ASIPP Critical Care Questions Flashcards Preview

Pain Med Board > ASIPP Critical Care Questions > Flashcards

Flashcards in ASIPP Critical Care Questions Deck (41):
1

1825. A patient with a score of 4 on the Riker Sedation – Agitation
scale can be best described as:
A. Very agitated
B. Very sedated
C. Unarousable
D. Sedated
E. Calm and cooperative

1825. Answer: E
Source: Day MR, Board Review 2005

2

1826. All of the following are true regarding the use of opioids
in patients with altered hepatic function except:
A. Smaller clearance of the opioid
B. Volume of distribution is increased
C. Prolonged elimination half-time
D. Relatively normal initial distribution
E. Accumulation of drug will occur

1826. Answer: B
Explanation:
Ref: Murphy. Chapter 16. Opioids. In: Clinical
Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
Lippincott, 1992, pg 431
Source: Day MR, Board Review 2003

3

1827. What is the mode of action of cocaine in the central
nervous system?
A. increasing the reuptake of norepinephrine
B. blocking dopamine receptors
C. activating GABA receptors
D. mediating its rewarding effect through dopamine cells
in the ventral tegmentum area that projects to the
basal ganglia
E. inhibiting acetylcholine esterase in the central nervous
system

1827. Answer: D
Explanation:
Cocaine acts by blocking reuptake of neurotransmitters
(norepinephrine, dopamine, and serotonin) at the synaptic
junctions, resulting in increased neurotransmitter
concentrations. Because norepinephrine is the primary
neurotransmitter of the sympathetic nervous system,
sympathetic stimulation results and leads to
vasoconstriction, tachycardia, mydriasis, and
hyperthermia. Central nervous system stimulation may
appear as increased alertness energy talkativeness,
repetitive behavior, diminished appetite, and increased
libido. Psychological stimulation by cocaine produces an
intense euphoria that is often compared to orgasm.
Pleasure and reward sensations in the brain have been
correlated with increased neurotransmission in the
mesolimbic or mesocortical dopaminergic tracts (or
both). Cocaine increases the functional release of
dopamine, which activates the ventral tegmental-nucleus
accumbens pathway, which seems to be major component
of the brain reward system. Activation of this pathway is
essential for the reinforcing actions of psychomotor
stimulants
Source: Laxmaiah Manchikanti, MD

4

1828. Which of the following is true regarding the use of Midazolam
for ICU sedation?
A. Rapid onset
B. Long duration of action
C. No tolerance of CNS effects after prolonged infusion
D. Will not cause hypotension even with high doses
E. Metabolites are inactive

1828. Answer: A
Source: Day MR, Board Review 2005

5

1829. The heart rate response to the infusion of a moderate
dose of phenylephrine in conscious patients is not
blocked by
A. Atropine
B. Hexamethonium
C. Phenoxybenzamine
D. Reserpine
E. Scopolamine

1829. Answer: D

6

1830. Which of the medical community, active euthanasia is
best defi ned as:
A. The withdrawal of life-sustaining measures
B. The provision by a physician of the means by which
patients can end their own lives
C. The intentional termination of a patient’s life by a
physician
D. The withholding of life-sustaining measures
E. The act of ending a patients life by a health care professional

1830. Answer: C
Explanation:
Ref: Breitbant, Possik, Rosenfeld. Chapter 46. Cancer,
Mind, and Spirit. In: Textbook of Pain, 4th Edition. Wall
and Melzack, Churchill Livingstone, 1999, pg 1082
Source: Day MR, Board Review 2003

7

1831. Intravenous administration of norepinephrine in a patient
already taking an effective dose of atropine will
often
A. Increase heart rate
B. Decrease total peripheral resistance
C. Decrease blood sugar
D. Increase skin temperature
E. Reduce pupil size

1831. Answer: A

8

1832. A patient in the coronary care unit has been receiving
warfarin for 2 weeks. As a result of this therapy, the
patient will probably have
A. Reduced plasma factor II activity
B. Reduced plasma factor VIII activity
C. Reduced plasma plasminogen activity
D. Increased tissue plasminogen activator
E. Increased platelet adenosine stores

