Chapter 5: Respiratory Flashcards
1
Q
- What pulmonary defense mechanism propels a mucous blanket that entraps particles moving toward the oropharynx?
a. Nasal turbinates
b. Alveolar macrophages
c. Cilia
d. Irritant receptors on the nares
A
c. Cilia
The submucosal glands of the bronchial lining produce mucus, contributing to the mucous blanket that covers the bronchial epithelium. The ciliated epithelial cells rhythmically beat this mucous blanket toward the trachea and pharynx, where it can be swallowed or expectorated by coughing. This selection is the only option that accurately identifies the pulmonary defense mechanism described.
2
Q
- Which term is used to identify the movement of gas and air into and out of the lungs?
a. Perfusion c. Respiration
b. Ventilation d. Diffusion
A
b
3
Q
- When an individual aspirates food particles, where would the nurse expect to hear decreased or absent breath sounds?
a. Left lung
c. Trachea
b. Right lung
d. Carina
A
B
The right mainstem bronchus extends from the trachea more vertically than the left main bronchus; therefore aspirated fluids or foreign particles tend to enter the right lung rather than the left or any of the other locations listed.
4
Q
- Aspiration is most likely to occur in the right mainstem bronchus because it:
a. Extends vertically from the trachea.
b. Is narrower than the left mainstem bronchus.
c. Comes into contact with food and drink first.
d. Is located at the site where the bronchi bifurcate.
A
A
The right mainstem bronchus extends from the trachea more vertically than the left mainstem bronchus; therefore aspirated fluids or foreign particles tend to enter the right lung rather than the left. The size of both mainstems is equal. The trachea comes into contact with food and drink first, and the carina is the site where the bronchi bifurcate.
5
Q
What is vital capacity?
A
Max amount of air a person could expel (inspiratory reserve volume + tidal volume + expiratory reserve volume)
6
Q
- Air passage among alveoli is collateral and evenly distributed because of the function of which structures?
a. Type I alveolar cells c. Acinus pores
b. Pores of Kohn
d. Alveolar pores
A
B
Tiny passages called pores of Kohn permit some air to pass through the septa from alveolus to alveolus, promoting collateral ventilation and even distribution of air among the alveoli. This selection is the only option that accurately describes the function that allows air passage among alveoli.
7
Q
- Surfactant produced by type II alveolar cells facilitates alveolar distention and ventilation by which mechanism?
a. Decreasing thoracic compliance
b. Attracting water to the alveolar surface
c. Decreasing surface tension in the alveoli
d. Increasing surface tension in the alveoli
A
C
Surfactant, a lipoprotein produced by type II alveolar cells, has a detergent-like effect that separates the liquid molecules, thereby decreasing alveolar surface tension. This selection is the only option that accurately describes the mechanism that allows surfactant to facilitate alveolar distention and ventilation.
8
Q
- Where in the lung does gas exchange occur?
a. Trachea
c. Alveolocapillary membrane
b. Segmental bronchi d. Main bronchus
A
c
9
Q
- Which part of the brainstem provides basic automatic rhythm of respiration by sending efferent impulses to the diaphragm and intercostal muscles?
a. Dorsal respiratory group (DRG) c. Pneumotaxic center
b. Ventral respiratory group d. Apneustic center
A
A
The basic automatic rhythm of respiration is set by the DRG, a cluster of inspiratory nerve cells located in the medulla that sends efferent impulses to the diaphragm and inspiratory intercostal muscles. This selection is the only option that accurately identifies the appropriate brainstem location.
10
Q
- Which structures secrete surfactant?
a. Type I alveolar cells c. Alveolar macrophages
b. Type II alveolar cells d. Stretch receptors
A
b. Type II alveolar cells
Two major types of epithelial cells appear in the alveolus. Type I alveolar cells provide structure, and type II alveolar cells secrete surfactant, a lipoprotein that coats the inner surface of the alveolus and facilitates its expansion during inspiration, lowers alveolar surface tension at end- expiration, and thereby prevents lung collapse. Neither alveolar macrophages nor stretch receptors secrete surfactant.
11
Q
- Which structure is not associated with any lymphatic vessels?
a. Trachea c. Acinus
b. Bronchi d. Terminal bronchioles
A
C
No lymphatic structures are located in the acinus. The other options are associated with lymphatic vessels.
acinus - region of the lung supplied with air from terminal bronchioles
12
Q
- Which describes the pressure in the pleural space?
a. Atmospheric c. Above atmospheric
b. Below atmospheric d. Variable
A
: B
Pressure in the pleural space is usually negative or subatmospheric (−4 to −10 mm Hg). This selection is the only option that accurately describes pleural space pressure.
13
Q
- The adequacy of a person’s alveolar ventilation is assessed best by monitoring which mechanism?
a. Ventilatory rate c. Respiratory effort
b. Ventilatory pattern d. Arterial blood gas
A
D
Observation of the ventilatory rate, pattern, or effort cannot determine the adequacy of alveolar ventilation. If a health care professional needs to determine the adequacy of ventilation, then an arterial blood gas analysis must be performed to measure partial pressure of arterial carbon dioxide (PaCO2).
14
Q
- Which normal physiologic change occurs in the aging pulmonary system?
a. Decreased flow resistance c. Stiffening of the chest wall
b. Fewer alveoli d. Improved elastic recoil
A
C
Normal alterations include (1) loss of elastic recoil, (2) stiffening of the chest wall, (3) alterations in gas exchange, and (4) increases in flow resistance (see Figure 34-18). The number of alveoli is not affected by age.
15
Q
- How is most of the oxygen in the blood transported?
a. Dissolved in plasma c. In the form of carbon dioxide (CO2)
b. Bound to hemoglobin d. Bound to protein
A
B
Oxygen is transported in the blood in two forms. A small amount dissolves in plasma, and the remainder binds to hemoglobin molecules. The other options are not involved in this process.
16
Q
- Stretch receptors and peripheral chemoreceptors send afferent impulses regarding ventilation to which location in the brain?
a. Pneumotaxic center in the pons
b. Apneustic center in the pons
c. Dorsal respiratory group (DRG) in the medulla oblongata
d. Ventral respiratory group (VRG) in the medulla oblongata
A
C
The respiratory center is made up of several groups of neurons located bilaterally in the brainstem: the DRG, the VRG, the pneumotaxic center, and the apneustic center. Of the options available, only the DRG group in the medulla oblongata receives afferent impulses in the situation described
17
Q
- Which substances cause airway epithelium to constrict?
a. Epinephrine and acetylcholine c. Bradykinin and thromboxane A
b. Histamine and prostaglandin d. Leukotrienes and prostacyclin
A
b
Constriction occurs if the irritant receptors in the airway epithelium are stimulated by irritants in inspired air, by endogenous substances (e.g., histamine, serotonin, prostaglandins), by many drugs, and by humoral substances. Of the options available, only histamine and prostaglandin cause constriction.
18
Q
- If a patient develops acidosis, the nurse would expect the oxyhemoglobin dissociation curve to react in which manner?
a. Shift to the right, causing more oxygen (O2) to be released to the cells
b. Shift to the left, allowing less O2 to be released to the cells
c. Show no change, allowing the O2 concentration to remain stable
d. Show dramatic fluctuation, allowing the O2 concentration to increase
A
a
A shift to the right depicts hemoglobin’s decreased affinity for O2 or an increase in the ease with which oxyhemoglobin dissociates and O2 moves into the cells. The oxyhemoglobin dissociation curve is shifted to the right by acidosis (low pH) and hypercapnia (increased partial pressure of arterial carbon dioxide [PaCO2]). This selection is the only option that accurately identifies what will happen to the oxyhemoglobin dissociation curve if acidosis occurs.
19
Q
- How is most carbon dioxide (CO2) in the blood transported?
a. Attached to oxygen c. Combined with albumin
b. In the form of bicarbonate d. Dissolved in the plasma
A
B
Approximately 60% of the CO2 in venous blood and 90% of the CO2 in arterial blood are carried in the form of bicarbonate.
20
Q
- The sternocleidomastoid and scalene muscles are referred to as which group?
a. Diaphragmatic muscles c. Intercostal muscles
b. Muscles of expiration d. Muscles of inspiration
A
A
The accessory muscles of inspiration are the sternocleidomastoid and scalene muscles. These muscles are not associated with the other options.
