RTBR 1
Which of the following can falsely exaggerate the size of the heart as seen on a chest radiograph? Select one: A. AP projection B. deep inspiration C. PA projection D. overexposure
A. AP projection The PA chest radiograph most accurately depicts heart size. Because heart lies primarily in the anterior portion of the chest, it is magnified on an AP film (the most common view obtained on critically ill patients). In addition, factors such as patient rotation or an incomplete inspiration can exaggerate heart size on both PA and AP views. For this reason, you should be careful concluding that a patient has cardiomegaly on an AP film, even if the CT ratio exceeds 50%. On the other hand if the CT ratio is less than 50% on an AP view, you can conclude that the heart is not enlarged. The correct answer is: AP projection
A patient is asked to inhale as deeply as possible and blow out all his air as hard as they can until empty. What test is being performed? Select one: A. FVC B. IC C. TLC D. MVV
A. FVC When a patient performs a maximal exhalation after a maximal inhalation, he is performing the forced vital capacity (FVC) maneuver. The correct answer is: FVC
Which of the following would provide the most information about a patient's orientation to time and place? Select one: A. The patient knows she is in a hospital B. The patient knows her diagnosis C. The patient recognizes her physician D. The patient says that she has been dizzy all day
A. The patient knows she is in a hospital A patient that is oriented x 3 is oriented to person, time and place. If the patient knows they are in a hospital, this is considered being oriented to place and somewhat to time. The correct answer is: The patient knows she is in a hospital
Rapid, deep ventilation is most likely to be observed in a patient with which of the following conditions? Select one: A. anxiety B. CNS depression C. hypothermia D. hyperoxemia
A. anxiety Feedback Fear, anxiety and pain all are strong stimuli that can cause a stress response and increase ventilatory drive. Hypoxemia also can increase ventilatory drive. CNS depression and hypothermia would tend to decrease ventilatory drive. The correct answer is: anxiety
Which of the following represent the most effective way for you to initially determine a patient's alertness? Select one: A. ask the patient who and where they are, and the date/time B. determine the patient's pupillary reactivity to light C. query the family regarding the patient's alertness D. check the medical record for a history of confusion
A. ask the patient who and where they are, and the date/time The conscious patient should be evaluated for orientation as to time, place, and person. This is referred to as evaluating the patient's sensorium. The alert patient, who is well-oriented as to time, place, and person is said to be "oriented x 3," and sensorium is considered normal. Adequate cerebral oxygenation must be present for the patient to be conscious, alert, and well oriented. The correct answer is: ask the patient who and where they are, and the date/time
In which of the following conditions are fine, late inspiratory crackles (rales) most likely to be heard on auscultation? Select one: A. atelectasis B. croup C. pleural effusion D. asthma
A. atelectasis Fine, late inspiratory crackles are thought to occur when collapsed bronchioles and/or alveoli 'pop' open toward the end of inspiration. Patients with disorders that reduce lung volume--such as atelectasis, pneumonia, pulmonary edema and fibrosis--are most likely to have late inspiratory crackles. Asthma is better associated with wheezing and croup with stridor. A pleural effusion normally decreases breath sound, but does by itself not cause crackles. The correct answer is: atelectasis
A patient who exhibits a wasted appearance and has poor skin turgor can best be described as: Select one: A. cachectic B. febrile C. bulimic D. cyanotic
A. cachectic Feedback Wasted appearance and loss of fat and protein which would result in poor skin turgor is indicative of a cachectic patient. The correct answer is: cachectic
A 67-year-old patient with COPD complains that she becomes breathless after brushing her hair and must sit down to catch her breath. This complaint is most closely related to which of the following? Select one: A. increased work of breathing B. cardiac tamponade C. increased pulmonary reserve D. orthopnea
A. increased work of breathing A patient who can not perform simple activities of daily living without experiencing dyspnea is showing classic signs of increased work of breathing. In fact, on the American Thoracic Society Breathlessness Scale, breathlessness occurring when involved in activities of daily living such as dressing rates as the severest form of dyspnea. The correct answer is: increased work of breathing
The chest X-ray of a patient admitted to ICU exhibits a large area of consolidation in the left lung. Which of the following is a potential cause of this finding? Select one: A. lobar pneumonia B. pulmonary barotrauma C. tension pneumothorax D. interstitial emphysema
A. lobar pneumonia On an X-ray consolidation appears as an increase in lung tissue density (increased radiopacity) that may be diffuse, patchy, or lobar in nature. Consolidation is most often associated with bacterial pneumonias, but is also seen in patients with traumatic injuries causing pulmonary contusions and when pulmonary embolization results in infarction. Consolidation may also occur in certain phases of acute respiratory distress syndrome (ARDS). The correct answer is: lobar pneumonia
Which of the following would probably characterize the emotional state of a patient with a tension pneumothorax? Select one: A. panic B. anger C. euphoria D. depression
A. panic Since a tension pneumothorax is a life-threatening event, the most common emotional response would be agitation and panic. The correct answer is: panic
Which of the following clinical observations is most commonly associated with right heart failure? Select one: A. peripheral edema B. muscle wasting C. tracheal deviation D. skin flushing
A. peripheral edema During right heart failure, fluid can back up into the venous system and overwhelm the peripheral circulation. The result is gravity-dependent peripheral edema. Other potential findings include jugular venous distension, ascites (fluid accumulation in the abdomen) and hepatomegaly. The correct answer is: peripheral edema
When inspecting the X-ray of a out-patient with nephrotic syndrome, you note a homogeneous area of increased density that obscures the left costophrenic angle. Which of the following is the most likely problem? Select one: A. pleural effusion B. bacterial pneumonia C. pulmonary edema D. atelectasis
