Adult Gerontology - Respiratory Problems

Hyperresonance on percussion of the chest occurs with A. emphysema. B. pneumonia. C. pleural effusion. D. lung tumor.

Answer: A Hyperresonance on percussion of the chest is found when too much air is present, such as occurs with emphysema or a pneumothorax. A dull sound on percussion indicates an abnormal density in the lungs, such as occurs with pneumonia, pleural effusion, a lung tumor, or atelectasis.

What percentage of persons who smoke at least one pack of cigarettes per day have a cough? A. 10% to 25% B. 40% to 60% C. 75% D. 100%

Answer: B Of persons who smoke at least one pack of cigarettes per day, 40% to 60% have a cough. It is defined as chronic bronchitis if the cough has been productive for at least 3 months during each of 2 consecutive years.

Mark, age 72, has been living in a shelter for 4 months. Today he appears at the clinic complaining of productive cough, weight loss, weakness, anorexia, night sweats, and generalized malaise. These have been bothering him for 8 weeks. What would be one of the first tests you order? A. Mantoux test B. Chest x-ray C. Complete blood work D. Sputum culture

Answer: A Although all of these tests might be indicated, the first test that should be ordered for a client presenting with productive cough, weight loss, weakness, anorexia, night sweats, and generalized malaise for 8 weeks' duration would be a Mantoux skin test for tuberculosis (TB). The client is at high risk for developing TB because of his residence in a shelter and his low socioeconomic status.

Which of the following conditions is characterized by intermittent episodes of airway obstruction caused by bronchospasm, excessive bronchial secretion, or edema of bronchial mucosa? A. Asthma B. Atelectasis C. Acute bronchitis D. Emphysema

Answer: A Asthma is characterized by intermittent episodes of airway obstruction caused by bronchospasm, excessive bronchial secretion, or edema of bronchial mucosa. Atelectasis is a collapse of alveolar lung tissue, and findings reflect the presence of a small, airless lung. It is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body. Acute bronchitis is an inflammation of the bronchial tree characterized by partial bronchial obstruction and secretions or constrictions. It results in abnormally deflated portions of the lung. Emphysema is a permanent hyperinflation of lung beyond the terminal bronchioles with destruction of the alveolar walls.

Sarah, age 25, has allergic rhinitis and is currently being bothered by nasal congestion. Which of the following medications ordered for allergic rhinitis would be most appropriate? A. A decongestant nasal spray B. An antihistamine intranasal spray C. Ipratropium (Atrovent) D. Omalizumab (Xolair)

Answer: A For Sarah, who has allergic rhinitis and nasal congestion, a decongestant nasal spray would be indicated. For rhinorrhea, an antihistamine intranasal spray or ipratropium (Atrovent) would be indicated. Omalizumab (Xolair) may be necessary for a grade 4 allergic rhinitis (severe persistent).

Other than smoking cessation, which of the following most slows the progression of COPD in smokers? A. Making sure the environment is free of all pollutants B. Eliminating all pets from the environment C. Engaging in moderate to high levels of physical activity D. Remaining indoors with air conditioning as much as possible

Answer: C Research has shown that engaging in moderate to high levels of physical activity slows the decline in smokers' lung function and may help prevent as many as 21% of COPD cases

Martin, age 76, has just been given a diagnosis of pneumonia. Which of the following is an indication that he should be hospitalized? A. Inability to take oral medications and multilobar involvement on chest x-ray B. Alert and oriented status, slightly high but stable vital signs, and no one to take care of him at home C. Sputum with gram-positive organisms D. A complete blood count (CBC) showing leukocytosis

Answer: A For a client diagnosed with pneumonia, the following are indications for hospitalization: inability to take oral medications; multilobar involvement on chest x-ray; acute mental status changes; a severe vital sign abnormality (pulse rate greater than 140 per minute, systolic blood pressure less than 90 mm Hg, or a respiratory rate greater than 30 per minute); a secondary suppurative infection such as empyema, meningitis, or endocarditis; or a severe acute electrolyte, hematological, or metabolic abnormality.

Of the following groups, which is at the highest risk for tuberculosis? A. Racial and ethnic minorities B. Foreign-born individuals C. Substance abusers D. Nursing home residents

Answer: A Groups at high risk for tuberculosis include racial and ethnic minorities (70% of all reported cases in the United States); foreign-born individuals (24% of all cases in the United States); substance abusers (5 to 20 times the normal risk); individuals with HIV infection (40 to 100 times the normal risk); and residents of prisons, nursing homes, and shelters (2 to 10 times the normal risk).

The most common mode of transmission of the common cold in adults is A. hand-to-hand transmission. B. persons coughing into the air. C. environmental pollutants. D. unclean food utensils.

Answer: A Hand-to-hand transmission (after handling fomites serving as reservoirs of infection) is the most common mode of transmission of the common cold in adults, underscoring the importance of frequent hand-washing in the prevention of new cases. Colds are also caused by viruses spread through direct inhalation of airborne droplet sprays aerosolized by the infected person while speaking, coughing, or sneezing.

Coughing up blood or sputum that is streaked or tinged with blood is known as A. hemoptysis. B. regurgitation. C. bloody sputum. D. rhinorrhea.

Answer: A Hemoptysis is defined as expectoration of blood. The client often reports coughing up blood or sputum that is streaked or tinged with blood. In addition, hemoptysis may be manifested as fresh (bright red) or old blood, or, in the case of bleeding from an infected lung cavity, it may present as slow oozing or frank bleeding. In cases of profuse hemoptysis, blood clots may be expectorated. Regurgitation is the expulsion of material from the pharynx or esophagus. Bloody sputum may be present in the mouth and remain there for some time. Rhinorrhea is a condition where the nasal cavity is filled with a significant amount of mucus fluid.

What would the tumor node metastasis (TNM) classification be for a lung tumor that had carcinoma in situ, metastasis to the lymph nodes in the peribronchial or the ipsilateral hilar region, and distant metastasis to the spine? A. T1SN1M1 B. T2N0M0 C. T3N1M1 D. T0N1M0

Answer: A A T1SN1M1 indicates that the lung carcinoma is in situ, has metastasis to the lymph nodes in the peribronchial or the ipsilateral hilar region, and has distant metastasis to the spine. Although the TNM system is generalized for all solid tumors, it is often adapted for specific types of cancers. T is for the relative tumor size, N indicates the presence and extent of lymph node involvement, and M denotes distant metastases. For specific lung cancer staging, the T may range from 0, with no evidence of primary tumor, to 4, which indicates that the tumor has invaded the mediastinum or involves the heart, great vessels, trachea, esophagus, vertebral body, or carina, and there is presence of malignant pleural effusion. The N may range from 0, indicating no regional lymph node metastasis, to 3, indicating metastasis to the contralateral, mediastinal, scalene, or supraclavicular nodes. The M is either X, indicating that the presence of distant metastasis cannot be assessed, or 1, meaning that distant metastasis is present.

A pulmonary function test, such as spirometry, is helpful in the diagnosis of A. chronic bronchitis. B. lung cancer. C. pneumonia. D. tuberculosis.

Answer: A A pulmonary function test, such as spirometry, is helpful in the diagnosis of restrictive lung disease and obstructive lung disease, including chronic bronchitis and asthma. Clients with postinfectious or cough-variant asthma may show mild obstruction, but they often have normal spirometry. A chest x-ray confirms the diagnosis of pneumonia. While spirometry may show a decrease in lung capacity with advanced lung cancer, it is not diagnostic.

After a total laryngectomy for laryngeal cancer, the client will have a A. permanent tracheostomy. B. temporary tracheostomy until the internal surgical incision heals. C. temporary tracheostomy until an implant can be done. D. patent normal airway.

Answer: A After a total laryngectomy for laryngeal cancer, the client will have a permanent tracheostomy because no connection exists between the trachea and the esophagus. This answer rules out the other answers.

Marci, age 15, has been given a diagnosis of step 1 (mild intermittent) asthma. What long term control therapy is indicated? A. None B. A single agent with anti-inflammatory activity C. An inhaled corticosteroid with the addition of long-acting bronchodilator if needed D. Multiple long-term control medications with oral corticosteroids if needed

Answer: A No long-term control therapy is indicated for clients with step 1 (mild intermittent) asthma, be they children, adolescents, or adults. Clients with step 1 asthma require only quick relief with a beta-2 agonist as needed. There is no indication for long-term control until they approach step 2 (mild persistent) asthma.

