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Test Bank For Little and Falace's Dental
Management
of the Medically Compromised Patient,
10thEditionby Craig
Miller,
Chapters 1 - 30
Little: Dental Management of the Medically Compromised Patient, 10th Edition Test
Bank
Table of Contents
PART ONE: PATIENT EVALUATION AND RISK ASSESSMENT
Chapter 1: Patient Evaluation and Risk Assessment
PART TWO: CARDIOVASCULAR DISEASE
Chapter 2: Infective Endocarditis
Chapter 3: Hypertension
Chapter 4: Ischemic Heart Disease
Chapter 5: Cardiac Arrhythmias
Chapter 6: Heart Failure (or Congestive Heart Failure)
PART THREE: PULMONARY DISEASE
Chapter 7: Pulmonary Disease
Chapter 8: Smoking and Tobacco Use
Cessation Chapter 9: Sleep-Related Breathing
Disorders PART FOUR:
GASTROINTESTIAL DISEASE
Chapter 10: Liver Disease
Chapter 11: Gastrointestinal Disease
PART FIVE: GENITOURINARY DISEASE
Chapter 12: Chronic Kidney Disease and
Dialysis Chapter 13: Sexually Transmitted
Diseases
PART SIX: ENDOCRINE AND METABOLIC DISEASE
Chapter 14: Diabetes Mellitus
Chapter 15: Adrenal Insufficiency
Chapter 16: Thyroid Diseases
Chapter 17: Pregnancy and Breast Feeding
PART SEVEN: IMMUNOLOGIC DISEASE
Chapter 18: AIDS, HIV Infection, and Related Conditions
Chapter 19: Allergy
Chapter 20: Rheumatologic and Connective Tissue
Disorders Chapter 21: Organ and Bone Marrow
Transplantation
PART EIGHT: HEMATOLOGIC AND ONCOLOGIC DISEASE
Chapter 22: Disorders of Red Blood Cells
Chapter 23: Disorders of White Blood Cells
Chapter 24: Acquired Bleeding and Hypercoagulable
Disorders Chapter 25: Congenital Bleeding and
Hypercoagulable Disorders Chapter 26: Cancer and Oral
Care of the Patient
PART NINE: NEUROLOGIC, BEHAVIORAL, AND PSYCHIATRIC DISORDERS
Chapter 27: Neurologic Disorders
Chapter 28: Anxiety, Eating Disorders, and Behavioral Reactions to Illness
Chapter 29: Psychiatric Disorders
Chapter 30: Drug and Alcohol Abuse
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Chapter 01: Patient Evaluation and Risk Assessment
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Elective dental care should be deferred for patients with severe, uncontrolled
hypertension, meaning that the blood pressure is greater than or equal to mm
Hg.
a. 200/14
0
b. 180/14
0
c. 180/11
0
d. 160/11
0
ANSWER: C
Elective dental care should be deferred for patients with severe, uncontrolled
hypertension, which is blood pressure greater than or equal to 180/110 mm Hg,
until the condition can be brought under control.
2. The American Heart Association currently recommends antibiotic prophylaxis for
a patient with which of the following cardiac conditions?
a. Mitral valve prolapse
b. Prosthetic heart valve
c. Rheumatic heart disease
d. Pacemakers for cardiac arrhythmias
ANSWER: B
Previously, the American Heart Association (AHA) recommended antibiotic
prophylaxis for many patients with heart murmurs caused by valvular disease (e.g.,
mitral valve prolapse, rheumatic heart disease) in an effort to prevent infective
endocarditis; however, current guidelines omit this recommendation on the basis of
accumulated scientific evidence. If a murmur is due to certain specific cardiac
conditions (e.g., previous endocarditis, prosthetic heart valve, complex congenital
cyanotic heart disease), the AHA continues to recommend antibiotic prophylaxis for
most dental procedures.
3. One consequence of chronic hepatitis (B or C) or cirrhosis of the liver is decreased
ability of the body tocertain drugs, including local anesthetics and analgesics.
a. absorb
b. distribute
c. metabolize
d. excrete
ANSWER: C
Patients also may have chronic hepatitis (B or C) or cirrhosis, with impairment
of liver function. This deficit may result in prolonged bleeding and less
efficient metabolism of certain drugs, including local anesthetics and
analgesics.
4. Which of the following symptoms and signs is most consistent with allergy?
a. Heart palpitations
b. Itching
c. Vomiting
d. Fainting
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ANSWER: B
Symptoms and signs consistent with allergy include itching, urticaria (hives), rash,
swelling, wheezing, angioedema, runny nose, and tearing eyes. Isolated signs and
symptoms such as nausea, vomiting, heart palpitations, and fainting generally are
not of an allergic origin but rather are manifestations of drug intolerance, adverse
side effects, or psychogenic reactions.
5. Which of the following is true of the patient with a history of tuberculosis?
a. A positive result on skin testing means that the person has active TB.
b. Most patients who become positive skin testers develop active disease.
c. Patients with acquired immunodeficiency syndrome (AIDS) have a high
incidence of tuberculosis.
d. A diagnosis of active TB is made by a purified protein derivative (PPD) skin test.
ANSWER: C
The potential coexistence of tuberculosis and acquired immunodeficiency syndrome
(AIDS) should be explored because patients with AIDS have a high incidence of
tuberculosis. A positive result on skin testing means specifically that the person has
at some time been infected with TB, not necessarily that active disease is present.
Most patients who become positive skin testers do not develop active disease. A
diagnosis of active TB is made by chest x-ray, imaging, sputum culture, and clinical
examination.
6. Vasoconstrictors should be avoided in patients who cocaine or
methamphetamine users because these agents may precipitate .
a. severe hypotension
b. severe hypertension
c. respiratory depression
d. cessation of intestinal peristalsis
ANSWER: B
Vasoconstrictors should be avoided in patients who are cocaine or
methamphetamine users because the combination may precipitate arrhythmias,
MI, or severe hypertension.
7. It has been shown that the risk for occurrence of a serious perioperative
cardiovascular event (e.g., MI, heart failure) is increased in patients who are
unable to meet a -MET (metabolic equivalent of task) demand during normal daily
activity.
a. 4
b. 6
c. 8
d. 10
ANSWER: A
Daily activities requiring 4 METs include level walking at 4 miles/hour or climbing a
flight of stairs. Activities requiring greater than 10 METs include swimming and
singles tennis. An exercise capacity of 10 to 13 METs indicates excellent physical
conditioning.
8. Which of the following alterations in the fingernails is associated with cirrhosis?
a. Yellowing
b. Clubbing
c. White discoloration
d. Splinter hemorrhages
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ANSWER: C
Alterations in the fingernails, such as clubbing (seen in cardiopulmonary
insufficiency), white discoloration (seen in cirrhosis), yellowing (from malignancy),
and splinter hemorrhages (from infective endocarditis) usually are caused by
chronic disorders.
9. A blood pressure cuff should be placed on the upper arm and inflated until .
a. the radial pulse disappears
b. the radial pulse disappears and then inflated an additional 20 to 30 mm Hg
c. two fingers cannot fit comfortably under the cuff
d. the pulse no longer can be heard with the stethoscope
ANSWER: B
While the radial pulse is palpated, the cuff is inflated until the radial pulse
disappears (approximate systolic pressure); it is then inflated an additional 20 to
30 mm Hg.
10. Which of the following is true of a patient classified ASA III according to the
American Society of Anesthesiologists (ASA) Physical Status Classification
System?
a. Patient has mild systemic disease.
b. Patient’s disease has significant impact on daily activity.
c. Patient’s disease is unlikely to have impact on anesthesia and surgery.
d. Patient is moribund.
ANSWER: B
Patient with severe systemic disease is a constant threat to life (e.g., recent
myocardial infarction, stroke, transient ischemic attach [<3 months], ongoing
cardiac ischemia, severe valve dysfunction, respiratory failure requiring mechanical
ventilation). Serious limitation of daily activity; likely major impact on anesthesia
and surgery.
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Chapter 02: Infective Endocarditis
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is true concerning infective endocarditis (IE)?
a. IE is always due to a bacterial infection.
b. Since the advent of antibiotics, morbidity and mortality associated with
IE have been virtually eliminated.
c. IE is currently classified as acute or subacute, to reflect the rapidity of
onset and duration.
d. Accumulating evidence questions the validity of antibiotic
prophylaxis in an attempt to prevent IE prior to certain invasive
dental procedures.
ANSWER: D
Antibiotics have been administered before certain invasive dental procedures in an
attempt to prevent infection. Of note, however, the effectiveness of such prophylaxis
in humans has never been substantiated, and accumulating evidence more and more
questions the validity of this practice.
2. Which of the following is currently the most common underlying condition
predisposing to infective endocarditis (IE)?
a. Aortic valve disease
b. Rheumatic heart disease (RHD)
c. Mitral valve prolapse (MVP)
d. Tetralogy of Fallot
ANSWER: C
Mitral valve prolapse, which accounts for 25% to 30% of adult cases of native
valve endocarditis (NVE), is now the most common underlying condition among
patients who acquire IE. Previously, rheumatic heart disease (RHD) was the most
common condition predisposing to endocarditis. In developed countries,
however, the frequency of RHD has markedly declined over the past several
decades.
3. The leading cause of death due to infective endocarditis (IE) is .
a. chronic obstructive pulmonary disease
b. heart failure
c. pulmonary emboli
d. atheromas
ANSWER: B
The most common complication of IE, and the leading cause of death, is heart failure,
which results from severe valvular dysfunction. This pathologic process most
commonly begins as a problem with aortic valve involvement, followed by mitral
and then tricuspid valve infection. Embolization of vegetation fragments often leads
to further complications, such as stroke.
Myocardial infarction can occur as the result of embolism of the coronary arteries,
and distal emboli can produce peripheral metastatic abscesses.
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4. The interval between the presumed initiating bacteremia and the onset of
symptoms of infective endocarditis (IE) is estimated to be less than in more
than 80% of patients with IE.
a. 1 week
b. 2 weeks
c. 1 month
d. 2 months
ANSWER: B
It is less than two weeks in more than 80% of patients with IE. In many cases of IE
that have been purported to be due to dentally induced bacteremia, the interval
between the dental appointment and the diagnosis of IE has been much longer than
2 weeks (sometimes months), so it is very unlikely that the initiating bacteremia was
associated with dental treatment.
5. Where are Janeway lesions located?
a. Tricuspid valve
b. Palms of the hands and soles of the feet
c. Pulp of the digits
d. Nail beds
ANSWER: B
Janeway lesions are small, nontender erythematous or hemorrhagic macular lesions
on the palms and soles. Janeway lesions are one of the peripheral manifestations of
IE due to emboli and/or immunologic responses.
6. Which of the following is true of the magnitude of bacteremia required to cause
infective endocarditis (IE)?
a. The magnitude of bacteremias resulting from dental procedures is more
likely to cause IE than that seen with bacteremias resulting from normal
daily activities.
b. Cases of IE caused by oral bacteria probably result from frequent
exposure to low inocula of bacteria in the bloodstream due to daily
activities and not a dental procedure.
c. The quality of oral hygiene has no appreciable effect on the
magnitude of bacteremia after toothbrushing.
d. The magnitude of bacteremia resulting from dental procedures is greater
than that needed to cause experimental bacterial endocarditis (BE) in
animals.
ANSWER: B
An assumption often made is that the magnitude of bacteremias resulting from
dental procedures is more likely to cause IE than that seen with bacteremias
resulting from normal daily activities. Published data do not support this
contention. Furthermore, the magnitude of bacteremia resulting from dental
procedures is relatively low (with bacterial counts of fewer than 104
colony-forming
units/mL), is similar to that of bacteremia resulting from normal daily activities,
and is far less than that (106
to 108
colony-forming units/mL) needed to cause
experimental BE in animals.
