You note in the chart of a patient's who is receiving volume control ventilation that the plateau pressure has been increasing over the last 6 hours, while the PEEP levels remains constant. Which of the following would b
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You note in the chart of a patient's who is receiving volume control ventilation that the plateau pressure has been increasing over the last 6 hours, while the PEEP levels remains constant. Which of the following would be the most likely cause of this change?
Select one:
A. development of pulmonary edema
B. water accumulation in the ventilator circuit
C. partial obstruction of the endotracheal tube
D. development of bronchospasm -✔✔ An increase in the plateau pressure relative to baseline (Pplat-PEEP) indicates a decrease in the patient's lung and/or thoracic compliance. Common causes of a decrease in lung compliance are pneumothorax, pulmonary edema, atelectasis and ARDS. Partial obstruction of the ET tube and development of bronchospasm would increase airway resistance and thus increase PIP and the PIP-Pplat pressure difference, but not affect Pplat.
The correct answer is: development of pulmonary edema
The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the:
Select one:
A. cerebral perfusion pressure
B. cerebral vascular resistance
C. blood-brain barrier pressure
D. jugular venous pressure -✔✔ The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the cerebral perfusion pressure (CPP); CPP = MAP - ICP. As this equation makes clear, any factor that increases ICP and/or lowers MAP will decrease CPP and thus potentially cause brain damage or death. In general perfusion is adequate if the CPP can be maintained between 60 to 100 mm Hg.
The correct answer is: cerebral perfusion pressure
Which of the following would provide the best bedside assessment of the need for mechanical ventilation in a patient with Guillain-Barre syndrome?
Select one:
A. FRC
B. VC
C. airway resistance
D. TLC -✔✔ Guillain-Barre syndrome is a restrictive neuromuscular disorder that results in hypoventilation. Airway resistance measures are not useful in diagnosing restrictive ventilatory impairments. Restrictive ventilatory impairments are characterized by low lung volumes. Of the volumes listed, only the vital capacity (VC) can be measured at bedside
The correct answer is: VC
The normal range of adult blood pressure (systolic/diastolic) is about:
Select one:
A. 80-100/40-70 mm Hg
B. 100-140/60-90 mm Hg
C. 120-140/90-100 mm Hg
D. 130-150/100-110 mm Hg -✔✔ Normal systolic pressure range from 100 to 140 mm Hg, with an average of 120 mm Hg. Normal diastolic pressures range from 60 to 90 mm Hg, with an average of 80 mm Hg. The blood pressure is recorded with systolic listed over diastolic; i.e., 120/80 mm Hg.
The correct answer is: 100-140/60-90 mm Hg
A patient admitted to the ED exhibits wheezing and hypoxemia on room air. Lab tests indicate a normal B-type natriuretic peptide (BNP) level. Which of the following conclusion can you draw from these findings?
Select one:
A. renal function likely is normal
B. a myocardial infarction is likely
C. congestive heart failure is unlikely
D. liver function likely is normal -✔✔ B-type natriuretic peptide (BNP) is a cardiac neurohormone secreted from membrane granules in the cardiac ventricles as a response to ventricular volume expansion and pressure overload. BNP levels that are less than 100 pg mL (normal is < 20 pg/mL) tend to rule out diagnosis of CHF, while values exceeding 500 pg/mL help rule in this diagnosis. Intermediate values are less helpful and may occur in conditions with similar symptoms, including renal insufficiency, cor pulmonale, and acute pulmonary embolism.
The correct answer is: congestive heart failure is unlikely
Normal lung compliance is approximately:
Select one:
A. 0.1 - 0.4 L/cm H2O
B. 0.4 - 0.8 L/cm H2O
C. 10 - 15 L/cm H2O
D. 15 - 20 L/cm H2O -✔✔ Normal compliance of the adult lung ranges from 0.1 to 0.4 L/cm H2O, with an average value of about 0.2 L/cm H2O. The volume component of the compliance is measured as the inhaled volume at any given pressure change. The pressure component represents the difference between the alveolar and pleural pressures (the transpulmonary pressure gradient).
The correct answer is: 0.1 - 0.4 L/cm H2O
Within one second after initiating a forced vital capacity (FVC) maneuver, a patient with normal lungs should be able exhale what percent of the FVC?