A. pleural effusion Feedback Pleural effusion is commonly associated with cardiac failure, but can also occur with certain infections, metastasis, renal disease (especially nephrotic syndrome) and collagen vascular disorders. On X-ray, pleural effusion appears as homogeneous areas of increased density that are position- dependent. If the patient is upright, fluid will accumulates in and 'blunt' or obscure the costophrenic angles. If the patient is placed in a decubitus position, the effusion will 'layer out' laterally. The correct answer is: pleural effusion
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
A. pulmonary edema 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
Which of the following abnormalities would appear as an area of increased radiodensity on a chest X-ray? Select one: A. pulmonary edema B. pneumopericardium C. hyperinflation D. pneumothorax
A. pulmonary edema The following conditions would appear as areas of increased radiodensity on a chest X-ray: atelectasis, consolidation, interstitial lung disease, pulmonary infiltrates/edema, pleural effusion, lung/mediastinal tumors, and calcification. An abnormal decrease in density or (aka increased radiolucency) would be observed anywhere air replaces tissue, such as with hyperinflation, pneumothorax or pneumopericardium. The correct answer is: pulmonary edema
The chest X-ray of a patient admitted to ICU exhibits a large area of consolidation in the left lung. Which of the following is the most likely cause of this finding? Select one: A. pulmonary infarction B. pulmonary barotrauma C. tension pneumothorax D. interstitial emphysema
A. pulmonary infarction On an X-ray consolidation appears as an increase in lung tissue density (increased radiopacity) that may be diffuse, patchy, or lobar in nature. Consolidation is most often associated with bacterial pneumonias, but is also seen in patients with traumatic injuries causing pulmonary contusions and when pulmonary embolization results in infarction. Consolidation may also occur in certain phases of acute respiratory distress syndrome (ARDS). The correct answer is: pulmonary infarction
Following airway clearance therapy, you auscultate a patient's chest and hear coarse, low-pitched, continuous sounds bilaterally around the upper chest. Which of the following terms would you record in the patient's chart or respiratory notes? Select one: A. rhonchi B. wheezes C. rales D. crackles
A. rhonchi Coarse, low-pitched, continuous sounds best describe rhonchi. Rhonchi heard in the vicinity of the large airways usually indicate retained secretions. In this scenario, you should assure secretion removal (coughing, suctioning, etc) before completing the therapy. The correct answer is: rhonchi
You are palpating a patient's chest and feel vibrations over the left lung. After the patient coughs, the vibrations are gone. Based on this, you would conclude: Select one: A. secretions were present in the left lung B. the patient has chronic bronchitis C. secretions were present in the right lung D. there is consolidation in the left lung
A. secretions were present in the left lung The presence of palpable vibrations due to excess secretions in the airways is known as rhonchial fremitus. It often will improve or clear altogether after an effective cough or after the patient has been suctioned. The correct answer is: secretions were present in the left lung
When inspecting the X-ray of a patient in ICU, you note radiolucent streaks within the soft tissues of the chest wall/neck. Which of the following is the most likely problem? Select one: A. subcutaneous emphysema B. pneumomediastinum C. pneumothorax D. interstitial infiltration
A. subcutaneous emphysema On chest X-ray, subcutaneous emphysema appears as streaks or bubbles of air within the soft tissues of the chest wall/neck. At the bedside, it can often be seen as a smooth bulging of the skin that produces an unusual crackling sensation when palpated (crepitus). Subcutaneous emphysema is a type of barotrauma seen in patients with chest trauma and/or those treated with positive pressure ventilation. Typically it occurs with the more dangerous types of barotrauma: pneumothorax, pneumomediastinum or pulmonary interstitial emphysema. The correct answer is: subcutaneous emphysema
On examination of a normal patient's neck, the midline of the trachea should be directly below the center of the: Select one: A. suprasternal notch B. midclavicular line C. midaxillary line D. anterior axillary line
A. suprasternal notch Normally, the trachea is located centrally in the neck of a forward facing patient. The midline of the neck can be located by palpation of the suprasternal notch at the base of the anterior neck. The midline of the trachea should be directly below the center of the suprasternal notch. The correct answer is: suprasternal notch
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
A. the jobs of all household members 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
In assessing a patient's breathing pattern, you note a rate of 35/min and observe that his abdomen moves outward while the lower rib cage moves inward during inspiration. Which of the following conclusions can you draw from this finding? Select one: A. the patient has a high work of breathing/muscle fatigue B. the patient is suffering from hyperventilation syndrome C. the patient has increased lung or thoracic compliance D. the patient is responding to hypoxemic stimulation
A. the patient has a high work of breathing/muscle fatigue Alone or in combination, tachypnea, increased accessory muscle use and asynchronous movement of the thorax and abdomen ('thoracoabdominal paradox') in adults indicate increased work of breathing and possible respiratory muscle fatigue. Additional findings (especially in infants and children) may include intercostal and subxiphoid retractions and nasal flaring. The correct answer is: the patient has a high work of breathing/muscle fatigue
Which of the following terms best describes an adult pulse rate of 125 per minute? Select one: A. bradycardia B. tachycardia C. pulsus paradoxus D. pulsus alternans
B. tachycardia Feedback The normal pulse rate for adults is 60-100 beats/min and is regular in rhythm. A pulse rate exceeding 100/min is termed tachycardia. Common causes of tachycardia include exercise, fear, anxiety, low blood pressure, anemia, fever, reduced arterial blood oxygen levels, and certain medications. The correct answer is: tachycardia
Which of the following questions would you ask to determine whether a patient has orthopnea? Select one: A. "Can you climb a flight of stairs without stopping?" B. "Do you have difficulty breathing when lying flat?" C. "Do you have any chest pain when walking?" D. "How much phlegm do you bring up when coughing?"