7. Visible bleeding during a dental procedure is a reliable predictor of bacteremia. It is
not clear which dental procedures are more or less likely to cause transient
bacteremia or to result in a greater magnitude of bacteremia than that caused by
routine daily activities such as chewing food, tooth brushing, or flossing.
a. Both statements are true.
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b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
ANSWER: D
It has been shown that visible bleeding during a dental procedure is not a reliable
predictor of bacteremia. Collective published data suggest that the vast majority of
dental office visits result in some degree of bacteremia, and that it is not clear which
dental procedures are more or less likely to cause transient bacteremia or to result in
a greater magnitude of bacteremia than that caused by bacteremia produced by
routine daily activities such as chewing food, tooth brushing, or flossing.
8. Which of the following is true regarding the efficacy of antibiotic prophylaxis?
a. Data show that a reduction in the incidence, nature, and duration of
bacteria caused by antibiotic therapy reduces the risk of or prevents IE.
b. Antibiotics given to at-risk patients before a dental procedure will
prevent or reduce a bacteremia.
c. Prospective randomized, placebo-controlled trials have been conducted to
examine the efficacy of antibiotic prophylaxis for preventing IE in patients
who undergo a dental procedure.
d. Investigators have concluded that dental or other procedures probably
only caused a small fraction of cases of IE, and that prophylaxis would
prevent only a small number of cases, even if it were 100% effective.
ANSWER: D
This conclusion came as the result of a study from the Netherlands by van der Meer
and colleagues that investigated the efficacy of antibiotic prophylaxis in preventing
IE in dental patients with native or prosthetic cardiac valves
9. The American Heart Association currently recommends antibiotic prophylaxis
before dental treatment to prevent endocarditis for patients with which of the
following cardiac conditions?
a. Mitral valve prolapse with regurgitation
b. Rheumatic heart disease
c. Prosthetic cardiac valve
d. A, B, and C
e. A and C
ANSWER: C
Prophylaxis with antibiotics before a dental procedure is recommended for a
prosthetic cardiac valve, previous infective endocarditis, and some forms of
congenital heart disease (see Box 2-2.)
10. Which of the following antibiotics is the best choice if a patient who requires
premedication before dental treatment is already taking penicillin for eradication
of an infection?
a. Amoxicillin
b. Clindamycin
c. Cephalosporins
d. Keep the patient on the penicillin because the blood level has
already been achieved
ANSWER: B
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The presence of viridians group streptococci that are relatively resistant to penicillin
or amoxicillin is likely in patients already taking penicillin or amoxicillin for
eradication of an infection. Clindamycin, azithromycin, or clarithromycin should be
selected for prophylaxis if treatment is immediately necessary. Cephalosporins
should be avoided due to cross resistance. Another approach is to wait for at least 10
days after the completion of antibiotic therapy before administration of prophylactic
antibiotics.
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Chapter03: Hypertension
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. In prehypertension, diastolic pressure ranges from mm Hg.
a. 80 to 89
b. 90 to 99
c. 100 to 109
d. 110 to 119
ANSWER: A
In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a
sustained diastolic blood pressure of 90 mm Hg or greater is defined as
hypertension. (Also see Table 3-1.)
2. Which of the following types of health professionals can make the diagnosis of
hypertension and decide on its treatment?
a. Physician
b. Dentist
c. Dental hygienist
d. A, B, and C
e. A and C only
ANSWER: A
Although only a physician can make the diagnosis of hypertension and decide on
its treatment, Joint National ComG
m
R
itA
teD
eE
on
SP
MrO
ev
R
eE
nt.
io
C
nO
, D
Metection, Evaluation,
and Treatment of
High Blood Pressure (JNC) guidelines specifically encourage the active
participation of all health care professionals in the detection of hypertension and
the surveillance of treatment compliance. Accordingly, the dental health
professional can play a significant role in the detection and control of
hypertension and may well be the first to detect a patient with an elevation in
blood pressure or with symptoms of hypertensive disease.
3. Which of the following is true about hypertension in America?
a. It is the second-most primary diagnosis behind congestive heart failure.
b. Its prevalence has been steadily increasing 1990.
c. Its prevalence is similar among all races and ethnicities.
d. Its prevalence is similar among men and women.
ANSWER: D
According to National Health and Nutrition Examination Survey (NHANES) data
for the period 2011 to 2012, at least 75 million adults in the United States have high
blood pressure or are taking antihypertensive medication. This estimate equals
about 29% of the U.S. population, compared with 24% when surveyed between
1988 and 1991. This marked increase is attributed to aging of the population and the
epidemic increase in obesity.
Accordingly, a typical practice population of 2000 patients will have about 580
patients who have hypertension.
4. It is estimated that about % of all blood pressure–related deaths from coronary
heart disease occur in persons with blood pressure in the prehypertensive range.
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a. less than
1
b. 5
c. 15
d. 25
ANSWER: C
About 15%. However, the higher the blood pressure, the greater the chances of heart
attack, heart failure, stroke, and kidney disease. For every increase in blood
pressure of 20 mm Hg systolic and 10 mm Hg diastolic, a doubling of mortality
related to ischemic heart disease and stroke occurs.
5. Which of the following groups is most often the first-line drug category of choice if
lifestyle modification is ineffective at lowering blood pressure?
a. Beta-blockers (BBs), 1-adrenergic blockers, central 2 agonists, as well as
other centrally acting drugs, and direct vasodilators
b. Diuretics, thiazide diuretics, calcium channel blockers (CCBs),
angiotensin receptor blockers, angiotensin-converting enzyme
inhibitors (ACEIs)
c. Any of the above.
d. None of the above; lifestyle modification should continue unless blood pressure is
>140/90 mm Hg
ANSWER: B
Many drugs are currently available to treat hypertension. The Eighth Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure (JNC 8) recommends diuretics, angiotensin-converting enzyme
inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel
blockers (CCBs) as first-line
choices for the general non-Black population. For the general Black population, a
thiazide diuretic or CCB is recommend
G
eR
dA
as
DiE
nS
itiM
al
OtR
he
E
r.
ap
C
yO
. O
Mther drugs used
as secondary choices
include beta-blockers (BBs), 1-adrenergic blockers, central 2 agonists, as well as
other centrally acting drugs and direct vasodilators.
6. Deferral of elective dental care and referral to a physician for evaluation and
treatment within 1 week are indicated for patients found to have asymptomatic
blood pressure of greater than or equal to mm Hg.
a. 160/90
b. 160/11
0
c. 180/90
d. 180/11
0
ANSWER: D
Patients with blood pressures less than 180/110 mm Hg can undergo any necessary
dental treatment, both surgical and nonsurgical, with very little risk of an adverse
outcome. For patients found to have asymptomatic blood pressure of 180/110 mm
Hg or greater (uncontrolled hypertension), elective dental care should be deferred,
and physician referral for evaluation and treatment within 1 week is indicated.
Patients with uncontrolled blood pressure associated with symptoms such as
headache, shortness of breath, or chest pain should be referred to a physician for
immediate evaluation.
7. Which of the following is recommended for stress management for dental
patients with hypertension?
a. Afternoon appointments
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b. Premedication with a barbiturate
c. Nitrous oxide plus oxygen for inhalation sedation
d. Keeping the dental chair in an upright position during treatment
ANSWER: C
Nitrous oxide plus oxygen for inhalation sedation is an excellent intraoperative
anxiolytic for use in patients with hypertension. Care is indicated to ensure
adequate oxygenation at all times, avoiding postdiffusion hypoxia at the
termination of administration. Short morning appointments seem best tolerated.
Oral premedication with a short-acting benzodiazepine can reduce anxiety for many
patients. Because many of the antihypertensive agents tend to produce orthostatic
hypotension as a side effect, rapid changes in chair position during dental treatment
should be avoided.
8. Why should rapid changes in chair position during dental treatment be avoided
for patients under medication for hypertension?
a. To lessen the chances of endogenous release of catecholamines.
b. Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce
orthostatic hypotension as a side effect.
c. Rapid chair position changes have nothing to do with antihypertensive
medications and drugs used in dental practice.
d. There is a high potential of triggering cardiovascular issues agents for
hypertensive dental patients in moving chairs if local anesthetics are used.
ANSWER: B
Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic
hypotension as a side effect, so rapid changes in chair position during dental
treatment should be avoided.
This effect can be potentiated by the actions of anxiolytic and sedative drugs.
.
9. Use of how many cartridges of 2% lidocaine with 1:100,000 epinephrine at one
time is considered to have little clinical risk for dental treatment of a patient
with hypertension?
a. 2
b. 4
c. 6
d. 8
ANSWER: A
The existing evidence indicates that use of modest doses (one or two cartridges of 2%
lidocaine with 1:100,000 epinephrine) carries little clinical risk in patients with
hypertension, the benefits of its use far outweighing any potential problems. Use of
more than this amount at one time may be tolerated well enough but with increasing
risk for adverse hemodynamic changes.
10. Which of the following is an adverse drug interaction that may occur if a dental
anesthetic containing a vasoconstrictor is administered to a patient being treated for
hypertension with a nonselective -adrenergic blocking agent?
a. Hypotension
b. Hypertension
c. Respiratory alkalosis
d. Respiratory acidosis
ANSWER: B
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The basis for concern with use of nonselective -adrenergic blocking agents (e.g.,
propranolol) is that the normal compensatory vasodilation of skeletal muscle
vasculature mediated by beta 2 receptors is inhibited by these drugs, and injection
of epinephrine, levonordefrin, or any other pressor agent may result in
uncompensated peripheral vasoconstriction because of unopposed stimulation of
alpha 1 receptors. This vasoconstrictive effect could potentially cause a significant
elevation in blood pressure and a compensatory bradycardia.
.
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Chapter 04: Ischemic Heart Disease
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is true concerning the incidence and prevalence of
ischemic heart disease in the United States?
a. About 50% of the population is estimated to have some form of
cardiovascular disease.
b. Cardiovascular disease begins in middle life.
c. The annual mortality rate for cardiovascular diseases has been
declining since 1970.
d. Cancer has replaced coronary heart disease as the leading cause of
death in the United States after age 65.
ANSWER: C
More than 85 million Americans (about 25% of the population) have some form of
cardiovascular disease, with about 15.5 million having coronary heart disease.
Cardiovascular disease begins early in life, and autopsy studies have shown that one
in six American teenagers already has pathologic intimal thickening of the coronary
arteries. The annual mortality rate for cardiovascular diseases as a group has been
declining since 1970. Despite this decline, cardiovascular diseases continue to be the
leading cause of death in America, accounting for about 31% of all deaths. Coronary
heart disease is the leading cause of death in the United States after age 65, and it is
responsible for 735,000 new or recurrent heart attacks annually, of which more than
40% are fatal.
.
2. Which of the following is the single MOST important modifiable risk factor for coronary
heart disease?
a. Diet high in cholesterol
b. Failure to exercise
c. Smoking cigarettes
d. Smoking cigars
ANSWER: C
Cigarette smoking is the single most important modifiable risk factor for coronary
heart disease. Multiple prospective studies have clearly documented that, compared
with nonsmokers, persons who smoke 20 or more cigarettes daily have a two- to
fourfold increase in coronary heart disease. This increased risk appears to be
proportionate to the number of cigarettes smoked per day, and quitting has well
documented benefits. Pipe and cigar smoking apparently convey minor risk for
development of heart disease.
3. Which of the following is NOT true of the relationship between periodontal
disease and cardiovascular disease?
a. Studies report the possibility of an association between periodontal
disease and cardiovascular disease.
b. A single risk factor—dental caries—has been found to be responsible
for the development of coronary atherosclerosis in patients over 50
years old.
c. Studies indicate a connection between tooth scaling and a decreased
risk of cardiovascular disease outcomes.
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d. There is a hypothesis that the chronic inflammatory burden of periodontal
disease may lead to impaired functioning of the vascular endothelium.
ANSWER: B
Numerous studies have reported an association between periodontal disease and
cardiovascular disease, raising the question of whether periodontal disease is a risk
factor for cardiovascular disease. Although the mechanism to explain this
relationship is unclear, it is hypothesized that the chronic inflammatory burden of
periodontal disease may lead to impaired functioning of the vascular endothelium.