21
Q
- An increase in surface tension caused by decreased surfactant production results in which alteration?
a. Decrease in alveolar macrophage production
b. Increase in lung compliance
c. Decrease in alveoli collapse
d. Increase in alveoli fluid collection
A
D
The decrease in surface tension caused by surfactant is also responsible for keeping the alveoli free of fluid. In the absence of surfactant, the surface tension tends to attract fluid into the alveoli. If surfactant production is disrupted or surfactant is not produced in adequate quantities, then the alveolar surface tension increases, causing alveolar collapse, decreased lung expansion, increased work of breathing, and severe gas-exchange abnormalities. The decrease in surface tension caused by surfactant is also responsible for keeping the alveoli free of fluid. The remaining options are not associated with decreased surfactant production.
22
Q
- Decreased lung compliance means that the lungs are demonstrating which characteristic?
a. Difficult deflation c. Stiffness
b. Easy inflation d. Inability to diffuse oxygen
A
C
A decrease in compliance indicates that the lungs or chest wall is abnormally stiff or difficult to inflate. This selection is the only option that accurately identifies the meaning of decreased compliance.
23
Q
- The lung is innervated by the parasympathetic nervous system via which nerve?
a. Vagus c. Brachial
b. Phrenic d. Pectoral
A
A
Fibers of the parasympathetic division of the autonomic nervous system (ANS) travel only in the vagus nerve to the lung.
24
Q
- What event is characteristic of the function in Zone 1 of the lung?
a. Blood flow through the pulmonary capillary bed increases in regular increments.
b. Alveolar pressure is greater than venous pressure but not greater than arterial pressure.
c. The capillary bed collapses, and normal blood flow ceases.
d. Blood flows through Zone 1, but it is impeded to a certain extent by alveolar pressure.
A
C
Alveolar pressure exceeds pulmonary arterial and venous pressures in Zone 1. The capillary bed collapses, and normal blood flow ceases. Zone II is the portion where alveolar pressure is greater than venous pressure but not greater than arterial pressure. Blood flows through zone II, but it is impeded to a certain extent by alveolar pressure. Zone II is normally above the level of the left atrium. In zone III, arterial and venous pressures are greater than alveolar pressure and blood flow is not affected by alveolar pressure. Zone III is in the base of the lung. Blood flow through the pulmonary capillary bed increases in regular increments from the apex to the base.
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24. Hypoventilation that results in the retention of carbon dioxide will stimulate which receptors in an attempt to maintain a normal homeostatic state?
a. Irritant receptors c. Peripheral chemoreceptors
b. Central chemoreceptors d. Stretch receptors
B
Central chemoreceptors indirectly monitor arterial blood by sensing changes in the pH of cerebrospinal fluid (CSF). The central chemoreceptors are sensitive to very small changes in the pH of CSF (equivalent to a 1 to 2 mm Hg change in partial pressure of carbon dioxide [PCO 2]) and are able to maintain a normal partial pressure of arterial carbon dioxide (PaCO 2) under many different conditions, including strenuous exercise. This selection is the only option that accurately identifies the receptors that are associated with the retention of carbon dioxide
26
25. What is the most important cause of pulmonary artery constriction?
a. Low alveolar partial pressure of arterial oxygen (PaO 2)
b. Hyperventilation
c. Respiratory alkalosis
d. Epinephrine
A
The most important cause of pulmonary artery constriction is a low alveolar PaO2.
27
26. Where does the tracheal bifurcation occur?
a. Larynx c. Carina
b. Bronchi d. Nasopharynx
C
The trachea, which is supported by U-shaped cartilage, connects the larynx to the bronchi, the conducting airways of the lungs. The trachea divides into the two main airways, or bronchi, at the carina (see Figure 34-1). The division occurs only at the carina.
28
27. How low must the partial pressure of arterial oxygen (PaO 2) drop before the peripheral chemoreceptors influence ventilation?
a. Below 100 mm Hg c. Below 70 mm Hg
b. Below 80 mm Hg d. Below 60 mm Hg
C
The PaO2 must drop well below normal (to approximately 60 mm Hg) before the peripheral chemoreceptors have much influence on ventilation.
29
28. Which receptors are located in the smooth muscles of airways?
a. Central chemoreceptors c. Peripheral chemoreceptors
b. Stretch receptors d. J-receptors
: B
Of the options available, only the stretch receptors are located in the smooth muscles of airways.
30
29. Which receptors are located near the respiratory center?
a. Peripheral chemoreceptors c. Central chemoreceptors
b. Stretch receptors d. J-receptors
c
Of the options available, only the central chemoreceptors are located near the respiratory center.
31
30. Which receptors are located in the aortic bodies, aortic arch, and carotid bodies?
a. Central chemoreceptors c. J-receptors
b. Stretch receptors d. Peripheral chemoreceptors
D
Of the options available, only the peripheral chemoreceptors are located in the aortic bodies, aortic arch, and carotid bodies at the bifurcation of the carotids, near the baroreceptors.
32
31. What is the purpose of the spirometry measurement?
a. To evaluate the cause of hypoxia
b. To measure the volume and flow rate during forced expiration
c. To measures the gas diffusion rate at the alveolocapillary membrane
d. To determine pH and oxygen and carbon dioxide concentrations
B
Spirometry measures volume and flow rate during forced expiration. The alveolar-arterial oxygen gradient is used to evaluate the cause of hypoxia. Diffusing capacity is a measure of the gas diffusion rate at the alveolocapillary membrane. Arterial blood gas analysis can be used to determine pH and oxygen and carbon dioxide concentrations.
33
32. Which structures belong to the upper conduction airway? (Select all that apply.)
a. Oropharynx
b. Larynx
c. Nasopharynx
d. Trachea
e. Bronchi
A, C
The conducting airways are the portion of the pulmonary system that provides a passage for the movement of air into and out of the gas-exchange portions of the lung. The nasopharynx, oropharynx, and related structures are often called the upper airway. The remaining options are not considered to be included in the upper conduction airway.
34
33. Regarding the respiratory process referred to as remodeling, which statements are true? (Select all that apply.)
a. Remodeling involves the vascular walls.
b. Scarring and thickening occurs during this respiratory process.
c. Remodeling results in a permanent change.
d. Pulmonary artery hypotension results.
e. Remodeling increases blood flow resistance.
A, B, C, E
Remodeling is a process by which the vascular wall becomes scarred and thickened, thus resulting in permanent decreases in luminal diameter, increased resistance to blood flow, and permanent pulmonary artery hypertension.
35
34. What are the effects of aging on the pulmonary system?
a. Decreased chest wall compliance
b. Decreased lung recoil
c. Reduced ventilatory reserve
d. Decreased partial pressure of arterial oxygen (PaO 2)
e. Reduced respiratory rate
A, B, C, D
Aging affects the mechanical aspects of ventilation by decreasing chest wall compliance and elastic recoil of the lungs. Changes in these elastic properties reduce ventilatory reserve. Aging causes the PaO2 to decrease but does not affect the partial pressure of arterial carbon dioxide (PaCO2) or respiratory rate.
36
Match the receptor with its function.
A. Irritant receptors
B. Stretch receptors
C. J-receptors
D. Peripheral chemoreceptors
E. Central chemoreceptors
35. Initiates rapid, shallow breathing
36. Monitors pH, partial pressure of carbon dioxide (PaCO2), and partial pressure of oxygen (PaO2) in arterial blood
37. Initiates cough reflex
38. Senses pH of cerebrospinal fluid
39. Hering-Breuer expiratory reflex
35. ANS: C PTS: 1 REF: Page 1234
MSC: J-receptors are sensitive to increased pulmonary capillary pressure, which stimulates them to initiate rapid, shallow breathing; hypotension; and bradycardia.
36. ANS: D PTS: 1 REF: Page 1234
MSC: Although the peripheral chemoreceptors are sensitive to changes in PaCO2 and pH, they are primarily sensitive to oxygen levels in arterial blood (PaO2) and are responsible for all of the increase in
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ventilation that occurs in response to arterial hypoxemia.