What should be considered in all clients with adult-onset asthma or in clients with asthma that worsens in adulthood? A. Occupational asthma B. A suppressed immune system C. Another immunologic disease D. Concurrent COPD

Answer: A Occupational asthma should be considered in all clients with adult-onset asthma or in clients with asthma that worsens in adulthood. As many as 1 in 5 cases of asthma may be a result of exposure to chemicals in the workplace. Approximately 250 chemicals have been found to cause occupational asthma symptoms, which usually appear soon after a worker is first exposed to the asthma-inducing chemical but sometimes may appear months to years later.

Dennis, age 54, has COPD. He has recently been experiencing diffi culty in breathing. His arterial blood gas screening reveals pH 7.3, Pa O2 57 Hg, Pa CO2 54 mm Hg, and oxygen saturation 84%. Dennis has A. respiratory acidosis. B. respiratory alkalosis. C. metabolic acidosis. D. metabolic alkalosis.

Answer: A Respiratory acidosis results when the serum PaCO2 is more than 45 mm Hg and the serum pH is lower than 7.35. It occurs when there is a reduction in the rate of alveolar ventilation in relation to the rate of carbon dioxide production. The end result is an accumulation of dissolved carbon dioxide or carbonic acid. Dennis's COPD leads to alveolar hypoventilation with an acute retention of carbon dioxide, resulting in acute respiratory acidosis. With respiratory alkalosis, hyperventilation is usually evident, the PaCO2 is less than 35 mm Hg, and the pH is higher than 7.45. In metabolic acidosis, the HCO3 is less than 22 mEq/L, and the pH is lower than 7.35. In metabolic alkalosis, the HCO3 is more than 26 mEq/L and the pH is higher than 7.45.

Which of the following underlying lung diseases is the most common cause of a secondary spontaneous pneumothorax? A. COPD B. Lung abscess C. Cystic fibrosis D. Tuberculosis

Answer: A Secondary spontaneous pneumothoraces are most often due to underlying emphysematous COPD or HIV-associated Pneumocystis jiroveci pneumonia (PCP). Other predisposing conditions include lung abscess, cystic fibrosis, and TB

The two most predominant organisms constituting the normal flora of the oropharynx are A. Streptococci and Staphylococci. B. Streptococci and Moraxella catarrhalis. C. Staphylococci and Candida albicans. D. various protozoa and Staphylococci.

Answer: A Streptococci (especially Streptococcus viridans ) and Staphylococci (especially Staphylococcus aureus ) are the two most predominant types of organisms constituting the normal flora of the oropharynx. They are followed by Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis, Neisseria species, and Lactobacilli .

Community-acquired bacterial pneumonia is most commonly caused by A. Streptococcus pneumoniae. B. Mycoplasma pneumoniae. C. Haemophilus infl uenzae. D. Staphylococcus aureus.

Answer: A Streptococcus pneumoniae causes 30% to 75% of all community-acquired bacterial pneumonia cases, followed by Mycoplasma pneumoniae (5%-35%), Haemophilus influenzae (6%-12%), and Staphylococcus aureus (3%-10%).

The CURB-65 criteria may be used to help assess whether a patient needs to be treated in the hospital or can be effectively treated at home. The R in CURB stands for A. respiratory rate. B. rapid pulse rate. C. retractions. D. recent use of antibiotics.

Answer: A The CURB-65 criteria, used to determine the severity of community-acquired pneumonia (CAP), is an objective, easy tool to remember. A point is given for each of the following if they are present. The C is for confusion (new documentation). The U is for a BUN greater than 19 mg/dL. The R is for a respiratory rate of 30 or more breaths per minutes. The B is for the BP (systolic less than 90 mm Hg or a diastolic pressure of 60 mm Hg or lower). A point is also given if the patient is age 65 or older. A score of 1 is low risk, and the patient may be treated at home. With a score of 2, there should be a short period of hospitalization or closely monitored outpatient treatment. A score of 3 or greater indicates severe pneumonia, and the patient should be hospitalized with consideration of ICU placement.

The causative agent of community acquired pneumonia that is most often seen in clients with an alcohol problem is A. Pneumococcus. B. Mycoplasma. C. Legionella. D. Haemophilus influenzae.

Answer: A The community-acquired pneumonia seen most often in the client with or without an alcohol problem is pneumococcal, which is caused by the gram-positive bacteria Pneumococcus (also called Streptococcus pneumoniae). Alcoholics are at risk for the usual pathogens, but they also have a higher incidence of pneumonia caused by gram-negative organisms (including Klebsiella pneumoniae, Legionella, and Haemophilus influenzae ) and anaerobic pneumonia secondary to aspiration than do people who are not alcohol abusers.

A definitive test for cystic fibrosis is A. the sweat test. B. a sputum culture. C. a fecal fat test. D. a Chymex test for pancreatic insufficiency.

Answer: A The definitive tests for cystic fibrosis (CF) are the sweat test and DNA analysis. The diagnosis is confirmed by a positive sweat test or by confirming the presence of two of the recognized CF mutations in DNA, one each on the maternally and paternally derived chromosome 7. Sweat testing can be performed at any age. However, newborns in the first few weeks of life may not produce a large enough volume of sweat to analyze, but in those who do produce enough sweat, the results will be accurate. Immunoreactive trypsinogen (IRT) levels are elevated in most infants with CF for the first several weeks of life; however, this test has relatively poor specificity because as many as 90% of the positives on the initial screen are false-positives. Early diagnosis of CF improves the poor prognosis for untreated CF. If untreated, most clients die by age 1 to 2 years. With current care, median survival is age 29. A sputum or throat culture positive for mucoid Pseudomonas aeruginosa is suggestive of CF. An abnormal Chymex test for pancreatic insufficiency is a supportive laboratory test to diagnose CF. A fecal fat test, while reliable, is not specific to CF; any condition affected by malabsorption or maldigestion will be associated with increased fecal fat.

Which shape of the thorax is normal in an adult? A. Elliptical B. Funnel C. Pectus carinatum D. Barrel

Answer: A The normal adult has a thorax that has an elliptical shape with an anteroposterior transverse diameter ratio of 1 to 2 or 5 to 7. Funnel breast (pectus excavatum) is a markedly sunken sternum and adjacent cartilages; it is congenital and usually not symptomatic. Pigeon breast (pectus carinatum) is a forward protrusion of the sternum with ribs sloping back at either side and vertical depressions along the costochondral junctions; it is less common than pectus excavatum and requires no treatment. A barrel-shaped chest is present when the anteroposterior and transverse diameters of the chest are equal and the ribs are horizontal instead of in the normal downward slope; it is associated with normal aging and with chronic emphysema and asthma caused by hyperinflation of the lungs.

You are examining the respiratory system of a 65-year-old female client in whom you suspect "impaired gas exchange." This finding may be demonstrated by A. clubbing of the fingers. B. nasal flaring. C. the use of accessory muscles. D. a cough.

Answer: A The nursing diagnosis of "impaired gas exchange" may be demonstrated by clubbing of the fingers. Nasal flaring and cough are present if the client has a nursing diagnosis of "ineffective airway clearance" or "ineffective breathing pattern." The use of accessory muscles to assist breathing may indicate a nursing diagnosis of "ineffective breathing pattern."

Which statement about chronic obstructive pulmonary disease (COPD) is true? A. The prevalence of COPD is directly related to increasing age. B. The incidence of COPD is about equal in men and in women. C. Cigar or pipe smoking does not increase the risk of developing COPD. D. Environmental factors such as smoke do not affect the potential for COPD.

Answer: A The prevalence of chronic obstructive pulmonary disease (COPD) is directly related to increasing age. Men are affected much more often than women because the percentage of men who smoke is greater than that of women. The risk of developing COPD is related to the number of cigarettes smoked and the duration of smoking. Cigar or pipe smoking also increases the risk of developing COPD, but to a lesser extent than does cigarette smoking. Environmental factors, including secondhand smoke, also affect the potential for COPD. The usual client with COPD is one who is older than age 50 and has smoked one pack of cigarettes per day for more than 20 years.