At present, despite studies showing that tooth scaling is associated with decreased
risk of cardiovascular disease outcomes and improved endothelial function, a direct
relationship (i.e., causation) between periodontal disease and cardiovascular disease
has not been established. Additional studies are required to further elucidate this
relationship.
4. Which of the following types of blood cells engulf lipid molecules to become foam cells?
a. Red blood cells
b. Macrophages
c. Neutrophils
d. Basophils
ANSWER: B
Atheroma formation is initiated by adherence of monocytes to an area of injured or
altered endothelium. The attached monocytes then migrate into the intima of the
vessel and become macrophages. Lipids derived from LDLs also enter through the
injured or dysfunctional endothelium, forming extracellular deposits or small pools.
Macrophages then engulf lipid molecules to become foam cells, which are
characteristic features of the fatty streak.
5. Which of the following is the G
im
R
p
A
or
D
ta
E
nS
t s
M
y
O
m
R
pE
to.
m
C
o
O
fM
coronary atherosclerotic heart
disease?
a. Pitting edema
b. Dysphagia
c. Dyspnea
d. Chest pain
ANSWER: D
Chest pain is the most important symptom of coronary atherosclerotic heart disease.
The pain may be brief, as in angina pectoris resulting from temporary ischemia of
the myocardium, or it may be prolonged, as in unstable angina or acute MI.
Ischemic myocardial pain results from an imbalance between the oxygen supply and
the oxygen demand of the muscle.
6. New-onset chest pain that increases in frequency or intensity has a changing
pattern, may possibly occur at rest, and is not readily relieved by nitroglycerin.
This best defines
.
a. acute coronary syndrome
b. Prinzmetal’s variant angina
c. unstable angina
d. stable angina
ANSWER: C
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Unstable angina is defined as new-onset pain with increasing frequency or intensity,
and that is precipitated by less effort than before or that occurs at rest. This pain is
not readily relieved by nitroglycerin. Stable angina is pain that is predictably
reproducible, unchanging, and consistent over time. This pain is typically
precipitated by physical effort, such as walking or climbing stairs, but also may
occur with eating or stress. Pain is relieved by cessation of the precipitating activity,
by rest, or with the use of nitroglycerin. Acute coronary syndrome describes a
continuum of myocardial ischemia, and Prinzmetal’s variant angina is a relatively
uncommon form of angina.
7. Which of the following is the most common cause of sudden cardiac death?
a. Ventricular fibrillation
b. Myocardial infarction
c. Coronary atherosclerosis
d. Pulmonary embolism
ANSWER: A
The most common cause of sudden cardiac death is ventricular fibrillation, a form of
abnormal electrical activity resulting from interruption of the heart’s electrical
conduction system.
8. Which of the following is a serum enzyme determination used to establish the
diagnosis of acute myocardial infarction (MI) and to determine the extent of
infarction?
a. Stress thallium-201 perfusion scintigraphy
b. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA)
c. Troponin I and troponin T
d. Streptokinase (SK)
ANSWER: C .
Cardiac serum biomarkers of acute MI include troponin I, troponin T, creatine kinase
isoenzyme (CK-MB), and myoglobin. The troponins and CK-MB are enzymes
released only when cell death (infarction) or injury occurs. Troponins are proteins
derived from the breakdown of myocardial sarcomeres. Troponin assays are the
most sensitive and specific in differentiating cardiac muscle damage from trauma to
skeletal muscle or other organs; and are virtually absent in the plasma of normal
persons and are found only after cardiac injury.
9. Which of the following is true for an MI with ST segment elevation (STEMI)?
a. It is due to partial blockage of coronary blood flow.
b. It is due to complete blockage of coronary blood flow.
c. Early fibrinolytic therapy will not improve the outcome for a patient with STEMI.
d. Morphine use for pain relief is never recommended for STEMI patients.
ANSWER: B
An MI with ST segment elevation is due to complete blockage of coronary blood flow
and more profound ischemia involving a relatively large area of myocardium. An MI
without ST segment elevation (non-STEMI) is due to partial blockage of coronary
blood flow. Early fibrinolytic therapy improves outcomes in STEMI but not in non-
STEMI. Morphine use for pain relief is recommended for STEMI; however, use of
morphine in non-STEMI patients is associated with increased mortality and should
be avoided in these patients.
10. When planning dental treatment for a patient with stable angina or a past
history of MI without ischemic symptoms, .
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a. administration of nitrous oxide should be avoided
b. a pulse oximeter should be used
c. nitroglycerin should be administered prophylactically
d. NSAIDs should be avoided
ANSWER: D
In several studies, the use of NSAIDs in patients with previous MI has been shown to
increase the risk for a subsequent myocardial infarction, even after only 7 days of
NSAID administration. Only naproxen did not increase the risk.
.
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Chapter 05: Cardiac Arrhythmias
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is the most common type of persistent arrhythmia?
a. Sinus arrhythmia
b. Premature atrial complexes
c. Atrial fibrillation
d. Ventricular flutter and fibrillation
ANSWER: C
The most common type of persistent arrhythmia is atrial fibrillation (AF). AF
affects more than 2.7 million people, and the majority is over age 60. In a dental
practice of 2000 adults, one can expect about 300 patients to have some type of
cardiac arrhythmia.
2. Which of the following sequences correctly depicts the normal pattern of sequential
depolarization of the structures of the heart? (1) Right and left bundle branches, (2)
sinoatrial (SA) node, (3) subendocardial Purkinje network, (4) bundle of His, (5)
atrioventricular (AV) node.
a. 5, 2, 4, 1, 3
b. 2, 5, 4, 1, 3
c. 2, 3, 4, 1, 5
d. 2, 5, 3, 1, 4
ANSWER: B .
The normal pattern of sequential depolarization involves the structures of the heart in the
following order: sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right
and left bundle branches, subendocardial Purkinje network.
3. Tachycardia in an adult is defined as a heart rate greater then beats/min, with
otherwise normal findings on the ECG.
a. 100
b. 125
c. 150
d. 175
ANSWER: A
Tachycardia in an adult is a heart rate greater than 100 beats/min. The rate usually is
between 100 and 180 beats/min. This condition most often is a physiologic response
to exercise, anxiety, stress, or emotion. Pathophysiologic causes include fever,
hypertension, hypoxia, infection, anemia, hyperthyroidism, and heart failure. Drugs
that may cause sinus tachycardia include atropine, epinephrine, alcohol, nicotine,
and caffeine.
4. Which of the following is a disorder of repolarization?
a. Mobitz type I (Wenckebach)
b. Wolff-Parkinson-White syndrome
c. Long QT syndrome
d. Torsades de pointes
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ANSWER: C
Long QT syndrome is a disorder of the conduction system in which the recharging of
the heart during repolarization (i.e., the QT interval) is delayed. It is caused by a
genetic mutation in myocardial ion channels and by certain drugs, or may be the
result of a stroke. Mobitz type I (Wenckebach) is a form of second-degree heart block.
Wolff-Parkinson-White syndrome is tachycardia involving the AV junction. Torsades
de pointes is a variant of ventricular tachycardia.
5. What is a specific advantage of implantable cardioverter-defibrillators (ICDs) in
contrast to pacemakers?
a. ICDs generally are smaller than pacemakers.
b. ICDs are capable of providing antitachycardia pacing (ATP) and
ventricular bradycardia pacing, while pacemakers are not capable of
providing such pacing.
c. ICDs have batteries that last much longer than pacemakers.
d. ICDs do not require antibiotic prophylaxis prior to dental treatment
whereas pacemakers do.
ANSWER: B
ICDs are capable not only of delivering a shock but of providing antitachycardia
pacing (ATP) and ventricular bradycardia pacing. ICDs generally are larger than
pacemakers, and their batteries do not last as long as those of a pacemaker.
6. Recent studies suggest dental devices do not cause significant with
pacemakers and ICDs probably because of increased internal _ .
a. interference; magnetic fields
b. defibrillation; EMI
c. cardiac arrhythmia; ATP .
d. EMI; shielding
ANSWER: D
Recent studies performed in humans together with previous data suggest that most
dental devices do not cause significant electromagnetic interference with the
sensing and pacing of pacemakers and ICDs. This probably reflects the increased
internal shielding provided in the newer pacemakers and ICDs.
7. Which of the following is classified as a significant arrhythmia according to
American College of Cardiology and American Heart Association guidelines?
a. Pathologic Q waves
b. Left bundle branch block
c. High-grade AV block
d. ST-T wave abnormalities
ANSWER: C
Patients with high-grade AV block, symptomatic ventricular arrhythmias in the
presence of cardiovascular disease, and supraventricular arrhythmias with an
uncontrolled ventricular rate are at major risk for complications and are not
candidates for elective dental care. The presence of pathologic Q waves is a clinical
predictor of intermediate risk for perioperative complications. Left ventricular
hypertrophy, left bundle branch block, and ST-T wave abnormalities are associated
with minor perioperative risk.
8. The use of what drugs in local anesthetics can pose problems for patients with arrhythmias?
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a. Digoxin
b. Vasoconstrictors
c. Beta-blockers
d. NSAIDs
ANSWER: B
The use of vasoconstrictors in local anesthetics poses potential problems for
patients with arrhythmias because of the possibility of precipitating cardiac
tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor may
be used as needed. They should also be avoided in patients taking digoxin because
of the potential for inducing arrhythmias.
9. If a vasoconstrictor in local anesthetic is deemed necessary, patients in the low to
intermediate risk category and those taking nonselective beta-blockers can safely be
given up to
cartridge(s) containing 1:100,000 epinephrine.
a. one
b. three
c. two
d. zero—epinephrine is an absolute contraindication
ANSWER: C
These patients can safely be given up to 0.036 mg epinephrine, which is the amount
in two cartridges containing 1:100,000 epinephrine. Greater quantities of
vasoconstrictor may well be tolerated, but increasing quantities are associated with
increased risk for adverse cardiovascular effects.
10. Due to the rapid absorption of a high concentration of epinephrine and the
potential for adverse cardiovascular effects, the use of gingival retraction cord
impregnated with
epinephrineshouldbeavoidedGfR
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risk. What might beusedasan
alternative?
a. Tetrahydrozoline
b. Oxymetazoline
c. Either A or B
d. Neither A nor B
ANSWER: C
For patients at all levels of cardiac risk, the use of gingival retraction cord
impregnated with epinephrine should be avoided because of the associated rapid
absorption of a high concentration of epinephrine and the potential for adverse
cardiovascular effects. As an alternative, plain cord saturated with tetrahydrozoline
HCl 0.05% or with oxymetazoline HCl 0.05% provides gingival effects equivalent to
those of epinephrine without the adverse cardiovascular effects.
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Chapter 06: Heart Failure (or Congestive Heart Failure)
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is the most common underlying cause of heart failure in
the United States?
a. Dilated cardiomyopathy
b. Coronary heart disease
c. Valvular heart disease
d. Hypertension
ANSWER: B
The most common underlying cause of heart failure in the United States is coronary
heart disease (secondary to atherosclerosis), accounting for 60% to 75% of cases,
with cardiomyopathy, hypertension, and valvular heart disease also well-
recognized contributory conditions. The second most common cause of heart
failure, accounting for about one fourth of all cases, is dilated cardiomyopathy.
2. Most of the acquired disorders that lead to heart failure result in initial failure of the
.
a. bundle of His
b. mitral valve
c. right ventricle
d. left ventricle
ANSWER: D .
Left ventricular heart failure (LVHF) often is followed by failure of the right
ventricle. In adults, left ventricular involvement is almost always present, even if
the clinical manifestations are primarily those of right ventricular dysfunction
(fluid retention without dyspnea or rales).
3. The outstanding symptom of left ventricular heart failure is .
a. dyspnea
b. dysphagia
c. cyanosis
d. rales
ANSWER: A
The outstanding symptom is dyspnea, which results from the accumulation or
congestion of blood in the pulmonary vessels—hence the designation congestive
heart failure. Acute pulmonary edema is often the result of left ventricular failure.
