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Flashcards in Chapter 02 - Gather Clinical Information Deck (56)
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1

On assessment of an acutely ill patient, you note all the following in the region of the left lower lobe: decreased expansion, a dull percussion note, and the absent of breath sounds/tactile fremitus. You also observe a shift in the trachea toward the left, more prominent during inspiration. These findings suggest:

  1. left-sided obstruction/atelectasis
  2. left-sided pneumothorax
  3. left-sided consolidation
  4. left-sided pleural effusion

1

A unilateral decrease in lung expansion, combined with a dull percussion note and the absent of breath sounds & tactile fremitus signifies either local lobar obstruction with atelectasis or a pleural effusion on the affected side. In general, the trachea shifts away from large effusions but toward areas of atelectasis.

2

A small child is admitted to the Emergency Department with fever, difficulty swallowing, drooling, and stridor. An AP X-ray of the neck area is negative, but a lateral neck film indicates supraglottic swelling. Which of the following is the most likely diagnosis?

  1. asthma
  2. croup
  3. foreign body obstruction
  4. epiglottitis

4

Based on the clinical signs and symptoms and the radiographs, the most likely diagnosis is epiglottitis. In this condition, the AP X-ray may appear normal, but the lateral neck film often reveals a prominent shadow caused by the swollen epiglottis, called the "Thumb sign."

3

When inspecting the X-ray of an out-patient with nephrotic syndrome, you note a homogeneous area of increased density that obscures the left costophrenic angle. Which of the following is the most likely problem?

  1. pleural effusion
  2. bacterial pneumonia
  3. pulmonary edema
  4. atelectasis

1

Pleural effusion is commonly associated with cardiac failure, but can also occur with certain infections, metastasis, renal disease (especially nephrotic syndrome) and collagen vascular disorders. On X-ray, pleural effusion appears as homogeneous areas of increased density that are position- dependent. If the patient is upright, fluid will accumulates in and 'blunt' or obscure the costophrenic angles. If the patient is placed in a decubitus position, the effusion will 'layer out' laterally.

4

A 67-year-old patient with COPD complains that she becomes breathless after brushing her hair and must sit down to catch her breath. This complaint is most closely related to which of the following?

  1. increased work of breathing
  2. cardiac tamponade
  3. increased pulmonary reserve
  4. orthopnea

1

A patient who cannot perform simple activities of daily living without experiencing dyspnea is showing classic signs of increased work of breathing. In fact, on the American Thoracic Society Breathlessness Scale, breathlessness occurring when involved in activities of daily living such as dressing rates as the severest form of dyspnea.

5

When using a numeric rating scale (NRS) to quantify a patient's pain intensity, the patient reports a level of 5 on the 10-point scale. You note that his last rating was a level of 2. Based on this rating and the reported change, you should:

  1. Immediately report the findings to the patient's physician
  2. Record your findings in the respiratory care progress notes
  3. Repeat the assessment to see if the results are reproducible
  4. Advise the patient to try and relax and focus on the positive

1

In general, whenever a patient reports a pain severity greater than 4 units or a change in pain score greater than 2 units on a 10-point numeric rating scale, you should be immediately report the findings to the patient's physician.

6

What type of sputum would be most common in a patient with an advanced bacterial infection of the respiratory tract?

  1. purulent sputum
  2. mucoid sputum
  3. bloody sputum
  4. frothy sputum

1

Most advanced bacterial infections cause purulent secretions. Mucoid secretions increase first. These secretions soon become infiltrated with fragmented bacteria, leukocytes, and tissue cells damaged by the inflammatory process. Cell disruption releases large amounts DNA and RNA. DNA gives secretions their purulent trait, yellow to greenish color, and high viscosity. This is in contrast to the colorless, clear or frothy, mucoid type seen in early infections.

7

A patient with inspiratory stridor most likely has which of the following conditions?

  1. Bronchospasm: Yes; Laryngeal edema: Yes; Secretions in large airways: Yes
  2. Bronchospasm: No; Laryngeal edema: Yes; Secretions in large airways: No
  3. Bronchospasm: Yes; Laryngeal edema: No; Secretions in large airways: Yes
  4. Bronchospasm: No; Laryngeal edema: No; Secretions in large airways: Yes

2

A patient with inspiratory stridor most likely has either laryngeal edema or a tumor or mass affecting the glottic area. If the patient is a child, foreign body obstruction is also a possibility. Secretions in the large airways typically manifest as rhonchi on auscultation and fremitus on palpation.