37. ANS: A PTS: 1 REF: Page 1234
MSC: Irritant receptors are sensitive to noxious aerosols (vapors), gases, and particulate matter (e.g., inhaled dusts), which cause them to initiate the cough reflex.
38. ANS: E PTS: 1 REF: Page 1234
MSC: Central chemoreceptors monitor arterial blood indirectly by sensing changes in the pH of cerebrospinal fluid (CSF).
39. ANS: B PTS: 1 REF: Page 1234
MSC: Stretch receptors decrease ventilatory rate and volume when stimulated, an occurrence sometimes referred to as the Hering-
37
1. How does chest wall compliance in an infant differ from that of an adult?
a. An adult’s chest wall compliance is lower than an infant’s.
b. An adult’s chest wall compliance is higher than an infant’s.
c. An adult’s chest wall compliance is the same as an infant’s.
d. An adult’s chest wall compliance is dissimilar to that of an infant’s.
: A
Chest wall compliance is higher in infants than it is in adults, particularly in premature infants.
38
2. Why is nasal congestion a serious threat to young infants?
a. Infants are obligatory nose breathers.
b. Their noses are small in diameter.
c. Infants become dehydrated when mouth breathing.
d. Their epiglottis is proportionally greater than the epiglottis of an adult’s
A
Infants up to 2 to 3 months of age are obligatory nose breathers and are unable to breathe in through their mouths. Nasal congestion is therefore a serious threat to a young infant. This selection is the only option that accurately describes why nasal congestion is a serious threat to young infants.
39
3. The risk for respiratory distress syndrome (RDS) decreases for premature infants when they are born between how many weeks of gestation?
a. 16 and 20 c. 24 and 30
b. 20 and 24 d. 30 and 36
d
Surfactant is secreted into fetal airways between 30 and 36 weeks. The other options are not true regarding the timeframe when the risk for RDS decreases.
40
4. Which type of croup is most common?
a. Bacterial c. Fungal
b. Viral d. Autoimmune
B
In 85% of children with croup, a virus is the cause, most commonly parainfluenza. However, other viruses such as influenza A or respiratory syncytial virus (RSV) also can cause croup
41
5. What is the chief predisposing factor for respiratory distress syndrome (RDS) of the newborn?
a. Low birth weight
b. Alcohol consumption during pregnancy
c. Premature birth
d. Smoking during pregnancy
C
RDS of the newborn, also known as hyaline membrane disease (HMD), is a major cause of morbidity and mortality in premature newborns. None of the other options are considered the chief predisposing factors for RDS.
PTS: 1 REF: Page
42
6. What is the primary cause of respiratory distress syndrome (RDS) of the newborn?
a. Immature immune system00 c. Surfactant deficiency
b. Small alveoli d. Anemia
c
RDS is primarily caused by surfactant deficiency and secondarily by a deficiency in alveolar surface area for gas exchange. None of the other options are related to the cause of RDS.
43
7. What is the primary problem resulting from respiratory distress syndrome (RDS) of the newborn?
a. Consolidation c. Atelectasis
b. Pulmonary edema d. Bronchiolar plugging
C
The primary problem is atelectasis, which causes significant hypoxemia and is difficult for the neonate to overcome because a significant negative inspiratory pressure is required to open the alveoli with each breath. None of the other options are considered a primary problem associated with RDS.
44
8. Which option shows the correct sequence of events after atelectasis develops in respiratory distress syndrome of the newborn?
a. Increased pulmonary vascular resistance, atelectasis, hypoperfusion
b. Hypoxic vasoconstriction, right-to-left shunt hypoperfusion
c. Respiratory acidosis, hypoxemia, hypercapnia
d. Right-to-left shunt, hypoxic vasoconstriction, hypoperfusion
B
Atelectasis results in a decrease in tidal volume, causing alveolar hypoventilation and hypercapnia. Hypoxia and hypercapnia cause pulmonary vasoconstriction, which increases intrapulmonary resistance and shunting. This results in hypoperfusion of the lung and a decrease in effective pulmonary blood flow. This selection is the only option that identifies the correct sequence of events.
45
9. Which statement about the advances in the treatment of respiratory distress syndrome (RDS) of the newborn is incorrect?
a. Administering glucocorticoids to women in preterm labor accelerates the maturation of the fetus’s lungs.
b. Administering oxygen to mothers during preterm labor increases their arterial oxygen before the birth of the fetus.
c. Treatment includes the instillation of exogenous surfactant down an endotracheal tube of infants weighing less than 1000 g.
d. Using continuous positive airway pressure (CPAP) supports the infant’s respiratory function.
B
Administering oxygen to the mother is not a valid treatment of RDS. The other statements provide correct information regarding RDS.
46
10. Bronchiolitis tends to occur during the first years of life and is most often caused by what type of infection?
a. Respiratory syncytial virus (RSV) c. Adenoviruses
b. Influenzavirus d. Rhinovirus
A
The most common associated pathogen is RSV, but bronchiolitis may also be associated with adenovirus, rhinovirus, influenza, parainfluenza virus (PIV), and Mycoplasma pneumoniae.
47
11. Which immunoglobulin (Ig) is present in childhood asthma?
a. IgM c. IgE
b. IgG d. IgA
C
Included in the long list of asthma-associated genes are those that code for increased levels of immune and inflammatory mediators (e.g., interleukin [IL]–4, IgE, leukotrienes), nitric oxide, and transmembrane proteins in the endoplasmic reticulum. None of the other options are associated with childhood asthma.
48
12. Which T-lymphocyte phenotype is the key determinant of childhood asthma?
a. Cluster of differentiation (CD) 4 T-helper Th1 lymphocytes
b. CD4 T-helper Th2 lymphocytes
c. CD8 cytotoxic T lymphocytes
d. Memory T lymphocytes
B
Asthma develops because the Th2 response (in which CD4 T-helper cells produce specific cytokines, such as interleukin [IL]–4, IL-5, and IL-13) promotes an atopic and allergic response in the airways. This selection is the only option that accurately identifies the appropriate T- lymphocyte phenotype.
49
13. Which cytokines activated in childhood asthma produce an allergic response?
a. Interleukin (IL)–1, IL-2, and interferon-alpha (IFN-α)
b. IL-8, IL-12, and tumor necrosis factor-alpha (TNF-α)
c. IL-4, IL-10, and colony-stimulating factor (CSF)
d. IL-4, IL-5, and IL-13
D
Related to asthma, IL-4 and IL-13 are particularly important for B-cell switching to favor immunoglobulin E (IgE) production, and IL-5 is crucial for local differentiation and enhanced survival of eosinophils within the airways. This selection is the only option that accurately describes how cytokines produce a childhood asthmatic response.
50
14. Which statement accurately describes childhood asthma?
a. An obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation
b. A pulmonary disease characterized by severe hypoxemia, decreased pulmonary compliance, and diffuse densities on chest x-ray imaging
c. A pulmonary disorder involving an abnormal expression of a protein, producing viscous mucus that lines the airways, pancreas, sweat ducts, and vas deferens
d. An obstructive airway disease characterized by atelectasis and increased pulmonary resistance as a result of a surfactant deficiency
a
Asthma is an obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation. This selection is the only option that accurately describes childhood asthma.
51
15. Which criterion is used to confirm a diagnosis of asthma in an 8-year-old child?
a. Parental history of asthma
b. Serum testing that confirms increased immunoglobulin E (IgE) and eosinophil levels
c. Reduced expiratory flow rates confirmed by spirometry testing
d. Improvement on a trial of asthma medication
C
Confirmation of the diagnosis of asthma relies on pulmonary function testing using spirometry, which can be accomplished only after the child is 5 to 6 years of age. Reduced expiratory flow rates that are reversible in response to an inhaled bronchodilator would be characteristic abnormalities. For younger children, an empiric trial of asthma medications is commonly initiated. The remaining options are major historical and physical factors that contribute but do not confirm the diagnosis of asthma in children.
