Chapter 32: Disorders of the Pleura Test Bank

Multiple Choice

1. Excessive amounts of pleural fluid may require drainage through a chest tube. What is the normal amount of fluid present in the pleural space?

a. 1 L b. 5 to 10 L c. 10 to 50 mL d. 1 to 5 mL

ANS: D

The pleural "space" is generally only a potential space with a normal fluid volume of 1 to 5 mL. The pleural membranes, however, are very thin and permeable to both liquid and gas; an estimated 5 to 10 L of fluid per day crosses from the parietal pleura to the visceral pleura in a normal adult.

REF: p. 623 a. Intracapillary hydrostatic pressure b. Subatmospheric pressure in the pleural space c. Pleural pressure d. Intra-alveolar pressure

2. Which of the following factors determines the amount of fluid present in the pleural space?

ANS: B

Several factors determine the amount of fluid in the pleural space. The intracapillary hydrostatic pressures tend to drive fluid out of the capillaries, whereas the pericapillary hydrostatic pressures tend to counterbalance this force. The plasma colloid osmotic pressures exert a force to retain fluid within the capillaries, whereas the pericapillary colloid osmotic pressure tends to favor fluid movement out of the capillaries. Changes in the balance of these forces determine how much fluid is retained within the pleural space.

REF: p. 623

3. Which of the following clinical conditions causes fluid to accumulate in the pleural space? a. Congestive heart failure b. Asthma c. Cor pulmonale d. Chronic obstructive pulmonary disease

ANS: A

Increased capillary permeability (e.g., acute respiratory distress syndrome), decreased intravascular colloid osmotic pressure (e.g., low serum albumin), and increased pulmonary venous pressure (e.g., heart failure) are common contributors to accumulation of fluid in the pleural space. Obstructed lymphatic drainage is another factor that favors accumulation of fluid in the pleural space.

REF: p. 623 a. Increased capillary permeability b. Decreased osmotic pressure c. Increased hydrostatic pressure d. Obstructed lymphatic drainage

4. Which of the following mechanisms explains the accumulation of fluid in the pleural space of patients with ARDS?

ANS: A

Increased capillary permeability (e.g., acute respiratory distress syndrome), decreased intravascular colloid osmotic pressure (e.g., low serum albumin), and increased pulmonary venous pressure (e.g., heart failure) are common contributors to accumulation of fluid in the pleural space. Obstructed lymphatic drainage is another factor that favors accumulation of fluid in the pleural space.

REF: p. 623

5. In which of the following body positions are radiographs generally taken to reveal the presence of excess fluid in the pleural space? a. Anteroposterior (AP) recumbent b. Posteroanterior (PA) recumbent c. Fowler d. Lateral decubitus

ANS: D

In healthy individuals the chest radiograph seldom demonstrates any pleural fluid. An estimated 4% of normal adults may have minor radiographic evidence of pleural fluid if the films are taken in the decubitus or Trendelenburg position.

REF: pp. 623-624 a. Wheezing; hyperresonance b. Crackles; bronchovesicular c. Crackles; dull d. Diminished; dull

6. What type of auscultatory and percussion findings often reveal evidence of a pleural effusion?

ANS: D

Pleural effusions may be suspected clinically when there is an area of decreased-intensity breath sounds on chest auscultation with an associated dullness to percussion over the corresponding area.

REF: p. 624

7. Which of the following clinical symptoms is associated with a pleural effusion? a. Chest pain b. Productive cough c. Dyspnea d. Dysphagia

ANS: A

The patient may experience few symptoms from a small pleural effusion but usually has symptoms of respiratory distress with larger accumulations. Chest pain, chest wall tenderness, dyspnea, and pain with coughing or deep breathing are often associated with pleural effusions.

REF: p. 624 a. Increased intracranial pressure b. Pneumothorax c. Pneumonia d. Consolidation

8. Which of the following conditions is considered a complication of a thoracentesis?

ANS: B

Complications of thoracentesis include pneumothorax, hemorrhage, and infection.