The well-established risk factor(s) for a nosocomial pneumonia caused by a multidrug-resistant organism is (are) A. antibiotic exposure and a hospital stay of more than 1 week. B. age greater than 65 and having COPD. C. having outpatient surgery. D. having allergies to multiple antibiotics.

Answer: A Treatment of nosocomial pneumonia is complicated by the frequent involvement of multi-drug resistant organisms. Prior exposure to antibiotics and a hospital stay of more than 1 week are well-established risk factors for infection with these organisms. Age and a history of COPD are not related to nosocomial infections caused by multi-drug-resistant organisms. Antibiotic allergies will limit the number of drug options used to treat such an infection. One advantage of outpatient surgery is that it minimizes patient exposure to infectious organisms in the hospital.

Which bacterial agent is the most common pathogen in an acute exacerbation of chronic bronchitis? A. Streptococcus pneumoniae B. Haemophilus influenzae C. Branhamella catarrhalis D. Moraxella catarrhalis

Answer: A While viral bronchitis requiring only supportive care is the most common etiology of acute exacerbations of chronic bronchitis, bacterial involvement must be considered when there is increased sputum production lasting over a week or new chest x-ray findings. Streptococcus pneumoniae is the most common agent, followed by Haemophilus influenzae and Moraxella catarrhalis, similar to the causative agents of sinusitis and community-acquired pneumonia. Branhamella catarrhalis and M. catarrhalis are the same organism.

In which condition would the trachea be deviated toward the nonaffected side? A. Pleural effusion and thickening B. Pneumonia C. Bronchiectasis D. Pulmonary fibrosis

Answer: A With pleural effusion and thickening, the trachea would be deviated toward the non-affected side because of fluid displacing the pleural space. The trachea is usually not displaced with pneumonia. With bronchiectasis, the trachea is midline or deviated toward the affected side, and with pulmonary fibrosis, the trachea is deviated to the more affected side.

Which drug category contains the drugs that are the first line of therapy for COPD? A. Corticosteroids B. Inhaled beta-2 agonist bronchodilators C. Inhaled anticholinergic bronchodilators D. Xanthines

Answer: B All the drugs listed may be appropriate for COPD, but inhaled short-acting beta-2 agonist bronchodilators are the first line of therapy in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in stage 1.

Which irregular respiratory pattern has a series of three to four normal respirations followed by a period of apnea and is seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis? A. Cheyne-Stokes respiration B. Biot's breathing C. Kussmaul's respiration D. Hypoventilation

Answer: B Biot's breathing is the term for an irregular respiratory pattern of a series of three to four normal respirations followed by a period of apnea. It is seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. Cheyne-Stokes respiration is similar except that the pattern is regular. The most common cause of Cheyne-Stokes respiration is severe congestive heart failure, followed by renal failure, meningitis, drug overdose, and increased intracranial pressure. This regular pattern occurs normally in infants and older adults during sleep. Kussmaul's respiration is hyperventilation with an increase in both the rate and depth of the breaths. Hypoventilation is a reduced rate and depth of breathing that causes an increase in carbon dioxide in the bloodstream.

To ease their breathing, clients with COPD often position themselves in A. an erect sitting position. B. a tripod position. C. a supine position. D. a prone position.

Answer: B Clients with COPD often sit in a tripod position— leaning forward with their arms braced against their knees, a chair, or a bed. This provides clients with leverage so that their rectus abdominal, intercostal, and accessory neck muscles can all assist with expiration. The other positions listed do not give them that leverage.

Which of the following workers are at risk for developing pneumoconiosis? A. Farmers B. Coal miners C. Construction workers D. Potters

Answer: B Coal miners are at risk for developing pneumoconiosis. Pneumoconiosis is caused by the inhalation of dust particles and is an occupational hazard in mining and stone cutting. Farmers may be at risk for grain and/or pesticide inhalation. Construction workers handling asbestos may develop asbestosis. Potters, stonecutters, and miners are at risk for silicosis from inhaling silica (quartz) dust. A related respiratory disease, histoplasmosis, is a systemic fungal respiratory disease caused by fungus in soil with a high organic content and undisturbed bird droppings, such as those around old chicken coops, caves, and so on.

Cough and congestion result when breathing A. carbon monoxide. B. sulfur dioxide. C. tear gas. D. carbon dioxide.

Answer: B Cough and congestion result when breathing sulfur dioxide. Carbon monoxide produces dizziness, headache, and fatigue. Tear gas irritates the conjunctiva and produces a flow of tears. Carbon dioxide produces sleepiness.

Sherri, age 49, has had asthma for several years but has never used a peak expiratory flow meter. Should you now recommend it? A. No, she has been managing fine without it. B. Yes, she might recognize early signs of a potential respiratory problem. C. Present the options and let Sally decide. D. No, at her age it is not recommended.

Answer: B Daily peak flow monitoring has long been recommended for clients with asthma. Guidelines from the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute increase the flexibility of this recommendation and suggest that the use of peak flow measurements be individualized. The guidelines recommend that all clients with persistent asthma assess peak flow each morning. Subsequent assessments are necessary during the day when the morning measurement is less than 80% of the client's personal best peak expiratory flow (PEF) measurement. The goal of daily PEF monitoring is to recognize early signs of deterioration in airway function so that corrective steps can be initiated.

With which voice sound technique do you normally hear a muffled eeee through the stethoscope on auscultating the chest when the client says "eeee?" A. Bronchophony B. Egophony C. Whispered pectoriloquy D. Tonometry

Answer: B Hearing a muffled (and sometimes nondistinct) eeee through the stethoscope when auscultating the chest when the client says "eeee" is known as egophony. When consolidation is present, the eeee sound changes to an aaaaa sound. With bronchophony, when the client repeats "99-99-99," normally you can hear a soft, muffl ed, indistinct sound but cannot distinguish what is being said. With whispered pectoriloquy, when the client whispers "1-2-3," a normal response is faint, muffled, and almost inaudible. Tonometry measures intraocular pressure.

Jamie, age 16, has had her asthma well controlled by using only a beta-adrenergic metered-dose inhaler. Lately, however, she has difficulty breathing during the night, and her sleep has been interrupted about three times a week. What do you do? A. Prescribe a short course of steroid therapy B. Prescribe an inhaled steroid C. Prescribe a longer-acting bronchodilator D. Prescribe oral theophylline

Answer: B If a client develops moderate asthma, defined as more than two episodes per week, an inhaled steroid should be prescribed and used in conjunction with the beta-2 adrenergic metered dose inhaler. With no improvement, a longer acting bronchodilator, such as salmeterol xinafoate (Serevent), may be added. If the asthma worsens, then a short course of oral steroids may be tried. Theophylline is no longer used except in extremely resistant cases.

Michael, age 52, has a gradual onset of dry cough, dyspnea, chills, fever, general malaise, headache, confusion, anorexia, diarrhea, myalgias, and arthralgias. Which diagnosis do you suspect? A. Bronchopneumonia B. Legionnaires' disease C. Primary atypical pneumonia D. Pneumocystis jiroveci pneumonia

Answer: B If a client has a dry cough, dyspnea, chills, fever, general malaise, headache, confusion, anorexia, diarrhea, myalgias, and arthralgias, suspect Legionnaires' disease. Legionnaires' disease has a gradual onset. Bronchopneumonia has a gradual onset with a cough, scattered crackles, minimal dyspnea and respiratory distress, and a low grade fever. Primary atypical pneumonia has a gradual onset with a dry, hacking, nonproductive cough; fever; headache; myalgias; and arthralgias. Pneumocystis jiroveci pneumonia occurs in clients with AIDS. It has an abrupt onset with a dry cough, tachypnea, shortness of breath, significant respiratory distress, and fever.

