Chapter 7 Clinical Skills/Critical Care For questions 1 to 6, match the anesthetic agent with the description. Each response may be used once, more than once, or not at all. A. enflurane B. etomidate C. halothane D. isoflurane E. ketamine F. thiopental 1. increases cerebral blood flow (CBF) and cerebral metabolic rate of oxygen consumption (CRMO2) 2. Of the volatile anesthetics, it increases CBF the least. 3. induces seizure discharges 4. dissociative anesthetic 5. decreases CBF and CRMO2 and produces cardiovascular depression 6. decreases CBF and CRMO2 and suppresses adrenocortical response to stress 7. Which antiemetic medication lowers seizure threshold? A. Phenergan B. droperidol C. Tigan D. Zofran E. Reglan 8. The most appropriate drug to administer to a stable patient with a narrow complex supraventricular tachycardia (no serious signs or symptoms) after vagal stimulation is A. adenosine B. figoxin C. procainamide D. quinidine E. verapamil 9. Each is true of fat embolism except A. Cerebral manifestations frequently occur in the absence of pulmonary manifestations. B. Increased serum lipase occurs in up to half of all patients. C. Petechia over the shoulders and chest is a classic finding. D. Symptoms typically occur 12 to 48 hours after trauma. E. Tachycardia and tachypnea are characteristic. 10. Gamma irradiation of blood helps prevent A. graft-versus-host disease B. hemolytic transfusion reactions C. hepatitis B transmission D. nonhemolytic transfusion reactions E. transfusion siderosis 11. Citrate toxicity from massive transfusions results from the A. binding of free ionized Ca2+ B. decrease of 2, 3-diphosphoglyceric acid (DPG) levels C. inactivation of factors 5 and 8 D. interaction with platelets, rendering them dysfunctional E. precipitation of autoimmune hemolytic anemia For questions 12 to 14, match the description with the disease. A. Cushing’s disease B. ectopic adrenocorticotropic hormone (ACTH) production C. both D. neither 12. Cortisol is suppressed with low-dose dexamethasone. 13. Cortisol is suppressed with high-dose dexamethasone. 14. increase in urinary 17-hydroxycorticosteroids after a metyrapone test. 15. Which of the following scenarios reflects hypochromic, microcytic anemia? A. decreased mean corpuscular volume (MCV) and decreased total iron binding capacity (TIBC) B. decreased MCV and increased TIBC C. decreased MCV and normal TIBC D. increased MCV and decreased TIBC E. increased MCV and increased TIBC 16. Prolongation of bleeding time usually occurs in I. von Willebrand’s disease II. use of nonsteroidal anti-inflammatory agents III. uremia IV. factor VII deficiency A. I, II, III B. I, III C. II, IV D. IV E. all of the above 17. Drugs that antagonize the anticoagulant effect of warfarin (Coumadin) include I. cholestyramine II. phenobarbital III. rifampin IV. cimetidine A. I, II, III B. I, III C. II, IV D. IV E. all of the above 18. Contraindications to the use of thiazide diuretics include I. diabetes mellitus II. hyperuricemia III. primary aldosteronism IV. lupus erythematosus A. I, II, III B. I, III C. II, IV D. IV E. all of the above 19. Plasma levels of phenytoin (Dilantin) are increased by all of the following except A. carbamazepine B. cimetidine C. Coumadin D. isoniazide E. sulfonamides 20. The most common electrocardiogram (EKG) finding in patients with pulmonary emboli is A. a peaked T wave B. an S1-Q3-T3 pattern C. rightward shift of the QRS axis D. sinus tachycardia (ST) and T wave changes E. tachycardia 21. Which of the following disorders leads to hypernatremia? A. Addison’s disease B. hyperaldosteronism C. hypothyroidism D. renal failure E. syndrome of inappropriate antidiuretic hormone (SIADH) 22. The most common acid-base disturbance in mild to moderately injured patients without severe renal, circulatory, or pulmonary decompensation is A. respiratory acidosis and metabolic alkalosis B. respiratory alkalosis and metabolic acidosis C. respiratory or metabolic acidosis D. respiratory or metabolic alkalosis 23. The reabsorption of Na+ ions in the thin ascending Henle’s loop A. is by active transport B. is by a Na+−K+ exchange pump C. passively follows the active transport of Cl− ions D. passively follows the active transport of water molecules A. abciximab (Reopro) B. aspirin C. clopidogrel (Plavix) D. eptifibatide (Integrilin) E. ticlopidine (Ticlid) 24. Of the two prodrugs that block the Gi-coupled platelet adenosine diphosphate (ADP) receptor, it has a slightly more favorable toxicity profile. 