PATHO 370: Week 3 Check Your Understanding: Ch. 16, 18, 19, 20

Patients with structural evidence of heart failure who exhibit no signs or symptoms are classified into which New York Heart Association heart failure class? A) Class I B) Class II C) Class III D) Class IV

ANSWER: A) Class I Patients who have structural heart disease but no signs or symptoms of heart failure are placed in Class I of the NYHA Classes. Class II patients have current or previous symptoms of heart failure. Class III patients have current or previous symptoms of heart failure, such as dyspnea or fatigue. Class IV patients have advanced structural heart disease and marked symptoms at rest.

Administration of which therapy is most appropriate for hypovolemic shock? A) Crystalloids B) Vasoconstrictor agents C) Inotropic agents D) 5% dextrose in water

ANSWER: A) Crystalloids Crystalloids are solutions that contain electrolytes. Isotonic solutions, such as lactated Ringers, are commonly used crystalloid solutions. These solutions are preferred for volume resuscitation, because they remain in the extracellular space and are more effective in increasing blood volume. Vasoconstrictor agents are contraindicated in hypovolemic shock. Isotonic crystalloids are the most appropriate fluid for volume resuscitation. Isotonic fluids are preferred over glucose or hypotonic electrolyte solutions.

Which serum biomarker(s) are indicative of irreversible damage to myocardial cells? A) Elevated CK-MB, troponin I, and troponin T B) Markedly decreased CK-MB and troponin I C) Elevated LDL D) Prolonged coagulation time

ANSWER: A) Elevated CK-MB, troponin I, and troponin T Elevated cardiac biomarkers are one indication of myocardial necrosis. Cardiac biomarkers may not be utilized if a patient presents with chest pain and evidence of acute ischemia on the electrocardiogram. Cardiac biomarkers are elevated in the presence of MI. Elevated LDL is a risk factor for coronary atherosclerosis. Coagulation times are not used to assess myocardial damage.

Hypertension with a specific, identifiable cause is known as _____ hypertension. A) primary B) orthostatic C) secondary D) malignant

ANSWER: C) Secondary Secondary hypertension has a specific identifiable cause such as a specific pathology or a condition that results in hypertension. Primary hypertension does not have a clearly identifiable etiology and is therefore an idiopathic disorder. Positional changes do not generally result in hypertension. Malignant hypertension is a hypertensive crisis.

While hospitalized, an elderly patient with a history of myocardial infarction was noted to have high levels of low-density lipoproteins (LDLs). What is the significance of this finding? A) Increased LDL levels are associated with increased risk of coronary artery disease. B) Measures to decrease LDL levels in the elderly would be unlikely to affect the progression of this disease. C) Increased LDL levels are indicative of moderate alcohol intake, and patients should be advised to abstain. D) Elevated LDL levels are an expected finding in the elderly and therefore are not particularly significant.

ANSWER: A) Increased LDL levels are associated with increased risk of coronary artery disease. High levels of low-density lipoproteins (LDLs), which are high in cholesterol, have been associated with the highest risk of coronary atherosclerosis. Even when lipid metabolism is normal, a high-fat diet can overwhelm the liver's ability to clear LDL cholesterol from the circulation and result in hyperlipidemia. Dietary fat restriction may be beneficial in reducing cholesterol in this case. Increased LDL levels are not indicative of alcohol intake. Elevated LDL levels are not an expected finding in the elderly and should be treated.

Which finding is indicative of orthostatic hypotension in a person with a supine blood pressure (BP) of 110/70 and a heart rate (HR) of 100? A) Sitting BP 88/60, HR 118 B) Sitting BP 108/68, HR 102 C) Sitting BP 110/78, HR 98 D) Sitting BP 120/80, HR 100

ANSWER: A) Sitting BP 88/60, HR 118 The definition of orthostatic hypotension is a decrease in systolic blood pressure greater than 20 mm Hg or a decrease in systolic pressure that is greater than 10 mm Hg within 3 minutes of moving to an upright position. The measurements of BP 108/68, HR 102 and BP 110/78, HR 98 are not indicative of orthostatic hypotension. An increase in blood pressure do not occur with orthostatic hypotension.

Disseminated intravascular coagulation is a serious complication of septic shock characterized by abnormal clot formation in the microvasculature throughout the body. A) True B) False

ANSWER: A) True Disseminated intravascular coagulation is a serious complication of septic shock characterized by abnormal clot formation in the microvasculature throughout the body.

Lactated Ringer solution and normal saline are commonly used crystalloid solutions that contain electrolytes. A) True B) False

ANSWER: A) True Lactated Ringer solution and normal saline are commonly used crystalloid solutions that contain electrolytes.

