinical indications that a patient has impending acute ventilatory failure include:

1. pH <7.35.

2. vital capacity (VC) <20 mL/kg.

3. PaCO2 >45 mm Hg. 4. Negative inspiratory force (NIF) <25 cm H2O. a. 1, 3 b. 1, 2, 3 c. 2, 4 d. 1, 2, 3, 4 ANS: B

A vital capacity of less than 20 mL/kg, a PCO2 exceeding 45 mm Hg, and a pH below 7.35 all indicate impeding ventilatory failure.

REF: p. 406 |p. 408 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.

REF: p. 406 |p. 408 10. Which of following has been shown to shorten the course of a severe case of Guillain-Barré

syndrome?

Renal dialysis Plasmapheresis Blood transfusion NSAIDs

a. b. c. d.

ANS: B

Plasmapheresis can shorten a severe case of Guillain-Barré by removing the antibodies that attack the peripheral nerves.

REF: p. 406 |p. 408 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.

REF: p. 406 |p. 408 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. 4 b. 1, 2 c. 3, 4 d. 1, 2, 3, 4 ANS: B

Diminished breath sounds and crackles are associated with GBS. REF: p. 407 13. A Guillain-Barré syndrome patient has autonomic nervous system dysfunction which can

result in all of the following EXCEPT: tachycardia. hypotension. urinary retention. fever.

a. b. c. d.

ANS: D

Among the symptoms resulting from dysautonomia are tachycardia, hypotension that often alternates with hypertension, and urinary retention.

REF: p. 407 14. A patient with Guillain-Barré syndrome developed atelectasis. His chest radiograph findings

would be expected to show: “ground-glass” appearance. “honeycombing.” increased opacity. blunted costophrenic angles.

a. b. c. d.

ANS: C

When atelectasis occurs, the chest radiograph will show increased opacity.

REF: p. 407 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

Approximately 10-30% of patients with GBS develop respiratory muscle paralysis.

REF: p. 405 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? Chlamydia psittaci and Campylobacter jejuni Cytomegalovirus and mononucleosis Campylobacter jejuni and cytomegalovirus Mononucleosis and parainfluenza 2

a. b. c. d.

ANS: C

Campylobacter jejuni and cytomegalovirus are implicated in the majority of respiratory and GI infections that precede the onset of GBS. REF: p. 405 17. In the United States and Europe, what is the most common subtype of GBS? a. Miller Fisher syndrome (MFS) b. Acute motor axonal neuropathy (AMAN) c. Acute pandysautonomic neuropathy (APN) d. Acute inflammatory demyelinating polyneuropathy (AIDP) ANS: D

The most common GBS subtype in the United States and Europe is acute inflammatory demyelinating polyneuropathy (AIDP).

REF: p. 404

Chapter 30: Myasthenia Gravis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 411 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 descends.

ANS: C

A common finding in myasthenia gravis patients is the return of muscle strength after a rest period.

REF: pp. 413-414 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. atelectasis. a. 1, 4 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: D

Alveolar consolidation, airway obstruction, mucus accumulation, and atelectasis are structural changes in the lungs associated with a myasthenia crisis.

REF: p. 412 4. Which demographic group(s) is/are most likely to develop myasthenia gravis?

1. African-American females >40 years of age 2. White males <40 years of age 3. Females 15 to 35 years of age 4. Males 40 to 70 years of age a. 1 b. 4 c. 2, 3 d. 3, 4 ANS: D

Females of any ethnic background between ages 15 and 35 years and males of any ethnic background between 40 and 70 years of age are the most likely groups to develop myasthenia gravis.

REF: p. 413 5. Which of the following is (are) signs and symptoms associated with myasthenia gravis?

1. Double vision 2. Weakness of neck muscles 3. Drooping of eyelids 4. Difficulty speaking a. 2 b. 1, 3 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: D

All of the listed symptoms are associated with myasthenia gravis.

REF: p. 413 6. What test is usually performed to confirm the diagnosis of myasthenia gravis? a. RNS b. PFT c. CBC d. EEG ANS: A

A repetitive nerve stimulation (RNS) is the most frequently used electrodiagnostic test performed to confirm the diagnosis of myasthenia gravis. It would show abnormal muscle weakness with repeated stimulation.

REF: pp. 413-414 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

If a patient with myasthenia gravis is given edrophonium (TensilonÒ), his or her muscle strength will improve for a short time. The effect lasts only about 10 minutes.

REF: pp. 413-414 8. Which of the following values would be associated with impending ventilatory failure in a

patient with myasthenia gravis?

1. NIF –15cm H2O 2. VC 10 mL/kg 3. PaCO2 43 mm Hg 4. pH 7.36 a. 1 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.

REF: p. 416 9. Which of the following are among the treatment options for the patient with myasthenia

gravis?

1. Pyridostigmine (MestinonÒ) 2. Plasmapheresis 3. Thymectomy 4. Mechanical ventilation a. 1, 3 b. 2, 4 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

All of the listed options may be required to help in the treatment and management of a patient with myasthenia gravis.

REF: pp. 416-417 10. Complications commonly associated with long-term use of steroids in the management of

myasthenia gravis include all of the following EXCEPT: infections. cataracts. pulmonary edema. osteoporosis.

a. b. c. d.

ANS: C

Pulmonary edema is not a common complication associated with the long-term use of corticosteroids in myasthenia gravis.

REF: p. 416 11. A 50-kg (110-lb) 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 DB&C 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.

REF: p. 416 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 happens because the thymus is the source of the AChR antibodies that lead to the muscle weakness.

REF: p. 416 13. A patient has a severe case of generalized myasthenia gravis. It is most important that the

patient be monitored for: urine output. atrial fibrillation. hypotension. apnea.

a. b. c. d.

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.

REF: p. 417 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.

REF: p. 415 15. During a myasthenia crisis, a patient was placed on mechanical ventilation but is now stable.

What will the chest radiograph most likely show?

Normal lungs Mediastinal shift Pericardial tamponade Ground glass appearance

a. b. c. d.

ANS: A

With an uncomplicated case of myasthenia gravis, the patient’s chest radiograph should show normal lung fields.

REF: p. 415 16. Which of the following disrupt(s) 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.