Left-sided heart failure leads to pulmonary hypertension, which increases the work
of the right ventricle, pumping against increased pressure, often culminating in
right-sided heart failure.
4. What is one reason the prognosis for patients with heart failure is poor?
a. The symptoms reflect respective ventricular dysfunction.
b. Because loss of life due to it cannot be modified by early
identification and treatment.
c. Primarily because auscultation often reveals a laterally displaced apical impulse
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caused by left ventricular hypertrophy.
d. It is a progressive disease with symptoms that worsen over time.
ANSWER: D
Heart failure also predisposes the patient to ischemic stroke, the risk for which is twice
as high as normal. The prognosis is better if the underlying cause can be treated. One
year after the diagnosis of heart failure, 20% of patients will succumb to the disease.
In people diagnosed with it, sudden death occurs six to nine times the rate for the
general population.
5. Which of these symptoms and signs of heart failure worsens when the patient
assumes a recumbent or semi-recumbent position?
a. Orthopnea
b. Paroxysmal nocturnal dyspnea (PND)
c. Cheyne–Stokes respiration
d. Tachycardia
ANSWER: A
Most patients with mild to moderate heart failure do not exhibit orthopnea when
treated adequately. Paroxysmal nocturnal dyspnea (PND) is an attack of sudden,
severe shortness of breath awakening the patient from sleep. PND is a common
clinical feature associated with Cheyne–Stokes respiration in heart failure patients.
With Cheyne–Stokes respiration, central regulation of respiration may be
impaired, resulting in alternating cycles of hyperventilation with periods of central
apnea. Tachycardia (increased pulse rate) indicates increased myocardial oxygen
demand, coronary blood flow, and overall myocardial performance.
6. What is a primary reason outcomes in the care of patients with heart
failure are not significantly improving? .
a. Management of heart failure is complex and generally applied in a graduated
approach.
b. An algorithm for drug treatment of heart failure has not been found.
c. Patient compliance with treatment recommendations is notoriously poor.
d. Drugs that modulate or decrease neurohormonal activity have not yet
become the foundation of treatment.
ANSWER: C
As with many conditions, a large degree of success of medical therapy depends
upon patient compliance with treatment recommendations. Since many of these
patients are treated with a plethora of drugs, it is important to monitor and/or
encourage their compliance. However, a relatively recent study has demonstrated
that even after telemonitoring and multiple verbal reminders, the overall impact
on improving outcomes in heart failure was not significant.
7. Which of the following categories of drugs is considered to be first-line
therapy for the treatment of heart failure?
a. Digitalis glycosides
b. -Adrenergic blockers
c. Angiotensin-converting enzyme (ACE) inhibitors
d. Angiotensin receptor blockers (ARBs)
ANSWER: C
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ACE inhibition with enalapril has been shown to reduce mortality from heart failure
by 20% to 40%. The ACE inhibitors are typically prescribed along with or following
diuretic therapy and they decrease the need for large doses of diuretics as well as
some of the adverse metabolic effects of the diuretics.
8. If drug therapy is found to be inadequate in controlling patients with severe,
refractory heart failure .
a. mechanical and/or surgical intervention may be introduced
b. end-of-life care with hospice is the only remaining option
c. medical therapy will depend solely upon patient compliance with
experimental recommendations
d. diuretic therapy becomes a patient’s “long shot” final attempt at improved health
ANSWER: A
Mechanical and surgical intervention may be provided. These measures may
include intra-aortic balloon counterpulsation, left ventricular assist device
(LVAD), and heart transplantation. Other therapies include implantable
cardioverter-defibrillator (ICD),
9. Dental patients with a previous history of heart failure or who are asymptomatic have
heart failure.
a. decompensated
b. compensated
c. provisional
d. orthopnea
ANSWER: B
With decreasing cardiac output, stimulation of the renin–angiotensin system and the
sympathetic nervous system (n
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s) occur in an attempt to
compensate for
the loss of function. The effects of these responses include increased heart rate and
myocardial contractility, increased peripheral resistance, sodium and water
retention, redistribution of blood flow to the heart and brain, and an increased
efficiency of oxygen utilization by the tissues. If these responses result in improved
cardiac output with an elimination of symptoms, the condition is termed compensated
heart failure. Symptomatic heart failure is termed decompensated.
10. To what key information source must a dentist refer in determining the risk
involved in treating a heart failure patient?
a. The New York Heart Association’s classification system of heart failure
b. Clinical manifestations of digitalis toxicity
c. All details the patient included in the dental history
d. The patient’s physician
ANSWER: D
In most cases, it will be necessary for the dentist to obtain a medical consultation
with the patient’s cardiologist in order to determine physical status, laboratory test
results, level of control, compliance with medications and recommendations, and
overall stability. The American College of Cardiology and the American Heart
Association have published guidelines which can help to make this determination.
These guidelines can be applied to the provision of dental care and be of significant
value to the dentist in making a determination of risk.
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Chapter 07: Pulmonary Disease
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. The most important cause of chronic obstructive pulmonary disease (COPD) in the world is
.
a. occupational pollutants
b. environment pollutants
c. tobacco smoking
d. allergy
ANSWER: C
Worldwide, tobacco smoking is the most important cause of COPD. Approximately
12.5% of current smokers, 9% of former smokers, and 8% of those exposed to
passive smoke have COPD. Smoking also accounts for 85% to 90% of COPD-related
deaths in both men and women. The risk for development of COPD is dose related
and increases with the number of cigarettes smoked per day and duration of
smoking.
2. Which of the following is true of the signs and symptoms associated with COPD for patients
who were historically referred to as “blue bloaters” or “pink puffers”?
a. Patients who had emphysema were traditionally known as “pink puffers”
because they demonstrated enlarged chest walls, giving them a “barrel-
chested” appearance.
b. Currently, it is recognized that most patients with COPD may exhibit
features of both diseases. .
c. “Blue bloaters” demonstrated weight loss with progression of the disease and a
lack of cyanosis.
d. A and B
e. B and C
ANSWER: D
“Blue bloaters” were presented as patients who had chronic bronchitis. They were
described as sedentary, overweight, cyanotic, edematous, and breathless. Patients
diagnosed with emphysema, “pink puffers,” exhibit weight loss with disease
progression, severe exertional dyspnea with a mild, nonproductive cough, lack of
cyanosis, and pursing of the lips with effort to forcibly exhale air from the lungs.
Most patients with COPD may exhibit features of both diseases.
3. Which two of the following are true of the arterial blood gas measurement for a
patient with emphysema?
1. Elevated partial pressure of carbon dioxide
2. Normal partial pressure of carbon dioxide
3. Decreased partial pressure of carbon dioxide
4. Decreased partial pressure of oxygen
5. Normal partial pressure of oxygen
a. 1, 4
b. 2, 4
c. 3, 4
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d. 1, 5
e. 2, 5
ANSWER: B
Patients with emphysema have a relatively normal partial pressure of carbon
dioxide and a decreased partial pressure of oxygen. Patients with chronic bronchitis
have an elevated partial pressure of carbon dioxide and a decreased partial pressure
of oxygen.
4. Which of the following is true of dental management for a patient with COPD?
a. The appointment should be rescheduled if pulse oximetry finds the
oxygen saturation level to be less than 91%.
b. The patient should be placed in a supine position for treatment in the dental chair.
c. Prilocaine is the only local anesthetic that is recommended for use
with this category of patient.
d. Nitrous oxide is preferred over diazepam (Valium) for a patient
with severe COPD.
ANSWER: A
A patient coming to the office for routine dental care who displays shortness of
breath at rest, a productive cough, upper respiratory infection, or an oxygen
saturation level less than 91% (as determined by pulse oximetry) is unstable, and the
appointment should be rescheduled and an appropriate referral for medical
attention should be made. Patients should be placed in a semisupine or upright
chair position for treatment, rather than in the supine position, to prevent orthopnea
and a feeling of respiratory discomfort. No contraindication to the use of local
anesthetic has been identified. If sedative medication is required, low-dose oral
diazepam may be used. Nitrous oxide–oxygen inhalation sedation should not be
used in patients with severe COPD and emphysema because gas may accumulate in
air spaces of the
diseased lung.
.
5. Which of the following chronic inflammatory diseases of the airways is
characterized by reversible episodes of increased airway hyperresponsiveness?
a. Emphysema
b. Asthma
c. Chronic bronchitis
d. A and B
e. B and C
ANSWER: B
Asthma is a chronic inflammatory disease of the airways characterized by reversible
episodes of increased airway hyperresponsiveness resulting in dyspnea, coughing,
and wheezing.
Chronic bronchitis and emphysema are forms of chronic obstructive pulmonary
disease (COPD), which is a general term for pulmonary disorders characterized
by chronic airflow limitation from the lungs that is not fully reversible.
6. Which of the following medications is associated with “triad asthmaticus”?
a. Methotrexate
b. Nonspecific beta-blockers
c. Aspirin
d. Penicillin
ANSWER: C
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Aspirin causes bronchoconstriction in about 10% of patients with asthma, and
sensitivity to aspirin occurs in 30% to 40% of people with asthma who have
pansinusitis and nasal polyps (the so-called triad asthmaticus). The ability of
aspirin to block the cyclooxygenase pathway appears causative.
7. Which of the following agents is currently regarded as the first-line medication for
long-term control of asthma?
a. -Adrenergic agonist
b. Corticosteroid
c. Theophylline
d. Cromolyn sodium
ANSWER: B
Current guidelines recommend a “stepwise” approach with the use of inhaled
antiinflammatory agents as first-line drugs (the preferred inhalational agent is a
corticosteroid preparation, with a leukotriene inhibitor as an alternative) for the
long-term management and prophylaxis of persistent asthma. -Adrenergic
agonists are recommended for intermittent asthma and are secondary agents that
should be added (i.e., not to be used alone) for persistent asthma when
antiinflammatory drugs are inadequate alone.
8. Which of the following is the drug of choice for relief of an acute asthma attack?
a. Oral anticholinergic
b. Inhalation corticosteroid
c. Short-acting 2-adrenergic agonist
d. Inhaled cromolyn sodium
ANSWER: C .
For relief of an acute asthma attack, inhaled short-acting 2-adrenergic agonists are
the drugs of choice because of their fast and notable bronchodilatory and smooth
muscle relaxation
properties. Short-acting 2-adrenergic agonists produce bronchodilation by
activating 2 receptors on airway smooth muscle cells, generally in 5 minutes or
less. Inhalation corticosteroids, inhaled cromolyn sodium, and oral
anticholinergics are not used for this purpose because of slow onset of action.
9. The use of local anesthetic without epinephrine or levonordefrin may be advisable for
patients with moderate to severe asthma because preservatives are found in
local anesthetic solutions that contain epinephrine or levonordefrin.
a. alum
b. sulfite
c. methylparaben
d. sodium chloride
ANSWER: B
In 1987, the U.S. Food and Drug Administration (FDA) warned that drugs
containing sulfites were a cause of allergic-type reaction in susceptible individuals.
Sulfite preservatives are found in local anesthetic solutions that contain epinephrine
or levonordefrin, although the amount of sulfite in a local anesthetic cartridge is less
than the amount commonly found in an average serving of certain foods.
10. According to the World Health Organization (WHO), approximately what percentage of the
world’s population is infected with tuberculosis?
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a. One tenth
b. One eighth
c. One quarter
d. One third
ANSWER: D
The World Health Organization (WHO) estimates that one third of the world’s
population— representing 2 billion people—is infected. This disease kills more
adults worldwide each year than does any other single pathogen.
11. Which of the following is true regarding laboratory tests for tuberculosis?
a. A positive tuberculin (Mantoux) skin test (TST) means that the
person has clinically active tuberculosis.
b. The interferon-gamma release assay (IGRA) is administered by
intradermal injection of 0.1 mL of purified protein derivative (PPD).
c. All dentists should undergo annual tuberculin skin testing.
d. The IGRA test can discriminate active from latent infection.