8

You note on inspection of an AP chest radiograph that the right hemidiaphragm is elevated above normal. Which of the following is the most likely cause of this abnormality?

  1. right pleural effusion
  2. right tension pneumothorax
  3. right phrenic nerve paralysis
  4. right lower lobe pneumonia

3

An elevated hemidiaphragm indicates phrenic nerve paralysis on the affected side or hepatomegaly (right side only). Pleural effusions blunt the costophrenic angles, whereas hyperinflation tends to flatten the hemidiaphragms, as does tension pneumothorax (on affected side).

9

In which of the following conditions are fine, late inspiratory crackles (rales) most likely to be heard on auscultation?

  1. pulmonary edema
  2. croup
  3. pleural effusion
  4. asthma

1

Fine, late inspiratory crackles are thought to occur when collapsed bronchioles and/or alveoli 'pop' open toward the end of inspiration. Patients with disorders that reduce lung volume--such as atelectasis, pneumonia, pulmonary edema and fibrosis--are most likely to have late inspiratory crackles. Asthma is better associated with wheezing and croup with stridor. A pleural effusion normally decreases breath sound, but does by itself not cause crackles.

10

When interviewing a patient, which of the following might be relevant to the patient’s pulmonary status?

  1. Occupational history: Yes; Medical history: Yes; Smoking history: Yes; Family history: No
  2. Occupational history: No; Medical history: Yes; Smoking history: No; Family history: Yes
  3. Occupational history: Yes; Medical history: No; Smoking history: Yes; Family history: No
  4. Occupational history: Yes; Medical history: Yes; Smoking history: Yes; Family history: Yes

4

In addition to a patient’s chief complaint, a variety of history relating to the patient’s occupation, family, smoking and past medical conditions, should be gathered to help in your assessment.

11

Inspection of a PA chest radiograph reveals a CT ratio of 60%. Based on this finding, the most likely problem is:

  1. pneumothorax
  2. pleural effusion
  3. cardiomegaly
  4. atelectasis

3

Normally, the heart width is less than 50% of the width of the thoracic cage. Cardiomegaly exits when the cardiac-to-thoracic width ratio (CT ratio) exceeds 50% on a PA chest radiograph. Pneumothorax, pleural effusion, atelectasis all can affect the position of the heart, but not its size.

12

Which of the following patients most likely has a health literacy limitation?

  1. One who cannot describe how to take medications: Yes; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: Yes
  2. One who cannot describe how to take medications: No; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: No
  3. One who cannot describe how to take medications: Yes; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: No
  4. One who cannot describe how to take medications: No; One who cannot correctly fill out a form: No; One who asks a lot of care-related questions: Yes

3

You should suspect health literacy problems when a patient offers excuses when asked to read, e.g. left their eyeglasses at home; does not reorient materials provided so as to be unreadable, e.g., up-side down; identifies medications by their appearance (e.g., color or shape) rather than by name; fails to correctly take medications or cannot describe how to take them; or has difficulty correctly filling out forms.

13

A comprehensive environmental history needs to include information on:

  1. the jobs of all household members
  2. home/apartment temperature settings
  3. commuting distance to/from work
  4. approximate hours per day spent on feet

1

In addition to work-related exposures, a comprehensive environmental history should include information on present and previous home locations, jobs of household members, home insulating and heating/cooling system, home cleaning agents, pesticide exposure, water supply, recent renovation/remodeling, air pollution (indoor and outdoor), hazardous wastes/spill exposure, and hobbies (e.g., painting, sculpting, ceramics, welding, woodworking, automobiles, gardening, etc.)

14

Which of the following is relevant information regarding a patient's occupational exposure history?

  1. cleaning agents used at home
  2. patient's residential water supply
  3. protective equipment worn on job
  4. patient's hobbies/avocational pursuits

3

Work-related practices relevant to a patient's occupational exposure history include the type of worksite ventilation, use of personal protective equipment (e.g., respirators, gloves, and coveralls), and on-the-job personal habits such as smoking and/or eating in work area or washing one's hands with solvents. Information regarding cleaning agents used at home, the patient's residential water supply, and a patient's hobbies/avocational pursuits are relevant to the environmental exposure history, but are not occupational or work-related.