Aortic regurgitation is associated with: A) diastolic murmur. B) elevated left ventricular/aortic systolic pressure gradient. C) elevated systemic diastolic blood pressure. D) shortened ventricular ejection phase.

ANSWER: A) diastolic murmur. Aortic regurgitation results from an incompetent aortic valve that allows blood to leak back from the aorta into the left ventricle during diastole. In aortic regurgitation, there is not an elevated left ventricular/aortic pressure gradient. Diastolic blood pressure is generally lower because of rapid runoff of blood into the ventricle. Aortic regurgitation is associated with a longer ventricular ejection phase.

A patient is diagnosed with heart failure with normal ejection fraction. This patient is most likely characterized by a(n) A) elderly woman without a previous history of MI. B) middle-aged man with a previous history of MI. C) young female athlete with cardiomegaly. D) young sedentary male with a high-stress job.

ANSWER: A) elderly woman without a previous history of MI. Heart failure with normal ejection fraction is particularly likely to develop in the elderly, in women, and in those without a history of MI. A middle-aged man with a previous history of MI may have heart failure, but the older woman fits the criteria of heart failure with normal ejection fraction. A young female athlete with cardiomegaly may experience heart failure, but is not the normal patient profile for this condition. A young sedentary male with a high-stress job may experience heart failure, but this patient does not fit the normal profile for this condition.

An erroneously low blood pressure measurement may be caused by: A) positioning the arm above the heart level. B) using a cuff that is too small. C) positioning the arm at heart level. D) measuring blood pressure after exercise.

ANSWER: A) positioning the arm above the heart level. An erroneous blood pressure result could occur with the arm above the level of the heart. It is important to measure blood pressure with the appropriate size cuff. The arm should be positioned at the level of the heart for a more accurate reading. Measuring pressure after exercise yields a higher measurement.

First-degree heart block is characterized by: A) prolonged PR interval. B) absent P waves. C) widened QRS complex. D) variable PR interval.

ANSWER: A) prolonged PR interval. First-degree block is generally identified by a prolonged PR interval (more than 0.20 second) on ECG. P waves are not absent in first-degree heart block. A widened QRS complex is associated with a particular dysrhythmia, but not first-degree heart block. A variable PR interval is found in type I second-degree block.

A patient with a history of myocardial infarction continues to complain of intermittent chest pain brought on by exertion and relieved by rest. The likely cause of this pain is: A) stable angina. B) myocardial infarction. C) coronary vasospasm. D) unstable angina.

ANSWER: A) stable angina Stable angina is the most common form of chest pain and is characterized by pain that is caused under conditions of increased myocardial workload, such as physical exertion or emotional strain. Pain related to myocardial infarction is not relieved by rest. Coronary vasospasm is characterized by unpredictable attacks of angina pain. A patient with unstable angina presents with symptoms similar to myocardial infarction.

The progressive stage of hypovolemic shock is characterized by A) tachycardia. B) hypertension. C) lactic acidosis. D) cardiac failure.

ANSWER: A) tachycardia In the progressive stage of hypovolemic shock, the patient is anxious and confused, with decreased blood pressure and heart rate greater than 120 beats/minute. In this stage of shock, the blood pressure is decreased. Lactic acidosis does not occur in the progressive stage of hypovolemic shock. Cardiac failure is not likely to occur in the earlier stages of hemorrhagic shock.

Which blood pressure reading is considered to be indicative of prehypertension according to the JNC-7 criteria? A) 118/78 B) 128/82 C) 140/88 D) 138/94

ANSWER: B) 128/82 In adults, a normal blood pressure is <120 mm Hg systolic and <80 mm Hg diastolic pressure. Stage 1 hypertension begins with a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg. Between these values, the individual is said to have prehypertension, and interventions related to lifestyle changes should be initiated for primary hypertension. 118/78 is considered normal. An individual with a reading of 140/88 or 138/94 may be considered to have stage 1 hypertension.

A middle-aged patient has a follow up visit for a recorded blood pressure of 162/96 mm Hg taken 3 weeks ago. The patient has no significant past medical history and takes no medications, but smokes 1 1/2 packs of cigarettes per day, drinks alcohol regularly, and exercises infrequently. The patient is about 40 lbs. overweight and admits to a high-fat, high-calorie diet. At the office visit today, the patient's blood pressure is 150/92 mm Hg. What is the least appropriate intervention for this patient at this time? A) Begin lifestyle modifications. B) Begin antihypertensive drug therapy. C) Recheck blood pressure in 4 to 6 weeks. D) Encourage smoking cessation.

