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I-129. Which of the following is true regarding drug effects after an overdose compared with a reference

dose?

A. Drug effects begin earlier, peak earlier, and last longer.

B. Drug effects begin earlier, peak later, and last longer.

C. Drug effects begin earlier, peak later, and last shorter.

D. Drug effects begin later, peak earlier, and last shorter.

E. Drug effects begin later, peak later, and last longer.

I-130. Which of the following statements regarding gastric decontamination for toxin ingestion is true?

A. Activated charcoal’s most common side effect is aspiration.

B. Gastric lavage via nasogastric tube is preferred over the use of activated charcoal when
therapeutic endoscopy may also be warranted.

C. Syrup of ipecac has no role in the hospital setting.

D. There are insufficient data to support or exclude a benefit when gastric decontamination is used
more than 1 hour after a toxic ingestion.

E. All of the above are true.

I-131. One of your patients is contemplating a trekking trip to Nepal at elevations between 2500 and 3000 m. Five years ago, while skiing at Telluride (altitude, 2650 m), she recalls having headache, nausea, and fatigue within 1 day of arriving that lasted about 2–3 days. All of the following are true regarding the development of acute mountain sickness in this patient EXCEPT:

A. Acetazolamide starting 1 day before ascent is effective in decreasing the risk.

B. Gingko biloba is not effective in decreasing the risk.

C. Gradual ascent is protective.

D. Her prior episode increases her risk for this trip.

E. Improved physical conditioning before the trip decreases the risk.

I-132. A 36-year-old man develops shortness of breath, dyspnea, and dry cough 3 days after arriving for helicopter snowboarding in the Bugaboo mountain range in British Columbia (elevation, 3000 m). Over the next 12 hours, he becomes more short of breath and produces pink, frothy sputum. An EMT-trained guide hears crackles on chest examination. All of the following are true regarding his illness EXCEPT:

A. Descent and oxygen are most therapeutic.

B. Exercise increased his risk.

C. Fever and leukocytosis may occur.

D. He should never risk return to high altitude after recovery.

E. Pretreatment with nifedipine or tadalafil would have lowered his risk.

I-133. Which of the following is considered an absolute contraindication to hyperbaric oxygen therapy?

A. Carbon monoxide poisoning

B. History of COPD

C. History of high altitude pulmonary edema

D. Radiation proctitis

E. Untreated pneumothorax

I-134. A 35-year-old woman is scuba diving while vacationing in Malaysia. During her last dive of the day, her regulator malfunctions, requiring her to ascend from 20 m to the surface rapidly. Upon returning to the boat, she feels well. However, about 6 hours after returning to shore, she develops diffuse itching and muscle aches, leg pain, blurred vision, slurred speech, and nausea. Which of the following statements regarding her condition is true?

A. Decompression illness is unlikely at 20-m water depth.

B. Inhalation of 100% oxygen is contraindicated.

C. She can never again scuba dive to a depth greater than 6 m.

D. She should receive recompression and hyperbaric oxygen therapy.

E. She should remain upright as much as possible.

I-135. Which of the following statements regarding the distinction between acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is true?

A. ALI and ARDS can be distinguished by radiographic testing.

B. ALI and ARDS can be distinguished by the magnitude of the PaO₂/FIO₂ ratio.

C. ALI can be diagnosed in the presence of elevated left atrial pressure, but ARDS can not.

D. ALI is caused by direct lung injury, but ARDS is the result of secondary lung injury.

E. The risk of ALI but not ARDS increases with multiple predisposing conditions.

I-136. Which of the following has been demonstrated to reduce mortality in patients with ARDS?

A. High-dose glucocorticoids within 48 hours of presentation

B. High-frequency mechanical ventilation

C. Inhaled nitric oxide

D. Low tidal volume mechanical ventilation

E. Surfactant replacement

I-137. A 38-year-old man is hospitalized in the ICU with ARDS after a motor vehicle accident with multiple long bone fractures, substantial blood loss, and hypotension. By day 2 of hospitalization, he is off vasopressors but is requiring a high FIO₂ and positive end-expiratory pressure (PEEP) to maintain

adequate oxygenation. His family is asking about the short- and long-term prognosis for recovery. All of the following statements about his prognosis are true EXCEPT:

A. He has a greater chance of survival than a patient with similar physiology who is older than 70
years old.

B. His overall mortality from ARDS is approximately 25–45%.

C. If he survives, he is likely to have some degree of depression or posttraumatic stress disorder.

D. If he survives, he likely will have normal or near normal lung function.

E. The most likely cause of mortality is hypoxemic respiratory failure.

I-138. Clinical trials support the use of noninvasive ventilation in which of the following patients?