1832. Answer: A

9

1833. True statements regarding the apnea test used to diagnose
brain death include all of the following except:
A. Absence of spontaneous breathing during disconnection
from the ventilator
B. Arterial pH below 7.30 at the end of the test
C. PaCO2 > 60 torr at the end of the test
D. Core body temperature higher than or equal to 35 degrees
Celcius at the start of the test
E. PaO2

1833. Answer: D
Explanation:
Ref: Grenick. Chapter 111. Brain Death and Permanently
Lost Consciousness. In: Textbook of Critical Care.
Shoemaker, Thompson, Holbrook; W.B. Sanders, 1984, pg
969
Source: Day MR, Board Review 2003

10

1834. A patient is admitted to the emergency room 2 hours
after taking an overdose of phenobarbital. The plasma
level of the drug at time of admission is 100 mg/L, and
the apparent volume of distribution, half-life, and
clearance of phenobarbital are 35 L, 4 days, and 6.1 L/d,
respectively. The ingested dose was approximately
A. 1 g
B. 3.5 g
C. 6.1 g
D. 40 g
E. 70 g

1834. Answer: B

11

1835. Following a very large overdose of a benzodiazepine, a
patient is admitted to hospital. Which one of the following
is not likely to be of therapeutic value in the
management of this patient?
A. Administration of naloxone
B. Gastric lavage if an endotracheal tube is in place
C. Intravenous fl umazenil
D. Protection of the airway
E. Ventilatory support

1835. Answer: A

12

1836. Which of the following is not true regarding continuous
epidural infusion of medication versus intermittent
bolus technique?
A. Easier to titrate medication via a continuous infusion
B. There are fewer fl uctuations in cerebral spinal fl uid
concentrations of drug with a continuous infusion
C. Tachyphylaxis is less common with the intermittent
bolus technique
D. Continuous epidural infusion provides better analgesia
than intermittent bolus
E. Higher risk for respiratory depression with the intermittent
bolus technique

1836. Answer: C
Explanation:
Ref: Anderson. Chapter 16. Continuous Regional
Analgesia. In: Textbook of Regional Anesthesia. Raj et al,
Churchill Livingstone, 2002, pg 239
Source: Day MR, Board Review 2003

13

1837. A patient is admitted to the emergency department for
treatment of a drug overdose. The identity of the drug
is unknown, but it is observed that when the urine pH
is acidic, the renal clearance of the drug is less than the
glomerular fi ltration rate and that when the urine pH
is alkaline, the clearance is greater than the glomerular
fi ltration rate. The drug is probably a
A. Strong acid
B. Weak acid
C. Nonelectrolyte
D. Weak base
E. Strong base

1837. Answer: B

14

1838. Which of the following opioids do not evoke the release
of histamine?
1. Sufentanil
2. Alfentanil
3. Fentanyl
4. Meperidine

1838. Answer: A (1,2, & 3)
Explanation:
Ref: Murphy. Chapter 16. Opioids. In: Clinical
Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
Lippincott, 1992, pg 416
Source: Day MR, Board Review 2003

15

1839. A post-op patient with intraabdominal bypass presents
with new complaints of back pain with bilateral leg
weakness, altered refl exes: knee left 1+, right 2+. The
patient is on heparin and Plavix with epidural catheter.
Next step in management of this patient is:
1. To stop infusion and reassess after 4 hours
2. To obtain surgical consult
3. To increase infusion
4. Order MRI of thoracic & lumbar spine

1839. Answer: D (4 Only)

16

1840. Which of the following criteria can be used to support
the diagnosis of brain death in the intensive care unit?
1. Light-fi xed pupils
2. An isoelectric electroencephalogram recorded in part
at full gain
3. No evidence of decerebrate or decorticate posturing
or shivering
4. Heart rate increase of less than 5 beats per minute after
intravenous atropine 0.04 mg/kg