25. is the Fab fragment of a monoclonal antibody directed against the IIb/IIIa receptor 26. is a cyclic peptide inhibitor of the arginine-glycine-aspartate (RGD) binding site on the glycoprotein IIb/IIIa 27. blocks production of thromboxane A2 28. Which laboratory findings in disseminated intravascular coagulation (DIC) correlates most closely with bleeding? A. decreased fibrinogen B. increased fibrin degradation products C. increased prothrombin time (PT) D. increased partial thromboplastin time (PTT) E. increased thrombin time (TT) 29. The definition of oxygen saturation is the A. amount of oxygen dissolved in plasma B. fractional concentration of inspired oxygen C. partial pressure of oxygen in the blood D. percentage of hemoglobin that is bound to oxygen E. ratio of unbound to bound hemoglobin 30. Metabolic responses to trauma include each of the following except A. hypoglycemia B. increased rate of lipolysis C. increased Na+ reabsorption D. increased water reabsorption E. metabolic alkalosis 31. A normal PT, a prolonged PTT, and a bleeding disorder would result from a deficiency of factor A. II B. V C. VIII D. X E. XII A. factor II B. factor VII C. factor VIII D. factor IX E. factor X 32. shortest half-life 33. reflects the extrinsic pathway 34. deficient or abnormal in hemophilia A (classic) 35. deficient in hemophilia B (Christmas disease) 36. All except this factor are vitamin K–dependent factors. 37. Deficiency of factor II or this factor results in prolonged PT and PTT. For questions 38 to 45, match the combination of laboratory values with the hematologic diagnosis. Each response may be used once, more than once, or not at all. A. abnormal PT, PTT, and bleeding time B. abnormal PT, normal PTT and bleeding time C. normal PT, PTT, and bleeding time D. normal PT, abnormal PTT and bleeding time E. hypercoagulable state F. normal PT, abnormal PTT, normal bleeding time 38. antithrombin III deficiency 39. DIC 40. von Willebrand’s disease 41. dysfibrinogenemia 42. malnutrition 43. factor VII deficiency 44. factor XIII deficiency 45. factor VIII deficiency A. increased anion-gap metabolic acidosis B. normal anion-gap metabolic acidosis C. metabolic alkalosis D. respiratory acidosis E. respiratory alkalosis 46. often occurs with hypokalemia 47. Addison’s disease 48. salicylate overdose (early stage) 49. myasthenia gravis 50. ethylene glycol overdose 51. Cushing’s disease 52. primary aldosteronism 53. The formula for mean arterial pressure is (DBP = diastolic blood pressure; SBP = systolic blood pressure) A. (DBP + SBP)/2 B. DBP + (SBP– DBP)/2 C. DBP/2 + SBP/3 D. DBP + (SBP – DBP)/3 E. DBP/2 + (SBP – DBP)/3 For questions 54 to 60, match the description with the syndrome. A. multiple endocrine neoplasia (MEN) type I (Werner’s syndrome) B. MEN type IIA (Sipple’s syndrome) C. both D. neither 54. parathyroid hyperplasia or adenoma 55. pancreatic islet cell hyperplasia, adenoma, or carcinoma 56. pituitary hyperplasia or adenoma 57. Pheochromocytomas are common. 58. Medullary thyroid carcinomas are common. 59. mucosal and gastrointestinal tumors 60. marfanoid features 61. Characteristics of hyperaldosteronism include each of the following except A. edema B. hypokalemia C. increased diastolic blood pressure D. metabolic alkalosis E. polyuria 62. Adequacy of pulmonary ventilation is assessed by A. FiO2 B. oxygen saturation C. Pa CO2 D. partial pressure of O2 in blood E. tidal volume For questions 63 to 68, match the abnormality in the EKG with the diagnosis. Each response may be used once, more than once, or not at all. A. atrial fibrillation B. J-point elevation C. peaked T wave D. prolonged QT interval E. U wave 63. hypocalcemia 64. hypokalemia 65. hyperkalemia 66. hypothermia 67. hyperthyroidism 68. quinidine toxicity 69. Which of the following is false of malignant hyperthermia? A. Calcium is released from the muscle cell’s sarcoplasmic reticulum. B. end-tidal pCO2 increases C. It is precipitated by the use of inhalational anesthetics. D. Treatment is with dantrolene. E. Use of succinylcholine can help prevent it. 70. Of the following, the best choice for Clostridium difficile enterocolitis is A. clindamycin orally B. metronidazole (Flagyl) orally C. penicillin G orally D. penicillin VK intravenously E. vancomycin intravenously For questions 71 to 73, match the description with the