52
16. Which statement best describes acute respiratory distress syndrome (ARDS)?
a. An obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation
b. A pulmonary disease characterized by severe hypoxemia, decreased pulmonary compliance, and the presence of bilateral infiltrates on chest x-ray imaging
c. A respiratory disorder involving an abnormal expression of a protein producing viscous mucus that lines the airways, pancreas, sweat ducts, and vas deferens
d. A pulmonary disorder characterized by atelectasis and increased pulmonary resistance as a result of a surfactant deficiency
B
ARDS is a condition that can result from either a direct or indirect pulmonary insult. It is defined as respiratory failure of acute onset characterized by severe hypoxemia that is refractory to treatment with supplemental oxygen, bilateral infiltrates on chest x-ray imaging, and no evidence of heart failure, as well as decreased pulmonary compliance. This selection is the only option that accurately describes ARDS.
53
17. When considering the signs and symptoms of acute respiratory distress syndrome (ARDS), the absence of which condition is considered characteristic?
a. Progressive respiratory distress c. Decreased pulmonary compliance
b. Bilateral infiltrates d. Heart failure
d
ARDS is characterized by progressive respiratory distress, severe hypoxemia refractory to treatment with supplemental oxygen, decreased pulmonary compliance, bilateral infiltrates on chest x-ray imaging, and no evidence of heart failure.
54
18. Examination of the throat in a child demonstrating signs and symptoms of acute epiglottitis may contribute to which life-threatening complication?
a. Retropharyngeal abscess c. Rupturing of the tonsils
b. Laryngospasms d. Gagging induced aspiration
B
Examination of the throat may trigger laryngospasm and cause respiratory collapse. Death may occur in a few hours. This selection is the only option that accurately identifies the life- threatening complication that can result from an examination of the throat of a child who demonstrates the signs and symptoms of acute epiglottitis.
55
19. Which statement best describes cystic fibrosis?
a. Obstructive airway disease characterized by reversible airflow obstruction, bronchial hyperreactivity, and inflammation
b. Respiratory disease characterized by severe hypoxemia, decreased pulmonary compliance, and diffuse densities on chest x-ray imaging
c. Pulmonary disorder involving an abnormal expression of a protein-producing viscous mucus that obstructs the airways, pancreas, sweat ducts, and vas deferens
d. Pulmonary disorder characterized by atelectasis and increased pulmonary resistance as a result of a surfactant deficiency
C
Cystic fibrosis is best described as a pulmonary disorder involving an abnormal expression of a protein-producing viscous mucus that obstructs the airways, pancreas, sweat ducts, and vas deferens. This selection is the only option that accurately describes cystic fibrosis.
56
20. Cystic fibrosis is caused by which process?
a. Autosomal recessive inheritance c. Infection
b. Autosomal dominant inheritance d. Malignancy
ANS: A
Cystic fibrosis is an autosomal recessive inherited disorder that is associated with defective epithelial ion transport. None of the other options cause cystic fibrosis.
57
21. What are the abnormalities in cytokines found in children with cystic fibrosis (CF)?
a. Deficit of interleukin (IL)–1 and an excess of IL-4, IL-12, and interferon-alpha (IFN-α)
b. Deficit of IL-6 and an excess of IL-2, IL-8, and granulocyte colony-stimulating factor (G-CSF)
c. Deficit of IL-10 and an excess of IL-1, IL-8, and TNF-α
d. Deficit of IL-3 and an excess of IL-14, IL-24, and colony-stimulating factor (CSF)
ANS: C
Abnormal cytokine profiles have been documented in CF airway fluids, including deficient IL- 10 and excessive IL-1, IL-8, and TNF-α, all changes conducive to promoting inflammation. This selection is the only option that accurately identifies the abnormalities in cytokines observed in children with CF.
58
22. Between which months of age does sudden infant death syndrome (SIDS) most often occur?
a. 0 and 1 c. 5 and 6
b. 2 and 4 d. 6 and 7
B
The incidence of SIDS is low during the first month of life but sharply increases in the second month of life, peaking at 2 to 4 months and is unusual after 6 months of age.
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23. Where in the respiratory tract do the majority of foreign objects aspirated by children finally lodge?
a. Trachea c. Bronchus
b. Left lung d. Bronchioles
C
Approximately 75% of aspirated foreign bodies lodge in a bronchus. The other options are not locations where children aspirate the majority of foreign objects.
60
24. What is the most common predisposing factor to obstructive sleep apnea in children?
a. Chronic respiratory infections c. Obligatory mouth breathing
b. Adenotonsillar hypertrophy d. Paradoxic breathing
B
In otherwise healthy children, the most common predisposing factor is adenotonsillar hypertrophy, which causes physical impingement on the nasopharyngeal airway. The other options are not associated with obstructive sleep apnea in children.
61
25. Which statement is true regarding alveoli? (Select all that apply.)
a. The number of functioning alveoli is determined by birth.
b. The alveoli begin to increase in size starting at 8 years of age.
c. The complexity of the alveoli increases into adulthood.
d. These structures produce surfactant.
e. Capillaries are the origin of alveoli
B, C, E
Capillaries grow into the distal respiratory units that keep subdividing (alveolarization) to maximize the surface area for gas exchange. The number of alveoli continues to increase during the first 5 to 8 years of life, after which the alveoli increase in size and complexity. Surfactant is a lipid-protein mix that is produced by type II alveolar cells.
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26. Children diagnosed with chronic asthma are likely to exhibit which symptoms? (Select all that apply.)
a. Nasal flaring
b. Musical expiratory wheezing
c. Clubbing of fingers and toes
d. Substernal retractions
e. Diaphoresis
A, B, D, E
On physical examination, expiratory wheezing that is often described as high pitched and musical is exhibited, along with prolongation of the expiratory phase of the respiratory cycle. Hyperinflation is sometimes visible. The respiratory rate is elevated, as is the heart rate. Nasal flaring and accessory muscle use are evident, with retractions in the substernal, subcostal, intercostal, suprasternal, or sternocleidomastoid areas. Infants may appear to be “head bobbing” because of sternocleidomastoid muscle use. Pulsus paradoxus may also be present. The child may appear anxious or diaphoretic, which are important signs of respiratory compromise.
Clubbing of fingers and toes is not typically associated with asthma.
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27. Which symptom is not a clinical manifestation of croup?
a. Rhinorrhea
b. Sore throat
c. Low-grade fever
d. Barking cough
e. Coarse rhonchi
E
Typically, a prodrome of rhinorrhea, sore throat, and low-grade fever is exhibited for a few days with croup. The child then develops the characteristic harsh (seal-like) barking cough, hoarse voice, and inspiratory stridor. Rhonchi are associated with lower respiratory diseases.
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28. What are the clinical manifestations of bacterial pneumonia in children? (Select all that apply.)
a. Fever with chills
b. Productive cough
c. Dyspnea
d. Respiratory alkalosis
e. Malaise
A, B, C, E
The clinical presentation of bacterial pneumonia, particularly pneumococcal, may include a preceding viral illness, followed by fever with chills and rigors, shortness of breath, and an increasingly productive cough. Auscultation usually reveals such abnormalities as crackles or decreased breath sounds. Other less specific findings may include malaise, emesis, abdominal pain, and chest pain. Respiratory alkalosis is not usually associated with bacterial pneumonia in children.
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Match the sound of stridor with the location of the problem.
A. Sonorous snoring
B. Muffled voice
C. High-pitched inspiratory sound, voice change, hoarse
D. Expiratory stridor or monophonic wheeze
E. Inspiratory wheezes
29. Tracheal problems
30. Laryngeal problems
31. Upper trachea obstruction
32. Nasopharyngeal obstruction, such as adenotonsillar hypertrophy.
33. Supralaryngeal obstructions
29. ANS: D PTS: 1 REF: Page 1293
MSC: Expiratory stridors or monophonic wheezes suggest tracheal problems.
30. ANS: C PTS: 1 REF: Page 1294
MSC: Abnormalities of voice or cry (weak or hoarse) suggest problems at the larynx.
31. ANS: E PTS: 1 REF: Page 1298
MSC: Foreign bodies lodged in the upper trachea typically produce inspiratory stridor.
32. ANS: A PTS: 1 REF: Page 1293
MSC: Sonorous snoring is associated with nasopharyngeal obstruction, such as adenotonsillar hypertrophy.