B. "Do you have difficulty breathing when lying flat?" Orthopnea is the inability to breathe easily while lying supine. This is usually manifested by a patient saying they need two or more pillows to be able to sleep. Chest pain, dyspnea on climbing and secretion production indicate other pulmonary problems. The correct answer is: "Do you have difficulty breathing when lying flat?"
An adult patient with acute hypoxemia would likely exhibit which of the following clinical signs? Tachycardia Wheezing Confusion Tachypnea A. Yes Yes No Yes B. Yes No Yes Yes C. Yes Yes Yes Yes D. No Yes Yes No Select one: A. A B. B C. C D. D
B. B Feedback Clinical signs of acute hypoxemia in adults include tachycardia, hypertension, tachypnea, cyanosis, restlessness, and confusion. Hypoxemia does not cause changes in breath sounds. Note that in neonates (especially preterm infants), hypoxemia is associated with bradycardia and apnea. The correct answer is: B
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
B. acute upper 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
Upon reviewing the patient's chart, results of a chest x-ray indicate: "Complete opacification of the left chest with a shift of the trachea and mediastinum to the left." These findings are consistent with which of the following? Select one: A. pneumothorax of the right lung B. atelectasis of the left lung C. diffuse pulmonary emphysema D. right-sided pleural effusion
B. atelectasis of the left lung Opacification of lung tissue on x-ray occurs due to consolidation or atelectasis. Moreover, if the area affected is large the trachea and mediastinum tend to shift towards the area of collapse, as seen here. Pneumothorax would cause hyperlucency on the affected side, with emphysema also showing hyperlucency, but more generally throughout all lung fields. Effusion is generally visualized on upright or sitting x-ray as affective only the basal areas, obscuring the costophrenic angle. The correct answer is: atelectasis of the left lung
When inspecting the chest of a patient with emphysema, you would most likely would observe which of the following? Select one: A. obesity B. barrel chest C. central cyanosis D. intercostal retractions
B. barrel chest The classic physical finding of a patient with severe emphysema is an increased in the A-P dimension above normal, approximating its lateral dimension, i.e., a 'barrel' chest. The correct answer is: barrel chest
Which of the following procedures require active patient cooperation to be effective? Select one: A. ventilator weaning B. breathing exercises C. mask CPAP D. mechanical cough assist
B. breathing exercises While it always is helpful to have a patient's cooperation, it is absolutely essential when having a patient perform breathing exercises. Ventilator weaning, mask CPAP, and mechanical cough assist (mechanical insufflation-exsufflation) only require spontaneous breathing effort. The correct answer is: breathing exercises
Which of the following would be the most likely cause of stridor in a child? Select one: A. asthma B. epiglottitis C. pneumonia D. cystic fibrosis
B. epiglottitis Feedback Stridor is a loud, high-pitched continuous sound heard primarily over the larynx or trachea during inhalation in patients with upper airway obstruction. Common childhood causes of stridor include croup, epiglottitis and foreign body aspiration. In adults, stridor occurs mainly as a complication of endotracheal extubation (edema of the vocal cords). The correct answer is: epiglottitis
A patient with asthma is in acute respiratory distress and presents to the emergency department with markedly diminished breath sounds. Following bronchodilator therapy, auscultation of the chest reveals rhonchi and wheezing. This change suggests which of the following? Select one: A. development of a pneumothorax B. improvement of the air flow C. onset of pneumonia D. development of pulmonary edema
B. improvement of the air flow This patient's markedly reduced breath sounds were most like the result of little air movement secondary to severe bronchoconstriction. The bronchodilator therapy apparently improved airflow sufficiently to allow for more pronounced, though abnormal, breath sounds. The presence of wheezing suggests that the patient still has some bronchoconstriction and the rhonchi indicate excessive airway secretions, both common findings with moderate asthmatic episodes. The correct answer is: improvement of the air flow
When questioning a patient regarding his environmental exposure history, you need to obtain information on: Select one: A. commuting distance from home to work B. job tasks, location, materials, and agents used C. lines of authority/job reporting structure D. position title and hourly or annual salary
B. job tasks, location, materials, and agents used When questioning patients regarding their environmental exposure history, you need to obtain information on (1) current and past exposure to metals, dust, fibers, fumes, chemicals, biologic hazards, radiation, noise; (2) typical workday activities (job tasks, location, materials, and agents used); (3) any changes in work routines or processes; and (4) whether other employees or household members have been similarly exposed or affected. The correct answer is: job tasks, location, materials, and agents used
You palpate your patient's neck and notice that the trachea is shifted to the patient's left. Which of the following conditions could explain this finding? Select one: A. left ventricular enlargement B. left upper lobe collapse C. right lower lobe collapse D. pleural effusion on the left
B. left upper lobe collapse Volume loss in the upper lobe will pull the trachea towards the collapsed lung. In this case the trachea has shifted to the left indicating that either volume loss has occurred on the left or a tumor on the right is pushing the trachea to the left. The correct answer is: left upper lobe collapse
Prior to giving an aerosol treatment, you find a note in the chart that states your patient had pink frothy secretions on admission to the ED. This is most indicative of: Select one: A. cor pulmonale B. left ventricular failure C. an electrolyte imbalance D. ARDS
B. left ventricular failure Frothy pink-tinged secretions are a hallmark sign of cardiogenic pulmonary edema, which is the result of left ventricular failure or CHF. The correct answer is: left ventricular failure
inspection of an AP chest film on a 44 year old homeless man with a history of alcoholism who is admitted for cold exposure reveals a circular area of central radiolucency with an air-fluid level. Which of the following is the most likely problem? Select one: A. bullous emphysema B. lung abscess C. pneuumothorax D. pleural effusion