15

When inspecting a chest radiograph, you note that the heart is shifted to the patient's left. Which of the following is the most likely cause of this finding?

  1. left sided atelectasis/lung collapse
  2. left sided pleural effusion
  3. left sided tension pneumothorax
  4. right sided pneumonectomy

1

The heart and mediastinum are pulled toward areas of decreased lung volume (e.g., atelectasis, fibrosis, surgical resection) and pushed away from space occupying lesions (e.g., pneumothorax, pleural effusion, large mass lesions). A shift of the heart position to the right would therefore be caused either decreased right-sided lung volume or a space occupying lesion on the left. Of the options listed, only left sided atelectasis/lung collapse would shift the heart's position to the left.

16

A patient with paradoxical chest wall movement most likely has:

  1. atopic asthma
  2. chronic bronchitis
  3. flail chest
  4. tension pneumothorax

3

Paradoxical chest wall movement is a common sign of flail chest. Flail chest occurs when 3 or more adjoining ribs are fractured in two or more places. This section of the chest wall becomes unstable and is 'sucked in' during inspiration and bulges out during expiration. Flail chest is usually the result of trauma.

17

In which of the following conditions are fine, late inspiratory crackles (rales) most likely to be heard on auscultation?

  1. atelectasis
  2. croup
  3. pleural effusion
  4. asthma

1

Fine, late inspiratory crackles are thought to occur when collapsed bronchioles and/or alveoli 'pop' open toward the end of inspiration. Patients with disorders that reduce lung volume—such as atelectasis, pneumonia, pulmonary edema and fibrosis—are most likely to have late inspiratory crackles. Asthma is better associated with wheezing and croup with stridor. A pleural effusion normally decreases breath sound, but does by itself not cause crackles.

18

In reviewing the chest x-ray report for a 62-year-old homeless person, you note the following: cavitation, infiltrates, and calcified nodules. These findings are most consistent with which of the following at diagnoses?

  1. acute asthma
  2. pulmonary edema
  3. pulmonary emphysema
  4. post-primary tuberculosis

4

The x-ray of a patient with post-primary (reactivation) TB usually reveals cavity formation, noncalcified round infiltrates and homogeneously calcified nodules (tuberculomas), usually 5-20 mm in size.

19

Which one of the following measures could be used to evaluate changes in symptoms occurring among participants in a pulmonary rehabilitation program?

  1. changes in sputum production
  2. changes in O2 consumption
  3. changes in blood pressure
  4. changes in O2 saturation

1

Measures useful in evaluating changes in symptoms occurring among participants in a pulmonary rehabilitation program include: dyspnea score comparisons (Borg scale); frequency of cough, sputum production or wheezing; weight loss or gain; and standardized psychological tests. Though potentially useful as measures of improvement, O2 consumption, O2 saturation and vital signs are not patient symptoms.

20

While assessing a patient's radial pulse, you note that the pulse feels full and bounding. Which of the following conditions would be the most probable cause of this finding?

  1. hypovolemia
  2. hypertension
  3. cardiovascular shock
  4. low cardiac output

2

A 'bounding' pulse is characterized by forceful pulsations that quickly disappear, indicating a high systolic pressure without a rise in diastolic pressure (increased pulse pressure). A bounding pulse is normal during exercise or as a result of a 'fight or flight' release of epinephrine. A bounding pulse also can signal an abnormal condition, most commonly hypertension due to atherosclerosis or disorders causing increased stroke volume. Hypovolemia, shock, and low cardiac output usually result in decreased systolic and pulse pressures.

21

What type of sputum would be most common in a patient with an advanced bacterial infection of the respiratory tract?

  1. purulent sputum
  2. mucoid sputum
  3. bloody sputum
  4. frothy sputum

1

Most advanced bacterial infections cause purulent secretions. Mucoid secretions increase first. These secretions soon become infiltrated with fragmented bacteria, leukocytes, and tissue cells damaged by the inflammatory process. Cell disruption releases large amounts DNA and RNA. DNA gives secretions their purulent trait, yellow to greenish color, and high viscosity. This is in contrast to the colorless, clear or frothy, mucoid type seen in early infections.

22

When checking for proper adult placement of an endotracheal or tracheostomy tube on chest X-ray, the distal tip of the tube should be positioned where?