33. ANS: B PTS: 1 REF: Page 1294
MSC: Muffling of the voice, especially in an acute condition, suggests supralaryngeal obstruction, such as epiglottitis
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1. Besides dyspnea, what is the most common characteristic associated with pulmonary disease?
a. Chest pain c. Cough
b. Digit clubbing d. Hemoptysis
C
Pulmonary disease is associated with many signs and symptoms, and their specific characteristics often help in identifying the underlying disorder. The most common characteristics are dyspnea and cough. Others include abnormal sputum, hemoptysis, altered breathing patterns, hypoventilation and hyperventilation, cyanosis, clubbing of the digits, and chest pain.
67
2. Sitting up in a forward-leaning position generally relieves which breathing disorder?
a. Hyperpnea c. Apnea
b. Orthopnea d. Dyspnea on exertion
B
Of the options available, only orthopnea is generally relieved by sitting up in a forward-leaning posture or supporting the upper body on several pillows
68
3. Kussmaul respirations as a respiratory pattern may be associated with which characteristic(s)?
a. Alternating periods of deep and shallow breathing
b. Pulmonary fibrosis
c. Chronic obstructive pulmonary disease
d. Slightly increased ventilatory rate, large tidal volumes, and no expiratory pause
D
Kussmaul respirations are characterized by a slightly increased ventilatory rate, very large tidal volume, and no expiratory pause. Kussmaul respirations are not associated with any of the other options.
69
4. Respirations that are characterized by alternating periods of deep and shallow breathing are a result of which respiratory mechanism?
a. Decreased blood flow to the medulla oblongata
b. Increased partial pressure of arterial carbon dioxide (PaCO 2), decreased pH, and decreased partial pressure of arterial oxygen (PaO2)
c. Stimulation of stretch or J-receptors
d. Fatigue of the intercostal muscles and diaphragm
a
Alternating periods of deep and shallow breathing are characteristic of Cheyne-Stokes respirations and are the result of any condition that slows the blood flow to the brainstem, which in turn slows impulses that send information to the respiratory centers of the brainstem. None of the remaining options are responsible for the described breathing pattern.
70
5. With a total hemoglobin of 9 g/dl, how many grams per deciliter of hemoglobin must become desaturated for cyanosis to occur?
a. 3 c. 7
b. 5 d. 9
B
Cyanosis generally develops when 5 g/dl of hemoglobin is desaturated, regardless of hemoglobin concentration.
71
6. Which statement is true regarding ventilation?
a. Hypoventilation causes hypocapnia.
b. Hyperventilation causes hypercapnia.
c. Hyperventilation causes hypocapnia.
d. Hyperventilation results in an increased partial pressure of arterial carbon dioxide (PaCO2).
: C
Hyperventilation is alveolar ventilation that exceeds metabolic demands. The lungs remove carbon dioxide at a faster rate than produced by cellular metabolism, resulting in decreased PaCO2 or hypocapnia. None of the remaining options are accurate statements.
72
8. Pulmonary edema and pulmonary fibrosis cause hypoxemia by which mechanism?
a. Creating alveolar dead space
b. Decreasing the oxygen in inspired gas
c. Creating a right-to-left shunt
d. Impairing alveolocapillary membrane diffusion
d. Impairing alveolocapillary membrane diffusion
Diffusion of oxygen through the alveolocapillary membrane is impaired if the alveolocapillary membrane is thickened or if the surface area available for diffusion is decreased. Abnormal thickness, as occurs with edema (tissue swelling) and fibrosis (formation of fibrous lesions), increases the time required for diffusion across the alveolocapillary membrane. None of the remaining options accurately describes the mechanism that triggers hypoxemia as a result of pulmonary edema or pulmonary fibrosis.
73
9. High altitudes may produce hypoxemia through which mechanism?
a. Shunting c. Decreased inspired oxygen
b. Hypoventilation d. Diffusion abnormalities
C
The presence of adequate oxygen content of the inspired air is the first factor. Oxygen content is lessened at high altitudes. At high altitudes none of the remaining options would be the cause of hypoxemia.
74
10. Which condition is capable of producing alveolar dead space?
a. Pulmonary edema c. Atelectasis
b. Pulmonary emboli d. Pneumonia
B
A pulmonary embolus that impairs blood flow to a segment of the lung results in an area where alveoli are ventilated but not perfused, which causes alveolar dead space. Alveolar dead space is not the result of any of the remaining options.
75
11. What is the most common cause of pulmonary edema?
a. Right-sided heart failure c. Mitral valve prolapse
b. Left-sided heart failure d. Aortic stenosis
: B
The most common cause of pulmonary edema is heart disease. When the left ventricle fails, filling pressures on the left side of the heart increase and cause a concomitant increase in pulmonary capillary hydrostatic pressure. The remaining options are not common triggers for pulmonary edema.
76
12. Pulmonary edema usually begins to develop at a pulmonary capillary wedge pressure or left atrial pressure of how many millimeters of mercury (mm Hg)?
a. 10 c. 30
b. 20 d. 40
B
Pulmonary edema usually begins to develop at a pulmonary capillary wedge pressure or left atrial pressure of 20 mm Hg.
77
13. The collapse of lung tissue caused by the lack of collateral ventilation through the pores of Kohn is referred to as what type of atelectasis?
a. Compression c. Absorption
b. Perfusion d. Hypoventilation
C
Absorption atelectasis is a result of the gradual absorption of air from obstructed or hypoventilated alveoli or from inhalation of concentrated oxygen or anesthetic agents. The other forms of atelectasis are not a result of the described mechanism.
78
14. In what form of bronchiectasis do both constrictions and dilations deform the bronchi?
a. Varicose c. Cylindric
b. Symmetric d. Saccular
A
Varicose bronchiectasis exists when both constrictions and dilations deform the bronchi. None of the other options involve both constriction and dilation, resulting in bronchi deformity.
79
15. Which pleural abnormality involves a site of pleural rupture that acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing during expiration?
a. Spontaneous pneumothorax c. Open pneumothorax
b. Tension pneumothorax d. Secondary pneumothorax
: B
In tension pneumothorax, the site of pleural rupture acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing up during expiration. As more and more air enters the pleural space, air pressure in the pneumothorax begins to exceed barometric pressure. None of the other options result from the pathologic condition described.
80
16. In which type of pleural effusion does the fluid become watery and diffuse out of the capillaries as a result of increased blood pressure or decreased capillary oncotic pressure?
a. Exudative c. Transudative
b. Purulent d. Large
c
In transudative pleural effusion, the fluid, or transudate, is watery and diffuses out of the capillaries as a result of disorders that increase intravascular hydrostatic pressure or decrease capillary oncotic pressure. The described mechanism is not associated with the other forms of pleural effusion.
81
17. Which condition involves an abnormally enlarged gas-exchange system and the destruction of the lung’s alveolar walls?
a. Transudative effusion c. Exudative effusion
b. Emphysema d. Abscess
B
Emphysema is abnormal permanent enlargement of gas-exchange airways (acini) accompanied by the destruction of alveolar walls without obvious fibrosis. The described mechanism is not associated with the other options.
82
18. Which term is used to identify a circumscribed area of suppuration and destruction of lung parenchyma?
a. Consolidation c. Empyema
b. Cavitation d. Abscess
D
An abscess is a circumscribed area of suppuration and destruction of lung parenchyma. The described pathologic abnormality is not associated with the other options.
83
19. Which condition is not a cause of chest wall restriction?
a. Pneumothorax c. Gross obesity
b. Severe kyphoscoliosis d. Neuromuscular disease
A
Unlike the other options that result in chest wall restriction, a pneumothorax is the presence of air or gas in the pleural space caused by a rupture in the visceral pleura (which surrounds the lungs) or the parietal pleura and chest wall.
84
20. What causes pneumoconiosis?
a. Pneumococci bacteria c. Exposure to asbestos
b. Inhalation of inorganic dust particles d. Inhalation of cigarette smoke
B
Pneumoconiosis represents any change in the lung caused by the inhalation of inorganic dust particles, which usually occurs in the workplace. Pneumoconiosis is not a result of any of the other options.
85
21. Which condition is a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury?
a. Acute respiratory distress syndrome (ARDS)
b. Pneumonia
c. Pulmonary emboli
d. Acute pulmonary edema
A
ARDS is a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury. The described pathologic characteristics are not associated with the other options.