REF: p. 413 17. What percentage of patients with only ocular myasthenia gravis are seropositive? a. <10% b. 25% c. 50% d. 90% ANS: C

Approximately half of patients with ocular myasthenia gravis have only seropositive myasthenia gravis.

REF: p. 413 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.

REF: pp. 413-414

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.

REF: pp. 413-414

Chapter 32. Sleep Apnea Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. All of the following are found during rapid eye movement sleep EXCEPT: a. the diaphragm functions normally. b. the person is easy to awaken. c. dreaming occurs. d. skeletal muscles are paralyzed.

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.

REF: p. 427 2. Signs and symptoms associated with obstructive sleep apnea include:

1. insomnia.

2. excessive daytime sleepiness.

3. hypothyroidism.

4. metabolic alkalosis. a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 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.

REF: p. 423 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.

REF: p. 421 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.

REF: p. 428 5. All of the following are evaluated during a polysomnographic sleep study EXCEPT: a. breath sounds. b. chest and/or abdominal movement. c. electro-oculogram (EOG). 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.

REF: p. 426 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).

REF: p. 423

7. Continuous positive airway pressure (CPAP) is useful in the management of the patient with

obstructive sleep apnea because it: pushes air into and out of the lungs like a mechanical ventilator. prevents airway collapse. stretches the J receptors in the chest wall to stimulate breathing. delivers a tidal volume breath to the patient.

a. b. c. d.

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.

REF: p. 432 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 negativepressure ventilation.

REF: p. 425 |p. 428 9. First-line treatment for the management of hyperventilation-related central sleep apnea

includes: CPAP. adaptive servo-ventilation (VPAP). mechanical ventilation. palatopharyngoplasty.

a. b. c. d.

ANS: A

Similar to OSA, continuous positive airway pressure (CPAP) has customarily been the firstline 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).

REF: pp. 434-435 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. 1, 2, 3, 4 ANS: C

Respiratory stimulants (like acetazolamide), supplemental oxygen, and adaptive servoventilation 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.

REF: p. 434 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?

Central sleep apnea COPD Obstructive sleep apnea Laryngeal edema (epiglottitis)

a. b. c. d.

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.

REF: p. 430 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. 1, 2, 3, 4 ANS: A

Sleep apnea is associated with an increase in both SVR and PVR. REF: p. 431 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.

REF: p. 431 14. The respiratory therapist is evaluating a patient for risk of obstructive sleep apnea. All of the

following are risk factors for obstructive sleep apnea EXCEPT: excess weight. neck size. hypertension. hypoglycemia. chronic nasal congestion.

a. b. c. d. e.

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.

REF: p. 424 15. All of the following may be an advantage of in-home portable sleep testing EXCEPT: a. convenience. b. patient acceptance. c. can be easily performed over multiple nights. d. decreased cost. e. published standards for scoring or interpretation.

ANS: E

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.

REF: pp. 428-429 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

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.

REF: p. 435

Chapter 33. The Newborn Disorders Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. Early clinical manifestations of an infant with respiratory distress include:

1. cyanosis.

2. substernal retractions.

3. expiratory grunting.

4. apnea. 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 or she will show cyanosis, sternal retractions, expiratory grunting, and other signs. He or she will have apnea and other signs later on.

REF: p. 446 2. Late clinical manifestations of an infant with respiratory distress include:

1. elevated diaphragm.

2. decreased respiratory rate.

3. CO2 retention.

4. lethargy. a. 2, 3 b. 1, 4 c. 1, 2, 3 d. 1, 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 or she will have lethargy and other signs early on. Elevated diaphragm is not an early or late sign of respiratory distress.

REF: p. 446 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 all of the following EXCEPT: cyanosis of dependent thoracic areas. “seesaw” breathing pattern. alveolar hyperinflation. intercostal retractions.

a. b. c. d.

ANS: C

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.

REF: p. 447 4. A neonate in respiratory distress will often dilate his or 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.

REF: p. 447 5. A neonatal patient is found to have grunting on expiration. What physiologic effect does this

produce? a. Increased vital capacity b. Increased PAO2 c. Decreased PaCO2 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.

REF: p. 447 6. Apnea of prematurity can be defined as:

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. 4 b. 2 c. 1, 3 d. 3, 4 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.

REF: p. 448

7. Apneic episodes in a premature neonate can be caused by all of the following EXCEPT: a. epiglottitis. b. immature central nervous system. c. immature airway receptors. d. immature chemoreceptors.

ANS: A

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.

REF: p. 448 8. Which of the following can trigger apnea in the premature infant?

1. Micrognathia 2. Intracranial hemorrhage 3. REM sleep 4. Hypothermia a. 2 b. 3, 4 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: D

All of the listed options can trigger apnea of prematurity. See Box 31-1 for the full list of possible triggering events or conditions.

REF: p. 448 9. Respiratory causes of persistent pulmonary hypertension of the newborn (PPHN) include:

1. congenital heart disease.

2. hypoxia.

3. meconium aspiration syndrome (MAS).

4. respiratory distress syndrome (RDS). 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 31-2 for the complete list.

REF: pp. 444-445 10. When a neonate has PPHN, what structure(s) does the blood flow through to bypass the

lungs?

1. Ductus venosus 2. Foramen ovale 3. Hypogastric arteries

4. Ductus arteriosus a. 2 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 Figure 31-3.

REF: p. 444 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 1st and 6th 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.

REF: pp. 444-445 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.

REF: pp. 444-445 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: 8.

5.

2.

1.

a. b. c. d.

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.

REF: p. 452 14. A newborn’s 5-minute Apgar score is 7. How should this be interpreted?

a. b. c. d.

Normal adjustment to being born Moderate distress; intubate the airway and suction the lungs Moderate distress; administer supplemental oxygen 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.

REF: pp. 449-450 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?

Hypoxemia Renal failure Intracranial hemorrhage Respiratory distress Septic shock

a. b. c. d. e.

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.

REF: p. 447 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 intra-pulmonary 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. e. The infant has shunting across the ductus venosus.

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.

REF: p. 445 17. A premature infant is suspected of having persistent pulmonary hypertension of the newborn.

How is this diagnosis confirmed? a. Arterial blood gas analysis b. Chest radiography

c. Pulmonary angiography d. Echocardiography e. Cardiac catheterization 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.