Select one:
A. 35-50% of the FVC
B. 50-70% of the FVC
C. 70-83% of the FVC
D. 84-93% of the FVC -✔✔ The normal range for the FEV1 as a percent of the FVC (FEV1%) is 70-83%. Patients with obstructive pulmonary disease will show a reduction in timed FEV% values, while patients with restrictive disorders will generally exhibit normal (or sometimes high) FEV% values.
The correct answer is: 70-83% of the FVC
Which of the following clinical findings would increase the probability that a patient with some perfusion defects on a V/Q scan has a pulmonary embolism?
Deep venousthrombosis
Recent history of cancer
Prolonged immobilization
A. Yes No Yes
B. Yes Yes Yes
C. No Yes Yes
D. Yes Yes No
Select one:
A. A
B. B
C. C
D. D -✔✔ The accuracy of V/Q scans in diagnosing pulmonary embolism (PE) can be improved by combining a set of clinical risk factors with the V/Q results. These factors (known as the Wells criteria) include signs and symptoms of deep venous thrombosis (DVT), prior diagnosis of DVT or PE, tachycardia, immobilization for three or more days or surgery during the prior month, hemoptysis and recent history of cancer.
The correct answer is: B
During auscultation of a patient's chest, you hear intermittent "bubbling" sounds at the lung bases. Which of the following chart entries best describe this finding?
Select one:
A. "bronchial sounds heard at lung bases"
B. "wheezes heard at lung bases"
C. "rhonchi heard at lung bases"
D. "crackles (rales) heard at lung bases" -✔✔ The preferred term for short, discontinuous adventitious lung sounds that are crackling or bubbling in nature is crackles. Many clinicians still use the term râles for these sounds. Crackles are caused either by movement of excessive secretions in the airways (course crackles), or by collapsed airways opening during inspiration (fine crackles).
The correct answer is: "crackles (rales) heard at lung bases"
A comprehensive environmental history needs to include information on:
Select one:
A. the jobs of all household members
B. home/apartment temperature settings
C. commuting distance to/from work
D. approximate hours per day spent on feet -✔✔ In addition to work-related exposures, a comprehensive environmental history should include information on present and previous home locations, jobs of household members, home insulating and heating/cooling system, home cleaning agents, pesticide exposure, water supply, recent renovation/remodeling, air pollution (indoor and outdoor), hazardous wastes/spill exposure, and hobbies (e.g., painting, sculpting, ceramics, welding, woodworking, automobiles, gardening, etc.)
The correct answer is: the jobs of all household members
Immediately following intubation of a patient's trachea, which of the following would yield the best information regarding ET tube position in the trachea?
Select one:
A. arterial blood gas analysis
B. chest X-ray
C. exhaled volume
D. PETCO2 -✔✔ While the PETCO2 can help determine lung vs esophageal placement of an ET tube, only a chest X-ray can confirm its proper placement in the trachea. On an adult A-P chest X-ray, the ET tube tip should be positioned about 4 to 6 cm above the carina or between T2 and T4. This position minimizes the chance of the tube moving down into the mainstem bronchi (endobronchial intubation) or up into the larynx (extubation).
The correct answer is: chest X-ray
In individuals with disorders causing an increased ELASTIC work of breathing, such as pulmonary fibrosis, which of the following breathing patterns results in the minimum work?
Select one:
A. slow and deep breathing
B. slow and shallow breathing
C. rapid and deep breathing
D. rapid and shallow breathing -✔✔ Individuals with disorders characterized by an increased elastic work of breathing, such as pulmonary fibrosis, tend to assume a rapid and shallow breathing pattern. For these patients, such a pattern results in the minimum mechanical work necessary to effectively ventilate the lungs.
The correct answer is: rapid and shallow breathing
The most likely cause of bilateral fluffy infiltrates on a chest x-ray is:
Select one:
A. pulmonary edema
B. neoplasm
C. pleural effusion
D. hemothorax -✔✔ Bilateral infiltrates indicate a global (lung-wide) as opposed to local pulmonary problem. "Fluffy" infiltrates usually indicate an alveolar condition. Only pulmonary edema is a global condition affecting the alveolar region (fluid transudation). Typically neoplasms, effusions and hemothoraces are revealed as a localized areas of increased radiopacity.
The correct answer is: pulmonary edema
The normal apical impulse (PMI) usually is identified where?