ANSWER: C
All persons who are at risk for development of TB—including dentists—should
undergo tuberculin skin testing annually. Without treatment, approximately 5% of
skin test converters develop TB within 2 years; another 5% develop it later. A
positive result on a tuberculin (Mantoux) skin test (TST) presumptively means that
the person has been infected. It does not mean that the person has clinically active
TB. IGRAs (interferon-gamma release assays) are performed on fresh whole blood.
Neither the TST nor the IGRA can discriminate active from latent infection.
12. For which of the following cat
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dentaloffice contraindicated?
1. Patients with a positive tuberculin test
2. Patients with a history of tuberculosis
3. Patients with clinically active sputum-positive tuberculosis
a. 1, 2, 3
b. 1, 2
c. 2, 3
d. 3
ANSWER: D
Patients with recently diagnosed, clinically active TB and positive sputum cultures
should not be treated on an outpatient basis. Treatment is best rendered in a
hospital setting with appropriate isolation, sterilization (mask, gloves, gown), and
special engineering control (ventilation) systems and filtration masks. The patient
with a history of tuberculosis who is found to be free of active disease and is not
immunosuppressed may be treated with the use of standard precautions. Patients
with a positive tuberculin skin test may be treated in a normal manner with the use
of standard precautions.
13. Any time a patient demonstrates unexplained, persistent signs or symptoms that
may be suggestive of TB, or has a positive result on skin testing or IGRA, and
has not been given follow-up medical care, .
a. it is appropriate to treat the patient using standard precautions
b. respiratory equipment should be used during provision of dental care
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c. only treatment that utilizes a rubber dam should be provided
d. dental care should not be rendered, and the patient should be
referred to a physician for evaluation
ANSWER: D
Dental care should not be rendered. If a health care provider is exposed to TB, the
provider should be evaluated for skin test conversion. Converters should be
treated promptly with isoniazid.
.
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Chapter 08: Smoking and Tobacco Use Cessation
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following causes the most preventable deaths in the United States?
a. Motor vehicle crashes
b. Acquired immunodeficiency syndrome (AIDS)
c. Smoking
d. Alcohol abuse and illicit drug use
ANSWER: C
Smoking is the leading cause of preventable death and disease in the United States,
resulting in nearly half a million premature deaths per year and over $200 billion in
direct health care costs and lost productivity. Smoking causes more than twice as
many deaths as human immunodeficiency virus (HIV) infection and acquired
immunodeficiency syndrome (AIDS), alcohol abuse, motor vehicle crashes, illicit
drug use, and suicide combined.
2. The nicotine in tobacco products contains complex addictive and behavioral effects
that are known to primarily affect what within the brain?
a. Neuroreceptors
b. Dopaminergic pathways
c. Centers of logic
d. It affects many other parts of the body, but not the brain in particular.
ANSWER: B .
Nicotine is a highly addictive drug that has been equated with heroin, cocaine, and
amphetamine in terms of addiction potential and its effects on brain neurochemistry.
The addictive and behavioral effects of nicotine are complex and are due primarily to
its effects on dopaminergic pathways.
3. How long does it take nicotine to reach the brain following inhalation of cigarette smoke?
a. 10 seconds
b. 60 seconds
c. 5 minutes
d. 15 minutes
ANSWER: A
A cigarette is a very efficient delivery system for the inhalation of nicotine. Nicotine is
rapidly distributed throughout the body after inhalation, reaching the brain in as
little as 10 seconds. A person who smokes about 30 cigarettes a day gets 300 hits of
nicotine to the brain every day, each one within 10 seconds after a puff.
4. Which of the following is true concerning the benefits of quitting smoking?
a. The risk of dying of lung cancer is double among smokers than in those
who have never smoked.
b. Persons who quit smoking before the age of 50 have half of the risk of
dying in the next 15 years compared with those who continue to smoke.
c. The risk of dying of coronary heart disease for smokers is double that for
lifetime nonsmokers, as is the risk of dying from a stroke.
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d. A and B
e. B and C
ANSWER: E
Data show that persons who quit smoking before the age of 50 have half the risk of
dying in the next 15 years compared with those who continue smoking. Risks of
dying of lung cancer are 22 times higher among male smokers and 12 times higher
among female smokers than in those who have never smoked. Smokers have twice
the risk of dying of coronary heart disease compared with lifetime nonsmokers.
5. Which of the following is true about interventions for smoking cessation?
a. Patients need to be “badgered” about quitting smoking.
b. The highest success rates are achieved by stopping “cold turkey.”
c. The chance for success increases when more than one option is used.
d. Use of telephone quit lines does not increase the chances of success.
ANSWER: C
In general, the chance for success increases when more than one option is used, and
counseling combined with nicotine replacement therapy (NRT) or medication
significantly improves outcomes. “Badgering” the patient is not advised. The 1-year
success rate with stopping cold turkey is about 5%. The use of telephone quit lines
or brief counseling roughly doubles the chance of success, as does the use of any of
the NRT products.
6. If a patient does not desire to stop smoking, what is a health care provider encouraged to do?
a. Prescribe smoking cessation medications for the patient.
b. Since it relates to a health issue, not to give up and to gently push the patient.
c. Refuse to offer services and refer the patient to another practitioner.
d. Point out the benefits of qu
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ANSWER: D
The patient should be made aware that you support and encourage quitting to
improve overall health and that you will assist in an effort to quit. If the patient
does not wish to quit, the provider is encouraged to point out the benefits of doing
so as a method of motivating the patient. If there is still, the topic should be dropped
and the patient not badgered. It is generally counterproductive to pursue the issue;
however, the patient can be told that if at any time they would like to quit, you
would be happy to speak with them about it.
7. Evidence has shown that the more intensive the counseling, the better the
success rate. Counseling typically consists of both and therapies.
a. smoking; addictive
b. pharmacological; psychological
c. Cessation; NRT
d. cognitive; behavioral
ANSWER: D
Counseling typically consists of both cognitive and behavioral therapies. Cognitive
therapy attempts to change the way a patient thinks about smoking, while
behavioral therapy attempts to help smokers avoid situations that might trigger the
desire to smoke. Evidence has shown that the more intensive the counseling, the
better the success rate, and that when counseling is combined with other forms of
therapy, such as nicotine replacement therapy or pharmacotherapy, it is even more
effective.
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8. How long does it take nicotine blood levels to return to baseline after smoking a cigarette?
a. 1 minute
b. 25 to 30 minutes
c. 3 to 5 hours
d. 1 day
ANSWER: B
Smoking one cigarette rapidly increases nicotine blood levels to 35 to 40 ng/mL,
producing the “hit” or “rush” experienced with smoking; this level then gradually
returns to baseline within about 25 to 30 minutes. To prevent withdrawal
symptoms, a smoker must maintain a baseline level of nicotine of about 15 to 18
ng/mL.
9. Why are e-cigarettes subject to government (FA) regulation?
a. Because they are designed to simulate the act of tobacco smoking
b. Because they contain nicotine derived from tobacco
c. Because little is known about their health risks
d. Because they are often promoted as safer alternatives to traditional cigarettes
ANSWER: B
In an effort to help protect the public from the dangers of tobacco use, the U.S. Food
and Drug Administration (FDA) has established a new rule for e-cigarettes and their
liquid solutions.
Because e-cigarettes contain nicotine derived from tobacco, they are now subject to
government regulation as tobacco products, including the requirement that both in-
store and online purchasers are at least 18 years of age.
10. Which pair of FDA-approved non-NRT pharmacotherapeutic smoking cessation
agents has proven more effective than anG
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a. Bupropion SR and varenicline
b. Monoamine oxidase inhibitors and opioid receptor antagonists
c. Bromocriptine and glucose tablets
d. Partial nicotine agonists and nicotine vaccines
ANSWER: A
Bupropion SR is a first-line, FDA-approved, non-NRT pharmacotherapeutic
cessation agent. It is an atypical antidepressant thought to affect the dopaminergic
and/or noradrenergic pathways involved in nicotine addiction. It is effective when
used alone or in combination with an NRT product and/or counseling. Another
FDA-approved agent is varenicline, an alpha4beta2 nicotinic receptor partial agonist
that stimulates dopamine and blocks nicotinic receptors, thus preventing the reward
and reinforcement associated with smoking. Other treatment strategies have less-
proven efficacy and there are various other approaches currently under
investigation.
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Chapter09: Sleep-Related Breathing Disorders
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is true about primary snoring?
a. Primary snoring is associated with fragmentation of sleep architecture.
b. Primary snoring is not associated with disrupted sleep or complaints of
daytime sleepiness.
c. Primary snoring is also known as upper airway resistance syndrome (UARS).
d. Primary snoring is characterized by episodes of complete cessation of
breathing due to airway obstruction during sleep.
ANSWER: B
Primary snoring is sometimes referred to as simple snoring or benign snoring. It
occurs as an independent entity and is not associated with disrupted sleep or
complaints of daytime sleepiness and occurs without abnormal ventilation.
Findings on an overnight sleep study, or polysomnogram (PSG), are normal. UARS
is a clinical entity midway between primary snoring and OSA that is characterized
by snoring, variable complaints of daytime sleepiness, and fragmentation of sleep.
2. Which of the following are the most common sites of airway narrowing or
closure during sleep for a patient with obstructive sleep apnea (OSA)?
a. The retropalatal and retroglossal regions
b. Septal deviation and enlarged turbinates
c. Hypertrophic adenoids and
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d. Redundant parapharyngeal folds
ANSWER: A
The most common sites of airway narrowing or closure during sleep are the
retropalatal and retroglossal regions. Most patients with OSA have more than one
site of narrowing.
3. Which of the following is characteristic of REM sleep?
a. Synchronous brain waves
b. Low-voltage EEG waves
c. Mental inactivity
d. Physiologic stability
ANSWER: B
A key feature of REM sleep is the presence of periodic rapid movement of the eyes with
low-voltage EEG waves resembling those typical of wakefulness. REM sleep is
characterized by asynchronous brain waves, an active brain, physiologic instability,
and muscular inactivity. The REM sleep state often is described as “an active brain
in a paralyzed body.” Dreaming occurs during REM sleep.
4. Most people who snore do not have OSA, but almost all patients with OSA snore.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
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ANSWER: A
In the Wisconsin Sleep Cohort Study of subjects aged 30 to 60 years, 44% of men and
28% of women were habitual snorers, but only 4% of the men and 2% of the women
had OSA.
5. Which of the following components of a polysomnogram (PSG) is used to
monitor eye movements?
a. ECG
b. EEG
c. EMG
d. EOG
ANSWER: D
The electrooculogram (EOG) is used to monitor eye movements. The
electrocardiogram (ECG) monitors heart rate and rhythm, the electroencephalogram
(EEG) is used to monitor brain waves, and the electromyogram (EMG) is used to
monitor jaw muscular activity.
6. Approximately what percentage of patients who try positive airway pressure
(PAP) for treatment of obstructive sleep apnea (OSA) are able to tolerate it?
a. 100
b. 75
c. 50
d. 25
ANSWER: C
Compliance with PAP has long been a problem, with only about 50% of patients
who try it able to tolerate it. Of those who do use PAP, the average patient uses it
for only about 4 to 5
hours per night and for onlyab
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are common and include mask leaks, skin ulceration or irritation under the mask,
epistaxis, rhinorrhea, nasal congestion, sinus congestion, dry eyes, conjunctivitis, ear
pain, and claustrophobia.
7. Which of the following is true of tongue-retaining devices (TRDs) used to treat
patients with sleep-related breathing disorders?
a. They typically are made of acrylic resin and are composed of two pieces
that cover the upper and lower dental arches.
b. Over 70 different types of TRDs have been approved by the FDA for
treatment of obstructive sleep apnea (OSA).
c. TRDs are capable of providing continuous positive airway pressure (CPAP).
d. TRDs generally are made of silicone in the shape of a bulb or cavity.