A. A 33-year-old man who was rescued from a motor vehicle accident. He is unarousable with
possible internal injuries. Room air blood gas is 7.30 (pH), PCO₂ 50 mmHg, PO₂ 60 mmHg.

B. A 49-year-old woman with end-stage renal disease admitted with presumed staphylococcal
sepsis from her hemodialysis catheter. She is somnolent, blood pressure is 80/50 mmHg, heart rate
is 105 beats/min, and room air oxygen saturation is 95%.

C. A 58-year-old woman with a history of cirrhotic liver disease admitted with a presumed
esophageal variceal bleed. Her blood pressure is 75/55 mmHg, and she has a heart rate of 110
beats/min. She is awake and alert.

D. A 62-year-old man with a long history of COPD admitted with an exacerbation related to an
upper respiratory tract infection. He is in marked respiratory distress but is awake and alert. Chest
radiograph only shows hyperinflation. His room air arterial blood gas is pH, 7.28; PCO₂, 75 mmHg;

and PO₂, 46 mmHg.

E. A 74-year-old man with cardiogenic shock and an acute ST-segment elevation myocardial
infarction. His blood pressure is 84/65 mmHg, heart rate is 110 beats/min, respiratory rate is 24
breaths/min, and room air oxygen saturation is 85%.

I-139. Yo u are caring for a patient on mechanical ventilation in the intensive care unit. Whenever the patient initiates a breath, no matter her spontaneous respiratory rate, she gets a fixed volume breath from the machine that does not change from breath to breath. After receiving a dose of sedation, she does not initiate any breaths, but the machine delivers the same volume breath at periodic fixed intervals during this time. Which of the following modes of mechanical ventilation is this patient receiving?

A. Assist control

B. Continuous positive airway pressure

C. Pressure control

D. Pressure support

E. Synchronized intermittent mandatory ventilation (SIMV)

I-140. A 68-year-old woman has been receiving mechanical ventilation for 10 days for community-acquired pneumonia. Yo u are attempting to decide whether the patient is appropriate for a spontaneous breathing trial. All of the following factors would indicate that the patient is likely to be successfully extubated EXCEPT:

A. Alert mental status

B. PEEP of 5 cmH₂O

C. pH greater than 7.35

D. Rapid shallow breathing index (respiratory rate/tidal volume) greater than 105

E. SaO₂ greater than 90% and FIO₂ less than 0.5

I-141. A 45-year-old woman with HIV is admitted to the intensive care unit with pneumonia and pneumothorax secondary to infection with Pneumocystis jiroveci. She requires mechanical ventilatory support, chest tube placement, and central venous access. The ventilator settings are PC mode; inspiratory pressure, 30 cmH₂O, 1.0; and PEEP, 10 cmH₂O. An arterial blood gas measured on these settings shows: pH 7.32, 46 mmHg, and 62 mmHg. All of the following are important supportive

measures for this patient EXCEPT:

A. Analgesia to maintain patient comfort

B. Daily change of ventilator circuit

C. Gastric acid suppression

D. Nutritional support

E. Prophylaxis against deep venous thrombosis

I-142. All of the following statements about the physiology of mechanical ventilation are true EXCEPT:

A. Application of PEEP decreases left ventricular preload and afterload.

B. High inspired tidal volumes contribute to the development of acute lung injury caused by
overdistention of alveoli with resultant alveolar damage.

C. Increasing the inspiratory flow rate will decrease the ratio of inspiration to expiration (I:E) and
allow more time for expiration.