In which condition would you assess vesicular breath sounds, moderate vocal resonance, and localized crackles with sibilant wheezes? A. Bronchiectasis B. Acute bronchitis C. Emphysema D. Asthma

Answer: B In acute bronchitis, the breath sounds are vesicular, vocal resonance is moderate, and the adventitious sounds are localized crackles with sibilant wheezes. In bronchiectasis, the breath sounds are usually vesicular, but vocal resonance is usually muffled and crackles are the adventitious sounds. In emphysema, the breath sounds are of decreased intensity and often with prolonged expiration, vocal resonance is muffled or decreased, and the adventitious sounds are occasional wheezes and often fine crackles in late inspiration. In asthma, the breath sounds are distant, vocal resonance is decreased, and wheezes are the adventitious sounds

Increased tactile fremitus occurs with A. pleural effusion. B. lobar pneumonia. C. pneumothorax. D. emphysema.

Answer: B Increased tactile fremitus occurs with compression or consolidation of lung tissue, such as occurs in conditions like lobar pneumonia. Decreased tactile fremitus occurs when anything obstructs the transmission of vibrations, such as in conditions like pleural effusion, pneumothorax, and emphysema, or with an obstructed bronchus.

Of all the adults who smoke, what percentage of those who attempt to quit are successful in their efforts? A. 2.5% B. 8% C. 15% D. 30%

Answer: B Nearly 17 million Americans try to quit smoking each year. Only about 1.3 million Americans are able to remain smoke free. Only 8% or so of smokers who quit smoking are successful in their efforts. Although the overall success rate of smoking cessation is disappointing, smoking cessation programs have been extremely helpful. Motivation is the key to a successful effort, along with making every clinical encounter an opportunity to discuss the topic. At the very least, every client should be asked about his or her smoking history. Clinicians should advise smokers to quit, assist them in setting a quitting date, provide self-help materials, and evaluate them for nicotine replacement therapy (patches, nasal spray, or gum) or pharmacological therapies.

Persons requiring home oxygen will have an oxygen saturation level below A. 90%. B. 85%. C. 80%. D. 75%.

Answer: B Requirements for home oxygen include (1) a PaO2 of 55 mm Hg or less or an oxygen saturation (Sa) below 85% and (2) a PaO2 of 55 to 59 mm Hg if erythrocytosis (hematocrit of 56% or more) or cor pulmonale (P wave more than 3 mm in leads II and III) is present. Because hypoxia leads to pulmonary hypertension and increases the work of the right ventricle, low-flow oxygen may help prevent development of cor pulmonale. The goal of therapy is a PaO2 of 60 mm Hg or SaO2 of 90%, which usually can be accomplished with 1 to 2 L of oxygen per minute for 15 hours per day.

What early acid-base disturbance occurs in a teenager admitted for an aspirin overdose? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Answer: B Respiratory alkalosis is the early acid-base disturbance that occurs in an aspirin overdose (salicylate intoxication). It results from direct stimulation of the respiratory center in the medulla, which causes an increase in pH and a decrease in PaCO2 . This leads to metabolic acidosis as the body compensates by renal excretion of bicarbonate to normalize the pH.

What is the definition of the spirometric assessment of residual volume? A. The sum of the vital capacity and the residual volume B. The amount of gas left in the lung after exhaling all that is physically possible C. The volume that can be maximally exhaled after a passive exhalation D. The measurement of the maximum flow rate achieved during the forced vital capacity maneuver

Answer: B The definition of the spirometric assessment of residual volume is the amount of gas left in the lung after exhaling all that is physically possible. This measurement is expressed as a ratio of total lung capacity to vital capacity. The total lung capacity is the sum of the vital capacity and the residual volume. The expiratory reserve volume is the volume that can be maximally exhaled after a passive exhalation. The peak flow is the measurement of the maximum flow rate achieved during the forced vital capacity maneuver.

Mr. Tanner, age 67, presents to the clinic with fever, chills, a productive cough with sputum that has changed color from clear to yellow, chest discomfort, fatigue, and myalgias. His wife is concerned because he is confused at times. His blood pressure is 100 over 54, his pulse rate is 92, and his respirations are 22 per minute. When percussing the chest, you detect dullness over the right lower lobe and suspect that Mr. Tanner has pneumonia. Your plan for Mr. Tanner includes A. outpatient treatment. B. inpatient treatment. C. macrolide antibiotic therapy. D. a respiratory fluoroquinolone.

Answer: B The first step in treatment is to determine the severity of the pneumonia and if the patient should be hospitalized. The CURB-65 criteria are (1) confusion, (2) uremia (BUN 20 mg/dL or higher), (3) respiratory rate more than 30 breaths per minute, (4) systolic BP less than 90 mm Hg or diastolic BP less than 60 mm Hg, and (5) age 65 or older. If the patient meets less than two of the criteria, is able to take oral medication, and is not hypoxic, then they may be treated as an outpatient. If the score is 2 or higher, inpatient treatment is indicated. Mr. Tanner meets three of the criteria and therefore should be treated as an inpatient. Macrolides are the first choice of antibiotic for patients who are previously healthy and have not used antimicrobials in the past 3 months, while respiratory flouroquinolone therapy is the first choice for patients with comorbidities. Both antimicrobials are options for outpatient therapy.

The most common cause of a persistent cough in children of all ages is A. an allergy. B. recurrent viral bronchitis. C. asthma. D. an upper respiratory infection.

Answer: B The most common cause of a persistent cough in children of all ages is recurrent viral bronchitis, which is most prevalent in preschool and young school-age children, and there may be a genetically determined host susceptibility to frequently recurring bronchitis. The key words are persistent cough . Young clients with recurrent cough often have asthma, but it is not usually persistent. Providers should be suspicious of underlying asthma contributing to a recurrent cough when there is a family history of allergies, atopy, or asthma. Similarly, allergies and an upper respiratory infection do not present with a persistent cough; rather, they present with an intermittent one.

What is the normal ratio of the anteroposterior chest diameter to the transverse chest diameter? A. 1 to 1 B. 1 to 2 C. 2 to 3 D. 2 to 1

Answer: B The normal anteroposterior diameter of the chest as compared with the transverse diameter is a ratio of approximately 1 to 2. An anteroposterior measurement that equals the transverse measurement is defined as a barrel chest, which usually indicates some obstructive lung disease.

When asthma does not respond to traditional therapy, it may be due to another syndrome that mimics asthma, such as A. lower airway obstruction. B. upper airway obstruction. C. COPD. D. bronchitis.

Answer: B When asthma does not respond to traditional therapy, it may be because the patient has another syndrome that mimics asthma or because he or she has a comorbid condition that complicates it. The two most common syndromes that mimic asthma are vocal cord dysfunction and upper airway obstruction. Both may result in dyspnea and apparent wheezing but not show any response to standard asthma therapy. COPD and bronchitis can be co-morbid conditions that may complicate asthma.

When teaching smokers about using nicotine gum to aid in smoking cessation, tell them to A. chew the gum like regular gum. B. discard the gum after 30 minutes. C. drink a cup of coffee before chewing the gum because it assists in the nicotine absorption. D. chew 6 to 9 pieces daily to help prevent nicotine withdrawal.

Answer: B When teaching smokers about using nicotine gum to aid in smoking cessation, tell them to discard the gum after 30 minutes. The gum should not be chewed like regular gum. A piece is chewed only long enough to release the nicotine, which produces a peppery taste, and then "parked" between the gums and buccal mucosa to allow for nicotine absorption. Drinking liquids while the gum is in the mouth should be avoided. Acidic beverages such as coffee should be avoided for 1 to 2 hours before the use of the gum. The smoker should be instructed to chew 9 to 12 pieces daily to help prevent nicotine withdrawal.

Which of the following statements about sarcoidosis is true? A. It commonly occurs in persons in their 50s. B. It is more common in whites than in blacks. C. Many organs may be involved, but the most involved organ is the lung. D. It occurs more frequently in men than in women.

Answer: C Sarcoidosis is a multisystem disorder of unknown cause that has a prevalence of about 20 in 10,000 cases. It usually occurs in clients ages 20 to 40, but it can occur at any age. Sarcoidosis occurs more frequently in women than in men; and in the United States, it is more common in blacks than in whites (a ratio of about 10 to 1). Although many organs may be involved, the most involved organ is the lung (90%).