B. lung abscess Feedback The most likely problem is a lung abscess. A lung abscess occurs as the result of a necrotizing infection, usually by anaerobic bacteria and most often due to aspiration associated with altered consciousness. The infection typically results in a cavitary lesion that accumulates pus. On X-ray the cavity usually appears radiolucent, with the pus forming a gravity-dependent air-fluid level. The correct answer is: lung abscess
During an interview with your patient you discover that he gets short of breath at night when he lays down so he often sleeps with several pillow propping his head up. What symptom is present? Select one: A. apnea B. orthopnea C. platypnea D. orthodeoxia
B. orthopnea Orthopnea is present when the patient has difficulty breathing upon lying down. In most cases this is due to pulmonary edema filling the lungs when the patient assumes a horizontal position. Keeping the patient's head up during sleep with the use of pillows reduces the collection of fluid in the lungs. The correct answer is: orthopnea
When inspecting a normal chest radiograph, you would expect the heart to be positioned: Select one: A. entirely to the left side of the patient's midline/spine B. primarily to the left side of the patient's midline/spine C. entirely to the right side of the patient's midline/spine D. primarily to the right side of the patient's midline/spine
B. primarily to the left side of the patient's midline/spine Within the mediastinum, the heart normally is visualized primarily to the left of the midline/spine (right side of X-ray), and consists mostly of the lateral border of the left ventricle. A smaller portion of the heart (the border of the right atrium) normally lies to the right of the midline/spine (left side of X-ray). Any lateral movement of the mediastinum away from the midline will also shift the heart position in the same direction. The correct answer is: primarily to the left side of the patient's midline/spine
When inspecting the X-ray of a patient in ICU, you note a large area of increased opacity in the right hemithorax, with the left lung appearing overinflated. The mediastinum is shifted slightly to the right, with the diaphragm elevated on that side. Which of the following is the most likely problem? Select one: A. pleural effusion B. right-sided atelectasis C. left-sided pneumothorax D. pulmonary edema
B. right-sided atelectasis The major radiological signs of atelectasis are increased density/opacity of the involved lung area combined with evidence of volume loss. Signs of volume loss include displacement of airways, lung fissures, and blood vessels and airways. A mediastinal shift with a displacement of the trachea and compensatory overinflation of adjacent lung tissue may be seen when entire lobes are involved. The diaphragm on the affected side may also be elevated. The correct answer is: right-sided atelectasis
You are evaluating a patient in the recovery room following an exploratory laparotomy. The patient appears to be asleep. His respiratory rate is 14/min and heart rate is 84/min. To determine the patient's level of consciousness, you speak to the patient, who does not respond. Which of the following should you do FIRST? Select one: A. wait 1 hour and then repeat the attempt B. shake the patient's arm gently C. call for help D. administer a sternal rub
B. shake the patient's arm gently If the patient does not respond to verbal commands, you should see if you can arouse the patient by gently shaking his or her shoulder. The correct answer is: shake the patient's arm gently
Which of the following respiratory signs noted on inspection of an adult patient would be considered ABNORMAL? Select one: A. ribs higher posteriorly than anteriorly at end-expiration B. sternocleidomastoid muscles used at rest C. costal angle of 90 degrees increases with inspiration D. respiratory rate of 18 breaths per minute
B. sternocleidomastoid muscles used at rest An adult's breathing rate should be between 10-20/min; the ribs should be higher posteriorly than anteriorly at end-expiration; both side of thorax should expand equally, and the costal angle should be about 90° but increase with inspiration. The accessory muscles of respiration (scalenes, sternocleidomastoids, pectoralis major) should NOT be used during quiet breathing. The correct answer is: sternocleidomastoid muscles used at rest
At one minute after birth, a newborn infant's extremities appear cyanotic, her heart rate is 80/min, her respirations are gasping, she exhibits some flexion of the extremities and grimaces when stimulated. What is her Apgar score? Select one: A. 1 B. 3 C. 5 D. 7
C. 5 The Apgar score typically is performed at 1 and 5 minutes after birth and assesses the following 5 elements, each on a scale of 0 to 2: Appearance (color), Pulse/heart rate, Grimace (response to stimulation), Activity (muscle tone), and Respiratory effort (note the A-P-G-A-R mnemonic) . As described in this scenario, each of these 5 elements would be scored 1, for a total Apgar score of 5. At 1 minute an Apgar score of 7-10 is considered normal (10 being the maximum). Scores of 4-6 (as here) are intermediate and usually dictate the need for more intensive support. Infants with Apgar scores of 0-3 usually undergo aggressive resuscitation. Needed interventions should never be delayed in order to obtain the Apgar score, nor should these scores dictate resuscitation procedures. The correct answer is: 5
Inspection of a PA chest radiograph reveals a CT ratio of 60%. Based on this finding, the most likely problem is: Select one: A. pneumothorax B. pleural effusion C. cardiomegaly D. atelectasis
C. cardiomegaly Normally, the heart width is less than 50% of the width of the thoracic cage. Cardiomegaly exits when the cardiac-to-thoracic width ratio (CT ratio) exceeds 50% on a PA chest radiograph. Pneumothorax, pleural effusion, atelectasis all can affect the position of the heart, but not its size. The correct answer is: cardiomegaly
Which of the following observations indicate that an infant's work of breathing may be abnormally high? Select one: A. palor B. digital clubbing C. chest wall retractions D. acrocyanosis
C. chest wall retractions Tachypnea, nasal flaring, grunting, and chest wall retractions are the most common signs of increased work of breathing in infants. Pallor or acrocyanosis are associated with circulatory problems insufficiency. Digital clubbing is associated with a variety of clinical conditions, including bronchiectasis, pulmonary fibrosis, cyanotic congenital heart disease, lung cancer, and cirrhosis of liver. However, clubbing does not indicate increased work of breathing. The correct answer is: chest wall retractions