ANSWER: B) Begin antihypertensive drug therapy. Antihypertensive drug therapy is not the first intervention in a person with modifiable risk factors. Therefore, lifestyle alterations are attempted first. Lifestyle alterations include exercise, smoking cessation, and weight loss. Blood pressure should be rechecked in 4 to 6 weeks. Smoking cessation counseling is an appropriate lifestyle alteration.

In which stage of shock is a patient who has lost 1200 mL of blood, who has normal blood pressure when supine, but who experiences orthostatic hypotension upon standing? A) Class I, Initial Stage B) Class II, Compensated Stage C) Class III, Progressive Stage D) Class IV, Refractory Stage

ANSWER: B) Class II, Compensated Stage In compensated stage hemorrhage (Class II), the blood loss is between 750 and 1500 mL. Blood pressure remains normal when the patient is supine but decreases upon standing. In initial stage hemorrhage (Class I) blood loss is up to 750 mL, and the patient's vital signs remain normal. Class III hemorrhage (progressive stage) is blood loss of 1500 and 2000 mL. Vital signs are changing. Severe Class IV hemorrhage (refractory stage) occurs when more than 2000 mL is lost. The patient is lethargic, with severe hypotension.

A type of shock that includes brain trauma that results in depression of the vasomotor center is cardiogenic. A) True B) False

ANSWER: B) False A type of shock that includes brain trauma that results in depression of the vasomotor center is neurogenic shock.

New-organ damage is a function of both the stage of hypertension and its duration. A) True B) False

ANSWER: B) False End-organ damage is a function of both the stage of hypertension and its duration.

The most commonly recognized outcome of hypertension is pulmonary disease. A) True B) False

ANSWER: B) False The most commonly recognized outcome of hypertension is cardiovascular disease.

The most reliable indicator that a person is experiencing an acute myocardial infarction (MI) is: A)severe, crushing chest pain. B)ST-segment elevation. C) dysrhythmias. D) pain radiating to the lower legs.

ANSWER: B) ST- segment elevation Injuries to cardiac tissue caused by myocardial ischemia and infarction are indicated on the ECG by ST-segment changes. ST-segment elevation on the ECG indicates that ischemic injury is ongoing and that efforts to improve perfusion or reduce oxygen demand may be effective in preserving myocardial muscle. In some instances, an MI is entirely asymptomatic. Dysrhythmias that accompany MI are attributed to injured and ischemic cells that have not yet become necrotic. Pain radiating to the jaw and neck, not the lower legs, is symptomatic of an MI.

Myocarditis should be suspected in a patient who presents with: A) chest pain and ST elevation. B) acute onset of left ventricular dysfunction. C) murmur and abnormal valves on echocardiogram. D) family history of cardiomyopathy.

ANSWER: B) acute onset of left ventricular dysfunction. Acute myocarditis is commonly characterized by left ventricular dysfunction or general dilation of all four heart chambers. Chest pain and ST elevation is indicative of myocardial infarction. Myocarditis is associated with viral infections. Dilated cardiomyopathy runs in families and has a genetic basis.

Patients presenting with symptoms of unstable angina and no ST segment elevation are treated with: A) cardiac catheterization. B) antiplatelet drugs. C) acute reperfusion therapy. D) cardiac biomarkers only.

ANSWER: B) antiplatelet drugs. Patients presenting with symptoms of unstable angina and no ST elevation on the ECG would be treated with antiplatelet drugs as a cornerstone of therapy. Coronary angiography may be used as an additional method of diagnosis but would not be the primary option. The patient with symptoms of unstable angina would not benefit from reperfusion strategies. Cardiac biomarkers may be assessed in the unstable angina patient, but are not the primary indicator.

Hypotension, distended neck veins, and muffled heart sounds are classic manifestations of: A) myocardial infarction. B) cardiac tamponade. C) congestive heart failure (CHF). D) cardiomyopathy.

ANSWER: B) cardiac tamponade The three classic symptoms of cardiac tamponade are hypotension, distended neck veins, and muffled heart sounds. There are many other manifestations as well. Myocardial infarction is not exhibited by the symptoms described. Classic symptoms of cardiac tamponade are hypotension, distended neck veins, and muffled heart sounds. Symptoms of CHF may include jugular venous distention. Cardiomyopathy is not exhibited by the symptoms described.

Low cardiac output in association with high preload is characteristic of ________ shock. A) hypovolemic B) cardiogenic C) anaphylactic D) septic

ANSWER: B) cardiogenic In cardiogenic shock, preload is high and cardiac output is low. In hypovolemic shock, preload and cardiac outputs are both low. In anaphylactic shock, blood volume may be normal. Septic shock is associated with infections.