REF: p. 445

Chapter 35. Meconium Aspiration Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. How may a fetus respond when he or 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 or 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.

REF: p. 463 2. What is the consequence of meconium aspiration if there is a “ball-valve” effect in the small

airways?

Air trapping on exhalation Apnea of prematurity Air trapping on inhalation Bronchiectasis

a. b. c. d.

ANS: A

A “ball-valve” effect in the small airways will cause air trapping on exhalation. In other words, air will be inhaled but cannot be fully exhaled. Apnea of prematurity and bronchiectasis are not related to the “ball-valve” effect.

REF: pp. 463-464 3. A patient has meconium aspiration syndrome (MAS) and a chemical pneumonitis as a result.

What effect(s) can this have?

1. Decreased surfactant production 2. Increased bacterial growth 3. Edema of bronchial mucosa 4. Excessive bronchial secretions a. 3 b. 3, 4 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

A chemical pneumonitis caused by MAS can result in all of the listed options.

REF: p. 463

4. A neonate with MAS has hypoxemia. Which of the following can be a pulmonary effect of

this?

Status asthmaticus Persistent pulmonary hypertension of the newborn (PPHN) Bronchopulmonary dysplasia (BPD) Pulmonary fibrosis

a. b. c. d.

ANS: B

MAS can cause hypoxemia, which, in turn, can lead to PPHN. Hypoxemia will not cause status asthmaticus, BPD, or pulmonary fibrosis.

REF: p. 464 5. About how many neonatal patients with MAS will require mechanical ventilation? a. 50% b. 30% c. 10% to 15% d. 4% ANS: B

Only about 30% of the infants who have MAS will require mechanical ventilation. About 10% to 15% may develop a pneumothorax. MAS has about a 4% mortality rate.

REF: p. 464 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 ANS: B

Infants who are older than 42 weeks’ gestation are at greater risk for MAS because they have strong peristalsis and sphincter tone. It does not matter how full the infant’s bowel is or that there is amniotic fluid in his or her stomach.

REF: p. 464 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.

REF: p. 464 8. Indications that a newborn has aspirated meconium include all of the following EXCEPT: a. high Apgar score. b. meconium in amniotic fluid. c. newborn is not actively breathing. d. meconium staining on skin.

ANS: A

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.

REF: p. 466 9. It is highly suspected that a newborn has aspirated meconium. What actions should be

immediately undertaken?

1. Instill exogenous surfactant.

2. Suction out the meconium.

3. Begin mechanical ventilation.

4. Intubate the infant. a. 2, 4 b. 1, 2 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: A

If a newborn has aspirated meconium, it must be immediately removed. This is best done by inserting an oral endotracheal tube into the newborn’s trachea and passing a suction catheter through the tube to suction out the meconium. In most cases, this will eliminate the need for mechanical ventilation. Some infants with severe meconium aspiration will need to be mechanically ventilated and given exogenous surfactant.

REF: pp. 466-467 10. What risk(s) is (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. 2 b. 3 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.

REF: pp. 466-467 11. If mechanical ventilation is needed to support a neonate with MAS, which of the following

settings is especially important?

High positive end-expiratory pressure (PEEP) level Long exhalation time High humidity level Give no more than 50% oxygen

a. b. c. d.

ANS: B

Because of the risk of 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.

REF: p. 467 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 an infant with periodic breathing.

REF: p. 465 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, 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. Chest assessment findings may include rhonchi and crackles for breath sounds because of meconium in the airways. If the neonate is hypoxic, he or she may display expiratory grunting. However, these last two findings are not directly associated with the more negative intrapleural pressures needed during inspiration.

REF: p. 465 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. REF: p. 466 15. Hyperinflation is noted on the chest radiograph of a patient with MAS. What sudden

development(s) must be watched for?

1. PPHN 2. Pneumothorax 3. Cardiomegaly 4. Pneumomediastinum a. 2 b. 2, 4 c. 1, 2, 3 d. 2, 3, 4 ANS: B

If an infant with MAS has air trapping, he or she can suddenly develop a pneumothorax (about 10% to 15% of the time) or pneumomediastinum. PPHN and cardiomegaly are slow to develop.

REF: p. 466 16. The major pathologic or structural changes associated with the physical presence of

meconium in MAS include all of the following EXCEPT: partially obstructed airways, air trapping, and alveolar hyperinflation. pulmonary air leak syndromes (pneumomediastinum or pneumothorax). totally obstructed airways and absorption atelectasis. pulmonary edema and alveolar flooding.

a. b. c. d.

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.

REF: p. 464

Chapter 36. Transient Tachypnea of the Newborn Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 470 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 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. REF: p. 470 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.

REF: p. 470 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.

a. b. c. d.

4. atelectasis.

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

REF: p. 470 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.

REF: p. 470 6. What respiratory rate would be expected during the physical exam of a patient with TTN? a. 80 to 120 breaths/min b. 30 to 40 breaths/min c. 20 to 30 breaths/min d. Less than 20 breaths/min ANS: A

Infants with TTN will show significant tachypnea with a respiratory rate of 80 to 120/min commonly seen.

REF: p. 471 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.

REF: p. 471

8. All of the following are usually performed in the general management of a patient with TTN

EXCEPT: oxygen therapy administration. administration of diuretics. proper stabilization. ruling out other serious conditions.

a. b. c. d.

ANS: B

General care includes proper stabilization, administration of oxygen therapy, and ruling out other serious conditions.

REF: p. 473 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.

REF: p. 472 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, 3 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3, 4 ANS: B

Clinical manifestations associated with the more negative intrapleural pressures needed during inspiration include, but are not limited to, intercostal retractions and nasal flaring.

REF: p. 472 11. Initially, a mild case of TTN manifests itself clinically as a(n) a. restrictive pulmonary b. obstructive pulmonary c. equally restrictive and obstructive

disorder.

d. initially obstructive and then a progressively restrictive ANS: A

TTN manifests itself clinically as a restrictive pulmonary disorder because excess fluid in the lungs limits inspiration.

REF: p. 472 12. An infant with a mild case of TTN will show which of the following arterial blood gas

value(s)?