REF: p. 624 a. Empyema b. Congestive heart failure c. Parapneumonic effusion d. Adenobacterial effusion

9. What is the most common cause of pleural effusion in the pediatric population?

ANS: C

The most common cause of pleural effusion in pediatrics is a parapneumonic effusion, which indicates that the pleural fluid is the result of an underlying pneumonia. Although typically a bacterial pneumonia, parapneumonic effusion can also result from a virus, fungus, or parasite, or from tuberculosis. If the pneumonia extends to infect the pleural space as well, the effusion is termed an empyema.

REF: p. 625

10. Fluid drained from a thoracentesis has the appearance of pus. Which of the following microorganisms should the therapist typically suspect in children with empyema? a.

Staphylococcus aureus b. Streptococcus pneumoniae c. Klebsiella pneumoniae d. Mycoplasma pneumoniae

ANS: B

Streptococcus pneumoniae is the most common organism causing pneumonia and empyema in children.

REF: p. 626 a. Determination of the causative microorganism b. pH determination c. Determination that the effusion is an exudate or a transudate d. Composition testing

11. Which of the following laboratory analyses would the respiratory therapist possibly conduct, using a sample of pleural fluid?

ANS: B

The respiratory therapist may be asked to determine the pleural fluid pH using a blood gas analyzer. The specimen must be collected anaerobically in a heparinized syringe and kept on ice until it is analyzed. A pH < 7.0 or < 0.15 pH unit below the arterial pH in a patient with parapneumonic effusion may indicate that the patient is at risk for prolonged effusion and subsequent lung entrapment. This has not been extensively studied in children.

REF: p. 626 a. Cough and headache b. Shortness of breath and chest pain c. Hemoptysis and chest pain d. Dry cough and dyspnea

12. Which of the following are the most common symptoms associated with pneumothorax?

ANS: C

A small percentage of patients with a pneumothorax are asymptomatic or have only mild and vague symptoms; however, it is much more common for chest pain and shortness of breath to accompany the pneumothorax.

REF: p. 626 a. Insertion of thoracostomy tubes b. Thoracotomy c. Thoracentesis with a large-bore needle d. Needle thoracostomy

13. What procedure should the therapist suggest to relieve a tension pneumothorax while awaiting more definitive treatment?

ANS: C

Treatment of the pneumothorax depends on whether it is under tension. The tension pneumothorax is an emergency and should be relieved as soon as possible. The pleural space is drained by thoracentesis with a large-bore needle while awaiting more definitive therapy.

REF: p. 627

14. The therapist is assessing a water seal and a collection chamber and observes bubbling in the water seal chamber. What should the therapist do at this time? a. Nothing because bubbling indicates normal function b. Increase the suction pressure c. Reassess the patient because bubbling indicates presence of air leak d. Remove the chest tube

ANS: C

The level of water in the suction control chamber determines the amount of negative pressure applied to the pleural space. Bubbling in the water seal chamber indicates ongoing air leaks, which are usually from the pleural space.

REF: p. 627

Chapter 33: Neurologic and Neuromuscular Disorders Test Bank

Multiple Choice

1. What are the names of the separate pathways in the spinal cord that support both voluntary and involuntary ventilation and transmit signals through descending pathways to motor neurons?

a. Voluntary, reticulospinal; involuntary, corticospinal b. Voluntary, cervicothoracic; involuntary, reticulospinal c. Voluntary, corticospinal; involuntary, reticulospinal d. Voluntary, corticospinal; involuntary, cervicothoracic

ANS: C

Separate pathways in the spinal cord support both voluntary (corticospinal) and involuntary (reticulospinal) ventilation and transmit signals through descending pathways to motor neurons in the cervicothoracic portion of the spinal cord. These motor neurons transmit signals through peripheral nerves and across the neuromuscular junctions to the muscles of respiration. Dysfunction in any part of this control system, from brainstem to respiratory muscles, can result in respiratory failure.

REF: p. 633 a. Internal intercostal muscles b. Transversus abdominis c. Sternocleidomastoid muscles d. Diaphragm

2. Which of the following muscles is considered a primary muscle of inspiration?

ANS: D

The main inspiratory muscle is the diaphragm, which contributes almost three quarters of the inspiratory capacity and increases the vertical dimension of the thorax. Cervical nerves 3 to 5 contribute to form the phrenic nerve, which drives the diaphragm. Additional inspiratory force is provided by the external intercostal muscles, which contract to expand the rib cage during inspiration. The innervation of the intercostal muscles occurs via the intercostal nerves, which come off the thoracic spinal nerve roots.