  1. 1 to 3 cm above the carina
  2. 1 to 3 cm below the larynx
  3. 4 to 6 cm above the carina
  4. 23 cm from the base of the tongue

3

An AP chest X-ray is the most common method used to confirm proper placement of an endotracheal or tracheostomy tube. Ideally, the tube tip should be positioned about 4 to 6 cm above the carina. This normally corresponds to a location between thoracic vertebrae T2 and T4, or about the same level as the superior border of the aortic knob.

23

A patient with an acute upper airway obstruction would have which of the following physical signs?

  1. inspiratory crackles
  2. unilateral lung expansion
  3. dullness to percussion
  4. inspiratory stridor

4

Signs of acute upper airway obstruction include marked respiratory distress, altered voice, dysphagia, stridor, decreased breath sounds, and tachycardia. Conscious patients also may exhibit the 'hand-to-the-throat' choking sign. If the obstruction is complete and not resolved by treatment, asphyxiation will progress to cyanosis, bradycardia, hypotension, and cardiovascular collapse.

24

Rapid, deep ventilation is most likely to be observed in a patient with which of the following conditions?

  1. anxiety
  2. CNS depression
  3. hypothermia
  4. hyperoxemia

1

Fear, anxiety and pain all are strong stimuli that can cause a stress response and increase ventilatory drive. Hypoxemia also can increase ventilatory drive. CNS depression and hypothermia would tend to decrease ventilatory drive Hypoxemia also can increase ventilatory drive.

25

A patient's respirations are characterized by a gradual increase and then a gradual decrease in the depth of breathing, followed by a period of apnea. This pattern is known as which of the following?

  1. Biot's breathing
  2. Cheyne-Stokes breathing
  3. Kussmaul's breathing
  4. apneustic breathing

2

Cheyne-Stokes breathing is characterized by a gradual increase and then a gradual decrease in tidal volume, followed by periods of apnea. This pattern is associated with brain injuries, especially to the respiratory centers in the brainstem (pons and medulla). It also is observed in some patients with chronic heart failure.

26

On examination of a normal patient's neck, the midline of the trachea should be directly below the center of the:

  1. suprasternal notch
  2. midclavicular line
  3. midaxillary line
  4. anterior axillary line

1

Normally, the trachea is located centrally in the neck of a forward facing patient. The midline of the neck can be located by palpation of the suprasternal notch at the base of the anterior neck. The midline of the trachea should be directly below the center of the suprasternal notch.

27

Hypoxia can occur without cyanosis in patients with what disorder?

  1. hypothermia
  2. hyperthermia
  3. polycythemia
  4. anemia

4

Central cyanosis generally occurs when hemoglobin (Hb) levels are at or above normal and the arterial oxygen saturation falls below 80%, corresponding to a Pao2 of about 45-50 torr. Patients with anemia have low Hb levels. Sand thus can be severely hypoxic before cyanosis ever appears.

28

All of the following findings are associated with potential difficulty orally intubating a patient EXCEPT:

  1. macroglossia
  2. soft palate not visible
  3. deviated septum
  4. short/thick neck

3

A short/thick neck, poor range of neck motion, macroglossia (enlarged tongue), and Mallampati Class 4 assessment of pharyngeal anatomy (soft palate, uvula and tonsils not visible; only hard palate visible) are all associated with the potential for difficult oral intubation. A deviated septum would only be a potential problem for nasal intubation.

29

Upon palpating a patient's pulse, you note 85 unevenly spaced beats, with a marked decreased in pulse strength during inspiration. Which of the following describes the patient's pulse?

  1. thready pulse
  2. bounding pulse
  3. pulsus alternans
  4. pulsus paradoxus

4

A decrease in pulse strength or blood pressure during inspiration is termed pulsus paradoxus. It is often seen in patients during severe episodes of airway obstruction (e.g., status asthmaticus) and also in patients with constrictive pericarditis or cardiac tamponade.

30

A 25-year-old comatose woman is seen in the emergency room. You observe that her respiratory rate is 24/min. and her tidal volume is consistently large. No periods of apnea have been observed. Which of the following breathing patterns would be most consistent with these observations?

  1. Kussmaul's breathing
  2. Cheyne-Stokes breathing
  3. Biot's breathing
  4. eupnea

1

Kussmaul's breathing is characterized by consistently large tidal volumes and an increase respiratory rate with no periods of apnea. It is most commonly observed in diabetic ketoacidosis (as respiratory compensation for metabolic acidosis).