1. Increased pH 2. Decreased pH 3. Low PaO2 4. Low PaCO2 a. 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.

REF: p. 472 13. What are the radiologic findings anticipated on a chest radiograph taken 2 hours after delivery

in a newborn suspected of having TTN? Normal lung fields Hyperlucency Flattened diaphragms Bulging intercostal spaces

a. b. c. d.

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.

REF: p. 473 14. All of the following radiologic findings would be expected in a 12-hour-old neonate with TTN

EXCEPT: air bronchograms. fluid in the interlobular fissures. elevated diaphragms. prominent perihilar streaking.

a. b. c. d.

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.

REF: p. 473 15. On a chest radiograph, starbursts are indicative of:

a. b. c. d.

bacterial pneumonia. carinal carcinoma. pulmonary vascular congestion. foreign body aspiration.

ANS: C

Starbursts, also called perihilar streaking, are indicative of pulmonary vascular congestion.

REF: p. 473 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.

REF: p. 473 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.

REF: p. 470

Chapter 37. Respiratory Distress Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 476 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 body. Pulmonary fibrosis is not associated with RDS. REF: p. 477 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?

Bacterial pneumonia Pulmonary fibrosis Acute respiratory distress syndrome (ARDS) Meconium aspiration syndrome (MAS)

a. b. c. d.

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.

REF: p. 476 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.

REF: p. 476 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.

REF: p. 476 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 d. 1, 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.

REF: p. 476 7. Which of the following are associated with an increased risk of developing RDS?

1. Low–birth weight infant 2. Prenatal asphyxia 3. Maternal bleeding 4. Second-born twin a. 1, 2 b. 3, 4

c. 2, 3, 4 d. 1, 2, 3, 4 ANS: D

All of the listed conditions, and others, increase the risk of the neonate developing RDS. REF: p. 478 8. All of the following amniotic fluid lab findings would indicate mature fetal lungs EXCEPT: a. S:A ratio is >55. b. PG is present. c. L:S ratio is 2:1. d. L:S ratio is 1:2.

ANS: D

An L:S ratio of 1:2 (anything less than a 2:1 ratio) would indicate immature lungs and increased risk of RDS. 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.

REF: p. 478 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.

REF: p. 478 10. What special environmental concerns are there with a neonate with RDS in order to avoid

compromising his or 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

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.

REF: p. 580 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 of 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.

REF: p. 580 12. Management of a neonate with RDS may include:

1. CPAP. 2. instilling surfactant into the lungs.

3. mechanical ventilation.

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

All of the listed options may be needed to support a neonate with RDS. REF: pp. 580-581 13. The respiratory pattern of a neonate with RDS will have which of these characteristics?

a. b. c. d.

1. Respiratory rate of about 50/min 2. Respiratory rate of >60/min 3. Cyclical breathing pattern 4. Hard and deep breaths 1 2, 3 1, 4 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.

REF: p. 479 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 4. Dependent thoracic areas are cyanotic a. 1, 4 b. 2, 4

c. 1, 2, 3 d. 1, 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. REF: p. 479 15. It is likely that a neonate with RDS will have which of the following chest radiograph

findings?

Airway dilation and distortion Fluffy infiltrates in the bases of the lungs Ground-glass appearance Cardiomegaly

a. b. c. d.

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 left-sided heart failure.

REF: p. 580 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: between 25 and 50. between 40 and 70. between 80 and 100.

95 or greater.

a. b. c. d.

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).

REF: p. 580 17. In assessing a patient with RDS, the respiratory therapist would expect to find all of the

following EXCEPT: intercostal retractions. acrocyanosis. flaring nostrils. wheezing. cyanosis.

a. b. c. d. e.

ANS: D

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. REF: p. 479 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. e. transcutaneous monitoring.

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).

REF: p. 479

Chapter 38. Pulmonary Air Leak Syndrome Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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?

Meconium aspiration syndrome (MAS) Respiratory distress syndrome (RDS) Transient tachypnea of the newborn (TTN) Apnea of prematurity

a. b. c. d.

ANS: B

Prior to the introduction of exogenous surfactant, pulmonary air leak syndromes commonly occurred in preterm neonates with RDS on mechanical ventilation.

REF: p. 483 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 b. 1, 2 c. 3, 4 d. 2, 4 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.

REF: p. 484 3. All of the following are associated with a pneumopericardium EXCEPT: a. systemic hypotension. b. reduced cardiac output. c. decreased stroke volume. d. increased cardiac index.

ANS: D

A pneumopericardium will cause reduced cardiac output, decreased stroke volume, and systemic hypotension.

REF: p. 485 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.

REF: p. 485 5. Following delivery, when do pulmonary air leak syndromes commonly occur in preterm

neonates?

1 to 4 hours after delivery 5 to 8 hours after delivery 12 to 24 hours after delivery 24 to 48 hours after delivery

a. b. c. d.

ANS: D

A pulmonary air leak will often occur within the first 24 to 48 hours of life.

REF: p. 485 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 b. 3, 4 c. 1, 3, 4 d. 1, 2, 3, 4 ANS: C

A prolonged inspiratory time, high PIP, and high levels of PEEP during mechanical ventilation increase the risk of pulmonary air leak syndromes in a preterm neonate.

REF: p. 485 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?

Selectively place the endotracheal tube into the left mainstem bronchus.

Selectively place the endotracheal tube into the right mainstem bronchus.

Replace the endotracheal tube with a tracheostomy tube.

Change to continuous positive airway pressure (CPAP).

a. b. c. d.

ANS: A

Selectively intubating the left mainstem bronchus and ventilating just the left lung may allow the right lung to heal.

REF: p. 487 8. A neonate on mechanical ventilation developed pulmonary air leak syndrome. What change

should the respiratory therapist now recommend?

a. b. c. d.

Initiate the bronchopulmonary hygiene therapy protocol.

Decrease the oxygen percentage.

Initiate high-frequency ventilation.

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.

REF: p. 487 9. During the physical exam of a neonate with early pulmonary air leak syndromes, what

respiratory rate would be expected? <20 breaths/min 20 to 30 breaths/min 40 to 60 breaths/min >60 breaths/min

a. b. c. d.

ANS: D

An infant with early pulmonary air leak syndromes would be expected to have an elevated respiratory rate exceeding 60 breaths/min.

REF: p. 486 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, 3 c. 1, 2, 3 d. 1, 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.