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22. Which structure(s) in acute respiratory distress syndrome (ARDS) release inflammatory mediators such as proteolytic enzymes, oxygen-free radicals, prostaglandins, leukotrienes, and platelet-activating factor?
a. Complement cascade c. Macrophages
b. Mast cells d. Neutrophils
D
The role of neutrophils is central to the development of ARDS. Activated neutrophils release a battery of inflammatory mediators, among them proteolytic enzymes, oxygen-free radicals (superoxide radicals, hydrogen peroxide, hydroxyl radicals), arachidonic acid metabolites (prostaglandins, thromboxanes, leukotrienes), and platelet-activating factor. These mediators cause extensive damage to the alveolocapillary membrane and greatly increase capillary membrane permeability. The described responses are not associated with the other options.
87
23. Pulmonary edema in acute respiratory distress syndrome (ARDS) is the result of an increase in:
a. Levels of serum sodium and water c. Capillary hydrostatic pressure
b. Capillary permeability d. Oncotic pressure
B
Increased capillary permeability, a hallmark of ARDS, allows fluids, proteins, and blood cells to leak from the capillary bed into the pulmonary interstitium and alveoli. The resulting pulmonary edema and hemorrhage severely reduce lung compliance and impair alveolar ventilation. The other options would not trigger ARDS-associated pulmonary edema.
88
24. In acute respiratory distress syndrome (ARDS), alveoli and respiratory bronchioles fill with fluid as a result of which mechanism?
a. Compression on the pores of Kohn, thus preventing collateral ventilation
b. Increased capillary permeability, which causes alveoli and respiratory bronchioles to fill with fluid
c. Inactivation of surfactant and the impairment of type II alveolar cells
d. Increased capillary hydrostatic pressure that forces fluid into the alveoli and respiratory bronchioles
C
Lung inflammation and injury damage the alveolar epithelium and the vascular endothelium. Surfactant is inactivated, and its production by type II alveolar cells is impaired as alveoli and respiratory bronchioles fill with fluid or collapse. The other options would not trigger the described response.
89
25. Which type of pulmonary disease requires more force to expire a volume of air?
a. Restrictive c. Acute
b. Obstructive d. Communicable
B
Obstructive pulmonary disease is characterized by airway obstruction that is worse with expiration. Either more force (i.e., the use of accessory muscles of expiration) or more time is required to expire a given volume of air. The other options are not associated with a need for an increase of force to expire air.
90
26. Which immunoglobulin (Ig) may contribute to the pathophysiologic characteristics of asthma?
a. IgA c. IgG
b. IgE d. IgM
B
Asthma is a familial disorder, and more than 100 genes have been identified that may play a role in the susceptibility of and the pathogenetic mechanisms that cause asthma, including those that influence the production of interleukin (IL)–4, IL-5, and IL-13; IgE; eosinophils; mast cells; adrenergic receptors; and leukotrienes. The pathophysiologic characteristics of asthma are not associated with the other immunoglobulins
91
27. Which statement about the late asthmatic response is true?
a. Norepinephrine causes bronchial smooth muscle contraction and mucus secretion.
b. The release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness.
c. The release of epinephrine causes bronchial smooth muscle contraction and increases capillary permeability.
d. Immunoglobulin G initiates the complement cascade and causes smooth muscle contraction and increased capillary permeability.
b
The late asthmatic response begins 4 to 8 hours after the early response when the release of toxic neuropeptides contributes to increased bronchial hyperresponsiveness. This selection is the only option associated with the late asthmatic response.
92
28. Clinical manifestations of inspiratory and expiratory wheezing, dyspnea, nonproductive cough, and tachypnea are indicative of which condition?
a. Chronic bronchitis c. Pneumonia
b. Emphysema d. Asthma
D
At the beginning of an attack, the individual experiences chest constriction, expiratory wheezing, dyspnea, nonproductive coughing, prolonged expiration, tachycardia, and tachypnea. Severe attacks involve the use of accessory muscles of respiration, and wheezing is heard during both inspiration and expiration. The presentations of none of the other options are consistent with the described symptoms.
93
29. The most successful treatment for chronic asthma begins with which action?
a. Avoidance of the causative agent
b. Administration of broad-spectrum antibiotics
c. Administration of drugs that reduce bronchospasm
d. Administration of drugs that decrease airway inflammation
A
Chronic management of asthma begins with the avoidance of allergens and other triggers. The effectiveness of the other options is reliant on the avoidance of triggers.
94
30. Which factor contributes to the production of mucus associated with chronic bronchitis?
a. Airway injury c. Increased Goblet cell size
b. Pulmonary infection d. Bronchospasms
C
Continual bronchial inflammation causes bronchial edema and increases the size and number of mucous glands and goblet cells in the airway epithelium. Thick, tenacious mucus is produced and cannot be cleared because of impaired ciliary function (see Figure 35-13). The lung’s defense mechanisms are therefore compromised, increasing a susceptibility to pulmonary infection, which contributes to airway injury. Frequent infectious exacerbations are complicated by bronchospasm with dyspnea and productive cough.
95
31. Clinical manifestations of decreased exercise tolerance, wheezing, shortness of breath, and productive cough are indicative of which respiratory disorder?
a. Chronic bronchitis c. Pneumonia
b. Emphysema d. Asthma
a
symptoms that lead individuals with chronic bronchitis to seek medical care include decreased exercise tolerance, wheezing, and shortness of breath. Individuals usually have a productive cough (“smoker’s cough”). The described symptoms are not associated with any of the other options.
96
32. Clinical manifestations that include unexplained weight loss, dyspnea on exertion, use of accessory muscles, and tachypnea with prolonged expiration are indicative of which respiratory disorder?
a. Chronic bronchitis c. Pneumonia
b. Emphysema d. Asthma
: B
Individuals with emphysema usually have dyspnea on exertion that later progresses to significant dyspnea, even at rest (see Table 35-3). Little coughing and very little sputum are produced. The individual is often thin, has tachypnea with prolonged expiration, and must use accessory muscles for ventilation. The anteroposterior diameter of the chest is increased (barrel chest), and the chest has a hyperresonant sound with percussion. The described symptoms are not associated with any of the other options.
97
33. Which of the following is the most common route of lower respiratory tract infection?
a. Aspiration of oropharyngeal secretions
b. Inhalation of microorganisms
c. Microorganisms spread to the lung via blood
d. Poor mucous membrane protection
A
Aspiration of oropharyngeal secretions is the most common route of lower respiratory tract infection; thus the nasopharynx and oropharynx constitute the first line of defense for most infectious agents. The other options are not common routes of lower respiratory tract infections.
98
34. What is the initial step in the management of emphysema?
a. Inhaled anticholinergic agents c. Cessation of smoking
b. Beta agonists d. Surgical reduction of lung volume
: C
Chronic management of emphysema begins with smoking cessation. Pharmacologic management includes inhaled anticholinergic agents, and beta agonists should be prescribed. Pulmonary rehabilitation, improved nutrition, and breathing techniques all can improve symptoms. Oxygen therapy is indicated in chronic hypoxemia but must be administered with care. In selected patients, lung volume reduction surgery or transplantation can be considered.
99
35. In tuberculosis, the body walls off the bacilli in a tubercle by stimulating which action?
a. Macrophages that release tumor necrosis factor–alpha (TNF-α)
b. Phagocytosis by neutrophils and eosinophils
c. Formation of immunoglobulin G to initiate the complement cascade
d. Apoptotic infected macrophages that activate cytotoxic T cells
D
In defense, macrophages and lymphocytes release interferon, which inhibits the replication of the microorganism and stimulates more macrophages to attack the bacterium. Apoptotic infected macrophages can also activate cytotoxic T cells (cluster of differentiation [CD] 8). Tuberculosis does not trigger the mechanisms described by the other options.
100
36. The progression of chronic bronchitis is best halted by which intervention?
a. Regular use of bronchodilators
b. Smoking cessation
c. Postural chest drainage techniques
d. Identification of early signs of infection
B
By the time an individual seeks medical care for symptoms, considerable airway damage is present. If the individual stops smoking, then disease progression can be halted. If smoking is stopped before symptoms occur, then the risk of chronic bronchitis decreases considerably and eventually reaches that of nonsmokers. The other interventions, although appropriate, are not directed toward halting the progression of the disease process.