Which of the following statements is true when trying to differentiate pulmonary from cardiac causes of dyspnea on exertion? A. When the cause is pulmonary, the rate of recovery to normal respiration is slow, and dyspnea abates eventually after cessation of exercise. B. Clients with dyspnea from cardiac causes remain dyspneic much longer after cessation of exercise. C. In dyspnea arising from cardiac causes, the heart rate will return to pre-exercise levels within a few minutes after cessation of exercising. D. Clients with pulmonary dyspnea have minimal dyspnea at rest.

Answer: B When trying to differentiate pulmonary from cardiac causes of dyspnea on exertion, it is important to remember that clients with dyspnea from cardiac causes remain dyspneic much longer after cessation of exercise. The heart rate also takes longer to return to pre-exercise levels. When the cause is pulmonary, the rate of recovery to normal respiration is fast; and the dyspnea is gone a few minutes after the cessation of exercise. Clients with pulmonary dyspnea usually do not have dyspnea at rest. Clients with severe cardiac dyspnea demonstrate a volume of respiration that is greater than normal at every level of exercise, and they experience the dyspnea sooner after beginning the exertion.

The inspiratory rate equals the expiratory rate with which breath sound? A. Bronchial B. Bronchovesicular C. Vesicular D. Tracheal

Answer: B With bronchovesicular breath sounds, the inspiratory rate equals the expiratory rate. With bronchial or tracheal breath sounds, the inspiratory rate is shorter than the expiratory rate; and with vesicular breath sounds, the inspiratory rate is greater than the expiratory rate.

During the history portion of a respiratory assessment, it is particularly important to ask if the client takes which of the following drugs? A. Beta-2 agonists B. Calcium channel blockers C. Angiotensin-converting enzyme (ACE) inhibitors D. Birth control pills

Answer: C A cough occurs in about 10% of clients who take ACE inhibitors such as lisinopril and enalapril (medication names ending in -pril ). A complete history of prescribed and over-the-counter (OTC) drugs, including any herbal preparations, should be taken. Knowing all drugs taken is important, but because of the potential for ACE inhibitors to cause a cough, it is particularly important to ask about this category of drugs when doing a respiratory assessment.

Risk factors for pulmonary embolism in women include which of the following? A. Extreme thinness B. Alcohol intake C. Cigarette smoking D. Hypotension

Answer: C A large prospective study in women showed that obesity, cigarette smoking, and hypertension increased their risk for pulmonary embolism. Alcohol intake does not predispose a woman to pulmonary embolism.

According to the Committee on Allergic Rhinitis and Its Impact on Asthma (ARIA), sinus cleansing should be followed by which of the following as first-line therapy for the treatment of allergic rhinitis? A. A leukotriene receptor antagonist B. An oral or spray decongestant C. An intranasal corticosteroid spray D. Sinus cleansing should be sufficient

Answer: C According to the ARIA guidelines, sinus cleansing should be followed with an intranasal corticosteroid spray as first-line therapy. Intranasal corticosteroid sprays are a primary means of reducing mast cell degranulation and reducing tissue inflammation. All of the other choices are also indicated in the treatment of allergic rhinitis.

When you teach clients about using steroid inhalers for asthma or COPD, what information is essential? A. Keep the inhaler in the refrigerator. B. Do not use another inhaler for 10 minutes after the steroid inhaler. C. Rinse your mouth after using the inhaler. D. Be careful not to shake the container before using.

Answer: C After using a steroid inhaler, the client should always rinse his or her mouth to prevent oral candidiasis ("thrush"). Brushing the teeth will get rid of any bad taste. The inhaler or diskus should be shaken first. If the client is also taking a beta-2 agonist, tell him or her to take that first, as that will open the airway, allowing more of the steroid medication to be administered.

Harvey has severe obstructive sleep apnea and has just been ordered a continuous positive airway pressure (CPAP) machine. What do you tell him about it? A. "You put it on at night after you've woken up several times." B. "You must use it at least 5 nights during the week." C. "You'll want to use it every night, all night long." D. "We'll discontinue it if you develop nasal dryness or rhinitis."

Answer: C CPAP administered through a nasal mask has become the most common treatment for obstructive sleep apnea (OSA). Depending on the patient's mode of breathing, a larger mask encompassing the mouth may also be used. CPAP dramatically eliminates apneas and hypopneas, improves sleep architecture, and reduces daytime sleepiness, even for those with mild sleep apnea. In order to be effective, the machine must be used all night long, every night. Minor adverse effects of CPAP include feelings of suffocation, nasal drying or rhinitis, ear pain, difficulty in exhaling, mask and mouth leaks, chest and back pain, and conjunctivitis. Most of these can be alleviated.

Which is the most notable clinical manifestation of glottis (tongue) cancer? A. Earache B. Halitosis C. Hoarseness D. Frequent swallowing

Answer: C Clinical manifestations of cancer of the larynx include earache, halitosis, hoarseness, change in the voice, painful swallowing, dyspnea, and a palpable lump in the neck. The most notable manifestation of glottic (tongue) cancer is hoarseness or a change in the voice because the tumor prevents complete closure of the glottis during speech.

What is the percentage of adults over age 65 who typically receive the pneumococcus vaccine? A. 10% B. 30% C. 60% D. 90%

Answer: C Despite widespread endorsement by numerous medical and nursing organizations, the pneumococcal vaccine was administered to only 60% of adults over age 65 in a recent year. Experts from the Advisory Committee on Immunization Practices estimate that as many as 90% of deaths attributed to Streptococcus pneumoniae could be prevented if use of the currently available vaccine were more common. Pneumococci account for more deaths than any other vaccine-preventable disease. Healthy People 2020 cites a target of 90% of noninstitutionalized adults over age 65 having the vaccine by 2020.

Which drug contributes to a decreased response to tuberculin skin testing (TST)? A. Antibiotics B. Inhaled allergy medications C. Corticosteroids D. Birth control pills

Answer: C Drugs such as corticosteroids and other immunosuppressive agents contribute to a decreased response to TST. Other factors that may contribute to a decreased response to TST include viral infections (measles, mumps, chickenpox, and HIV), bacterial infections (typhoid fever, and pertussis), nutritional factors (severe protein depletion), diseases affecting lymphoid organs, and stress (surgery and burns).

You are teaching Holly, age 14, who has asthma, to use a home peak expiratory flowmeter daily to measure gross changes in peak expiratory flow. Which "zone" would rate her expiratory compliance as 50% to 80% of her personal best? A. White zone B. Green zone C. Yellow zone D. Red zone

Answer: C Holly should perform a peak expiratory flowmeter reading daily during a 2-week period when she feels well. The highest number recorded during this period is her "personal best." A green zone (80%-100% of her personal best) is when no asthma symptoms are present, and she should continue with her normal medication regimen. A yellow zone (50%-80% of her personal best) occurs when asthma symptoms may be starting and signals caution. A red zone (below 50% of her personal best) indicates that an asthma attack is occurring and that Holly should take her inhaled beta-2 agonist and repeat the peak flow assessment. There is no white zone.

Laura, age 36, has an acute onset of dyspnea. Associated symptoms include chest pain, faintness, tachypnea, peripheral cyanosis, low blood pressure, crackles, and some wheezes. Her history reveals that she is taking birth control pills and that she smokes. What do you suspect? A. Asthma B. Bronchitis C. Pulmonary emboli D. Pneumothorax

Answer: C If a client presents with an acute onset of dyspnea with associated symptoms of chest pain, faintness, tachypnea, peripheral cyanosis, low blood pressure, crackles, and some wheezes and has a history of taking birth control pills and smoking, suspect pulmonary emboli. Other signs and symptoms associated with pulmonary emboli include loss of consciousness and a pleural friction rub. Precipitating and aggravating factors include the use of oral contraceptives and prolonged recumbency. Acute dyspnea would also occur with asthma, but the physical findings would include bilateral wheezing; sibilant, whistling sounds; and prolonged expiration. With bronchitis, dyspnea is not necessarily the presenting symptom. A cough precedes the dyspnea, and there would be rhonchi present on auscultation. With a pneumothorax, there is an acute onset of dyspnea, and the physical findings would include decreased or absent breath sounds with a tracheal shift.