process. A. cardiac tamponade B. tension pneumothorax C. both D. neither 71. pulsus paradoxus 72. increased venous pressure 73. increased pulse pressure 74. Meningitis occurring within 72 hours after a basilar skull fracture is most commonly secondary to A. Haemophilus influenzae B. Neisseria meningitides C. Staphylococcus aureus D. Staphylococcus epidermidis E. Streptococcus pneumoniae 75. Postoperative shunt infections are most commonly caused by A. coagulase-negative staphylococci B. H. influenzae C. Pseudomonas species D. S. aureus E. S. pneumoniae 76. The most likely cause of a fever occurring in the first 24 hours after surgery is A. atelectasis B. deep vein thrombosis C. pneumonia D. urinary tract infection E. wound infection For questions 77 to 81, match the description with the drug. A. dobutamine B. dopamine C. both D. neither 77. a positive inotropic agent 78. has very little effect on α-adrenergic receptors 79. is the second-line drug for symptomatic bradycardia 80. has no effect on β2 receptors 81. has a dose-related effect 82.Of the following, the most common cause of neonatal meningitis is A. H. influenzae B. Listeria species C. N. meningitides D. staphylococci E. streptococci 83. Each of the following is true of nitroprusside except A. Cyanide is produced when the ferrous ion in the nitroprusside molecule reacts with sulfhydryl-containing compounds in the red blood cells. B. The cyanide is reduced to thiocyanate in the liver. C. The half-life of thiocyanate is 3 to 4 days. D. Thiocyanate is excreted in the gastrointestinal (GI) tract. E. With prolonged administration, accumulation of thiocyanate may cause an acute toxic psychosis. 84. Isoproterenol A. acts almost exclusively on â receptors B. decreases SBP C. increases DBP D. increases peripheral vascular resistance (PVR) E. relaxes smooth muscle 85. Splenectomy for hereditary spherocytosis A. corrects the anemia B. corrects the defects in red blood cells C. has no effect on red blood cell survival D. is never followed by relapse E. should be performed before age 3 For questions 86 to 92, match the time period after creation of a wound with the event occurring during wound healing. Each response may be used once, more than once, or not at all. A. 12 hours B. 5 days C. 17 days D. 42 days E. 2 years 86. Epithelial migration occurs. 87. Increase in tensile strength occurs at least up to this point. 88. Wound contraction begins. 89. Maximum amount of total collagen occurs at this time. 90. Visible collagen synthesis begins. 91. Significant gain in tensile strength begins at this time. 92. The rapid increase in collagen content slows considerably at this point. 93. Each of the following is consistent with the Zollinger-Ellison syndrome except a(n) A. decrease in serum gastrin with secretin injection B. duodenal ulcer C. duodenal wall gastrinoma D. pancreatic gastrinoma E. increased serum gastrin level For questions 94 to 99, match the description with the disease. A. type I (distal) renal tubular acidosis (RTA) B. type II (proximal) RTA C. both D. neither 94. nonanion gap acidosis 95. hyperkalemia 96. Nephrocalcinosis commonly occurs. 97. urine pH > 5.5 98. defect in reabsorption of bicarbonate 99. hypokalemia 100. The percentage of total body weight represented by total extracellular fluid volume is approximately A. 5% B. 15% C. 20% D. 40% E. 60% 101. Each of the following occurs in venous air embolism except a(n) A. decrease in cardiac output B. increase in end-tidal pCO2 C. increase in pulmonary artery pressure D. increase in pulmonary vascular resistance E. ventilation-perfusion mismatch 102. The most sensitive noninvasive monitor of venous air embolism is A. auscultation of the chest with a stethoscope B. end-tidal pCO2 C. end-tidal pN2 D. precordial Doppler E. pulmonary artery catheterization 103. Which EKG change in the anterior leads is the most characteristic finding in subendocardial ischemia? A. hyperacute T wave B. Q wave C. ST depression D. ST elevation E. T wave inversion 104. Which set of laboratory values is most consistent with hypothyroidism of hypothalamic or pituitary origin? A. Decreased thyroid-stimulating hormone (TSH) and decreased free thyroxine (T4) B. decreased TSH and increased free T4 C. decreased TSH and normal free T4 D. increased TSH and decreased free T4 E. increased TSH and increased free T4 105. Of the following treatment options for hyperkalemia, which one does not alter serum potassium? A. calcium B. cation-exchange resins C. hemodialysis D. insulin E. sodium bicarbonate For questions 106 to 111, match the acid-base disturbance with the arterial blood gas result. Each response may be used once, more than once, or not at all. A. respiratory acidosis B. respiratory acidosis and metabolic acidosis C. metabolic acidosis D. metabolic acidosis and compensatory respiratory alkalosis E. respiratory alkalosis F. respiratory alkalosis and compensatory metabolic acidosis G. uninterpretable 106. pH = 7.5, pCO2 = 30, HCO3 = 19 107. pH = 7.3, pCO2 = 52, HCO3 = 29 108. 