1840. Answer: E (All)
Explanation:
(Shoemaker, pp 968-969.)
The defi nition of brain death is the permanent loss of all
integrated brain functions. The patient is not experiencing
pain or suffering. As such, it is extremely important to
elimate all medications and correct hemodynamic
variables that may be contributing to the comatose
conditions before one declares the patient brain dead. The
patient should have adequate blood pressure and
temperature above 34°C ( 93.2°F) and be free of alcohol,
toxins, and medications that could depress brain function.
A detailed and thoroughly documented clinical
examination should be performed and then repeated no
sooner than 2 h after the initial examination. Body
temperature, blood ethanol level, and toxicology screens
should be documented. In the absence of muscle relaxants,
there should be no spontaneous movement and no
evidence of decerebrate to decorticate posturing or
shivering and there should be no spontaneous breathing
for 3 min ( at Paco2 > 60 torr at the end of the test).
If the patient has pulmonary disease, the Pao2 must be
less than 50 torr at the end of the test. The patient must
have light-fi xed pupils and the absence of corneal
refl exes, response to painful stimuli, response to upper
and lower airway stimulation, ocular response to head
turning, and ocular response to ear irrigation
with 50 mL of ice water. Intravenous atropine
0.04 mg/kg should fail to increase the heart rate by more
than 5 beats per minute. An isoelectric
electroencephalogram recorded in part at full gain should
also be obtained. The ultimate criterion of brain death is
the complete absence of cerebral blood fl ow, which can be
documented by bilateral internal carotid and vertebral
anteriography or by radionuclide cerebral imaging.
Source: Kahn and Desio

17

1841. The pharmacokinetics of which the following drug/s
is/are not changed in the presence of hepatic or renal
diseases:
1. Dexmetetomidine
2. Etomidate
3. Thiopental
4. Propofol

1841. Answer: D (4 only)
Source: Day MR, Board Review 2005

18

1842. True statements regarding delirium tremens includes:
1. Can be treated with Haloperidol
2. Benzodiazepine are the preferred sedatives
3. Rarely fatal if untreated
4. Clonidine can be used to treat hypertension associated
with withdrawal

1842. Answer: C (2 & 4)
Source: Day MR, Board Review 2005

19

1843. True statements regarding the use of ketamine in trauma
patients include:
1. It may be used as the sole agent for trauma surgery
2. It possesses sympathomimetic action
3. At lower doses it is an analgesic
4. It can be used in trauma patients with head injuries

1843. Answer: A (1, 2, & 3)
Explanation:
Ketamine produces a profound analgesia and may be used
in high doses as the sole agent for emergency and trauma
surgery.
This agent possesses sympathomimetic action, which may
be benefi cial in injured patients with a depressed
cardiovascular system because of sharp.
At lower doses, it can be used as an analgesic.
Ketamine increases intracranial pressure, however, and is
contraindicated in head injuries.

20

1844. In patients with carbon monoxide (CO) poisoning,
1. Carboxyhemoglobin (COHb) is greater than 20%
2. pulse oximetry is a reliable measure of COHb
3. the half-life of COHb in room air is 5 h
4. hyperbaric O2 is the treatment of choice

1844. Answer: B (1 & 3)
Explanation:
(Miller, 4/e. pp 2431-2432.)
Carbon monoxide is normally present and bound at about
1 percent of oxygen binding sites in hemoglobin. When a
person is exposed to smoke, CO concentrations can rise
dramatically; 20% defi nes poisoning. Because CO has 200
times greater affi nity for hemoglobin than oxygen and is
slow to be released, hypoxia can result. COHb and
hemoglobin have similar absorption characteristics.
Therefore, pulse oximetry will not give a reliable measure
of COHb, overestimating the amount of hemoglobin
available to tissues. The half-life of CO in room air is
about 5 h. The treatment of choice is 100% O2, which
reduces the half-life to 1 h. Hyperbaric O2 can speed this
process but is not necessary.
Source: Curry S.