REF: p. 486 11. A neonate with pulmonary interstitial emphysema has developed a pneumothorax. In the early

stages, a pneumothorax will manifest itself clinically as an equally restrictive and obstructive an obstructive pulmonary a restrictive pulmonary neither a restrictive nor an obstructive

disorder.

a. b. c. d.

ANS: C

In the early stages, a pneumothorax will manifest itself clinically as a restrictive pulmonary disorder.

REF: p. 486 12. A physician is performing transillumination to determine whether a neonate has a

pneumothorax. What finding would confirm the presence of a pneumothorax?

The trachea will be illuminated.

Light will shine through the hole in the lung.

There will be increased illumination on the unaffected side.

There will be increased illumination on the affected side.

a. b. c. d.

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.

REF: p. 486 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. 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.

REF: p. 487 14. Which of the following conditions is described as dissection of gas into the fascial planes of

the skin and neck?

ASIHD Intravascular air embolism PIE Subcutaneous emphysema

a. b. c. d.

ANS: D

Subcutaneous emphysema is the dissection of gas into the fascial planes of the neck and skin.

REF: p. 484 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

Diuretics may be beneficial in the treatment of SIADH (syndrome of inappropriate antidiuretic hormone).

REF: p. 489 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.

REF: p. 588

Chapter 39. Respiratory Syncytial Virus Infection (Bronchiolitis) Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 491 2. Anatomic alterations related to an RSV infection can lead to all of the following EXCEPT: a. pneumomediastinum. b. partial airway obstruction. c. decreased airway lumen. d. complete airway obstruction.

ANS: A

Pneumomediastinum is associated with a pulmonary air leak syndrome. RSV can lead to a decreased airway lumen or partial or complete airway obstruction.

REF: p. 491 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, 4 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.

REF: p. 491 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. REF: pp. 491-492 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 ANS: A

An adult with a compromised immune system who is over age 65 is at increased risk for a severe case of RSV. A history of asthma or being under age 30 is not an increased risk factor for RSV. REF: pp. 491-492 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

Most small children will recover within 1 to 2 weeks. However, even after recovery they may still spread the virus for 1 to 3 weeks.

REF: p. 492 7. Outbreaks of RSV are usually found in all of the following seasons of the year EXCEPT: a. spring.

b. summer. c. fall. d. winter.

ANS: B

RSV outbreaks are unusual in the summer months. The cold and flu season months have outbreaks of RSV. REF: p. 492 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. Consolidation a. 1, 2 b. 3, 4 c. 1, 2, 4 d. 1, 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. REF: p. 491 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) d. A sympathomimetic agent 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.

REF: p. 496 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. 1, 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. REF: p. 493 11. The physical examination of a neonate with RSV will often reveal all of the following

EXCEPT: change in point of maximum impulse (PMI). excessive secretions. expiratory grunting. cyanosis.

a. b. c. d.

ANS: A

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.

REF: p. 493 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. REF: p. 494 13. Infants with RSV do NOT benefit from which of the following? a. Chest percussion and drainage (CPT & D) b. High-flow nasal cannula therapy (HFNC) c. Bulb suctioning of the nares d. Nebulized hypertonic saline ANS: A

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.

REF: p. 496 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.

REF: p. 496 15. The diagnosis of RSV is most often confirmed with a sample obtained by: a. tracheal suctioning. b. venipuncture. c. arterial blood sampling. d. urine specimen. e. nasopharyngeal aspirate.

ANS: E

RSV is most commonly 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 office or emergency department.

The test is a rapid screen and is usually reliable—but a negative RSV-EIA does not rule out RSV. REF: p. 492

Chapter 40. Chronic Lung Disease of Infancy Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. What would contribute to the development of “new” bronchopulmonary dysplasia (BPD) in

an infant delivered at 25 weeks’ gestation?

Interruption of the canalicular stage of lung development Transient tachypnea of the newborn (TTN) Low Apgar scores Laryngotracheobronchitis

a. b. c. d.

ANS: A

An infant delivered at 25 weeks of gestation would have an interruption of the canalicular stage of lung development. This would result in a decreased number of alveoli (alveolar hypoplasia) and lead to BPD. REF: pp. 501-502 2. Which of the following “new” BPD criteria would indicate a mild case of the condition?

1. Breathing room air upon discharge 2. Needed nasal continuous positive airway pressure (CPAP) 3. Needs <30% oxygen upon discharge 4. Needed supplemental oxygen for 28 days a. 2, 3 b. 1, 4 c. 2, 3, 4 d. 1, 2, 4 ANS: B

Neonatal patients with a mild case of “new” BPD would have required supplemental oxygen for at least 28 days but are now breathing room air upon discharge.

REF: p. 503 3. Which of the following “new” BPD criteria would indicate a severe case of the condition?

1. Requires >30% oxygen upon discharge 2. Requires nasal CPAP at discharge 3. Requires room air upon discharge 4. Required supplemental oxygen for first 28 days of life a. 1, 2 b. 2, 4 c. 1, 2, 4 d. 3, 4 ANS: C

Infants with a severe case of “new” BPD require supplemental oxygen for at least 28 days and require >30% oxygen and/or nasal CPAP at discharge.

REF: p. 503 4. Which of the following can increase an infant’s likelihood of developing BPD? a. Birth weight >3000 g b. Overfeeding c. Use of beta2-agonists d. Bacterial sepsis ANS: D

Bacterial sepsis can increase an infant’s likelihood of developing BPD. REF: p. 504 5. All of the following ventilator parameters have been linked to the development of BPD

EXCEPT: a. high peak inspiratory pressure. b. ventilatory rate of 40 breaths/min. c. tidal volumes <5 mL/kg. d. high mean airway pressure.

ANS: C

Tidal volumes in the 4 to 6 mL/kg range are recommended to reduce volutrauma and would not contribute to the development of BPD. REF: p. 504 6. What changes result when stress fractures of the capillary endothelium and basement

membranes develop during mechanical ventilation?

Fluid leakage into alveolar spaces Bronchospasm Pulmonary embolism TTN

a. b. c. d.

ANS: A

Fluid leakage into alveolar spaces will occur if overinflation of the lungs causes stress fractures of the capillary endothelium and basement membranes.