D. Mechanical ventilation provides assistance with inspiration and expiration.

E. PEEP helps prevent alveolar collapse at end-expiration.

I-143. A 64-year-old man requires endotracheal intubation and mechanical ventilation for chronic obstructive pulmonary disease. He was paralyzed with rocuronium for intubation. His initial ventilator settings were AC mode; respiratory rate 10 breaths/minute; FIO₂ 1.0; Vt (tidal volume) 550 mL; and

positive end-expiratory pressure 0 cm H₂O. On admission to the intensive care unit the patient remains paralzyed; arterial blood gas is pH 7.22, PCO₂ 78 mmHg, PO₂ 394 mmHg. The FIO₂ is decreased to 0.6. Thirty minutes later you are called to the bedside to evaluate the patient for hypotension. Current vital signs are blood pressure 80/40 mmHg, heart rate, 133 beats/min; respiratory rate, 24/minute; and oxygen saturation 92%. Physical examination shows the patient is agitated and moving all extremities, a prolonged expiration with wheezing continuing until the initiation of the next breath. Breath sounds are heard in both lung fields. The high-pressure alarm on the ventilator is triggering. What should be done first in treating this patient’s hypotension?

A. Administer a fluid bolus of 500 mL.

B. Disconnect the patient from the ventilator.

C. Initiate a continuous IV infusion of midazolam.

D. Initiate a continuous IV infusion of norepinephrine.

E. Perform tube thoracostomy on the right side.

I-144. All of the following are relative contraindications for the use of succinylcholine as a paralytic for endotracheal intubation EXCEPT:

A. Acetaminophen overdose

B. Acute renal failure

C. Crush injuries

D. Muscular dystrophy

E. Tumor lysis syndrome

I-145. Match the following vasopressors with the statement that best describes their action on the

cardiovascular system.

1. Dobutamine

2. Low-dose dopamine (2-4 |ig/kg/min)

3. Norepinephrine

4. Phenylephrine

A. Acts solely at a-adrenergic receptors to cause vasoconstriction

B. Acts at p_radrenergic receptors and dopaminergic receptors to increase cardiac contractility and

heart rate; also causes vasodilatation and increased splanchnic and renal blood flow

С Acts at p_r and, to a lesser extent, p₂-adrenergic receptors to increase cardiac contractility, heart

rate, and vasodilatation

D. Acts at a- and Pj-adrenergic receptors to increase heart rate, cardiac contractility, and

vasoconstriction

1-146.An 86-year-old nursing home resident is brought by ambulance to the local emergency department. He was found unresponsive in his bed immersed in black stool. Apparently, he had not been feeling well for 1-2 days, had complained of vague abdominal pain, and had decreased oral intake; no further history is available from the nursing home staff. His past medical history is remarkable for Alzheimer's dementia and treated prostate cancer. The emergency responders were able to appreciate a faint pulse and obtained a blood pressure of 91/49 mmHg and a heart rate of 120 beats/min. In the emergency department, his pressure is 88/51 mmHg and heart rate is 131 beats/min. He is moaning and obtunded, localizes to pain, and has flat neck veins. Skin tenting is noted. A central venous catheter is placed that reveals CVP less than 5 mmHg, specimens for initial laboratory testing are sent off, and electrocardiogram and chest x-ray are obtained. Catheterization of the bladder yields no urine. Anesthesiology has been called to the bedside and is assessing the patient's airway. What is the best immediate step in management?

A. Infuse hypertonic saline to increase the rate of vascular filling.

B. Infuse isotonic crystalloid solution via IV wide open.
С Infuse a colloidal solution rapidly.

D. Initiate inotropic support with dobutamine.

E. Initiate IV pressors starting with Levophed.

1-147.In the patient described above, which of the following is true regarding his clinical condition?

A. Loss of 20-40% of the blood volume leads to shock physiology.

B. Loss of less than 20% of the blood volume will manifest as orthostasis.
С Oliguria is a crucial prognostic sign of impending vascular collapse.

D. Symptoms of hypovolemic shock differ from those of hemorrhagic shock.

E. The first sign of hypovolemic shock is mental obtundation.

1-148.A 52-year-old man presents with crushing substernal chest pain. He has a history of coronary artery disease and has had two non-ST-segment elevation myocardial infarctions in the past 5 years, both requiring percutaneous intervention and intracoronary stent placement. His electrocardiogram shows ST elevations across the precordial leads, and he is taken emergently to the catheterization

laboratory. After angioplasty and stent placement, he is transferred to the coronary care unit. His vital signs are stable on transfer; however, 20 minutes after arrival, he is found to be unresponsive. His radial pulse is thready, extremities are cool, and blood pressure is difficult to obtain; with a manual cuff, it is 65/40 mmHg. The nurse turns to you and asks what you would like to do next. Which of the following accurately represents the physiologic characteristics of this patient's condition?