21

1845. The following statements regarding hydration in terminal
situation are true?
1. Hydration is always helpful in terminal patients
2. Hydration can help to reduce delirium and opioid
side-effects
3. Hydration improves fatigue
4. Some patients can die comfortably without hydration

1845. Answer: C (2 & 4)
Source: Reddy et al. Pain Practice: Dec 2001, March 2002

22

1846. Carbon monoxide (CO) may be characterized by which
of the following statements?
1. Poisoning results in increased minute ventilation
2. CO has twice the affi nity for hemoglobin that oxygen
has
3. CO shifts the oxyhemoglobin dissociation curve to
the right
4. CO produces carboxyhemoglobin that absorbs the
same frequency of light as oxyhemoglobin

1846. Answer: D (4 Only)
Explanation:
(Stoelting, Anesthesia and Co-Existing Disease, 3/e. p
536.)
Carotid and aortic bodies increase minute ventilation in
response to a decreased PaO2 , not decreased
hemoglobin saturation. Carbon monoxide has over 200
times the affi nity for hemoglobin that oxygen has.
Carboxyhemoglobin shifts the oxyhemoglobin
dissociation curve to the left. Because carboxyhemoglobin
absorbs the same frequency of light as oxyhemoglobin,
oxyhemoglobin saturation may be overestimated in the
presence of CO poisoning.
Source: Curry S.

23

1847. True statements in relation to patients with transplanted
hearts include
1. atherosclerosis of the donated heart is a frequent complication
2. hepatic toxicity, usually manifested by elevated levels
of transaminase, is the most common organs toxicity
associated with use of cyclosporine
3. azathioprine (Imuran) often causes leukopenia
4. newer immunosuppressants, which have become the
standard of care in these patients, have made opportunistic
infections rare

1847. Answer: B (1 & 3)
Explanation:
(Stoelting, Pharmacology, 2/e. p 233.)
Up to 50 percent of these patients develop atherosclerosis
within 5 years of transplantation regardless of the age of
the transplanted heart. Angina is rare because of
denervation of the heart. Renal toxicity is the most common side effect of cyclosporine. These patients are
markedly immunocompromised, and strict sterile
technique should be observed for every invasive
procedure.
Source: Curry S.

24

1848. Factors contributing to delirium include:
1. Extremes of aging
2. Underlying psychotic or neurotic disorder
3. Central nervous system disease
4. Alkalosis

1848. Answer: A (1,2, & 3)
Explanation:
Ref: Dull. Chapter 8. Recovery Management of the
Healthy Patient. In: Principles and Practice of
Anesthesiology. Rogers et al, Mosly, 1993, pg 136
Source: Day MR, Board Review 2003

25

1849. Advantages of propofol over the other sedative –hypnotics
is/are:
1. Short duration of effect
2. Short recovery period
3. Minimal side effects
4. No tolerance with prolonged administration

1849. Answer: A (1,2, & 3)
Explanation:
Ref: Hemelrijck, Gonzales, White, Chapter 53.
Pharmacology of Intravenous Anesthetic Agents. In:
Principles and Practice of Anesthesiology. Rogers et al,
Mosly, 1993, pg 1147
Source: Day MR, Board Review 2003

26

1850. Intermittent epidural morphine injections for hospitalized
in patients are acceptable because
1. Respiratory depression is extremely rare, predictable,
and easily treated
2. The incidence of urinary retention is not higher than
intermittent intramuscular (IM) injections
3. Nurses do not mind giving epidural injections
4. There is low incidence of respiratory depression, and
catheter-related problems are minimal

1850. Answer: D (4 Only)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

27

1851. Drugs known to increase digoxin levels include
1. Quinidine
2. Hydrochlorothiazide
3. Amiodarone
4. propranolol

1851. Answer: B (1 & 3)
Explanation:
(Stoelting, Pharmacology, 2/e. pp 291-292, 350-351.)
Quinidine and amiodarone both increase serum digoxin
levels, which may lead to toxicity. Hydrochlorothiazide
may lead to dig toxicity by reducing potassium levels but
not by raising digoxin levels. Propranolol has no effect on
dig levels.
Source: Curry S.