ANSWER: D
The tongue is stuck into the bulb, which is then squeezed and released, producing a
suction that holds the tongue forward in the bulb. Mandibular advancement devices
(MADs) typically are made of acrylic resin and cover the upper and lower dental
arches. Only one design of tongue-retaining device has been approved by the FDA
for treatment of OSA.
8. Of the surgical procedures advocated to treat OSA (to varying degrees of success),
which is almost uniformly effective in curing OSA?
a. Laser-assisted uvulopalatoplasty (LAUP)
b. Tracheostomy
c. Maxillary and mandibular advancement osteotomy (MMO)
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d. Nasopharyngoscopy
ANSWER: B
Tracheostomy, which bypasses all obstruction in the entire upper airway, is almost
uniformly effective in curing OSA. Its use is limited, however, in that it is
unacceptable to most patients but may be used for the occasional patient with very
severe OSA who is intolerant of CPAP and who requires urgent treatment.
9. Which of the following is the most successful surgical treatment for OSA in children?
a. Uvulopalatopharyngoplasty (UPPP)
b. Radiofrequency volumetric tissue reduction (RVTR)
c. Adenotonsillectomy
d. Laser-assisted uvulopalatoplasty (LAUP)
ANSWER: C
Adenotonsillar hypertrophy is the most common cause of upper airway
obstruction in children; adenotonsillectomy is curative in 75% to 100% of such
cases.
10. Which of the following statements regarding mandibular advancement devises
(MADs) and tongue-retaining devices (TRDs) is NOT true?
a. Both are associated with increased airway size in both the
retropalatal and retroglossal regions.
b. Both provide similar treatment effects; however, TRDs are not tolerated
by users as well as MADs.
c. Both offer attractive for patients unable to tolerate positive airway
pressure (PAP) devices.
d. Both are oral appliances that directly engage the tongue and hold it in a forward
position. .
ANSWER: D
The two basic types of oral appliances are MADs, which engage the mandible and
reposition it (and indirectly, the tongue) in an anterior or forward position, and
TRDs, which directly engage the tongue and hold it in a forward position. Oral
appliances offer an alternative treatment option for patients unable to tolerate or
refuse to use a PAP. Oral appliances exert their effects by mechanically increasing
the volume of the upper airway in the retropalatal and retroglossal areas.
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Chapter 10: Liver Disease
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which of the following is a form of infectious (rather than serum) hepatitis?
a. Hepatitis a
b. Hepatitis b
c. Hepatitis c
d. Hepatitis d
ANSWER: A
Hepatitis A and hepatitis E are forms of infectious hepatitis; they are spread largely
by the fecal–oral route, are associated with poor sanitary conditions, are highly
contagious, occur in outbreaks as well as sporadically, and cause self-limited
hepatitis only. Hepatitis B, hepatitis C, and hepatitis D are forms of serum
hepatitis, are spread largely by parenteral routes and less commonly by intimate or
sexual exposure, and are not highly contagious but instead occur sporadically and
rarely cause outbreaks.
2. Which of the following is thought to be the major factor in the pathogenesis of liver injury?
a. Antibody-dependent cellular cytotoxicity
b. Proinflammatory cytokines
c. Cytotoxic T cell responses
d. Natural killer cell activity
ANSWER: C .
The timing and histologic appearance of hepatocyte injury in viral hepatitis suggest that
immune responses, particularly cytotoxic T cell responses to viral antigens
expressed on hepatocyte cell membranes, may be the major effectors of injury.
Other proinflammatory cytokines, natural killer cell activity, and antibody-
dependent cellular cytotoxicity also may play modulating roles in cell injury and
inflammation during acute viral hepatitis infection.
3. Which of the following is the most reliable prognostic factor in acute hepatic
failure due to hepatitis?
a. Changes in personality
b. The degree of prolongation of prothrombin time
c. Serum aminotransferase levels
d. Viral titers
ANSWER: B
The most reliable prognostic factor in acute hepatic failure is the degree of
prolongation of the prothrombin time; other signs of poor prognosis are persistently
worsening jaundice, ascites, and decreases in liver size. Serum aminotransferase
levels and viral titers have little prognostic value and often decrease with worsening
hepatic failure.
4. (A/An) _ syndrome develops during the preicteric phase in
approximately 10% to 20% of patients with acute hepatitis.
a. chronic fatigue
b. irritable bowel
c. serum sickness–like
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d. aspirin triad syndrome
ANSWER: C
In 10% to 20% of patients with acute hepatitis, a serum sickness–like syndrome
marked by variable combinations of rash, arthralgias, and fever develops during the
preicteric phase. This immune complex-like syndrome often is mistakenly attributed
to other illnesses until the onset of jaundice, at which time the fever, hives, and
arthralgias quickly resolve.
5. Which of the following is true regarding the diagnosis of acute viral hepatitis?
a. Acute viral hepatitis is marked by a prominent fibrosis observed during
histologic evaluation.
b. Immunohistochemical stains for hepatitis antigens are positive during
the acute disease.
c. There are reliably distinctive features in the liver that separate the five
viral forms of acute hepatitis from one another.
d. Serologic tests are adequate for the diagnosis of acute viral hepatitis, so
liver biopsy is not recommended unless the diagnosis remains unclear
and a therapeutic decision is needed.
ANSWER: D
Serologic tests are adequate for diagnosis. If biopsy is required, the histologic pattern
in acute viral hepatitis is characterized by widespread parenchymal inflammation
and spotty necrosis. Inflammatory cells are predominantly lymphocytes,
macrophages, and histiocytes. Fibrosis is absent. Immunohistochemical stains for
hepatitis antigens generally are negative during the acute disease, and there are no
reliably distinctive anatomic features in the liver that separate the five viral forms of
acute hepatitis from each other.
6. Which of the following is the G
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a. Consumption of shellfish from contaminated waterways
b. Fecal contamination of food or water
c. Direct person-to-person exposure
d. Blood transfusions
ANSWER: C
Investigation of the sources of infection for hepatitis A reveals that most cases are
due to direct person-to-person exposure and, to a lesser extent, to direct fecal
contamination of food or water. Consumption of shellfish from contaminated
waterways is a well-known but quite uncommon means of acquiring hepatitis A.
Rare instances of hepatitis A being spread by blood transfusions and administration
of pooled plasma products have been described.
7. Which of the following is associated with immunity to hepatitis B?
a. HBsAg
b. HBcAg
c. HBeAg
d. Anti-HBs
e. Anti-HBe
ANSWER: D
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Anti-HBs is a long-lasting antibody that is associated with immunity. Generally,
HBV DNA, and HBeAg begin to fall at the onset of illness and may be undetectable
at the time of peak clinical illness. HBsAg becomes undetectable and anti-HBs
appears during recovery, several weeks to months after loss of HBsAg.
8. Which of the following is true regarding prevaccination screening and booster
doses of hepatitis B vaccine?
a. Prevaccination screening and booster doses are recommended for all
persons receiving the hepatitis B vaccination.
b. Prevaccination screening is not recommended; however, booster
doses are recommended for all persons receiving the hepatitis B
vaccination.
c. Prevaccination screening is not recommended except for adults in high-
risk groups. Booster doses are not routinely recommended but may be
appropriate for persons at high risk if titers of anti-HBs fall below what
is considered protective.
d. Neither prevaccination screening, nor booster doses of hepatitis B
vaccine are recommended for anyone.
ANSWER: C
Prevaccination screening for anti-HBs is not recommended except in adults in high-
risk groups. Postvaccination testing for anti-HBs to document seroconversion is not
recommended routinely except in persons whose subsequent clinical management
depends on knowledge of their immune status, particularly health care and public
safety workers. At present, booster doses are not recommended but may be
appropriate for persons at high risk if titers of
anti-HBs fall below what is considered protective (10 IU/mL). Current guidelines
published by the Centers for Disease Control and Prevention (CDC) Advisory
Committee on Immunization Practices recommend booster doses only for persons
who did not respond to the primary vaccine series. .
9. Which of the following is the most common means of transmission of hepatitis C?
a. Maternal-infant
b. Sexual exposure
c. Injection drug use
d. Needlestick accidents
ANSWER: C
Current studies of acute hepatitis C indicate that more than 60% of cases are
attributable to injection drug use; 15% to 20% to sexual exposure; and only a small
proportion to
maternal-infant spread, needlestick accidents, and iatrogenic causes.
Approximately 10% of cases are not associated with any history of potential
exposure and remain unexplained.
10. Which of the following hepatitis viruses is second most likely (following hepatitis
B) to be transmitted occupationally to a dental healthcare worker?
a. HAV
b. HCV
c. HEV
d. Non-A-E
ANSWER: B
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Little to no risk exists for transmission of HAV, HEV, and non-A-E hepatitis viruses
from occupational exposure of dental health care workers to persons infected with
these viruses. Risk for transmission of HBV is well recognized, and a lesser risk is
present for HCV infection after occupational exposure to infected blood or body
fluids containing infected blood. After percutaneous or other sharps injury in health
care workers involving exposure to contaminated blood, the risk of contracting
HBV infection is reported to range from 6% to 30%. The seroconversion rate for
accidental blood exposure to HCV is between 2% and 8%.
11. Chronic active hepatitis B is diagnosed by the presence of in blood serum.
a. HBsAg
b. HBcAg
c. HBeAg
d. A, B, and C
e. A and C
ANSWER: E
Chronic active hepatitis B is characterized by HBsAg and HBeAg in the serum,
signs and symptoms of chronic liver disease, persistent hepatic cellular necrosis,
and elevation of liver enzymes for longer than 6 months.
12. According to CDC guidelines, what should be done first if a vaccinated health care
worker sustains a needlestick or puncture wound involving exposure to blood from
a patient known to be HBsAg-positive?
a. Nothing, because the health care worker has already been vaccinated.
b. The health care worker should be tested for an adequate titer of anti-HBs
if those levels are unknown.
c. The health care worker sho
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d. The health care worker should immediately receive an injection of the hepatitis B
vaccine as a booster dose.
ANSWER: B
The health care worker should be tested for an adequate titer of anti-HBs. If the
levels are inadequate, the worker should immediately receive an injection of
HBIG and a vaccine booster dose. If the antibody titer is adequate, however,
nothing further is required.
13. Which of the following is true of the pathophysiology of alcoholic liver disease?
a. Fatty liver is not reversible.
b. Alcoholic hepatitis may be fatal if damage is widespread.
c. In some patients with cirrhosis, blood from bleeding ulcers and
esophageal varices is incompletely metabolized to ammonia.
d. A and B
e. B and C
ANSWER: E
Fatty liver is considered completely reversible. For the most part, alcoholic hepatitis
is considered a reversible condition; however, it can be fatal if damage is
widespread. In some patients with cirrhosis, blood is metabolized to ammonia,
which travels to the brain and contributes to encephalopathy.
14. Which of the following tests is the best way to screen for problems before dental
treatment of an alcoholic patient?
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a. Bilirubin total
b. Alkaline phosphatase total
c. LDH total
d. A complete blood count (CBC)
ANSWER: D
A CBC with differential and determinations of AST and ALT, bleeding time,
thrombin time, and prothrombin time are sufficient to screen for potential problems.
Abnormal laboratory values, on a background of suggestive findings on the clinical
examination or a positive history, constitute the basis for referral to a physician for
definitive diagnosis and treatment.
15. Which of the following types of breath odor is associated with liver failure?
a. Sweet, musty
b. Breadlike
c. Ammonia
d. Garlic
ANSWER: A
A sweet, musty odor to the breath is associated with liver failure, as is jaundiced
mucosal tissue.
.
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Chapter 11: Gastrointestinal Disease
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. Which is the most common location for peptic ulcers in Western populations?
a. Stomach
b. Duodenum
c. Jejunum
d. Ileum
ANSWER: B
The first portion of the duodenum is the location of most ulcers in Western
populations, whereas gastric ulcers are more frequent in Asia. The upper jejunum
rarely is involved. Peptic ulcers develop principally in regions of the gastrointestinal
tract that are proximal to acid and pepsin secretions.