Jill, age 49, has daily symptoms of asthma. She uses her inhaled short-acting beta-2 agonist daily. Her exacerbations affect her activities, and they occur at least twice weekly and may last for days. She is affected more than once weekly during the night with an exacerbation. Which category of asthma severity is Jill in? A. Mild intermittent B. Mild persistent C. Moderate persistent D. Severe persistent

Answer: C In step 1 (mild intermittent) asthma, symptoms are no more frequent than twice weekly and nocturnal symptoms are no more frequent than twice per month. In step 2 (mild persistent) asthma, symptoms are more frequent than twice weekly but less than once a day; exacerbations may affect activity, and nocturnal symptoms occur more than twice per month. Jill is in the step 3 (moderate persistent) category of asthma severity. This is because she has daily symptoms along with exacerbations affecting her activity and nocturnal symptoms that occur more than once per week. In step 4 (severe persistent) asthma, the client has continuous symptoms with limited physical activity, frequent exacerbations, and frequent nocturnal symptoms.

In trying to differentiate between chronic bronchitis and emphysema, you know that chronic bronchitis A. usually occurs after age 50 and has insidious progressive dyspnea. B. usually presents with a cough that is mild and with scant, clear sputum, if any. C. presents with adventitious sounds, wheezing and rhonchi, and a normal percussion note. D. results in an increased total lung capacity with a markedly increased residual volume.

Answer: C In trying to differentiate between chronic bronchitis and emphysema, remember that chronic bronchitis presents with adventitious sounds, wheezing and rhonchi, and a normal percussion note. Chronic bronchitis usually occurs after age 35, with recurrent respiratory infections. There is usually a persistent, productive cough of copious mucopurulent sputum, and pulmonary function studies show normal or decreased total lung capacity with a moderately increased residual volume. In a client with emphysema, the onset is usually after age 50. There is an insidious progressive dyspnea, and the cough is usually absent or mild with scant, clear sputum, if any. There are also distant or diminished breath sounds and a hyperresonant percussion note. The pulmonary function studies show an increased total lung capacity with a markedly increased residual volume.

Which of the following individuals most likely will have a false-negative reaction to the Mantoux test? A. Marvin, age 57 B. Jane, who is on a short course of corticosteroid therapy for an acute exacerbation of asthma C. Jerry, who has lymphoid leukemia D. Mary, who recently was exposed to someone coughing

Answer: C Individuals predisposed to have a false-negative reaction to the Mantoux test include newborns and those older than age 60; persons in an immunosuppressive state, such as those taking long-term corticosteroids and anticancer agents or those with HIV infection or chronic renal failure; persons with a neoplasm, especially lymphoid leukemia and lymphomas; and persons with an acute infection, such as measles, mumps, chickenpox, typhoid fever, brucellosis, typhus, and pertussis. Tuberculosis had been close to eradication until HIV appeared. Coughing alone is not predictive of TB.

Which of the following medications commonly prescribed for tuberculosis cannot be taken by pregnant women? A. Isoniazid (INH) B. Rifampin (RIF) C. Pyrazinamide (PZA) D. Ethambutol (EMB)

Answer: C Pyrazinamide (PZA) should not be taken by pregnant women. Active tuberculosis should be treated with isoniazid and ethambutol and continued for at least 18 months to prevent relapse. Two-drug regimens are not recommended if isoniazid resistance is suspected. If a third drug or a more potent drug is necessary due to extensive or severe disease, rifampin could be added. Because of the risk of ototoxicity, streptomycin should not be prescribed. Isoniazid is the safest drug during pregnancy.

Which of the following statements is true regarding the recurrence of a spontaneous pneumothorax? A. A primary spontaneous pneumothorax is more likely to recur than a secondary one. B. A secondary spontaneous pneumothorax is more likely to recur than a primary one. C. Recurrence rates for both primary and secondary spontaneous pneumothorax are similar. D. Spontaneous pneumothorax rarely recurs.

Answer: C Recurrence rates for both primary and secondary spontaneous pneumothorax are similar. Recurrence rates range from 10% to 50%, and about 60% of those clients will have a third recurrence. After three episodes, the recurrence rate exceeds 85%. Repeated spontaneous pneumothorax should be treated by pleurodesis or surgical intervention, including parietal pleurectomy.

What is the gold standard for the diagnosis of asthma? A. Validated quality-of-life questionnaire B. Client's perception of "clogged" airways C. Spirometry D. Bronchoscopy

Answer: C Spirometry remains the gold standard for the diagnosis of asthma as well as for periodic monitoring of the condition. Routine use of validated quality-of-life questionnaires may detect impairment and severity of the disease. The client's perception may be greatly exaggerated. A bronchoscopy may be necessary to diagnose several conditions, including a chronic cough or infection. If a client is not having an asthma attack, the bronchus may not appear constricted.

You have completed a physical exam on Sandra, age 32, who presented to the clinic for a cough that is particularly worse at night. She has been experiencing episodes of recurrent tightness in the chest with wheezing. She tells you that exercise and changes in the weather make her symptoms occur or worsen. Which test is performed to diagnose asthma? A. Bronchoprovocation with methacholine, histamine, cold air, or exercise challenge B. Peak expiratory flow meter monitoring C. Spirometry testing D. Chest x-ray

Answer: C Spirometry tests are done to diagnose asthma in patients who are ages 5 years and older. Measurements should include forced expiratory volume in 1 second (FEV 1 ), forced expiratory volume in 6 seconds (FEV 6 ), forced vital capacity (FVC), and FEV 1 /FVC. These measurements should be performed before and after the patient inhales a short-acting bronchodilator. Bronchoprovocation is done when asthma is suspected, but the spirometry testing is normal. A positive bronchoprovocation test is diagnostic for airway hyperresponsiveness, which may also be present in other conditions. Peak flow meters are used for monitoring asthma. A chest x-ray is performed to exclude other disease

How does pregnancy affect asthma? A. During pregnancy asthma usually improves. B. During pregnancy asthma usually worsens. C. Symptoms in about one-third of pregnant women with asthma improve, about one third are unchanged, and about one-third worsen. D. Symptoms in about one-half of pregnant women improve; those of the other half worsen.

Answer: C Symptoms in about one-third of pregnant women with asthma will improve during pregnancy; about one-third will be unchanged; and about one-third will worsen. Pregnancy is associated with changes in lung volume. There is an increase in tidal volume and a 20% to 50% increase in minute ventilation. The clinical course of asthma during pregnancy may be predicted by the course during the first trimester, and most clients have the same pattern of response with repeated pregnancies. The treatment of asthma during pregnancy follows the same principles as with other clients. Medications not specifically required should not be given in the first trimester, and all medications should be given at their minimal effective dose and frequency.

Evidence-based practice has shown that clients with COPD will benefit the most from which of the following single modalities? A. Nutritional supplementation B. Routine use of inspiratory muscle training C. Pulmonary rehabilitation D. Psychosocial interventions

Answer: C The Joint American College of Chest Physicians (ACCP) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) evidence-based clinical practice guidelines for pulmonary rehabilitation offer evidence that pulmonary rehabilitation is beneficial for clients with COPD and those with other chronic lung conditions. Pulmonary rehabilitation improves the symptom of dyspnea, improves the health-related quality of life, reduces the number of hospital days and other measures of health-care utilization, and is cost effective. Evidence is insufficient to support the routine use of nutritional supplementation in pulmonary rehabilitation of clients with COPD. Current practice and expert opinion support including psychosocial interventions as a component of comprehensive pulmonary rehabilitation programs for clients with COPD, but clients benefit the most from pulmonary rehabilitation.

The antibiotic of choice for the treatment of Streptococcus pneumoniae infection is A. dicloxacillin. B. erythromycin. C. penicillin. D. ampicillin clavulanate.

Answer: C The antibiotic of choice for the treatment of Streptococcus pneumoniae pneumonia is penicillin. However, the number of penicillin-resistant pneumococcal infections is increasing. These cases require treatment with more powerful antibiotics. Alternative choices are erythromycin and clindamycin. Dicloxacillin is the antibiotic of choice for infections caused by Staphylococcus aureus, erythromycin is the antibiotic of choice for infections caused by Mycoplasma pneumoniae, and ampicillin clavulanate is the antibiotic of choice for Moraxella catarrhalis infections. Fever that continues more than 24 hours after initiating therapy usually does not indicate failure of the antibiotic; rather, the usual response to therapy is a gradual reduction in the maximum daily temperature.