Which of the following findings would you expect to observe on the AP chest radiograph of a patient suffering from advanced stages of pulmonary emphysema? Select one: A. decreased radiolucency B. increased vascular markings C. decreased C/T ratio D. elevated hemidiaphragms
C. decreased C/T ratio Flat diaphragms and increase radiolucency throughout the lung fields are common in the AP/PA chest X-ray of patients with emphysema, as is a decrease in peripheral vascular markings. In addition, a lateral film typically will show an increase in the width of the retrosternal airspace. Also typical of the chest X-ray of patients with emphysema is a smaller than normal heart and thus decreased C/T ratio. The correct answer is: decreased C/T ratio
A patient with paradoxical chest wall movement most likely has: Select one: A. atopic asthma B. chronic bronchitis C. flail chest D. tension pneumothorax
C. flail chest Paradoxical chest wall movement is a common sign of flail chest. Flail chest occurs when 3 or more adjoining ribs are fractured in two or more places. This section of the chest wall becomes unstable and is 'sucked in' during inspiration and bulges out during expiration. Flail chest is usually the result of trauma. The correct answer is: flail chest
Which of the following statements regarding CENTRAL cyanosis is TRUE? Select one: A. it is a reliable indicator of the severity of hypoxemia and hypoxia B. it is best observed in the extremities (finger/toe nailbeds) C. it results from excessive reduced Hb in the arterial blood D. its presence always signals inadequate O2 delivery to the tissues
C. it results from excessive reduced Hb in the arterial blood Central cyanosis is due to a reduction in the arterial Hb saturation, and is best observed in the capillaries of the lips or gums (excessive reduced Hb in the venous blood causes peripheral cyanosis). Detection generally requires > 5 gm/dL reduced capillary Hb. Both central and peripheral cyanosis may occur in the presence of adequate O2 delivery, and can be masked by many factors. Thus neither is a reliable indicator of hypoxia. The correct answer is: it results from excessive reduced Hb in the arterial blood
The cardinal sign of complete airway obstruction is: Select one: A. inspiratory stridor B. increased work of breathing C. lack of any air flow D. use of accessory muscles
C. lack of any air flow Airway obstruction may also be classified by degree as either partial or complete. Partial airway obstruction varies in severity from a slight impairment to ventilation, with mild increases in the work of breathing, to almost complete obstruction, with associated stridor and marked respiratory difficulty. Complete airway obstruction results in no air flow, although exaggerated respiratory efforts (including retractions and accessory muscles use) may occur. The correct answer is: lack of any air flow
How would you assess the level of nicotine dependence of a patient who smokes her first cigarette about 15 minutes after waking and smokes 25 cigarettes a day? Select one: A. extreme nicotine dependence B. heavy nicotine dependence C. moderate nicotine dependence D. light nicotine dependence
C. moderate nicotine dependence To objectively assess a patient's level of nicotine dependence, ask and score the response to the following two simple questions (the abbreviated Fagerstrom Test for Nicotine Dependence): Question 1: How soon after waking do you smoke first cigarette? < 5 minutes: 3 points 5 to 30 minutes: 2 points 31 to 60 minutes: 1 point > 60 minutes: 0 points Question 2: How many cigarettes do you smoke per day? > 30 per day: 3 points 21 to 30 per day: 2 points 11 to 20 per day: 1 point < 11 per day: 0 points After obtaining the patient's responses to these questions, you simply sum their point values and interpret as follows: Heavy nicotine dependence: 5-6 points; Moderate nicotine dependence: 3-4 points; Light nicotine dependence: 0-2 points. In this example the patient smokes his first cigarette about 15 minutes after waking (2 point) and smokes 15 cigarettes a day (2 point) and thus is judged as being moderately nicotine dependence (4 points total). The correct answer is: moderate nicotine dependence
You and a nurse are performing a procedure on a 2-year-old child. To assess the level of pain that the child is experiencing you would: Select one: A. use a visual analog pain scale B. ask the nurse's for her judgment C. observe for crying or facial grimacing D. confirm when last pain medication was given
C. observe for crying or facial grimacing A visual analog or numeric pain scale is not useful for young children or patients who cannot express themselves. The best way to assess the pain level of a young child is to get the input of a family member. Without such information, you may have to rely on observing patient behaviors that indicate severe pain, such as moaning, crying, or grimacing. The correct answer is: observe for crying or facial grimacing
A patient involved in a motor vehicle accident presents with respiratory distress. A chest X-ray confirms the presence of multiple rib fractures on the left side. Which of the following physical findings would be expected during palpation of the chest? Select one: A. trachea deviated to the left B. paradoxical motion of the abdomen C. paradoxical motion of the left chest D. tympany over the right chest
C. paradoxical motion of the left chest When the chest wall loses the stabilizing support of the ribs (usually two or more ribs broken in two or more places), it will move in during inspiration and outward during exhalation, i.e., exhibit 'paradoxical' motion. This is the one of the clinical findings characterizing a 'flail chest' injury. The correct answer is: paradoxical motion of the left chest
In examining the neck of a patient, you note that the trachea is not positioned in the midline. Which of the following conditions would be the mostly likely cause of this observation? Select one: A. pulmonary fibrosis B. asthma C. pneumothorax D. pulmonary edema
C. pneumothorax Any voumetric change to either side of the movable mediastinum will cause a shift in the position of the trachea. In general, the mediastinum and trachea are pulled toward areas of decreased lung volume (e.g., lobar collapse, atelectasis, surgical resection) and pushed away from space occupying lesions (e.g., tension pneumothorax, large pleural effusions or mass lesions). Diseases or disorders that affect the lungs as a whole, such as asthma or pulmonary fibrosis do not normally cause a shift in the mediastinum and trachea. The correct answer is: pneumothorax
Upon palpating a patient's radial artery for 1 minute, you note a repeating pattern of a strong beat followed by a weak one. Which of the following describes the patient's pulse? Select one: A. thready pulse B. bounding pulse C. pulsus alternans D. pulsus paradoxus