2. Which of the following is the most common cause of peptic ulcer disease?
a. Cytomegalovirus infection
b. Acid hypersecretion
c. H. pylori infection
d. Use of nonsteroidal anti-inflammatory medication
ANSWER: C
The primary etiologic factor is H. pylori. This organism is present in 80% of duodenal ulcers.
Use of NSAIDs is the second most common cause of peptic ulcer disease. Other risk
factors include advanced age, psycholG
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smoking, use of certain drugs, and major comorbid disease. Cystic fibrosis also
predisposes to ulcers. Cytomegalovirus infection is a rare cause noted in human
immunodeficiency virus (HIV)–positive patients.
3. Which of the following is characteristic of gastric peptic ulcers rather than
duodenal peptic ulcers?
a. Epigastric pain that is long-standing
b. Diffuse rather than localized epigastric pain
c. Symptoms rapidly relieved in most cases by ingestion of food, milk, or antacids
d. Pain that most commonly manifests 90 minutes to 3 hours after eating
ANSWER: A
Many patients with an active peptic ulcer report no ulcer symptoms; however, most
experience epigastric pain that is long-standing, sharply localized, and recurrent. The
pain is described as “burning” or “gnawing,” but may be “ill-defined” or “aching.”
The discomfort of a duodenal ulcer manifests most commonly on an empty stomach,
and frequently awakens the patient in the middle of the night. Ingestion of food,
milk, or antacids provides rapid relief in most cases. In contrast, patients with gastric
ulcers are unpredictable in their response to food; in fact, eating may precipitate
abdominal pain.
4. Which of the following is/are components of currently recommended therapy
when a peptic ulcer is confirmed and H. pylori is present?
a. Inhibitors of gastric acid secretion
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b. Dissection of the vagus nerves from the gastric fundus
c. Antimicrobial agents
d. A, B, and C
e. A and C
ANSWER: E
Combination therapy is recommended because antisecretory drugs, such as
histamine H2 receptor antagonists and PPIs, provide rapid relief of pain and
accelerate healing, and antibiotics are effective in eradicating H. pylori. Elective
surgical intervention largely has been abandoned in the management of peptic
ulcer disease. Today, surgery is reserved primarily for complications of peptic ulcer
disease, such as significant bleeding, perforation, and gastric outlet obstruction.
5. Which of the following is true of Crohn’s disease?
a. Crohn’s disease is limited to the large intestine and the rectum.
b. Crohn’s disease affects men and women equally.
c. Crohn’s disease occurs more often in smokers.
d. Most patients who have Crohn’s disease require at least one operation
for their condition.
ANSWER: D
Most patients with Crohn’s disease require at least one operation. Crohn’s disease is a
transmural process that may produce “patchy” ulcerations at any point along the
alimentary canal, from the mouth to the anus, but most commonly involves the
terminal ileum. Ulcerative colitis affects men and women equally, whereas Crohn’s
disease is slightly more common among women. Crohn’s disease occurs more often
in nonsmokers, whereas smoking protects against ulcerative colitis.
.
6. Patients with inflammatory bowel disease (IBD) who have fewer than bowel
movements per day with little or no blood, no fever, few symptoms, and a
sedimentation rate below 20 mm/hour are considered to have mild disease and
can receive dental care in the dentist’s office.
a. two
b. four
c. six
d. eight
ANSWER: B
Patients with fewer than four bowel movements per day can receive dental care in
the dentist’s office. Patients with moderate disease or severe disease—the latter
defined as having siz or more bowel movements per day with blood, fever, anemia,
and a sedimentation rate higher than 30 mm/hour—are poor candidates for dental
care and should be referred to their physician.
7. Which of the following is the most common oral complication associated with
inflammatory bowel disease (IBD)?
a. Petechiae
b. Vascular pools
c. Sialadenitis
d. Aphthous-like lesions
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ANSWER: D
Aphthous-like lesions occur in up to 20% of patients with ulcerative colitis. They
typically are located on the alveolar, labial, and buccal mucosa, as well as the soft
palate, uvula, and retromolar trigone, and they may be difficult to distinguish from
aphthous lesions.
Pyostomatitis vegetans also can affect patients with ulcerative colitis and may aid in
the diagnosis. Unique oral manifestations of Crohn’s disease occur in
approximately 20% of patients and may precede the diagnosis of gastrointestinal
disease by several years. Features include atypical mucosal ulcerations and diffuse
swelling of the lips and cheeks.
8. Which of the following organisms is the causative agent in 90% to 99% of
cases of pseudomembranous colitis?
a. H. pylori
b. C. difficile
c. S. aureus
d. C. albicans
ANSWER: B
Pseudomembranous colitis is a severe and sometimes fatal form of colitis that results
from the overgrowth of Clostridium difficile in the large colon. C. difficile is a gram-
positive,
spore-forming anaerobic rod that has been found in sand, soil, and feces. C. difficile
produces and releases potent enterotoxins that induce colitis and diarrhea.
9. Which of the following is the most common presenting manifestation of
pseudomembranous colitis?
a. “Red man” syndrome
b. Diarrhea
c. Peptic ulcer .
d. Acute hypertension
ANSWER: B
Diarrhea is the most common presenting manifestation of pseudomembranous
colitis. In mild cases, the stool is watery and loose. In severe cases, bloody diarrhea
is accompanied by abdominal cramps, tenderness, and fever. Severe dehydration,
metabolic acidosis, hypotension, peritonitis, and toxic megacolon are serious
complications of untreated disease.
10. What is the recommendation to dental practitioners regarding
patients with pseudomembranous colitis desiring elective dental
care?
a. It does not have to be delayed until the condition has resolved.
b. It should be delayed until after the condition has resolved.
c. It should proceed ONLY after the use of certain systemic antibiotics.
d. It does not have to be delayed except in the cases of elderly or debilitated patients.
ANSWER: B
Elective dental care should be delayed until after pseudomembranous colitis has
resolved. The practitioner should be cognizant that the use of certain systemic
antibiotics—especially clindamycin, ampicillin, and cephalosporins—is associated
with a higher risk of pseudomembranous colitis in elderly, debilitated patients, and
in those with a previous history of pseudomembranous colitis. Use of these drugs
with pseudomembranous colitis patients can result in fungal overgrowth
(candidiasis) in the oral cavity.
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Chapter 12: Chronic Kidney Disease and Dialysis
Little: Dental Management of the Medically Compromised Patient, 10th Edition
MULTIPLE CHOICE
1. According to the National Kidney Foundation, which stage of chronic kidney
disease (CKD) is characterized by a loss of 50% or more of normal renal function?
a. Stage 2
b. Stage 3
c. Stage 4
d. Stage 5
ANSWER: B
Stage 3 is evidenced as a moderately decreased glomerular filtration rate (GFR), with
loss of 50% or more of normal renal function. Stage 4 is defined by a severely
decreased GFR. Stage 5 is reflected by renal failure, wherein 75% or more of the
approximately 2 million nephrons have lost function.
2. In which of the following populations is end-stage renal disease (ESRD)
increasing most rapidly?
a. Polycystic kidney disease
b. Patients over age and in those with diabetes mellitus and hypertension
c. Hypertension
d. Chronic glomerulonephritis
ANSWER: B .
The prevalence of CKD is increasing by approximately 4% per year, most rapidly in patients
over age 65 and in those who have diabetes and hypertension. CKD occurs more
commonly in men; African, Native, and Asian Americans; and those between the ages
of 45 and 64 years.
24.5% of people 60 years and older have CKD, and more than 90% of patients with
kidney failure are older than 18 years of age.
3. Failing kidneys are unable to concentrate and filter the intake of .
a. sodium
b. potassium
c. iron
d. phosphate
ANSWER: A
Failing kidneys are unable to concentrate and filter the intake of sodium, which
contributes to the drop in urine output, development of fluid overload,
hypertension, and risk for severe electrolyte disturbances and cardiac disease.
4. Which of the following sequences correctly depicts the sequence of osseous changes
observed in the patient with renal osteodystrophy?
1. Osteosclerosis
2. Osteomalacia
3. Osteitis fibrosa
a. 1, 2, 3
b. 1, 3, 2
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c. 2, 3, 1
d. 2, 1, 3
ANSWER: C
The progression of osseous changes is (increased unmineralized bone matrix),
followed by osteitis fibrosa (bone resorption with lytic lesions and marrow fibrosis)
and then osteosclerosis of variable degree (enhanced bone density).
5. Which of the following tests is a measure of muscle breakdown and filtration
capacity of the nephron?
a. Glomerular filtration rate (GFR)
b. Blood urea nitrogen (BUN)
c. Serum creatinine
d. Creatinine clearance
ANSWER: C
The serum creatinine level is a measure of muscle breakdown and filtration
capacity of the nephron. The creatinine concentration is proportional to the
glomerular filtration and tubular excretion rates, and this ratio commonly is used
as the index of creatinine clearance in a
24-hour urine collection. BUN is a commonly used indicator of kidney function, but
the BUN level is not as specific as creatinine clearance or serum creatinine level.
6. How do most dialysis patients in the United States receive hemodialysis?
a. Continuous cyclic peritoneal dialysis (CCPD)
b. Chronic ambulatory peritoneal dialysis (CAPD)
c. Through an arteriovenous graft, usually placed in the forearm
d. Through a central catheter
.
ANSWER: C
More than 80% of the people who receive hemodialysis in the United States do so
through a permanent and surgically created arteriovenous graft or fistula, usually
placed in the forearm. Approximately 18% of patients receive dialysis through a
temporary or permanent central catheter, while the permanent access site is healing
or when all other access options have been exhausted. The principal use of peritoneal
dialysis is in patients in acute renal failure or in those who require only occasional
dialysis.
7. Which of the following viruses has been reported to be transmitted nosocomially in
dialysis centers in the United States?