28

1852. Which of the following statements is true regarding the
use of opioids in the mechanically ventilated patient?
1. Depression of the cough refl ex increases tolerance of
the endotracheal tube
2. Depression of the ventilation helps prevent the patient
from “fi ghting the ventilator”
3. Sedation decreases anxiety
4. Analgesia increases patient comfort

1852. Answer: E (All)
Explanation:
Ref: Murphy. Chapter 16. Opioids. In: Clinical
Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
Lippincott, 1992, pg 432
Source: Day MR, Board Review 2003

29

1853. Which of the following are useful for control of burn
pain in a pediatric patient?
1. Epidural local anesthetic
2. Epidural morphine
3. Fentanyl intravenous
4. Propofol infusion

1853. Answer: A (1,2, & 3)

30

1854. True statements regarding the withdrawal of life support
include:
1. A distinction has to be made between a competent and
a noncompetent patient
2. Recent cases have based the right to withdraw life support
on the Fifth Amendment to the United States
Constitution and Bill of Rights which guarantees the
right to liberty and self-determination
3. An incompetent patient who had expressed a desire
while competent not to be maintained on life support
should be treated as a competent individual
4. Our judicial system encourages the use of judicial review
for all termination of life-support issues

1854. Answer: A (1,2, & 3)
Explanation:
Ref: Benesch. Chapter 112. Legal Aspects of Brain Death
Certifi cation and Withdrawal of Life Support. In:
Textbook of Critical Care. Shoemaker, Thompson,
Holbrook; W.B. Sanders, 1984, p 979
Source: Day MR, Board Review 2003

31

1855. Clinical signs to confi rm brain death include the following:
1. Pupils non-reactive to light stimulation
2. Isoelectric electroencephalogram recorded at full gain
3. Absent ocular response to head turning (no eye movement)
4. Presence of decorticate posturing

1855. Answer: A (1,2, & 3)
Explanation:
Ref: Grenick. Chapter 111. Brain Death and Permanently
Lost Consciousness. In: Textbook of Critical Care.
Shoemaker, Thompson, Holbrook; W.B. Sanders, 1984, pg
968B
Source: Day MR, Board Review 2003

32

1856. True statements regarding nonsteroidal anti-infl ammatory
drugs are:
1. Slowly absorbed after oral administration
2. Tissue distribution is extensive
3. Signifi cantly dependent on renal elimination
4. Low clearances

1856. Answer: D (4 Only)
Explanation:
Ref: Katz. Chapter 33. Nonsteroidal Anti-infl ammatory
Analgesics. In: Practical Management of Pain, 3rd
Edition. Raj et al, Mosby, 2000, pg 480
Source: Day MR, Board Review 2003

33

1857. A patient with a fl ail chest and lower-extremity fractures
is consulted by the trauma team to provide pain management.
The most appropriate plan would be
1. Small IV doses of opiates
2. Lumbar epidural with a hydrophilic opiate to promote
cephalad distribution to thoracic dermatomes
3. Thoracic epidural with opiate and local anesthetic
4. Thoracic epidural with local anesthetic alone and
systemic PCA

1857. Answer: D (4 Only)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

34

1858. Important considerations for patients with serious burn
injuries include which of the following?
1. In the fi rst 24 h after the burn, patients should be given
fl uid at approximately 8 mL/kg per hour for each
percent of body area burned
2. Patients are resistant to nondepolarizing muscle relaxants
primarily because the volume of distribution for
these drugs is vastly increased
3. Patients have a decreased requirement for opioids
4. Patients do not respond normally to succinylcholine
and may suffer cardiac arrest

1858. Answer: D (4 Only)
Explanation:
(Barash, 3/e. pp 1188-1190, 1196.)
Fluid needs are great, but the recommended amount is
2 to 4 mL/kg per hour for each percent of body
burned. Follow vital signs and urine output as fi nal
monitors. Evaporative losses, high metabolism, and
exposure tend to lead to hypothermia in burn patients.
Burn patients receiving succinylcholine can have an
abnormally high release of potassium, leading to cardiac
arrest. Resistance to nondepolarizing muscle relaxants is
due to the proliferation of extrajunctional receptors,
which are less responsive to these drugs. These patients
have severe pain and require high doses of narcotics.
Source: Curry S.