The definitive test for sleep apnea is A. a Holter monitor. B. a trial period of a continuous positive air pressure (CPAP) appliance. C. an overnight polysomnogram. D. an ear, nose, and throat (ENT) specialist confi rming an abnormal uvula.

Answer: C The defi nitive test for sleep apnea is an overnight polysomnogram. This all-night recording of the client's sleep, performed in a sleep center, is the gold standard for identifying the presence, type, and severity of sleep apnea.

Which sympathomimetic agents are the drugs of choice for asthma? A. Alpha agonists B. Beta-1 agonists C. Beta-2 agonists D. Alpha antagonists

Answer: C The sympathomimetic agents that are the fi rst-line drugs of choice for hyperreactive airway disease— asthma—are the beta-2 agonists. There are different adrenergic receptors in different tissues. Beta-2 adrenergic agents (agonists) are more specific in their action to promote bronchodilation and are less likely to be associated with side effects. In addition to promoting bronchodilation, these agents also increase secretion of electrolytes by the airways and enhance mucociliary activity. Protein kinase A levels increase within the smooth-muscle cells, resulting in inhibition of myosin phosphorylation and smooth-muscle cell relaxation. Alpha agonists cause vasoconstriction, and beta-1 adrenergic agents (agonists) increase cardiac contractility and heart rate, effects that are undesirable in clients with asthma. Alpha antagonist is not a drug class.

What do you include in your teaching about tiotropium (Spiriva) when you initially prescribe it for your client with COPD? A. Use it every time you use your beta-2 agonist. B. Stop taking all your other COPD medications. C. Use this once per day. D. Stop taking Spiriva if you develop the adverse effect of dry mouth.

Answer: C Tiotropium (Spiriva) is a once-daily, longacting anticholinergic. It results in improved lung function studies and reduction in the use of rescue medication and in COPD exacerbations. The most frequently reported adverse side effect is that of dry mouth, which is easily remedied with increased hydration. The patient may use a beta-2 agonist several times per day, as tiotropium is not for the relief of acute symptoms. Certainly the patient should not stop taking other medications until the clinician sees the effectiveness of tiotropium.

Mary, age 69, has COPD. Her oxygen saturation is less than 85%. She is to start on oxygen therapy to relieve her symptoms. How often must she be on oxygen therapy to actually improve her oxygen saturation? A. On an as-needed basis B. 6 to 12 hours per day C. 15 hours per day D. 24 hours per day

Answer: C To decrease mortality in clients with COPD whose oxygen saturations are less than 85%, oxygen must be used at least 15 hours per day to be of more than symptomatic benefit. The oxygen can be either a specific concentration delivered by mask or a flow rate administered through a nasal cannula. It is needed to maintain adequate oxygenation levels during both activity and rest. The goal of therapy is a PaO2 of 60 mmHg or SaO2 of 90%.

Sharon, who is pregnant, has just been given a diagnosis of tuberculosis. What do you do? A. Wait until Sharon delivers and then begin therapy immediately. B. Begin therapy with isoniazid (Nydrazid), rifampin (Rimactane), and pyrazinamide now. C. Begin therapy with isoniazid, rifampin, and ethambutol (Myambutol) now. D. Begin therapy with isoniazid now, wait to see how Sharon tolerates it, and then add rifampin, pyrazinamide, or ethambutol.

Answer: C Treatment of tuberculosis in pregnant women is essential and should not be delayed; therefore, Sharon's treatment should begin now. The preferred initial treatment is isoniazid (Nydrazid), rifampin (Rimactane), and ethambutol (Myambutol). The teratogenicity of pyrazinamide is undetermined, so it is not wise to use this drug unless resistance to the other drugs is demonstrated or is likely.

An unexplained nocturnal cough in an older adult should suggest A. allergies. B. asthma. C. congestive heart failure. D. viral syndrome.

Answer: C Unexplained nocturnal cough in an older adult should suggest congestive heart failure. Older adults, whose physical activity may be restricted by arthritis or other associated diseases, may not present with the usual symptom of dyspnea on exertion. The main complaint instead may be a chronic unexplained cough that may occur only at night while the client is recumbent or a cough that may worsen at night.

Tina, age 49, is on multiple drug therapy or tuberculosis. She asks you how long she needs to take the drugs. You respond, A. "6 weeks to 2 months." B. "4 to 6 months." C. "6 to 9 months." D. "1 year."

Answer: C With the use of multiple drug therapy for TB, the duration of the therapy has shortened from 1 year to a standard of 6 to 9 months. The current minimal acceptable duration for treatment of all children and adults with culture-positive TB is 6 months. An alternative regimen for persons who cannot take PZA (e.g., pregnant women) consists of a 9-month regimen of INH and RIF. If the client has a drug-resistant organism or is immunodeficient, the precise duration of therapy is uncertain but may extend from 1 to 2 years in some cases.

Which statement is true regarding primary spontaneous pneumothorax? A. It usually occurs after individuals have recently started an exercise program. B. It occurs more commonly in thin, elderly men. C. It usually occurs in healthy individuals without preexisting lung disease. D. It frequently occurs in Marfan's syndrome.

Answer: C A primary spontaneous pneumothorax usually occurs in healthy individuals without preexisting lung disease. It occurs more commonly in young, tall, asthenic men and is an accumulation of air in the normally airless pleural space between the lung and chest wall. Persons with Marfan's syndrome are more prone to aortic aneurysms, not to pneumothorax.

When should a rescue course of prednisolone be initiated for an attack of asthma? A. When the client is in step 1 (intermittent stage) B. When the client is in step 2 (mild persistent stage) C. When the client is in step 4 (severe persistent stage) D. Whenever the client needs it, at any time and at any step

Answer: D A rescue course of prednisolone should be initiated for an attack of asthma whenever the client needs it, at any time, and at any step. Attempts should be made to use systemic corticosteroids in an acute or rescue fashion—a short burst followed by tapering to the lowest dose possible and preferably discontinued—with inhaled steroids prescribed for chronic or maintenance therapy.

What is a common inhaled allergen in allergic asthma (extrinsic asthma)? A. Smoke B. Cold air C. Strong smells D. Pet dander

Answer: D Allergic asthma (extrinsic asthma) is a chronic inflammatory disorder of the airways. The symptoms of allergic and nonallergic asthma are the same, but the triggers are not. Allergic asthma is triggered by inhaled exposure to allergens. The most common of these are dust mites, pet dander, pollens, mold, grass, and ragweed. Nonallergic asthma triggers generally do not cause inflammation but can aggravate airways, especially if they are already inflamed. Nonallergic triggers include smoke, exercise, cold air, strong smells like chemicals and perfume, air pollutants, and intense emotions.

What is effective in the treatment of pneumonia, atelectasis, and cystic fibrosis? A. Deep breathing B. Oxygen C. Inhalers D. Chest physiotherapy

Answer: D Chest physiotherapy is effective in the treatment of pneumonia, atelectasis, and diseases resulting in weak or ineffective coughing, such as cystic fibrosis. This technique uses percussion and postural drainage along with coughing and deep breathing exercises. It is performed by positioning the client so that the involved lobes of the lung are placed in a dependent drainage position and then using a cupped hand or vibrator to percuss the chest wall. Nasotracheal suctioning is quite uncomfortable but still useful in the appropriate clinical setting in the absence of signifi cant coagulopathy.

Which of the following drugs cause a cough by inducing mucus production (bronchorrhea)? A. Tobacco and/or marijuana B. Beta-adrenergic blockers C. Aspirin and NSAIDs D. Cholinesterase inhibitors

Answer: D Cholinesterase inhibitors cause a cough by inducing mucus production (bronchorrhea). Tobacco and marijuana cause a cough by being direct irritants. Beta-adrenergic blockers, aspirin, and NSAIDs cause a cough by potentiating reactive airway disease.

Which of the following medications prescribed for asthma acts to prevent binding of IgE receptors on basophils and mast cells? A. Anti-inflammatory agents B. Bronchodilators C. Mast cell stabilizers D. Immunomodulators

Answer: D Immunomodulators such as omalizumab (Xolair), a monoclonal antibody, prevents biding of IgE receptors on basophils and mast cells. Mast cell stabilizers stabilize mast cells and interfere with chloride channel function. Anti-inflammatory agents calm inflammation, and bronchodilators dilate the bronchus.