C. pulsus alternans Feedback This pattern best describes pulsus alternans, in which alternating strong and weak pulses are palpated. Pulsus alternans almost always indicates left ventricular systolic failure, as can occur in mitral or aortic valve disease and hypertrophic and congestive cardiomyopathy. This is not be confused with pulsus paradoxus, in which an abnormal decrease in pulse strength (and blood pressure) occurs during inspiration. Pulsus paradoxus is commonly seen in patient with hyperinflation and air trapping (e.g., COPD, asthma, croup) and may also be observed in those with pericarditis or cardiac tamponade. The correct answer is: pulsus alternans
You note that a patient's pulse strength decreases with spontaneous inhalation. Which of the following terms would you use to chart this finding? Select one: A. bradycardia B. thready pulse C. pulsus paradoxus D. pulsus alterans
C. pulsus paradoxus A decrease in the strength of a patient's pulse during spontaneous inhalation is referred to as pulsus paradoxus. This response in otherwise normal individuals is probably caused by a momentary decrease in cardiac output occurring when pleural pressure first falls. The correct answer is: pulsus paradoxus
When auscultating a patient with chronic bronchitis you hear harsh, low-pitched sounds that are continuous in character. Which of the following terms would you use to describe these sounds in the patient's chart? Select one: A. wheezes B. crepitus C. rhonchi D. crackles
C. rhonchi The correct medical term for continuous, course, low-pitched breath sounds is rhonchi. Most commonly rhonchi occur when air passes through airways partially obstructed by excess secretions. Wheezes are continuous high-pitched ("musical") sounds consistent with airway narrowing due to bronchospasm or edema. Crackles (aka rales) are discontinuous "popping" sounds often heard in patients with congestive heart failure or pneumonia. Crepitus is the crackling sensation felt under the skin due to the presence of air in the subcutaneous tissue (subcutaneous emphysema). The correct answer is: rhonchi
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"
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 rales for these sounds. Crackles are caused either by movement of excessive secretions in the airways, or by collapsed airways opening during inspiration. The correct answer is: "crackles (rales) heard at lung bases"
On physical examination of a patient with chronic bronchitis, you would expect to find which of the following? Course bilateral rhonchi Weight loss/ cachexia Signs of cor pulmonale Increased AP chest diameter A. Yes Yes Yes Yes B. No Yes Yes No C. Yes Yes No Yes D. Yes No Yes No Select one: A. A B. B C. C D. D
D. D A patient with chronic bronchitis typically will exhibit a 'noisy' chest (due to increased secretions) and signs of cor pulmonale (due to chronic hypoxemia). Distention of the thorax and weight loss are more common findings in patients suffering from pulmonary emphysema. The correct answer is: D
On physical examination of a patient with pulmonary emphysema, you would expect to find which of the following? Course bilateral rhonchi Weight loss/ cachexia Signs of cor pulmonale Increased AP chest diameter A. Yes Yes Yes Yes B. No Yes Yes No C. Yes No No Yes D. No Yes No Yes Select one: A. A B. B C. C D. D
D. D A patient with COPD due primarily to emphysema typically will exhibit a "quiet chest" with marked overdistention of the thorax (increased AP diameter). Sputum is usually scanty and mucoid, while weight loss may be severe and the patient appear malnourished (cachexia). Signs of cor pulmonale, so common in chronic bronchitis, are usually absent. The correct answer is: D
A patient's record indicates a history of substance abuse. Which of the following substances could be involved? readily available chemicals prescription medications illicit/illegal drugs 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
D. D Abused substances may include illicit/illegal drugs; readily available chemicals such as alcohol or glue; over-the-counter drugs; or prescription medications. In the case of prescription drugs, they may initially have been legally prescribed, with the pattern of use subsequently diverging from the original medically-indicated use
Upon visually inspecting the thorax of a 73-year-old male, you notice that his chest appears overinflated, with the ribs held in a horizontal position. Upon further inspection you observe that the transverse chest diameter almost equals the AP diameter. Which of the following terms best describes this thoracic configuration? Select one: A. kyphoscoliosis B. bucket-handle movement C. pectus excavatum D. barrel chest
D. barrel chest The AP diameter of the normal adult thorax is less than the transverse diameter. An abnormal increase in AP diameter is referred to clinically as 'barrel chest.' When the AP diameter increases, the slope of the ribs lose their normal 45-degree angle in relation to the spine and become more horizontal. The correct answer is: barrel chest
Auscultation of a patient's chest revealing wheezes would indicate the presence of which of the following: Select one: A. pleural effusion B. pneumothorax C. laryngospasm D. bronchoconstriction
D. bronchoconstriction Feedback Wheezing generally indicates bronchoconstriction, mucosal edema, presence of increased mucus or partial foreign body obstruction in the lower airways. Laryngospasm (upper airway) typically causes stridor, not wheezing. Pleural effusion and pneumothorax would tend to cause a decrease in breath sounds but not wheezing. The correct answer is: bronchoconstriction
The first step in implementing a respiratory care treatment protocol is to: Select one: A. formulate a treatment plan B. set physician notification criteria C. review the relevant medical literature D. conduct an initial patient evaluation
D. conduct an initial patient evaluation The firat step in implementing a respiratory care treatment protocol is to perform an initial patient evaluation. This includes: (1) checking the physician order for the protocol, (2) reviewing the medical record, (3) initiating patient contact (using universal precautions) and (4) assessing the patient (e.g., vital signs; chest inspection, palpation, percussion, auscultation; bedside spirometry; pulse oximetry; and other diagnostic evaluations as needed, such as arterial blood gases. The correct answer is: conduct an initial patient evaluation
A patient in ICU develops a supraventricular tachycardia at a rate of 165/min. Which of the following effects would this have on cardiac function? Select one: A. increased end-diastolic volume B. mitral valve regurgitation C. increased stroke volume D. decreased end-diastolic volume