35

1859. A patient in the intensive care unit is in a persistent
vegetative state and has total loss of cortical layers
demonstrated on CT scan of the brain. The patient is
able to breathe spontaneously. Which of the following
interventions would be appropriate in the care of this
patient?
1. New infusions of vasopressors to maintain hemodynamics
2. Mechanical ventilation if spontaneous respiration
deteriorates
3. Insertion of an intraaortic balloon pump to augment
cardiac function
4. Continued nutrition via a nasogastric tube

1859. Answer: D (4 Only)
Explanation:
(shoemaker, p 969-972.)
A patient who is not brain dead but had permanently
lost consciousness can be describedas one whose
personality, memory, interaction with others, and
emotional states are gone, but whose physical
vegetative functions and refl exes persist. If cerebral
arteriography and modifi ed CT scanning of the brain
demonstrate total loss of cortical layers, the irreversibility
of the patient’s unconscious state can be verifi ed. At that
point, it is justifi able to proceed on the premise that lifesustaining
therapies will no longer benefi t the patient and
are therefore not indicated. A patient on ventilator may be
weaned in spite of deteriorating vital signs and blood
gases. Even nutrition may be withheld, through commonly
it will be continued while new therapies, ventilation, antibiotics, and pressor support are withheld.
Source: Kahn and Desio

36

1860. Advantages of patient-controlled epidural analgesia
over conventional epidural continuous infusion is/are:
1. Increased effi ciency
2. Higher satisfaction
3. Decreased sedation
4. Reduced opioid use

1860. Answer: E (All)
Explanation:
Ref: Anderson. Chapter 16. Continuous Regional
Analgesia. In: Textbook of Regional Anesthesia. Raj et al,
Churchill Livingstone, 2002, pg 243
Source: Day MR, Board Review 2003

37

1861. Which of the following implantable drug-delivery
systems would be appropriate for a patient with a life
expectancy of a few days to several weeks?
1. Simple epidural catheter
2. Reservoir/port
3. Tunneled epidural catheter
4. Implantable continuous infusion

1861. Answer: B (1 & 3)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

38

1862. Which of the following is/are goals of ICU sedation?
1. Reduce fears
2. Reduce anxiety
3. Reduce agitation
4. Alleviate pain

1862. Answer: A (1,2, & 3)
Explanation:
Ref: Ebert. Current Strategies in ICU Sedation. In:
Anesthesiology News Special Report. March 2001
Source: Day MR, Board Review 2003

39

1863. A terminal patient is experiencing intractable cancer
pain that is well localized to one side of the pelvis.
Which of the following invasive procedures would be
most appropriate for treating the pain?
1. Percutaneous cordotomy
2. Midline myelotomy
3. Epidural block
4. Subarachnoid phenol saddle block

1863. Answer: E (All)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

40

1864. A patient with multi-organ failure in the intensive case
unit complains of back pain. Vitals signs include low
blood pressure (90/60), and tachycardia, and decreased
urine output. The most appropriate analgesic(s) for
this patient is/are:
1. Ketoralac
2. Morphine
3. Meperidine
4. Fentanyl

1864. Answer: D (4 Only)
Explanation:
The nsaid, meperidine and morphine are contraindicated
with renal insuffi ciency. Fentanyl is the best choice.

41

1865. Cardiac transplantation is accurately characterized by
which of the following statements?
1. Atropine, in usual doses, is the initial drug of choice
in a cardiac transplant patient who becomes bradycardic
intraoperatively
2. Vagal stimulation has more profound on heart rate in a
cardiac transplant patient than in a normal patient
3. The peak vasopressor effect of ephedrine is more
rapid in a cardiac transplant patient than in normal
patients
4. Usual doses of antimuscarinic agents, such as atropine
or glycopyrrolate, should be given to these patients
when muscle relaxants are reverses with neostigmine
or edrophonium

1865. Answer: D (4 Only)
Explanation:
(Barash, 3/e. pp 1271-1272. Stoelting, Pharmacology, 2/e,
p 233.)
The vagus is not connected to the transplanted heart;
therefore, vagal tone does not affect heart rate, nor does
atropine. Elevated heart rates can be achieved via beta
agonists such as isoproterenol. Drugs with primarily
indirect effects, such as ephedrine, take longer to act
because of sympathetic denervation of the heart.
Vasopresssor effects require release of norepinephrine
from intact sympathetic nerve endings followed by
transport via the circulation of the heart, where direct
alpha and beta agonism can take place. Although cardiac
muscarinic effects are unlikely with anticholinesterase
drugs in a patient with a transplanted heart, pulmonary
and gastrointestinal muscarinic effects do occur and
should be blocked with antimuscarinic agents.
Source: Curry S.