REF: p. 633

3. What are the consequences of bulbar muscle dysfunction?

I. Dysphagia

II. Impaired coughing

III. Dysarthria

IV. Impaired inspirationa. II and IV only b. I and III only c. I, II, and III only d. II, III, and IV only

ANS: C

The bulbar muscles are enervated by the motor neurons emanating from the brainstem. This muscle group controls the epiglottis and other glottic structures, tongue, mouth, larynx, and throat. Bulbar muscle weakness impairs swallowing, coughing, speech, and other throat and pharyngeal activities. Bulbar muscle weakness also leads to severe fixed and variable extrathoracic upper airway obstruction on forced inspiratory and expiratory respiratory efforts.

REF: p. 634 a. Laughing b. Sleeping c. Eating d. Crying

4. Ondine’s curse, or congenital central hypoventilation syndrome, occurs during which activity?

ANS: B

One of the best examples of a CNS disorder that affects breathing is congenital central hypoventilation syndrome. Also known as Ondine’s curse, this represents a condition involving hypoventilation associated with sleep.

REF: p. 634

5. The therapist is asked to evaluate a young child with a diagnosis of Chiari malformation. Which of the following signs and symptoms should the therapist expect to see?

I. Irregular breathing

II. Difficulty swallowing

III. Vomiting

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

ANS: D

Younger children with Chiari malformations may present with difficulty swallowing, choking, irregular breathing patterns, or apnea.

REF: p. 635

6. The therapist is performing an airway clearance technique to a 5-month-old child with a diagnosis of aspiration pneumonia. The child has a very weak cough and, although he appears alert, he cannot move. Which of the following disorders of the motor nerve should the therapist suspect? a. Polio b. Myasthenia gravis c. Spinal muscular atrophy d. Guillian-Barré

ANS: C

SMA type I, also called Werdnig-Hoffmann disease, is the acute infantile form, which usually presents within the first 6 months of life. In these children, limb weakness develops rapidly, whereas the facial muscles are slower to fail and the extraocular muscles are essentially spared. The result is a child who appears alert and responsive but cannot move. The respiratory effects of SMA type I include weakness of the bulbar, abdominal, and intercostal muscles, which makes feeding difficult and leads to aspiration and a weak, ineffective cough. A weak cough results in recurrent pneumonias and poor airway clearance. Even relatively minor viral infections result in severe airway and ventilator compromise. Without intervention, most infants will die of respiratory insufficiency and infection before reaching 1 year of age.

REF: p. 635

7. Which of the following forms of poliomyelitis affects the nerves in the cervical spine region that control diaphragmatic function? a. Spinal b. Bulbar c. Bulbospinal d. Bulbosacral

ANS: C

Depending on the site of paralysis, paralytic polio is classified as spinal, affecting the nerves of the trunk and extremities; bulbar, affecting the nerves that control breathing, speaking, and swallowing; or bulbospinal, representing a combination of these two forms. Bulbospinal polio is particularly problematic because it affects the nerves in the cervical spine region that control diaphragm function. Destruction of these nerves makes independent respiration, swallowing, and effective coughing impossible. Lifelong ventilator support and airway clearance is essential for the survival of these patients.

REF: p. 635

8. Which of the following diseases is characterized by demyelination of sheaths that coat peripheral nerves? a. Poliomyelitis b. Guillain-Barré syndrome c. Chiari malformations d. Infantile botulism

ANS: B

Although its cause is not completely understood, Guillain-Barré syndrome (GBS) is probably triggered by an acute infectious process, which leads to antibody-mediated destruction of the myelin sheaths that coat peripheral nerves.