REF: p. 504 7. Which of the following can increase an infant’s likelihood of developing BPD? a. Use of inhaled parasympatholytic agents b. Patent ductus arteriosus (PDA) c. High Apgar scores d. Meconium aspiration syndrome (MAS) ANS: B

A PDA has a high correlation with the incidence of BPD. None of the other listed options is associated with BPD. REF: p. 504 8. Which nutrient is essential for maintaining the epithelial cells of the tracheobronchial tree?

a. b. c. d.

Vitamin A Vitamin C Carbohydrates Proteins

ANS: A

Vitamin A is an essential nutrient in maintaining the epithelial cells of the tracheobronchial tree.

REF: p. 506 9. What agent can be administered to a preterm infant to help reduce lung inflammation and the

incidence of BPD? Vitamin D Bronchodilators Ribavirin (VirazoleÒ) Corticosteroids

a. b. c. d.

ANS: D

If a preterm infant is given corticosteroids, lung inflammation will be reduced and the chance of BPD will be reduced.

REF: p. 506 10. An infant is beginning to develop BPD. What can be given to promote pulmonary

vasodilation? a. Furosemide (LasixÒ) b. Inhaled nitric oxide (iNO) c. Inhaled albuterol d. FIO2 >50% ANS: B

Inhaled nitric oxide has been shown to be a pulmonary vasodilator and may be beneficial in infants with evolving BPD. REF: p. 506 11. Which of the following clinical manifestations are associated with BPD?

1. Expiratory grunting 2. Wheezes and crackles 3. Flaring nostrils 4. Intercostal retractions a. 1, 3 b. 1, 3, 4 c. 1, 2, 4 d. 1, 2, 3, 4 ANS: D

All of the listed clinical manifestations are associated with BPD. REF: p. 505

12. A neonate is reported to have classic Stage IV BPD 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 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).

REF: p. 505 13. A patient with classic Stage 1 BPD will have which of the following chest radiograph

findings?

Ground-glass granular pattern Emphysematous bullae Honeycomb appearance Mediastinal shift

a. b. c. d.

ANS: A

A patient with Stage 1 BPD will have chest radiograph findings of the ground-glass granular pattern found over the lung fields.

REF: p. 506 14. If a patient has an advanced stage of BPD, 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

During an advanced stage of BPD the neonate may develop cor pulmonale (right heart failure). This will be identified on the chest radiograph as an enlarged heart.

REF: p. 506 15. What is the most common chronic lung disease of premature infants? a. BPD b. Asthma c. Cystic fibrosis d. TTN ANS: A

BPD is the most common chronic lung disease of premature infants.

REF: p. 500 16. What is the major anatomic pathology associated with new BPD? a. Alveolar hypoplasia b. Alveolar hyperplasia c. Alveolar atelectasis d. Alveolar-capillary wall thickening ANS: A

Alveolar hypoplasia is the major anatomic pathology associated with new BPD. REF: pp. 501-502 17. What is the most significant treatment of the neonate for the prevention of BPD? 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 BPD. REF: p. 506

Chapter 41. Congenital Diaphragmatic Hernia Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. All of the following anatomic alterations may be found in a patient with a congenital

diaphragmatic hernia EXCEPT: lungs are compressed. atelectasis. hyperinflation. complete lung collapse.

a. b. c. d.

ANS: C

The lungs of a patient with a CDH are compressed rather than hyperinflated. This can lead to atelectasis or complete lung collapse.

REF: p. 511 2. What pulmonary change is associated with a Bochdalek hernia? a. Pulmonary hypoplasia b. Respiratory distress syndrome (RDS) c. Pulmonary edema d. Meconium aspiration ANS: A

Because of intestines in the chest cavity, the lungs are compressed in utero and pulmonary hypoplasia can result.

REF: p. 509 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.

REF: p. 510 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

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.

REF: p. 510 5. Which of the following are major pathologic and structural changes associated with a CDH?

1. Reduced 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. 1, 2, 3, 4 ANS: D

An infant with a CDH may have all of the listed problems.

REF: p. 510 6. The prognosis of an infant with a diaphragmatic hernia depends on which of the following

factors?

1. Success of the surgical diaphragmatic closure 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. 1, 2, 3, 4 ANS: D

All of the listed options will impact the prognosis for an infant with a CDH. The mortality rate for this condition is about 40%.

REF: p. 510 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 ANS: C

Immediately administer supplemental oxygen. The newborn should then have an endotracheal tube inserted and mechanical ventilation should be initiated.

REF: p. 512 8. What initial ventilator setting(s) would be recommended for a newborn with a CDH?

1. PEEP of 2-3 cm H2O 2. FIO2 of 1.0 3. Peak inspiratory pressure of 18-20 cm H2O 4. Respiratory rate of 40 breaths/min a. 2 b. 3, 4 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: D

All of the listed settings are appropriate. After the patient has been stabilized and arterial blood gas results have been evaluated, appropriate adjustments can be made per protocols.

REF: p. 512 9. What additional procedures or treatments might be required for a patient with a CDH and

significant pulmonary hypoplasia?

Plasmapheresis ECMO Cardiac pacemaker Bronchoscopy

a. b. c. d.

ANS: B

ECMO might be implemented when significant pulmonary hypoplasia exists to help improve oxygenation.

REF: pp. 512-513 10. An infant with a CDH also has pulmonary hypertension. Which of the following can be

administered to relieve this problem?

Inhaled nitric oxide (iNO) Inhaled parasympatholytic agent 80% helium–20% oxygen Corticosteroids

a. b. c. d.

ANS: A

It has been shown that iNO causes vasodilation and is used to treat pulmonary hypertension.

REF: p. 513 11. Which of the following auscultation findings would be associated with a CDH?

1. Bilateral bruits 2. Apical heartbeat heard over the unaffected side 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, 4 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.

REF: p. 511 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.

REF: p. 511 13. What effect would a substantial left-sided CDH have on pulmonary function test findings? a. A restrictive pulmonary disorder b. An obstructive pulmonary disorder c. An equally restrictive and obstructive disorder d. A restrictive disorder with increased DLCO ANS: A

A CDH manifests itself clinically as a restrictive pulmonary disorder because the displaced abdominal organs limits lung expansion and result in reduced lung volumes.

REF: p. 511 14. All of the following chest radiograph findings would be associated with a CDH EXCEPT: 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. REF: p. 512 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.