Lusitropic impairment refers to: A) poor contractile force. B) impaired diastolic relaxation. C) altered action potential conduction rate. D) altered automaticity.

ANSWER: B) impaired diastolic relaxation. Lusitropic impairment refers to an energy-requiring process that removes free calcium ions from the cytoplasm by pumping them back into the sarcoplasmic reticulum and across the cell membrane into the extracellular fluid. Ischemia interferes with this process in the active phase of diastolic relaxation. Poor contractile force is not associated with lusitropic impairment. The conduction rate is not associated with the energy-requiring process known as lusitropy. Automaticity is not a factor in lusitropy.

Rheumatic heart disease is most often a consequence of: A) chronic intravenous drug abuse. B) viral infection with herpesvirus. C) β-hemolytic streptococcal infection. D) cardiomyopathy.

ANSWER: C) β-hemolytic streptococcal infection. Rheumatic heart disease is an uncommon but serious consequence of rheumatic fever. Rheumatic fever is an acute inflammatory disease that follows infection with group A β-hemolytic streptococci. Rheumatic heart disease is not associated with chronic IV drug abuse. Rheumatic fever is an acute inflammatory infectious disease. Cardiomyopathy does not cause rheumatic heart disease.

A patient who was involved in a fall from a tree becomes short of breath. The lung sounds are absent on one side. This patient is experiencing ________ shock. A) cardiogenic B) obstructive C) hypovolemic D) distributive

ANSWER: B) obstructive This type of obstructive shock is the result of a tension pneumothorax and is caused by shifting and compression of mediastinal structures including the heart, which compromise left ventricular filling. Accumulation of air in the pleural space may occur because of trauma. Prompt relief of the obstructive event is necessary to restore cardiac output and prevent cardiovascular collapse. Cardiogenic shock is not related to a traumatic event. Hypovolemic shock results when circulating blood volume is inadequate to perfuse tissues. Distributive shock is characterized by an abnormally expanded vascular space caused by excessive vasodilation.

Hypotension associated with neurogenic and anaphylactic shock is because of: A) hypovolemia. B) peripheral pooling of blood. C) poor cardiac contractility. D) high afterload.

ANSWER: B) peripheral pooling of blood. Profound peripheral vasodilation of both arterioles and veins leads to peripheral pooling of blood and hypotension. Decreased venous return to the heart results in decreased cardiac output and hypotension. Hypovolemia is not the source of the hypotension involved in neurogenic and anaphylactic shock. Cardiac output is generally adequate in neurogenic and anaphylactic shock. Hypotension in neurogenic and anaphylactic shock is not related to high afterload.

Beta-blockers are advocated in the management of heart failure because they: A) increase cardiac output. B) reduce cardiac output. C) enhance sodium absorption. D) reduce blood flow to the kidneys.

ANSWER: B) reduce cardiac output. Beta-blockers are advocated in the management of heart failure to inhibit the cardiac effects of sympathetic activation. These drugs are negative inotropes and have the potential to reduce cardiac output. The goal with the use of beta-blockers in heart failure is to reduce cardiac output. Beta-blockers do not affect sodium reabsorption. Angiotensin II and aldosterone enhance sodium and water reabsorption by the kidney, contributing to an elevated blood volume.

The common denominator in all forms of heart failure is A) poor diastolic filling. B) reduced cardiac output. C) pulmonary edema. D) tissue ischemia.

ANSWER: B) reduced cardiac output. The common manifestation of all forms of heart failure is the failure of the heart to pump blood adequately. The clinical presentation may differ depending on which ventricle fails (left or right, or both). Poor diastolic filling is not seen in all forms of heart failure. Pulmonary edema is seen in left-sided failure. Tissue ischemia is directly related to myocardial infarction, which may induce heart failure.

Massive release of histamine with consequent vasodilation and hypotension occurs with what type of shock? A) Cardiogenic B) Hypovolemic C) Anaphylactic D) Neurogenic

ANSWER: C) Anaphylactic Exposure to a specific antigen causes receptors on mast cells and basophils to cross-link and activate histamine. The release of histamine along with other vasoactive chemicals produces bronchoconstriction. Cardiogenic shock is not associated with histamine release. Hypovolemic shock is not associated with histamine release. Histamine release does not occur with neurogenic shock.