7.35, pCO2 = 17, HCO3 = 9 109. 7.55, pCO2 = 32, HCO3 = 12 110. 7.22, pCO2 = 55, HCO3 = 22 111. 7.25, pCO2 = 28, HCO3 = 12 112. If Qs and Qt are pulmonary shunt and total blood flow, respectively, and Cc, Ca, and Cv are the oxygen contents of end-capillary, arterial, and mixed venous blood, respectively, then the shunt fraction Qs/Qt= A. Cc/(Cc− Cv) B. (Ca− Cv)/Cv C. (Cv− Ca)/Cc D. (Cc− Ca)/(Cc−Cv) E. (Ca + Cv)/(Ca + Cc + Cv) 113. Atropine toxicity produces each of the following except A. blurred vision B. decreased intestinal peristalsis C. dry mouth D. increased pulse E. increased sweating 114. Each of the following is true of hyperosmolar coma except A. Free fatty acid concentration is lower than in ketoacidosis B. Glucose concentration is higher than in ketoacidosis C. It is more common in insulin-dependent diabetes mellitus (IDDM) than in non-insulin-dependent diabetes mellitus (NIDDM) D. Mortality is more than 50% E. Volume depletion is usually severe For questions 115 to 119, match the autonomic drug with the description. Each response may be used once, more than once, or not at all A. clonidine B. isoproterenol C. phenoxybenzamine D. phentolamine E. prazosin 115. β agonist 116. pure α1 antagonist 117. noncompetitive α antagonist 118. competitive, nonselective α antagonist 119. central α2 agonist 120. The most appropriate cholinergic agent to be used in urinary retention is A. acetylcholine B. bethanechol C. carbachol D. choline E. methacholine 121. Which of the following is false of polycythemia vera? A. Budd-Chiari syndrome is common. B. Hyperuricemia can complicate the disorder. C. It is the most common of the myeloproliferative disorders. D. Massive splenomegaly is usually the presenting sign. E. The use of alkylating agents should be avoided. 122. The serum osmolarity of a patient with a sodium level of 130 meq/L, K of 4.0 meq/L, glucose of 126 mg/dL, and blood urea nitrogen (BUN) of 28 mg/dL, is A. 276 B. 285 C. 296 D. 304 E. 310 123. Each of the following is a result of the use of positive end-expiratory pressure (PEEP) in the ventilated patient except A. decreased cerebral perfusion pressure B. decreased physiologic dead space C. decreased work of breathing D. improved lung compliance E. predisposition to barotraumas 124. The oxyhemoglobin dissociation curve is shifted to the right (decreased oxygen affinity) by I. acidosis II. decreased 2,3-diphosphoglyceric acid (2,3-DPG) III. fever IV. banked blood A. I, II, III B. I, III C. II, IV D. IV E. all of the above 125. Gastrointestinal carcinoids are most frequently found in the A. appendix B. colon C. ileum D. rectum E. stomach 126. Alkalinization of the urine promotes excretion of I. salicylates II. tricyclic antidepressants III. phenobarbital IV. amphetamines A. I, II, III B. I, III C. II, IV D. IV E. all of the above For questions 127 and 128, match the description with the substance. A. cryoprecipitate B. fresh frozen plasma C. both D. neither 127. reliably effective in von Willebrand’s disease 128. used in the treatment of hemophilia B 129. The free water deficit in a dehydrated 70 kg man with a Na+ of 160 is A. 2 L B. 4 L C. 6 L D. 7 L E. 8 L A. amrinone B. dopamine C. epinephrine D. neosynephrine E. norepinephrine 130. pure α agonist 131. does not interact with α or β receptors 132. Effects vary significantly with dose administered. 133. primarily an α agonist with mild β1 activity 134. balanced α and β agonist properties 135. Thallium intoxication causes each of the following except A. cardiac dysfunction B. GI disturbance C. hirsutism D. lower extremity joint pain E. peripheral neuropathy 136. Which of the following symptoms is least characteristic of acute intermittent porphyria? A. abdominal pain B. hypotension C. polyneuropathy D. psychosis E. tachycardia
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