Select one:
A. 3rd right intercostal space, left sternal border
B. 3rd left intercostal space, anterior axillary line
C. 5th right intercostal space, midclavicular line
D. 5th left intercostal space, midclavicular line -✔✔ The normal apical impulse is produced by the thrust of the contracting left ventricle and usually is identified near the midclavicular line in the left fifth intercostal space. This systolic thrust, referred to as the point of maximal impulse, or PMI, may be felt and visualized in most normal individuals.
The correct answer is: 5th left intercostal space, midclavicular line
When asking a patient who he is, where he is, and the time of day, you are trying to assess the patient's:
Select one:
A. level of consciousness
B. reaction to chronic illness
C. understanding of the language
D. ability to cooperate -✔✔ Asking patients the time of day, where they are, and who they are is a quick way to assess their level of consciousness or "sensorium." Alert patients are well-oriented as to time, place, and person, or "oriented ×3." The most common reasons for a patient not being well-oriented to time, place, and person are neurologic injury, pharmacologic sedation and severe hypoxemia or hypercapnia. In general, only alert patients can be expected to cooperate and fully participate in their own care.
The correct answer is: level of consciousness
While conducting a fluoroscopic exam, a doctor has a patient perform a short, sharp inspiratory effort through his nose. During this maneuver, the right hemidiaphragm rises, while the left descends. The most likely problem is:
Select one:
A. right phrenic nerve paralysis
B. atrophy of the diaphragm
C. left phrenic nerve paralysis
D. bilateral phrenic nerve paralysis -✔✔ The maneuver being performed by the patient is a 'sniff' test, used to identify phrenic nerve dysfunction. During this maneuver, if one or the other hemidiaphragm moves upinstead of down, the likely problem is unilateral phrenic nerve paralysis/palsy. In this case it is the right phrenic nerve that is not functioning.
The correct answer is: right phrenic nerve paralysis
On the physical assessment of a patient who appears acutely ill, you note the following: severely labored breathing, accessory muscle use, and stridor. These findings suggest:
Select one:
A. acute tension pneumothorax
B. acute upper airway obstruction
C. pneumonia with consolidation
D. chronic airway obstruction -✔✔ The patient with an acute upper airway obstruction is usually in acute distress and exhibits labored breathing. Accessory muscles commonly are used during inhalation. Breath sounds may be clear but can be difficult to discern through the characteristic stridor. The lungs may be normal to percussion and palpation. Since ventilation is at risk, the patient should not be left alone, and the assessment must be quick and accurate to allow proper treatment.
The correct answer is: acute upper airway obstruction
Which of the following methods could be used to assess the intensity of pain being experienced by an elderly, confused patient who is unable to express himself?
Interview a family member Observe patient for grimacing
Use a numeric rating scale
A. No Yes Yes
B. Yes No Yes
C. Yes Yes No
D. Yes Yes Yes
Select one:
A. A
B. B
C. C
D. D -✔✔ A numeric rating scale is not useful for young children or patients who are confused or unable to express themselves. As an alternative, interviewing family members may help provide information about pain history, typical behaviors when the patient has pain, and activities that may cause or aggravate pain. Lacking such information, the health professional may have to rely on overt patient behaviors (e.g., groaning/moaning, 'doubling over,' etc.) and/or facial expressions indicative of severe pain (e.g., grimacing, eye tearing, etc).
The correct answer is: C
During an interview, a patient complains about coughing. What further information would you seek regarding this symptom?
Onset (e.g. what brings it on?)
Characteristics (e.g. productive?)
Course (e.g. progress over time)
A. No Yes Yes
B. Yes No Yes
C. Yes Yes Yes
D. Yes Yes No
Select one:
A. A
B. B
C. C
D. D -✔✔ When exploring a patient's symptoms, you should use probing questions to elaborate on the onset, characteristics, and course of each subjective complaint. Since a patient's subjective evaluation of a symptom is related to factors such as pain tolerance and perception, you also should evaluate the intensity or severity of a symptom in terms of it's observable interference with the patient's ability to function.
The correct answer is: C
Which of the following observations during inspection of the extremities indicate poor peripheral circulation?
Digital Clubbing
Peripheral Cyanosis
Impaired Capillary Refill
Skin Warm to Touch
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