1-149.All of the following are factors that are related to the increased incidence of sepsis in the United States EXCEPT:

A. Aging of the population

B. Increased longevity of individuals with chronic disease

С Increased risk of sepsis in individuals without comorbidities

D. Increased risk of sepsis in individuals with AIDS

E. Increased use of immunosuppressive drugs

1-150.A 68-year-old woman is brought to the emergency department for fever and lethargy. She first felt ill yesterday and experienced generalized body aches. Overnight, she developed a fever of 39.6°C and had shaking chills. By this morning, she was feeling very fatigued. Her son feels that she has had periods of waxing and waning mental status. She denies cough, nausea, vomiting, diarrhea, and abdominal pain. She has a medical history of rheumatoid arthritis. She takes prednisone, 10 mg daily, and methotrexate, 15 mg weekly. On examination, she is lethargic but appropriate. Her vital signs are blood pressure of 85/50 mmHg, heart rate of 122 beats/min, temperature of 39.1°C, respiratory rate of 24 breaths/min, and oxygen saturation of 97% on room air. Physical examination shows clear lung fields and a regular tachycardia without murmur. There is no abdominal tenderness or masses. Stool is negative for occult blood. There are no rashes. Hematologic studies show a white blood cell count of 24,200/uL with a differential of 82% PMNs, 8% band forms, 6% lymphocytes, and 3% monocytes. Hemoglobin is 8.2 g/dL. A urinalysis has numerous white blood cells with gram-negative bacteria on Gram stain. Chemistries reveal the following: bicarbonate of 16 meq/L, BUN of 60 mg/dL, and creatinine of 2.4 mg/dL. After fluid administration of 2 L, the patient has a blood pressure of 88/54 mmHg and a heart rate of 112 beats/min with a central venous pressure of 18 cmH₂0. There is 25 mL of

urine output in the first hour. The patient has been initiated on antibiotics with cefepime. What should be done next for the treatment of this patient's hypotension?

A. Dopamine, 3 |ig/kg/min IV

B. Hydrocortisone, 50 mg IV every 6 hours
С Norepinephrine, 2 |ig/min IV

D. Ongoing colloid administration at 500-1000 mL/h

E. Transfusion of 2 units of packed red blood cells

1-151.All of the following statements about the pathogenesis of sepsis and septic shock are true EXCEPT:

A. Blood cultures are positive in only 20-40% of cases of severe sepsis.

B. Microbial invasion of the bloodstream is not necessary for the development of severe sepsis.
С Serum levels of TNF-alpha are typically reduced in patients with severe sepsis or septic shock.

D. The hallmark of septic shock is a marked decrease in peripheral vascular resistance that occurs
despite increased plasma levels of catecholamines.

E. Widespread vascular endothelial injury is present in severe sepsis and is mediated by cytokines
and procoagulant factors that stimulate intravascular thrombosis.

1-152.Which of the following treatments is recommended to improve mortality in septic shock?

A. Activated protein С (drotrecogin alpha)

B. Administration of antibiotics within 1 hour of presentation
С Bicarbonate therapy for severe acidosis

D. Erythropoietin

E. Vasopressin infusion

1-153.All of the following statements regarding cardiogenic shock are true EXCEPT:

A. Approximately 80% of cases of cardiogenic shock complicating acute myocardial infarction are
attributable to acute severe mitral regurgitation.

B. Cardiogenic shock is more common in ST-segment elevation than non-ST-segment elevation
myocardial infarction.

C. Cardiogenic shock is uncommon in inferior wall myocardial infarction.

D. Cardiogenic shock may occur in the absence of significant coronary stenosis.

E. Pulmonary capillary wedge pressure is elevated in cardiogenic shock.

1-154.Aortic counterpulsation with an intra-aortic balloon pump has which of the following as an advantage over therapy with infused vasopressors or inotropes in a patient with acute ST-segment elevation myocardial infarction and cardiogenic shock?