101
37. Clinical manifestations of inspiratory crackles, increased tactile fremitus, egophony, and whispered pectoriloquy are indicative of which respiratory condition?
a. Chronic bronchitis c. Pneumonia
b. Emphysema d. Asthma
C
Physical examination may reveal signs of pulmonary consolidation, such as inspiratory crackles, increased tactile fremitus, egophony, and whispered pectoriloquy, which support a diagnosis of pneumonia. The presentations of the other options are not consistent with the described symptoms.
102
38. Pulmonary artery hypertension (PAH) results from which alteration?
a. Narrowed pulmonary capillaries c. Destruction of alveoli
b. Narrowed bronchi and bronchioles d. Ischemia of the myocardium
A
PAH is characterized by endothelial dysfunction with an overproduction of vasoconstrictors (e.g., thromboxane, endothelin) and decreased production of vasodilators (e.g., nitric oxide, prostacyclin), resulting in narrowed pulmonary capillaries. None of the remaining options result in pulmonary hypertension
103
39. Squamous cell carcinoma of the lung is best described as a tumor that causes which alterations?
a. Abscesses and ectopic hormone production
b. Airway obstruction and atelectasis
c. Pleural effusion and shortness of breath
d. Chest wall pain and early metastasis
B
Typically, the tumors are centrally located near the hila and project into bronchi. Because of this central location, nonproductive cough or hemoptysis is common. Pneumonia and atelectasis are often associated with squamous cell carcinoma. Chest pain is a late symptom associated with large tumors. These tumors can remain fairly well localized and tend not to metastasize until late in the course of the disease. Squamous cell carcinomas are not associated with any of the other options.
104
43. Which statement is true regarding hypoxemia?
a. Hypoxemia results in the increased oxygenation of arterial blood.
b. Respiratory alterations cause hypoxemia.
c. Hypoxemia results in the decreased oxygenation of tissue cells.
d. Various system changes cause hypoxemia.
B
Hypoxemia, or reduced oxygenation of arterial blood (PaO 2), is caused by respiratory alterations, whereas hypoxia, or reduced oxygenation of cells in tissues, may be caused by alterations of other systems as well.
105
44. Which medication classification is generally included in the treatment of silicosis?
a. Corticosteroids c. Bronchodilators
b. Antibiotics d. Expectorants
A
No specific treatment exists for silicosis, although corticosteroids may produce some improvement in the early, more acute stages. The other options are not generally prescribed.
106
45. What medical term is used for a condition that results from pulmonary hypertension, creating chronic pressure overload in the right ventricle?
a. Hypoxemia c. Bronchiectasis
b. Hypoxia d. Cor pulmonale
D
Cor pulmonale develops as pulmonary hypertension and creates chronic pressure overload in the right ventricle similar to that created in the left ventricle by systemic hypertension. None of the other options identify the condition.
107
46. What are the causes of dyspnea? (Select all that apply.)
a. Decreased pH, increased partial pressure of arterial carbon dioxide (PaCO 2) and decreased partial pressure of arterial oxygen (PaO2)
b. Decreased blood flow to the medulla oblongata
c. Stimulation of stretch or J-receptors
d. Presence of anxiety
e. Presence of pain
, C, D
Dyspnea can be triggered by decreased pH, increased PaCO 2, and decreased PaO2. Stimulation of either stretch or J-receptors is also known as a cause of dyspnea. Dyspnea may be the result of pulmonary disease or many other conditions, such as pain, heart disease, trauma, and anxiety. No data are available to support the role of decreased blood flow to the medulla oblongata as being a cause of dyspnea
108
47. Which inflammatory mediators are produced in asthma? (Select all that apply.)
a. Histamine
b. Bradykinin
c. Leukotrienes
d. Prostaglandins
e. Neutrophil proteases
A,, B, C, D
A large number of inflammatory mediators, such as histamine, prostaglandins, and leukotrienes, are produced by asthma. Neutrophil proteases are not produced in relationship to asthma.
109
48. Which clinical manifestation is associated with pulmonary hypertension? (Select all that apply.)
a. Systemic blood pressure greater than 130/90 mm Hg
b. Rhonchi bilaterally
c. Dyspnea on exertion
d. Peripheral edema
e. Jugular venous distention
ANS: C, D, E
Symptoms of fatigue, chest discomfort, tachypnea, and dyspnea on exertion, palpitations, and cough are common. Examination may reveal peripheral edema, jugular venous distention, a precordial heave, and accentuation of the pulmonary compartment of the second heart sound. Neither rhonchi nor a systemic blood pressure of 130/90 mm Hg are associated with pulmonary hypertension.
110
49. Which statements are true regarding exudative effusion? (Select all that apply.)
a. Exudative effusion contains high concentrations of white blood cells.
b. Exudative effusion produces a very thick exudate.
c. Exudative effusion may occur in response to an inflammatory process.
d. The presence of a malignant cancer can trigger exudative effusion.
e. Exudative effusion is a result of increased capillary permeability.
A, C, D, E
Exudative effusion is less watery and contains high concentrations of white blood cells and plasma proteins. Exudative effusion occurs in response to inflammation, infection, or malignancy and involves inflammatory processes that increase capillary permeability.
111
50. Which characteristics are symptomatic of a flail chest? (Select all that apply.)
a. Involves the fracture of several consecutive ribs.
b. Involves multiple fractures to individual ribs.
c. Can involve the fracture of the sternum.
d. Is generally a result of the inflammatory process.
e. Is more common among the older adult population.
A, B, C
A flail chest results from the fracture of several consecutive ribs in more than one place or the fracture of the sternum and several consecutive ribs. Age and inflammation are not generally considered factors in this disorder.
112
51. Which statements regarding Mycobacterium tuberculosis are true regarding the bacilli’s ability to go into dormancy? (Select all that apply.)
a. Neutrophils and macrophages all play a role in its dormancy.
b. Mycobacterium tuberculosis is capable of dormancy but for only a short period.
c. The immune system is the controlling factor regarding its length of dormancy.
d. The bacilli are sealed off in tubercles to allow for dormancy.
e. An attack by lymphocytes brings the bacilli out of their dormant state.
A, C, D
Neutrophils, lymphocytes, and macrophages seal off the colonies of bacilli, forming a granulomatous lesion called a tubercle. Once the bacilli are isolated in tubercles and immunity develops, tuberculosis may remain dormant for life. If the immune system is impaired, however, or if live bacilli escape into the bronchi, active disease occurs and may spread through the blood and lymphatic system to other organs. This microorganism can remain dormant for extended periods. Reverting from dormancy is not related to a lymphocyte attack.
113
114
Flu type found in humans, pigs, dogs
Type C. milder, less harmful
115
Which flu type is more contagious, mutates more rapidly?
Type A
116
Infection that often causes epiglottitis
Haemophilus influenzae B (Hib)
117
Clinical manifestations of epiglottitis
fever, sore throat, muffled speech, dysphagia, drooling, tripoding, inspiratory stridor, "thumb print" xray
118
What percentage of people who contract TB go on to have an active, symptomatic infection?
10%
119
Case 1: Susan is a 16-year-old with sudden onset of severe sore throat for the past day. She feels like she had a fever but did not check her temperature (i.e., subjective fever). She states it is very painful to swallow, and she thinks she sees white spots on her throat. She denies cough, rhinorrhea, nausea, otalgia, shortness of breath, or headache. She reports no exposure to sick individuals.
* Medications: none
* Allergies: none
* Social history: nonsmoker and drinks alcohol (two to three beers) one to two times a month
Physical exam:
* Vital signs: temperature 101.0°F; pulse 100 beats per minute; respirations 18 per minute; blood pressure 110/66 mmHg
* General: ill and tired appearance
* Head, Eyes, Ears, Nose, and Throat: unremarkable except for erythematous oropharynx with small petechiae and white tonsillar exudate.
* Neck: anterior cervical lymphadenopathy; two on right, three on left; all small (<0.5 cm) and tender
* Cardiovascular, Lungs, and Abdomen: unremarkable
1. What is the most likely diagnosis and pathogen causing this disorder, and what is the mode of transmission?
The most likely diagnosis is bacterial pharyngitis caused by Streptococcus pyogenes (i.e., strep). The mode of transmission is through saliva and nasal secretions from person to person.