D. decreased end-diastolic volume As the heart rate increases, the time available for ventricular filling (during diastole) decreases. This leads to a reduction in both end-diastolic volume and stroke volume (Starling principle). However, two compensatory mechanisms minimize these changes. First, because any increase in heart rate also decreases the duration of systole, the decrease in diastolic filling time is less than it would were the rate change due only to a shortened diastole. Second, faster heart rates are accompanied by increased contractility, which augments stroke volume (the Treppe or Boditch effect). The result is that cardiac output normally is not adversely affected by until the heart rate exceeds 170-180/min. A decrease in cardiac output also may occur at lower rates in the absence of atrial contractions, e.g., in patients with atrial fibrillation. The correct answer is: decreased end-diastolic volume
You ask a patient what day of the week it is and which hospital he is in. Which of the following are you trying to assess? Select one: A. verbal skills B. emotional status C. desire to cooperate D. degree of alertness
D. degree of alertness By simply being with a patient, certain key signs of mental status can be noted. The first important sign is the patient's orientation to time, place, and person. By asking the patient who they are, where they are, and the date and/or time, one can quickly determine the degree of alertness and orientation to the environment. The correct answer is: degree of alertness
A small child is admitted to the Emergency Department with fever, difficulty swallowing, drooling, and stridor. An AP X-ray of the neck area is negative, but a lateral neck film indicates supraglottic swelling. Which of the following is the most likely diagnosis? Select one: A. asthma B. croup C. foreign body obstruction D. epiglottitis
D. epiglottitis Based on the clinical signs and symptoms and the radiographs, the most likely diagnosis is epiglottitis. In this condition, the AP X-ray may appear normal, but the lateral neck film often reveals a prominent shadow caused by the swollen epiglottis, called the "Thumb sign." The correct answer is: epiglottitis
While palpating the chest of a patient in the ED suffering trauma due to a motor vehicle accident, you notice paradoxical movement on the right side. Which of the following conditions may be present? Select one: A. atelectasis in the right lung B. right main stem aspiration C. pneumothorax on the left side D. flail chest
D. flail chest Feedback When the chest wall loses the stabilizing support of the ribs (usually with two or more ribs broken in two or more places), it will move in during inspiration and outward during exhalation, i.e., exhibit 'paradoxical' motion. This is the one of the clinical findings characterizing a 'flail chest' injury. The correct answer is: flail chest
A patient who complains of platypnea has difficulty breathing: Select one: A. all the time B. in the supine position C. on exertion D. in the standing position
D. in the standing position Platypnea is a condition in which a patient has difficulty breathing in the upright or standing position (the opposite of orthopnea). Platypnea is a common finding in some neuromuscular disorders, especially those causing diaphragmatic paralysis. The correct answer is: in the standing position
Which of the following procedures require active patient cooperation to be effective? Select one: A. ventilator weaning B. tracheal suctioning C. mask CPAP D. incentive spirometry
D. incentive spirometry Feedback While it always is helpful to have a patient's cooperation, it is absolutely essential when having a patient perform incentive spirometry. In regard to weaning and mask CPAP, only spontaneous breathing effort is required. And tracheal suctioning requires no patient cooperation. The correct answer is: incentive spirometry
While observing the breathing of a newborn infant, you note indrawing of chest wall muscle and tissue between the ribs during inspiration. Which of the following descriptions would you note in your respiratory chart entry? Select one: A. paradoxical breathing B. inspiratory grunting C. suprasternal retractions D. intercostal retractions
D. intercostal retractions The indrawing of chest wall muscle and tissue between bony chest wall structures is called retractions. Retractions can occur alone or in combination in the suprasternal, substernal, and intercostal regions. Their presence indicates an increase in total impedance and work of breathing, especially due to decreased lung compliance. The correct answer is: intercostal retractions
Which of the following methods would be the best way to confirm a diagnosis of substance abuse or dependence? Select one: A. screening questionnaires B. patient interview/history C. physical examination D. laboratory testing
D. laboratory testing Feedback Screening questionnaires, patient interview/history, and physical examination can point to a diagnosis of substance abuse or dependence. However, information provided by questionnaire or interview may not always be accurate and physical examination may not be sufficiently sensitive to identify substance abuse. The only objective way to confirm such a diagnosis is via laboratory testing, such as a drug screen. The correct answer is: laboratory testing
When performing posterior thoracic palpation of an adult, you note minimal left-side diaphragmatic movement as the patient takes a full, deep breath. Right-sided movement is normal. Which of the following conditions would best explain this finding? Select one: A. right-sided pleural effusion B. right lower lobe atelectasis C. pulmonary emphysema D. left phrenic nerve paralysis
D. left phrenic nerve paralysis Feedback A unilateral reduction in chest expansion may occur with lobar consolidation, atelectasis, pleural effusion, pneumothorax or phrenic nerve paralysis (on the affected side). Diseases that affect expansion of hemidiaphragms/lungs (such as COPD) cause a bilateral reduction in chest expansion. The correct answer is: left phrenic nerve paralysis
Upon exam of an acutely dyspneic and hypotensive patient, you note the following (all limited to the left hemithorax): reduced chest expansion, hyperresonance to percussion, absent of breath sounds and tactile fremitus, and a tracheal shift to the right. These findings suggest: Select one: A. left-sided pleural effusion B. left-sided consolidation C. left lobar obstruction/atelectasis D. left-sided pneumothorax
D. left-sided pneumothorax An acutely ill patient with dyspnea, hypotension, unilateral findings of reduced chest expansion, a hyperresonant percussion note, absent of breath sounds and tactile fremitus, and a tracheal shift to the right has most likely suffered a large pneumothorax on the affected side. If the pneumothorax is severe enough to disrupt cardiac function, blood pressure will also fall. The correct answer is: left-sided pneumothorax