A. Increased heart rate

B. Increased left ventricular afterload
С Lower diastolic blood pressure

D. Not contraindicated in acute aortic regurgitation

E. Reduced myocardial oxygen consumption

1-155.Which of the following is the most common electrical mechanism to explain sudden cardiac death?

A. Asystole

B. Bradycardia

C. Pulseless electrical activity (PEA)

D. Pulseless ventricular tachycardia (PVT)

E. Ventricular fibrillation

1-156. All of the following statements regarding successful resuscitation from sudden cardiac death are true EXCEPT:

A. Advanced age does not affect the likelihood of immediate resuscitation, only the probability of
hospital discharge.

B. After cardiac out of hospital cardiac arrest, survival rates are approximately 25% if
defibrillation is administered after 5 minutes.

C. If the initial rhythm in an out-of-hospital cardiac arrest is pulseless ventricular tachycardia, the
patient has a higher probability of survival than asystole.

D. Prompt CPR followed by prompt defibrillation improves outcomes in all settings.

E. The probability of survival from cardiac arrest is higher if the event takes place in a public
setting than at home.

1-157. A 28-year-old woman has severe head trauma after a motor vehicle accident. One year after the accident, she is noted to have spontaneous eye opening and is able to track an object visually at times. She does not speak or follow any commands. She breathes independently but is fed through a gastrostomy tube. She can move all extremities spontaneously but without purposeful movement. What term best describes this patient's condition?

A. Coma

B. Locked-in

C. Minimally conscious state

D. Persistent vegetative state

E. Vegetative state

1-158. A 52-year-old man is evaluated after a large subarachnoid hemorrhage (SAH) from a ruptured cerebral aneurysm There is concern that the patient has brain death. What test is most commonly used to diagnose brain death in this situation?

A. Apnea testing

B. Cerebral angiography

C. Demonstration of absent cranial nerve reflexes

D. Demonstration of fixed and dilated pupils

E. Performance of transcranial Doppler ultrasonography

1-159. Which of the following neurologic phenomena is classically associated with herniation of the brain through the foramen magnum?

A. Third-nerve compression and ipsilateral papillary dilation

B. Catatonia

С "Locked-in" state D. Miotic pupils

E. Respiratory arrest

1-160.A 72-year-old woman is admitted to the intensive care unit after a cardiac arrest at home. She had a witnessed collapse, and her family immediately began to perform cardiopulmonary resuscitation. Emergency medical service arrived within 10 minutes, and the initial cardiac rhythm demonstrated ventricular fibrillation. Spontaneous circulation returned after defibrillation, and the estimated time the patient was without a pulse was 15-20 minutes. The patient is brought to hospital and remains intubated, paralyzed, and sedated in the coronary care unit. She is being treated with medically induced hypothermia and is completely unresponsive to all stimuli 12 hours after the initial event. Her pupils are 3 mm and respond sluggishly to light. She has no cough or gag reflex. Intermittent myoclonic jerks are seen. The family has concerns about her neurologic prognosis after her prolonged cardiac arrest. What advice do you give the family regarding prognosis in this situation?

A. An MRI scan of the brain should be performed before determining neurologic outcome.

B. Apnea testing will be performed at the first opportunity to determine if the patient has suffered
brain death.

C. Given the immediate actions of the family to initiate cardiopulmonary resuscitation, the patient
has a greater than 50% chance to have good neurologic outcomes.

D. It is impossible to predict the patient's likelihood of neurologic recovery as her examination is
unreliable in the face of sedation and hypothermia.

E. No information regarding prognosis can be determined until 72 hours have passed.

1-161.A 52-year-old man presents to the emergency department complaining of the worst headache of his life that is unresolving. It began abruptly 3 days before presentation and is worse with bending over. It rapidly increased in intensity over 30 minutes, but he did not seek medical care at that time. Over the ensuing 72 hours, the headache has persisted although lessened in intensity. He has not lost consciousness and has no other neurologic symptoms. His vision is normal, but he does report that light is painful to his eyes. His past medical history is notable for hypertension, but he takes his medications irregularly. Upon arrival to the emergency department, his initial blood pressure is 232/128 mmHg with a heart rate of 112 beats/min. No nuchal rigidity is present. A head CT shows no acute bleeding and no mass effect. What is the next best step in the management of this patient?