REF: p. 509 16. Which of the following is described as abnormal elevation of an intact diaphragm into the

chest cavity?

Diaphragmatic eventration Morgagni’s hernia Bochdalek’s hernia Diaphragmatic altimetry

a. b. c. d.

ANS: A

An abnormal elevation of an intact diaphragm is called diaphragmatic eventration.

REF: p. 509 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 FIO2s delivered by the device can cause oxygen toxicity and ROP. d. The high tidal volumes may result in pulmonary interstitial emphysema.

ANS: A

Bag and mask ventilation should not be used on a newborn with CDH. It could result in air swallowing, which expands the stomach and intestines and further compresses the affected lung.

REF: p. 512

Chapter 42. Congenital Heart Disease Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 516 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. 1, 2, 3, 4 ANS: C

PDA, ASD, and VSD are examples of defects with left-to-right shunts and therefore are noncyanotic defects.

REF: p. 516 3. Which cardiac anomaly is associated with coeur-en-sabot on a chest radiograph? a. TOF b. ASD c. VSD d. PDA ANS: A

The coeur-en-sabot or boot shape on the chest radiograph is the hallmark of tetralogy of Fallot (TOF).

REF: p. 521 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.

REF: pp. 516-517 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. REF: pp. 518-519 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.

REF: pp. 519-520 7. What is the most common congenital heart disorder? a. ASD b. VSD c. TGA d. TOF ANS: B

Ventricular septal defects are the most common of the congenital disorders and account for almost half of all congenital heart disease.

REF: pp. 519-520 8. All of the following are associated with tetralogy of Fallot EXCEPT: a. pulmonary artery stenosis. b. dextroposition of the aorta. c. right ventricular hypertrophy. d. atrial septal defect.

ANS: D

An atrial septal defect is not associated with tetralogy of Fallot.

REF: p. 521

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.

REF: pp. 523-524 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.

REF: pp. 523-524

Chapter 43. Croup and Croup-like Syndromes: Laryngotracheobronchitis, Bacterial Tracheitis and Acute Epiglottitis Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th Edition MULTIPLE CHOICE 1. When a patient has laryngotracheobronchitis (LTB), which of the following is the primary

anatomic alteration that is found?

Edema of the mucous membranes Airway smooth muscle contraction Excessive alveolar fluid Epiglottitis

a. b. c. d.

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.

REF: p. 528 2. All of the following anatomic alterations may be found in a patient with LTB EXCEPT: a. increased secretions. b. ineffective cilia. c. narrowed airway lumen. d. excessive surfactant production.

ANS: D

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. REF: pp. 528-529 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.

REF: pp. 528-529 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.

REF: p. 529 5. Most cases of LTB occur during which season(s) of the year?

1. Spring 2. Summer 3. Fall 4. Winter a. 1 b. 4 c. 3, 4 d. 1, 2, 3 ANS: C

LTB cases occur primarily during the fall and winter months.

REF: p. 529 6. The diagnosis of LTB is made by all of the following EXCEPT the child: a. has inspiratory stridor and barking cough. b. has a normal temperature or low fever. c. has a significant fever. d. can drink without difficulty.

ANS: C

A high fever is associated with epiglottitis rather than LTB. A patient with LTB may show the other listed findings.

REF: p. 529 7. Childhood vaccination is done to prevent which of the following possible causes of

epiglottitis?

Haemophilus influenza type B Streptococcus pneumoniae Diphtheria Parainfluenza viruses

a. b. c. d.

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.

REF: p. 529 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 or her tongue. a. 1, 2 b. 3, 4 c. 2, 3, 4 d. 1, 2, 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 or 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.

REF: p. 529 9. Management of LTB usually includes all of the following EXCEPT: a. close observation for breathing difficulties. b. having the child drink fluids. c. placement into a cool aerosol tent. d. endotracheal intubation.

ANS: D

A patient with LTB does not usually need an artificial airway. Care of a child with LTB can include close monitoring, oral fluids, and placement into a cool aerosol tent.

REF: p. 531 10. The medication racemic epinephrine (Micronefrin, Vaponefrin) is given to a patient with LTB

because it: is an effective bronchodilator. causes mucosal vasoconstriction. causes bradycardia. has an appealing taste and smell.

a. b. c. d.

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 bronchodilator, it is not given for this effect. The drug may cause tachycardia as a side effect. There should not be any particular taste to the drug because it is nebulized.

REF: p. 531 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 b. 4

c. 2, 4 d. 1, 3 ANS: C

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.

REF: p. 531 12. All of the following would be expected during the assessment of a young child with LTB

EXCEPT: decreased respiratory rate. diminished breath sounds. use of accessory muscles. hypoxemia.

a. b. c. d.

ANS: A

Assessment findings will likely include increased respiratory rate, diminished breath sounds, the use of accessory muscles, and hypoxemia.

REF: p. 530 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 tent 3. Antibiotics 4. Endotracheal or tracheostomy tube a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 1, 2, 3, 4 ANS: A

Treatment for LTB can include, but is not limited to, inhaled nebulized racemic epinephrine and a cool mist tent. Epiglottitis treatment often includes antibiotics and intubation.

REF: p. 531 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. 3 b. 2, 3 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.

REF: p. 531 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.

REF: p. 529 16. A patient has been diagnosed with bacterial epiglottitis. Which of the following antibiotics

should the respiratory therapist most likely recommend?

Amikacin (Amikin) Tobramycin (Nebcin) Cefalexin (Keflex) Ampicillin/sulbactam (Unasyn)

a. b. c. d.

ANS: D

Because acute epiglottitis almost always is caused by H. influenzae type B, appropriate antibiotic therapy MUST be part of the treatment plan. Ceftriaxone (Rocephin) and ampicillin/sulbactam (Unasyn) often are prescribed to cover the most common organisms that cause acute epiglottitis.

REF: p. 532 17. 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.

REF: p. 527

Chapter 44: Near Drowning/Wet Drowning Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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.

REF: p. 535 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 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. REF: p. 535 3. In comparing the pathologic changes to the lungs caused by fresh water versus salt water,

which of the following can be stated?

Salt water causes more damage.

Fresh water causes more damage.

Both cause identical pathologic changes.

Cold water of either type causes more damage than warm water of either type.

a. b. c. d.