REF: p. 635

9. A therapist is administering incentive spirometry to a patient who demonstrates ptosis, diplopia, and a weak cough. The patient has a history of a minimal chronic respiratory disease. Which of the following disorders is likely affecting this patient? a. Guillain-Barré syndrome b. Becker muscular dystrophy c. Duchenne muscular dystrophy d. Myasthenia gravis

ANS: D

The initial features of both the ocular and generalized forms are usually ptosis, diplopia, or both. Prepubertal onset is associated with a slight male bias and ocular symptoms only, whereas postpubertal onset is associated with a strong female bias and generalized myasthenia. Patients with myasthenia gravis (MG) often have little chronic respiratory compromise and are symptomatic only during periods of myasthenia crisis, when symptoms, particularly bulbar symptoms, suddenly escalate. During one such crisis patients may have sudden paralysis of the respiratory muscles, temporarily requiring assisted ventilation.

REF: p. 636

10. Which of the following neuromuscular diseases is characterized in early childhood by progressive muscle weakness, followed by skeletal and respiratory muscle weakness, and in adolescence by confinement to a wheelchair and requirement for ventilatory assistance? a.

Amyotrophic lateral sclerosis b. Duchenne muscular dystrophy c. Glycogen storage disease d. Becker muscular dystrophy

ANS: B

The muscle weakness is progressive and eventually leads to profound skeletal and respiratory muscle weakness in all cases. By adolescence, all patients with DMD are wheelchair bound and require assistance with ventilation.

REF: p. 637

11. Which of the following diseases is characterized by chronic, slowly progressive muscle wasting and weakness, cataracts, heart conduction defects, and endocrine disorders? a.

Glycogen storage disease b. Spinal muscular atrophy c. Myotonic dystrophy d. Becker muscular dystrophy

ANS: C

Myotonic dystrophy is a highly variable inherited disease characterized by chronic, slowly progressive muscle wasting and weakness, cataracts, heart conduction defects, and endocrine disorders.

REF: p. 637

12. Which of the following glycogen storage diseases has the most severe respiratory symptoms? a. Pompe disease b. Diabetes c. Von Gierke d. Forbes-Cori disease

ANS: A

In terms of respiratory involvement, glycogen storage disease type II (also called Pompe disease or acid maltase deficiency) has the most severe symptoms.

REF: p. 637

13. Which of the following measurements is the main determinant of respiratory compromise in pediatric patients with neuromuscular disease? a. Forced vital capacity b. Forced expiratory volume in 1 second c. Forced inspiratory volume d. Flows during coughing

ANS: D

The use of pulmonary function tests (PFTs) in diagnosing and monitoring the progression of neuromuscular disease has been well established in adults, but pediatric testing remains a challenge. Although newer techniques for respiratory muscle strength testing are being introduced, the majority of school-age children and adolescents are best monitored by standard spirometry with maximal inspiratory and expiratory pressure monitoring. Additional testing includes assessment of cough flows because they are the main determinant of respiratory compromise.

REF: p. 638

14. Which of the following diagnostic evaluations is/are appropriate for children with neuromuscular dysfunction who exhibit progressive carbon dioxide retention, increasing muscle weakness, and advancing concerns regarding nighttime hypoventilation? a.

Spirometry studies b. Complete pulmonary function studies c. Home overnight oximetry d. Arterial blood gas analysis and pulse oximetry

ANS: C

With further progression of carbon dioxide retention and muscle weakness and advancing concerns regarding nighttime hypoventilation, home overnight oximetry or polysomnography may be useful in determining the early need for assisted respiratory support.

REF: p. 638 a. Airway clearance techniques b. Oxygen therapy c. Ventilatory support d. Hydration

15. Which of the following therapeutic strategies should the therapist deem as the most important in patients with neuromuscular disease?

ANS: A

Children with neuromuscular weakness may have trouble with each phase of coughing. Inspiratory muscle weakness reduces vital capacity and maximal inhaled volume, bulbar muscle weakness can lead to impaired glottic closure, and expiratory muscle weakness reduces the maximal intrathoracic pressure and expulsive force. The significance of this cannot be overstated: in patients with neuromuscular disease, most episodes of acute respiratory failure result from the inability to eliminate airway secretions and mucus during otherwise benign chest infections. A peak cough flow less than 160 L/minute is associated with impaired secretion clearance, but early intervention at 250 to 270 L/minute is recommended for beginning cough assistance.

REF: p. 639