A. Cerebral angiography

B. СТ angiography
С Lumbar puncture

D. Magnetic resonance angiography

E. Treat with sumatriptan

1-162.A 56-year-old man is admitted to intensive care with a subarachnoid hemorrhage. Upon admission, he is unresponsive, and his head CT shows evidence of blood in the third ventricle with midline shift. He undergoes successful coiling of an aneurysm of the anterior cerebral artery. All of the following would be indicated in the management of this patient EXCEPT:

A. Glucocorticoids

B. Hypernatremia
С Nimodipine

D. Ventriculostomy

E. Volume expansion

1-163.A 56-year-old man is admitted to the intensive care unit with a hypertensive crisis after cocaine use. Initial blood pressure is 245/132 mmHg. On physical examination, the patient is unresponsive except to painful stimuli. He has been intubated for airway protection and is being mechanically ventilated, with a respiratory rate of 14 breaths/min. His pupils are reactive to light, and he has normal corneal, cough, and gag reflexes. The patient has a dense left hemiparesis. When presented with painful stimuli, the patient responds with flexure posturing on the right side. Computed tomography (CT) reveals a large area of intracranial bleeding in the right frontoparietal area. Over the next several hours, the patient deteriorates. The most recent examination reveals a blood pressure of 189/100 mmHg. The patient now has a dilated pupil on the right side. The patient continues to have corneal reflexes. You suspect rising intracranial pressure related to the intracranial bleed. All but which of the following can be done to decrease the patient's intracranial pressure?

A. Administer intravenous mannitol at a dose of 1 g/kg body weight.

B. Administer hypertonic fluids to achieve a goal sodium level of 155-160 meq/L.
С Consult neurosurgery for an urgent ventriculostomy.

D. Initiate intravenous nitroprusside to decrease the mean arterial pressure (MAP) to a goal of 100
mmHg.

E. Increase the respiratory rate to 30 breaths/min.

1-164.A 64-year-old man presents to the emergency department complaining of shortness of breath and facial swelling. He smokes 1 pack of cigarettes daily and has done so since the age of 16 years. On physical examination, he has dyspnea at an angle of 45 degrees or less. His vital signs are heart rate of 124 beats/min, blood pressure of 164/98 mmHg, respiratory rate of 28 breaths/min, temperature of 37.6°C (99.6°F), and oxygen saturation of 89% on room air. Pulsus paradoxus is not present. His neck veins are dilated and do not collapse with inspiration. Collateral venous dilation is noted on the upper chest wall. There is facial edema and 1+ edema of the upper extremities bilaterally. Cyanosis is present. There is dullness to percussion and decreased breath sounds over the lower half of the right lung field. Given this clinical scenario, what would be the most likely finding on CT examination of the chest?

A. A central mass lesion obstructing the right mainstem bronchus

B. A large apical mass invading the chest wall and brachial plexus
С A large pericardial effusion

D. A massive pleural effusion leading to opacification of the right hemithorax

E. Enlarged mediastinal lymph nodes causing obstruction of the superior vena cava

1-165.In the scenario in question 1-165, the initial therapy of this patient includes all of the following EXCEPT:

A. Administration of furosemide as needed to achieve diuresis

B. Elevation of the head of the bed to 45 degrees

C. Emergent radiation

D. Low-sodium diet

E. Oxygen

1-166. A 58-year-old woman with known stage IV breast cancer presents to the emergency department with an inability to move her legs. She has had lower back pain for the past 4 days and has found it difficult to lie down. There is no radiating pain. Earlier today, the patient lost the ability to move either of her legs. In addition, she has been incontinent of urine recently. She has been diagnosed previously with metastatic disease to the lung and pleura from her breast cancer but was not known to have spinal or brain metastases. Her physical examination confirms absence of movement in the bilateral lower extremities associated with decreased to absent sensation below the umbilicus. There is increased tone and 3+ deep tendon reflexes in the lower extremities with crossed adduction. Anal sphincter tone is decreased, and the anal wink reflex is absent. What is the most important first step to take in the management of this patient?

Date: 2016-04-22; view: 651