ANS: C

The pathologic changes and injury to the lungs from fresh water and salt water near drownings are identical.

REF: p. 535 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, 2, 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.

REF: p. 535 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, 2, 3, 4 ANS: B

A younger age and colder water temperature increase the likelihood of surviving a neardrowning incident.

REF: p. 536 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 104° F c. Between 70° F and 98° F 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.

REF: p. 536 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, 3, 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.

REF: p. 538 8. Hospital management of near-drowning victims includes all of the following EXCEPT: a. measurement of arterial blood gas values. b. rewarming if the patient is hypothermic. c. measurement of venous blood gas values. d. chest radiography.

ANS: C

Venous blood gas values are not typically needed in the management of a near-drowning victim.

REF: p. 538 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, 4 ANS: A

Because of the lung changes that occur when water is inhaled, mechanical ventilation with PEEP will be needed by most patients.

REF: pp. 538-539 10. Warming techniques for a cold-water near-drowning victim include all of the following

EXCEPT: cooling the extremities and warming the body core. warming the inspired oxygen. heated intravenous solutions. heated lavage of the pericardial space.

a. b. c. d.

ANS: A

It would be counterproductive to cool the extremities while warming the core of the coldwater near-drowning victim.

REF: p. 539 11. After an extended time underwater, a near-drowning victim will most likely have:

a. b. c. d.

tachypnea. a normal respiratory rate. bradypnea. apnea.

ANS: D

The longer a victim is submerged, the more likely it is that he or she will be apneic.

REF: p. 537 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.

REF: p. 537 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.

REF: p. 537 14. The initial chest radiograph appearance of a near-drowning victim may include:

1. normal lung fields.

2. atelectasis.

3. pulmonary edema.

4. pencil point sign. a. 1, 3 b. 2, 4 c. 1, 2, 3 d. 1, 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.

REF: p. 538 15. In the United States, what percentage of pediatric drowning victims are male? a. 20% b. 40% c. 60% d. 80% ANS: D

According to the CDC, nearly 80% of pediatric drowning victims are male.

REF: p. 536 16. According to the World Health Organization, where does drowning rank worldwide as a cause

of unintentional death?

It’s the leading cause of unintentional death.

It’s the second leading cause of unintentional death.

It’s the third leading cause of unintentional death.

It ranks twenty-third among the causes of unintentional death.

a. b. c. d.

ANS: C

According to the WHO, drowning ranks third among the causes of unintentional deaths worldwide.

REF: p. 536 17. What is the upper time limit that a cold-water near-drowning victim can be submerged and

survive?

10 minutes 20 minutes 40 minutes 60 minutes

a. b. c. d.

ANS: D

Sixty minutes appears to be the limit that a near-drowning victim can remain submerged in cold water and survive.

REF: p. 536

Chapter 44: Smoke Inhalation, Thermal Injuries, and Carbon Monoxide Intoxication Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 8th 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. 1, 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.

REF: pp. 542-543 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. 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.

REF: p. 543 3. Which of the following conditions occurs in 20% to 30% of hospitalized fire victims with

facial burns?

Acute respiratory distress syndrome (ARDS) Upper airway obstruction Pneumonia Pulmonary embolism

a. b. c. d.

ANS: B

Between 20% and 30% of hospitalized patients with facial burns develop an upper airway obstruction.

REF: p. 543 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.

REF: pp. 544-545 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 compared with having a single problem.

REF: pp. 544-545 6. Which portion of the pulmonary system will be affected by the inhalation of low–water

solubility gases such as hydrogen chloride and phosgene?

Distal airways and alveoli Pulmonary vascular bed Upper airway Pulmonary lymphatic system

a. b. c. d.

ANS: A

Low–water solubility gases will penetrate and damage the distal airways and alveoli.

REF: pp. 544-545 7. All of the following will be typically found in the air of an enclosed house fire EXCEPT: a. steam. b. carbon monoxide. c. hydrogen cyanide. d. hydrogen chloride.

ANS: A

The burning of typical household materials will result in the release of carbon monoxide, hydrogen cyanide, and hydrogen chloride.

REF: pp. 544-545 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?

Perform a bronchoscopy to evaluate the trachea.

Perform endotracheal intubation.

Monitor her SpO2 once per shift.

Administer an aerosol treatment with racemic epinephrine.

a. b. c. d.

ANS: B

Endotracheal intubation should be performed as soon as possible because the patient is at a high risk for airway obstruction.

REF: p. 549 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.

REF: p. 550 10. All of the following classes of medications are commonly used in the care of patients with

smoke inhalation injury EXCEPT: parasympatholytics. mucolytics. sympathomimetics. monoclonal antibody.

a. b. c. d.

ANS: D

A monoclonal antibody, such as omalizumab, would not be indicated in the treatment of a smoke inhalation injury.

REF: p. 550 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, 4 ANS: B

Inspiratory stridor and painful swallowing are two of the clinical signs associated with acute upper airway obstruction due to thermal injury.

REF: p. 546 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.

REF: pp. 544-545 13. What COHb level is associated with a throbbing headache, nausea, vomiting, and impaired

judgment?

1% to 10% 10% to 20% 20% to 30% 30% to 50%

a. b. c. d.

ANS: C

With COHb levels between 20% and 30%, throbbing headaches, nausea and vomiting, and impaired judgment would be expected.

REF: p. 548 14. Which of the following radiographic findings would be associated with the intermediate stage

of recovery from a serious smoke inhalation injury?

Pulmonary edema/ARDS Patchy or segmental infiltrates Empyema Normal/full recovery

a. b. c. d.

ANS: A

During the intermediate stage (2 to 5 days after inhalation), signs of pulmonary edema and ARDS may appear on the chest radiograph.

REF: p. 548 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?

1 mL/kg of body weight 4 mL/kg of body weight 6 mL/kg of body weight 10 mL/kg of body weight

a. b. c. d.

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.

REF: p. 549 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

Cyanide poisoning can be treated with amyl nitrate.

REF: p. 549 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.

REF: p. 548 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?

27% 36% 45% 54%

a. b. c. d.

ANS: C

Approximately 45% of the patient’s BSA was burned: head and neck (9%), both arms (9% × 2 = 18%), and anterior trunk (18%).

REF: pp. 544-545