Which of the following statements is true regarding pulmonary tuberculosis? A. Manifestations are usually confined to the respiratory system. B. Dyspnea is usually present in the early stages. C. Crackles and bronchial breath sounds are usually present in all phases of the disease. D. Night sweats are often noted as a manifestation of fever.

Answer: D In the client with pulmonary tuberculosis, night sweats are often noted as a manifestation of fever. With pulmonary tuberculosis, systemic manifestations are usually present; symptoms are not confined to the respiratory system. Fever occurs in 50% to 80% of cases, and symptoms such as malaise and weight loss are frequent. Dyspnea, an ominous feature, usually occurs with widespread advanced disease. Crackles and bronchial breath sounds may be present, but more often there are no abnormal findings, even in well-developed pulmonary disease.

Keaton, age 6, comes to the clinic with his mother for a 3-month follow-up visit for his asthma. His mother reports he has symptoms 2 days a week but not more than once on each day, he has had only 1 episode of nighttime awakening because of his asthma, he is able to play soccer without provoking an attack, and his peak flow personal best is 80% or higher. His current treatment includes a short-acting beta-agonist and a leukotriene receptor antagonist. Based on the level of control, your plan for adjusting therapy includes A. considering a short course of oral systemic corticosteroids. B. stepping up one step. C. stepping up two steps. D. maintaining the current step.

Answer: D Keaton's asthma symptoms are well controlled, and he is at step 2. Recommendations for well-controlled asthma include maintaining the current step, following up every 1 to 6 months, and considering a step down if the asthma is well-controlled for at least 3 months. For very poorly controlled asthma, recommendations include considering a short course of oral systemic corticosteroids and stepping up one to two steps. For asthma that is not well controlled, step up at least one step and consider one to two steps in patients ages 12 years and older.

Increased severity of underlying illness, presence of an indwelling urethral catheter, and use of broad spectrum antibiotics are risk factors predisposing clients to the development of A. tuberculosis. B. decreased mobility. C. pressure ulcers. D. nosocomial pneumonia

Answer: D Risk factors predisposing clients to the development of nosocomial (hospital-acquired) pneumonia include increased severity of the underlying illness, presence of an indwelling urethral catheter, use of broad-spectrum antibiotics (which increase the risk of superinfection), previous hospitalization, presence of intravascular catheters, intubation (especially prolonged intubation), and recent thoracic or upper abdominal surgery.

Which of the following statements is true regarding weight and smoking cessation? A. Smokers weigh 10 to 20 lb. less than nonsmokers. B. When smokers quit, 90% of them gain weight. C. Men gain more weight than women when they quit. D. Smokers gain weight after smoking cessation because they replace cigarettes with food.

Answer: D Smokers weigh 5 to 10 lb less than nonsmokers of comparable age and height. When smokers quit, 80% of them gain weight; the average weight gain is 5 lb, but about 10% of that 80% who gain weight gain more than 25 lb. On average, women gain more weight than men—8 lb as compared with 5 lb. Heavy smokers (those who smoke two or more packs per day) gain more weight than light smokers. This weight gain is caused by replacing the habit of smoking cigarettes with eating to satisfy the need for oral gratifi cation.

A cough caused by a postnasal drip related to sinusitis is more prevalent at what time of day? A. Continuously throughout the day B. In the early morning C. In the afternoon and evening D. At night

Answer: D Some conditions have a characteristic timing of a cough. A cough caused by a postnasal drip related to sinusitis is more prevalent at night. A cough associated with an acute illness, such as a respiratory infection, is continuous throughout the day. A cough in the early morning is usually caused by chronic bronchial inflammation from habitual smoking. A cough in the afternoon and/or evening may reflect exposure to irritants at work.

Stridor can be heard on auscultation when a client has A. atelectasis. B. asthma. C. diaphragmatic hernia. D. acute epiglottitis.

Answer: D Stridor, a high-pitched inspiratory crowing sound, can be heard on auscultation when a client has acute epiglottitis or croup. Persistent fine crackles can be heard with atelectasis, expiratory wheezes with asthma, and persistent peristaltic sounds with diminished breath sounds on the same side with a diaphragmatic hernia.

Which of the following is the most frequent contributor to the incidence of carcinoma of the lung? A. Chronic pneumonia B. Exposure to materials such as asbestos, uranium, and radon C. Chronic interstitial lung disease D. Cigarette smoking

Answer: D The following contribute to the incidence of carcinoma of the lung: cigarette smoking; exposure to materials such as asbestos, uranium, and radon; and chronic interstitial lung diseases, such as pulmonary fibrosis arising from scleroderma. It is estimated that approximately 2 million persons will develop carcinoma of the lung in each of the next several years; 80% to 90% of all lung carcinomas are secondary to cigarette use.

Which of the following is considered a therapeutic indication for a bronchoscopy? A. Evaluate indeterminate lung lesions B. Stage cancer preoperatively C. Determine the extent of injury secondary to burns, inhalation, or other trauma D. Remove a foreign body lodged in the trachea

Answer: D There are both diagnostic and therapeutic indications for a bronchoscopy. The therapeutic uses include removal of mucous plugs, secretions, and foreign bodies; assistance with difficult endotracheal intubations; and treatment of endobronchial neoplasms. Diagnostic uses include evaluation of indeterminate lung lesions (abnormal chest film); preoperative staging of cancer; determination of the extent of injury secondary to burns, inhalation, or other trauma; assessment of airway patency, including problems associated with endotracheal tubes, wheeze, and stridor; investigation of unexplained symptoms (cough, hemoptysis, stridor, and so on) or unexplained findings (recurrent laryngeal nerve paralysis or recent diaphragmatic paralysis); evaluation of suspicious or malignant sputum cytology; bronchoalveolar lavage for interstitial lung disease; and specimen collection for selective cultures or suspected infection. The key word is therapeutic .

You have been counseling your client about her asthma. You realize she does not understand your suggestions when she tells you that she will do which of the following? A. Cover the mattress and pillows in airtight, dustproof covers B. Wash the bedding weekly and dry it on a hot setting for 20 minutes C. Avoid sleeping on natural fibers such as wool or down D. Open the windows and air out the room daily

Answer: D To control the common asthma trigger of dust mites, the following measures are recommended: Cover the mattress and pillows in airtight, dust proof covers; wash the bedding weekly and dry it on a hot setting for 20 minutes; avoid sleeping on natural fibers such as wool or down; remove all carpeting from bedrooms; and reduce indoor humidity to less than 50%. Opening the windows daily would allow allergens to enter.

The diagnosis of tuberculosis does not need to be reported when A. the client's Mantoux test shows an induration of 15 mm. B. a case of tuberculosis is only suspected. C. an asymptomatic client has a positive chest x-ray for pulmonary tuberculosis. D. the Mantoux test shows a raised injected or red area without induration.

Answer: D Tuberculosis is a reportable disease. Every potential case must be reported to the local health department. This includes when the client's Mantoux test shows an induration of 15 mm, when a case of tuberculosis is merely suspected, and when an asymptomatic client has a positive chest x-ray for pulmonary tuberculosis. Screening tests in higher-risk areas with suspected infection that do not have a positive reaction do not need to be reported. These include the appearance of a red area with an induration of less than 10 mm on the first test (less than 5 mm on employees with a yearly screen).

Which is the accepted mass screening test for lung cancer? A. An annual physical examination B. A chest x-ray C. Sputum cytology D. There is no accepted mass screening test for lung cancer.

Answer: D Currently, there is no accepted mass screening test for lung cancer. Because of cost, mass screening for lung cancer in healthy individuals with no risk factors is not recommended. Individuals who are at high risk (those who are cigarette smokers, have been exposed to radon or asbestos, or have a strong family history) should be periodically screened through the use of an annual physical examination, chest x-ray, and possibly sputum cytology. Suspicious chest x-rays should be followed by further diagnostic tests. Asymptomatic smokers or how have quit smoking within 15 years starting at age 55 - 80 - Annual low dose CT for screening