2. Discuss data that support your decision.
Sudden onset of sore throat, dysphagia, and fever (subjective per patient and objective 101°F) all support this diagnosis. Also, the absence of cough is consistent with streptococcal pharyngitis (strep). Other data that supports strep are anterior cervical lymphadenopathy, oropharynx erythema with small petechiae, and white tonsillar exudates. Also, her age group is one in which strep is more prevalent.
3. What diagnostic test, if any, should be performed?
Although the diagnosis can be made clinically, confirmation can be done with the rapid antigen detection test or a throat culture.
120
Case 2: Mr. Jones is a 54-year-old man with complaints of a scratchy, raw sore throat and painful swallowing, mild productive cough, and runny nose for the past 2 days. He says his sputum is whitish-yellow. His ears feel full, and he feels like he is getting achy. He reports taking throat lozenges and denies nausea, fever, shortness of breath, chest pain, or headache. He states he teaches in a high school and a lot of his students have had colds.
* Medications: none.
* Allergies: none.
* Social history: nonsmoker and does not drink alcohol
Physical exam:
* Vital signs: temperature 99.0°F; pulse 84 beats per minute; respirations 18 per minute; blood pressure 120/70 mmHg
* General: cough during exam
* HEENT: unremarkable except for mild erythematous oropharynx with no exudates; nares with mild erythema and scant yellowish discharge
* Neck, CV, Lungs, Abdomen: unremarkable
1. What is the most likely diagnosis and pathogen causing this disorder, and what is the mode of transmission
The most likely diagnosis is infectious rhinitis that has affected his throat and a coexisting viral pharyngitis. Most cases are caused by rhinovirus, coronaviruses (e.g., SARS-CoV-1), influenza A and B, etc. The mode of transmission is person to person through inhalation, close contact touching, and surfaces.
2. Discuss data that support your decision.
Complaints of scratchy, raw sore throat with dysphagia, cough/runny nose with whitish sputum, ear fullness, and generalized myalgias all support the diagnosis. Physical examination with mild erythema and no exudates in oropharynx, nares with erythema, and yellow discharge also support the diagnosis.
121
Case 2: Mr. Menendez is a 65-year-old man presenting with 2 to3 days of coughing up thick yellow sputum, shortness of breath, fever (he did not check the actual temperature), and chills. He states his chest hurts when he breathes. He denies headache, rhinorrhea, sinus pain, and nausea. He reports no exposure to sick individuals.
* Medications: lisinopril 10 mg a day by mouth
* Allergies: no known drug allergy
* Social history: smokes 1 pack of cigarettes per day (has done so for 30 years); denies alcohol use; works as a landscaper
Physical exam:
* Vital signs: temperature 101°F; pulse 98 beats per minute; respiratory rate 22 per minute; blood pressure 140/86 mmHg; pulse oximeter 93%
* General: ill and tired appearance, coughing during visit with thick yellow sputum noted
* HEENT: unremarkable
* Neck: small anterior and posterior cervical nodes
* Cardiovascular: unremarkable
* Lungs: right basilar crackles with dullness to percussion in right lower lobe
* Abdomen: unremarkable
1. What is the most likely diagnosis and pathogen causing this disorder? Discuss the mode of transmission. Discuss the data that support your decision.
The most likely cause of his symptoms is community-acquired pneumonia. The gram-positive bacteria Streptococcus pneumoniae (i.e., pneumococcal pneumonia) is responsible for most cases of community-acquired pneumonia. Pathogens can enter the lung parenchyma as a result of aspirating oropharyngeal secretions or inhaling particles in the air through coughing, sneezing, or particles that have been aerosolized from equipment such as a respiratory mask. The introduction of devices such as endotracheal tubes and suction catheters can be a portal of entry for pathogens. Contiguous (adjacent) spread occurs when a site close to the lung is infected and causes a direct spread of the pathogen to the lung (e.g., amebic liver abscess). Another route for pathogens to enter the lungs is hematogenously (via bloodstream). The hematogenous mechanism is not as common but can occur with central line infection, urinary tract infection, endocarditis, or from any other bacteremic process.
Clinical manifestations of pneumonia vary depending on type. General signs and symptoms that Mr. Menendez has include the following: productive cough with thick yellow sputum, fatigue, pleuritic pain, dyspnea, fever, chills, crackles, consolidation signs (e.g., dullness to percussion), decreased breath sounds, and tachypnea. Other manifestations that Mr. Menendez is not exhibiting but could be present include mental status changes.
2. What diagnostic test, if any, should be performed?
A history and physical may be sufficient to diagnose pneumonia; however, a chest X-ray is an important diagnostic test as findings may aid in determining the pathogen, identifying pleural effusions, or detecting the development of cavities (walled hollow structures in the lungs). The information from the chest X-ray can then be used to choose efficacious treatments to expeditiously treat the pneumonia.
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Now that we have learned what can go wrong in the pulmonary system, let us put that knowledge into practice. While working in the emergency department, the following patients need to be triaged.
* A 2-year-old with a history of asthma with a fever, lethargy, and multiple uses of short-acting beta agonist treatments prior to arrival
* A 25-year-old male with nasal drainage and hoarseness
* A 40-year-old female with fever, severe body aches, and nasal congestion
* A 59-year-old male with stage III bronchogenic carcinoma who reports increased shortness of breath
1. Which patient would have the highest priority? Explain why.
2. What are possible diagnoses in each scenario? What clinical manifestations would be consistent with each possible diagnosis?
Now that we have learned what can go wrong in the pulmonary system, let us put that knowledge into practice. While working in the emergency department, the following patients need to be triaged.
* A 2-year-old with a history of asthma with a fever, lethargy, and multiple uses of short-acting beta agonist treatments prior to arrival
* A 25-year-old male with nasal drainage and hoarseness
* A 40-year-old female with fever, severe body aches, and nasal congestion
* A 59-year-old male with stage III bronchogenic carcinoma who reports increased shortness of breath
1. Which patient would have the highest priority? Explain why.
2. What are possible diagnoses in each scenario? What clinical manifestations would be consistent with each possible diagnosis?
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What is total lung capacity?
Max amount of air that can be held in the lungs (inspiratory reserve volume + tidal volume + expiratory reserve volume + residual volume)
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What is tidal volume?
Amount of air in a normal inhale/exhale (≈500mL)
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What is minute respiratory volume?
Amount of air inhaled/exhaled in 1 minute (tidal volume x respiration rate) (≈6L)
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What is inspiratory reserve volume?
Amount of air beyond tidal volume that could be inhaled with deepest inhalation (≈2-3L)
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What is expiratory reserve volume?
Amount of air beyond tidal volume that can be forcibly exhaled (≈1-1.5L)
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What is residual volume?
Amount of air always present in the lungs, allowing for efficient and consistent gas exchange (≈1-1.5L)
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What is forced expiratory volume in 1 second (FEV1)?
Amount of air able to be forcibly exhaled in 1 second
Normal
Men = 3.5-4.5 L
Women = 2.5-3.25 L
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What is forced vital capacity?
Max amount of air a person can exhale forcefully after taking a deep breath
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How is asthma diagnosed?
Calculating ratio of FEV1 to FVC
Normal is about 70-80%
In asthma, FEV1 divided by FVC is less than 75%, and improves by 10% after bronchodilator treatment
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Structures of the upper respiratory system
Nose, nasal cavity/sinuses, mouth, pharynx, larynx
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Structures of the lower respiratory tract
Trachea, bronchi, bronchioles, lungs/alceoli
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2 glycoproteins in RSV
F and G
FuckinG RSV
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CURB 65 CRITERIA
The CURB-65 is a severity score for CAP, comprising 5 variables, attributing 1 point for each item: new onset confusion; urea >7 mmol/L; respiratory rate ≥30/minute, systolic blood pressure <90 mmHg and/or diastolic blood pressure ≤60 mmHg; and age ≥65 years.
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fever, night sweats, unexplained weight loss, productive cough
possible diagnosis
tuberculosis
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most common cause of bronchiolitis
rsv
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glycoproteins for flu a
h and n
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1) What part of the brain regulates breathing function?
A) Pons
B) Frontal lobe
C) Medulla oblongata
D) Occipital lobe
c) medulla oblongata
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What is the most common cause of mononucleosis?
epstein barr virus
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