Restriction of which electrolytes is recommended in the management of high blood pressure? A) Calcium B) Potassium C) Sodium D) Magnesium

ANSWER: C) Sodium The balance of the intake of water and sodium with their excretion by the kidney remains the central feature of long-term blood pressure maintenance. Sodium is not rapidly eliminated by the kidney like water and adds to the body's fluid volume. It is not necessary to restrict the intake of calcium when managing high blood pressure. Potassium does not need to be restricted in the management of high blood pressure. Magnesium does not play a role in the management of high blood pressure.

Patent ductus arteriosus is accurately described as a(n): A) opening between the atria. B) stricture of the aorta that impedes blood flow. C) communication between the aorta and the pulmonary artery. D) cyanotic heart defect associated with right-to-left shunt.

ANSWER: C) communication between the aorta and the pulmonary artery. A patent ductus arteriosus is a normal channel between the pulmonary artery and the aorta that remains open during intrauterine life. A patent ductus arteriosus is not an opening or a stricture in the atria. Patent ductus arteriosus is an acyanotic congenital defect.

Administration of a vasodilator to a patient in shock would be expected to: A) decrease vascular resistance. B) increase contractility. C) decrease left ventricular afterload. D) increase tissue perfusion.

ANSWER: C) decrease left ventricular afterload. Vasodilators are used to decrease the workload of the heart by decreasing left ventricular afterload. Nitroprusside and nitroglycerin are examples of vasodilators. Dobutamine is used to decrease vascular resistance. Positive inotropic drugs are used to increase contractility. Positive inotropes include β-adrenergic agonists, which have the ability to increase tissue perfusion.

The prevalence of high blood pressure is higher in: A) non-Hispanic white adults. B) Mexican-American adults. C) non-Hispanic black adults. D) Asian children.

ANSWER: C) non-Hispanic black adults. The prevalence of high blood pressure remains higher among non-Hispanic black adults. Non-Hispanic white adults have a lower prevalence of high blood pressure. Mexican-American adults have a lower prevalence than black adults. Asian children do not display a high prevalence for high blood pressure.

Cor pulmonale refers to: A) biventricular failure. B) left ventricular hypertrophy secondary to lung disease. C) right ventricular hypertrophy secondary to pulmonary hypertension. D) right ventricular failure secondary to right ventricular infarction.

ANSWER: C) right ventricular hypertrophy secondary to pulmonary hypertension. Pulmonary disorders that result in increased pulmonary vascular resistance impose a high afterload on the right ventricle. The resultant right ventricular hypertrophy known as cor pulmonale may progress to right ventricular failure as the lung disease worsens. Biventricular failure is most often the result of primary left ventricular failure that progresses to the right. Cor pulmonale is not associated with left ventricular hypertrophy. Only 3% of MIs occur in the right ventricle.

An abnormally wide (more than 0.10 second) QRS complex is characteristic of: A) paroxysmal atrial tachycardia. B) supraventricular tachycardia. C) junctional escape rhythm. D) premature ventricular complexes.

ANSWER: D) premature ventricular complexes. The QRS of the premature complex is prolonged (greater than 0.10 second) and bizarre in appearance. Paroxysmal atrial tachycardia does not display a QRS complex that is greater than 0.10 seconds. Supraventricular tachycardia does not display a wide QRS complex. Escape rhythms may have a P wave that is inverted and located before, during, or after the QRS.

The majority of tachydysrhythmias are believed to occur because of: A) triggered activity. B) enhanced automaticity. C) defective gap junctions. D) reentry mechanisms.

ANSWER: D) reentry mechanisms. Reentry is thought to be the culprit in most tachydysrhythmias. Reentry is a complex process in which a cardiac impulse continues to depolarize in a part of the heart after the main impulse has finished its path. Triggered activity occurs when an impulse is generated during or just after repolarization. Alterations in automaticity create electrolyte imbalances. Defective gap junctions are not related to tachydysrhythmias.

A patient with cold and edematous extremities, low cardiac output, and profound hypotension is likely to be experiencing a progressive stage of ________ shock. A)cardiogenic B)hypovolemic C) obstructive D) septic

ANSWER: D) septic In the progressive stage of septic shock, some patients deteriorate to a hypodynamic state. This is characterized by decreased cardiac output and cold, clammy skin as a result of narrowed pulse pressure. Profound hypotension generally occurs which is unresponsive to treatment. Cardiogenic shock is evidenced by decreased cardiac output, elevated left ventricular end-diastolic pressure, S3 heart sounds, and pulmonary edema. Hypotension occurs with hypovolemic shock, but extremities are not likely to be cold and edematous. Cold edematous extremities along with low cardiac output and profound hypotension are not manifestations of obstructive shock.