Which of the following observations indicate that an infant's work of breathing may be abnormally high? Select one: A. palor B. digital clubbing C. acrocyanosis D. nasal flaring
D. nasal flaring Tachypnea, nasal flaring, grunting, and chest wall retractions are the most common signs of increased work of breathing in infants. Pallor or acrocyanosis are associated with circulatory problems insufficiency. Digital clubbing is associated with a variety of clinical conditions, including bronchiectasis, pulmonary fibrosis, cyanotic congenital heart disease, lung cancer, and cirrhosis of liver. However, clubbing does not indicate increased work of breathing. The correct answer is: nasal flaring
Which of the following aspects of a patient's social history is most important in the diagnosis of lung disease? Select one: A. marital status B. cultural background C. education D. occupational history
D. occupational history Of the items list, occupational history is most important in the diagnosis of lung disease. Many lung diseases are associated with inhalation of dusts or toxic chemicals in the work setting. The correct answer is: occupational history
When assessing a patient, you observe paradoxical movement of the right side of the chest during inspiration. The most likely problem is: Select one: A. tuberculosis B. pulmonary edema C. pulmonary embolism D. phrenic nerve dysfunction
D. phrenic nerve dysfunction Paradoxical movement of one side of the chest wall during inspiration (unilateral paradox) can be either neurologic or mechanical in origin. The most common neurologic cause of unilateral paradox is left or right phrenic nerve dysfunction, which can be detected using the "sniff test." During the sniff test, the patient is instructed to make short, sharp inspiratory effort through the nose. With unilateral phrenic nerve dysfunction, the affected side of the diaphragm (hemidiaphragm) moves up instead of down. Unilateral paradox due to mechanical disruption of the thoracic cage occurs in flail chest, in which the multiple rib fractures result in portions of the rib cage being sucked inward during inspiration. However, that cause is not an option here. The correct answer is: phrenic nerve dysfunction
Which of the following would be the most likely cause of stridor in an adult? Select one: A. asthma B. croup C. epiglottitis D. post-extubation edema
D. post-extubation edema Feedback Stridor is a loud, high-pitched continuous sound heard primarily over the larynx or trachea during inhalation in patients with upper airway obstruction. In adults, stridor occurs mainly as a complication of endotracheal extubation (edema of the vocal cords). Common childhood causes of stridor include croup, epiglottitis and foreign body aspiration. The correct answer is: post-extubation edema
In inspecting a patient with pulmonary emphysema, which of the following would you most likely observe? Select one: A. obese body habitus B. dependent edema C. tachypnea D. pursed-lip breathing
D. pursed-lip breathing In patients with pulmonary emphysema, destruction changes in the lung cause loss of the tissues supporting the small airways, which makes them prone to collapse during expiration. By generating back-pressure in the airways during exhalation, pursed-lip breathing helps prevent premature closure of these small airways. This technique, which most patients with emphysema learn on their own, also prolongs the expiratory phase and thus decreases the overall rate of breathing. Dependent edema (indicating core pulmonale) and obesity are more characteristic of patients with chronic bronchitis than those with emphysema. The correct answer is: pursed-lip breathing
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
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
You note that a patient's respiratory rate is 35 per minute. Which of the following terms would you use to chart this finding? Select one: A. bradypnea B. tachycardia C. hyperventilation D. tachypnea
D. tachypnea The normal resting adult rate of breathing is 12-20 breaths/min. TACHYPNEA is the term used to describe respiratory rates above this normal range. Tachypnea is associated with exercise, fever, arterial hypoxemia, metabolic acidosis, anxiety, and pain. The correct answer is: tachypnea
Which of the following respiratory signs noted on inspection of an adult patient would be considered ABNORMAL? Select one: A. inspiratory time is shorter than expiratory time B. ribs slope downward from spine at end-expiration C. AP diameter of thorax is less than its transverse diameter D. thorax expands, abdomen draws in during inspiration
D. thorax expands, abdomen draws in during inspiration Normally, inspiration should be shorter than expiration; at end-expiration the ribs should slope downward (be higher posteriorly than anteriorly); the AP diameter of thorax should be less than its transverse diameter; the abdomen and thorax should rise together during inspiration; and both side of thorax should expand equally. The correct answer is: thorax expands, abdomen draws in during inspiration
A home care patient is able to dress and feed herself but has difficulty getting in/out of bed, going to/from the bathroom and bathing on her own. She also significant problems with bladder incontinence. You would recommend: Select one: a. daily caregiver support b. limited activity out of bed c. Foley catheterization d. admission to a nursing home
a. daily caregiver support Your answer is correct. A patient who is unable to carry out 4 or more of the 6 common activities of daily living (bathing, dressing, toileting, transferring, continence and feeding) has a severe functional impairment and normally would need daily caregiver support to overcome these limitation. The correct answer is: daily caregiver support
Which of the following statements by patients indicates the most severe level of dyspnea? Select one: A. "I get short of breath when walking up a slight hill." B. "I get out of breath when I exercise strenuously." C. "I get short of breath when dressing or undressing." D. "I need to catch my breath after a few minutes of walking."
exercise strenuously." C. "I get short of breath when dressing or undressing." According to the ATS Breathlessness Scale, a patient who is either too breathless to leave the house or experiences breathlessness when dressing or undressing has the highest/most severe level of dyspnea (Grade 4). In descending order of severity would be breathlessness after a short walk, breathlessness when walking up a slight hill, and breathlessness after strenuous exercise. The correct answer is: "I get short of breath when dressing or undressing."