1. Hepatitis B
2. Hepatitis C
3. Human immunodeficiency virus (HIV)
a. 1, 2, 3
b. 1, 2
c. 2, 3
d. 1 only
ANSWER: B
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf
TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf

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TEST BANK For Little and Falace's Dental Management of the Medically Compromised Patient, 10th Edition by Craig Miller, Verified Chapters 1 - 30, Complete Newest Version.pdf

  • 1. Test Bank For Little and Falace's Dental Management of the Medically Compromised Patient, 10thEditionby Craig Miller, Chapters 1 - 30
  • 2. Little: Dental Management of the Medically Compromised Patient, 10th Edition Test Bank Table of Contents PART ONE: PATIENT EVALUATION AND RISK ASSESSMENT Chapter 1: Patient Evaluation and Risk Assessment PART TWO: CARDIOVASCULAR DISEASE Chapter 2: Infective Endocarditis Chapter 3: Hypertension Chapter 4: Ischemic Heart Disease Chapter 5: Cardiac Arrhythmias Chapter 6: Heart Failure (or Congestive Heart Failure) PART THREE: PULMONARY DISEASE Chapter 7: Pulmonary Disease Chapter 8: Smoking and Tobacco Use Cessation Chapter 9: Sleep-Related Breathing Disorders PART FOUR: GASTROINTESTIAL DISEASE Chapter 10: Liver Disease Chapter 11: Gastrointestinal Disease PART FIVE: GENITOURINARY DISEASE Chapter 12: Chronic Kidney Disease and Dialysis Chapter 13: Sexually Transmitted Diseases PART SIX: ENDOCRINE AND METABOLIC DISEASE Chapter 14: Diabetes Mellitus Chapter 15: Adrenal Insufficiency Chapter 16: Thyroid Diseases Chapter 17: Pregnancy and Breast Feeding PART SEVEN: IMMUNOLOGIC DISEASE Chapter 18: AIDS, HIV Infection, and Related Conditions Chapter 19: Allergy Chapter 20: Rheumatologic and Connective Tissue Disorders Chapter 21: Organ and Bone Marrow Transplantation PART EIGHT: HEMATOLOGIC AND ONCOLOGIC DISEASE Chapter 22: Disorders of Red Blood Cells Chapter 23: Disorders of White Blood Cells Chapter 24: Acquired Bleeding and Hypercoagulable Disorders Chapter 25: Congenital Bleeding and Hypercoagulable Disorders Chapter 26: Cancer and Oral Care of the Patient PART NINE: NEUROLOGIC, BEHAVIORAL, AND PSYCHIATRIC DISORDERS Chapter 27: Neurologic Disorders
  • 3. Chapter 28: Anxiety, Eating Disorders, and Behavioral Reactions to Illness Chapter 29: Psychiatric Disorders Chapter 30: Drug and Alcohol Abuse
  • 4. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 01: Patient Evaluation and Risk Assessment Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Elective dental care should be deferred for patients with severe, uncontrolled hypertension, meaning that the blood pressure is greater than or equal to mm Hg. a. 200/14 0 b. 180/14 0 c. 180/11 0 d. 160/11 0 ANSWER: C Elective dental care should be deferred for patients with severe, uncontrolled hypertension, which is blood pressure greater than or equal to 180/110 mm Hg, until the condition can be brought under control. 2. The American Heart Association currently recommends antibiotic prophylaxis for a patient with which of the following cardiac conditions? a. Mitral valve prolapse b. Prosthetic heart valve c. Rheumatic heart disease d. Pacemakers for cardiac arrhythmias ANSWER: B Previously, the American Heart Association (AHA) recommended antibiotic prophylaxis for many patients with heart murmurs caused by valvular disease (e.g., mitral valve prolapse, rheumatic heart disease) in an effort to prevent infective endocarditis; however, current guidelines omit this recommendation on the basis of accumulated scientific evidence. If a murmur is due to certain specific cardiac conditions (e.g., previous endocarditis, prosthetic heart valve, complex congenital cyanotic heart disease), the AHA continues to recommend antibiotic prophylaxis for most dental procedures. 3. One consequence of chronic hepatitis (B or C) or cirrhosis of the liver is decreased ability of the body tocertain drugs, including local anesthetics and analgesics. a. absorb b. distribute c. metabolize d. excrete ANSWER: C Patients also may have chronic hepatitis (B or C) or cirrhosis, with impairment of liver function. This deficit may result in prolonged bleeding and less efficient metabolism of certain drugs, including local anesthetics and analgesics. 4. Which of the following symptoms and signs is most consistent with allergy? a. Heart palpitations
  • 6. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ANSWER: B Symptoms and signs consistent with allergy include itching, urticaria (hives), rash, swelling, wheezing, angioedema, runny nose, and tearing eyes. Isolated signs and symptoms such as nausea, vomiting, heart palpitations, and fainting generally are not of an allergic origin but rather are manifestations of drug intolerance, adverse side effects, or psychogenic reactions. 5. Which of the following is true of the patient with a history of tuberculosis? a. A positive result on skin testing means that the person has active TB. b. Most patients who become positive skin testers develop active disease. c. Patients with acquired immunodeficiency syndrome (AIDS) have a high incidence of tuberculosis. d. A diagnosis of active TB is made by a purified protein derivative (PPD) skin test. ANSWER: C The potential coexistence of tuberculosis and acquired immunodeficiency syndrome (AIDS) should be explored because patients with AIDS have a high incidence of tuberculosis. A positive result on skin testing means specifically that the person has at some time been infected with TB, not necessarily that active disease is present. Most patients who become positive skin testers do not develop active disease. A diagnosis of active TB is made by chest x-ray, imaging, sputum culture, and clinical examination. 6. Vasoconstrictors should be avoided in patients who cocaine or methamphetamine users because these agents may precipitate . a. severe hypotension b. severe hypertension c. respiratory depression d. cessation of intestinal peristalsis ANSWER: B Vasoconstrictors should be avoided in patients who are cocaine or methamphetamine users because the combination may precipitate arrhythmias, MI, or severe hypertension. 7. It has been shown that the risk for occurrence of a serious perioperative cardiovascular event (e.g., MI, heart failure) is increased in patients who are unable to meet a -MET (metabolic equivalent of task) demand during normal daily activity. a. 4 b. 6 c. 8 d. 10 ANSWER: A Daily activities requiring 4 METs include level walking at 4 miles/hour or climbing a flight of stairs. Activities requiring greater than 10 METs include swimming and singles tennis. An exercise capacity of 10 to 13 METs indicates excellent physical conditioning.
  • 7. 8. Which of the following alterations in the fingernails is associated with cirrhosis? a. Yellowing b. Clubbing c. White discoloration d. Splinter hemorrhages
  • 8. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ANSWER: C Alterations in the fingernails, such as clubbing (seen in cardiopulmonary insufficiency), white discoloration (seen in cirrhosis), yellowing (from malignancy), and splinter hemorrhages (from infective endocarditis) usually are caused by chronic disorders. 9. A blood pressure cuff should be placed on the upper arm and inflated until . a. the radial pulse disappears b. the radial pulse disappears and then inflated an additional 20 to 30 mm Hg c. two fingers cannot fit comfortably under the cuff d. the pulse no longer can be heard with the stethoscope ANSWER: B While the radial pulse is palpated, the cuff is inflated until the radial pulse disappears (approximate systolic pressure); it is then inflated an additional 20 to 30 mm Hg. 10. Which of the following is true of a patient classified ASA III according to the American Society of Anesthesiologists (ASA) Physical Status Classification System? a. Patient has mild systemic disease. b. Patient’s disease has significant impact on daily activity. c. Patient’s disease is unlikely to have impact on anesthesia and surgery. d. Patient is moribund. ANSWER: B Patient with severe systemic disease is a constant threat to life (e.g., recent myocardial infarction, stroke, transient ischemic attach [<3 months], ongoing cardiac ischemia, severe valve dysfunction, respiratory failure requiring mechanical ventilation). Serious limitation of daily activity; likely major impact on anesthesia and surgery.
  • 9. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 02: Infective Endocarditis Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is true concerning infective endocarditis (IE)? a. IE is always due to a bacterial infection. b. Since the advent of antibiotics, morbidity and mortality associated with IE have been virtually eliminated. c. IE is currently classified as acute or subacute, to reflect the rapidity of onset and duration. d. Accumulating evidence questions the validity of antibiotic prophylaxis in an attempt to prevent IE prior to certain invasive dental procedures. ANSWER: D Antibiotics have been administered before certain invasive dental procedures in an attempt to prevent infection. Of note, however, the effectiveness of such prophylaxis in humans has never been substantiated, and accumulating evidence more and more questions the validity of this practice. 2. Which of the following is currently the most common underlying condition predisposing to infective endocarditis (IE)? a. Aortic valve disease b. Rheumatic heart disease (RHD) c. Mitral valve prolapse (MVP) d. Tetralogy of Fallot ANSWER: C Mitral valve prolapse, which accounts for 25% to 30% of adult cases of native valve endocarditis (NVE), is now the most common underlying condition among patients who acquire IE. Previously, rheumatic heart disease (RHD) was the most common condition predisposing to endocarditis. In developed countries, however, the frequency of RHD has markedly declined over the past several decades. 3. The leading cause of death due to infective endocarditis (IE) is . a. chronic obstructive pulmonary disease b. heart failure c. pulmonary emboli d. atheromas ANSWER: B The most common complication of IE, and the leading cause of death, is heart failure, which results from severe valvular dysfunction. This pathologic process most commonly begins as a problem with aortic valve involvement, followed by mitral and then tricuspid valve infection. Embolization of vegetation fragments often leads to further complications, such as stroke. Myocardial infarction can occur as the result of embolism of the coronary arteries, and distal emboli can produce peripheral metastatic abscesses.
  • 10. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM 4. The interval between the presumed initiating bacteremia and the onset of symptoms of infective endocarditis (IE) is estimated to be less than in more than 80% of patients with IE. a. 1 week b. 2 weeks c. 1 month d. 2 months ANSWER: B It is less than two weeks in more than 80% of patients with IE. In many cases of IE that have been purported to be due to dentally induced bacteremia, the interval between the dental appointment and the diagnosis of IE has been much longer than 2 weeks (sometimes months), so it is very unlikely that the initiating bacteremia was associated with dental treatment. 5. Where are Janeway lesions located? a. Tricuspid valve b. Palms of the hands and soles of the feet c. Pulp of the digits d. Nail beds ANSWER: B Janeway lesions are small, nontender erythematous or hemorrhagic macular lesions on the palms and soles. Janeway lesions are one of the peripheral manifestations of IE due to emboli and/or immunologic responses. 6. Which of the following is true of the magnitude of bacteremia required to cause infective endocarditis (IE)? a. The magnitude of bacteremias resulting from dental procedures is more likely to cause IE than that seen with bacteremias resulting from normal daily activities. b. Cases of IE caused by oral bacteria probably result from frequent exposure to low inocula of bacteria in the bloodstream due to daily activities and not a dental procedure. c. The quality of oral hygiene has no appreciable effect on the magnitude of bacteremia after toothbrushing. d. The magnitude of bacteremia resulting from dental procedures is greater than that needed to cause experimental bacterial endocarditis (BE) in animals. ANSWER: B An assumption often made is that the magnitude of bacteremias resulting from dental procedures is more likely to cause IE than that seen with bacteremias resulting from normal daily activities. Published data do not support this contention. Furthermore, the magnitude of bacteremia resulting from dental procedures is relatively low (with bacterial counts of fewer than 104 colony-forming units/mL), is similar to that of bacteremia resulting from normal daily activities, and is far less than that (106 to 108 colony-forming units/mL) needed to cause experimental BE in animals.
  • 11. 7. Visible bleeding during a dental procedure is a reliable predictor of bacteremia. It is not clear which dental procedures are more or less likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that caused by routine daily activities such as chewing food, tooth brushing, or flossing. a. Both statements are true.
  • 12. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true. ANSWER: D It has been shown that visible bleeding during a dental procedure is not a reliable predictor of bacteremia. Collective published data suggest that the vast majority of dental office visits result in some degree of bacteremia, and that it is not clear which dental procedures are more or less likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that caused by bacteremia produced by routine daily activities such as chewing food, tooth brushing, or flossing. 8. Which of the following is true regarding the efficacy of antibiotic prophylaxis? a. Data show that a reduction in the incidence, nature, and duration of bacteria caused by antibiotic therapy reduces the risk of or prevents IE. b. Antibiotics given to at-risk patients before a dental procedure will prevent or reduce a bacteremia. c. Prospective randomized, placebo-controlled trials have been conducted to examine the efficacy of antibiotic prophylaxis for preventing IE in patients who undergo a dental procedure. d. Investigators have concluded that dental or other procedures probably only caused a small fraction of cases of IE, and that prophylaxis would prevent only a small number of cases, even if it were 100% effective. ANSWER: D This conclusion came as the result of a study from the Netherlands by van der Meer and colleagues that investigated the efficacy of antibiotic prophylaxis in preventing IE in dental patients with native or prosthetic cardiac valves 9. The American Heart Association currently recommends antibiotic prophylaxis before dental treatment to prevent endocarditis for patients with which of the following cardiac conditions? a. Mitral valve prolapse with regurgitation b. Rheumatic heart disease c. Prosthetic cardiac valve d. A, B, and C e. A and C ANSWER: C Prophylaxis with antibiotics before a dental procedure is recommended for a prosthetic cardiac valve, previous infective endocarditis, and some forms of congenital heart disease (see Box 2-2.) 10. Which of the following antibiotics is the best choice if a patient who requires premedication before dental treatment is already taking penicillin for eradication of an infection? a. Amoxicillin b. Clindamycin c. Cephalosporins d. Keep the patient on the penicillin because the blood level has
  • 14. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM The presence of viridians group streptococci that are relatively resistant to penicillin or amoxicillin is likely in patients already taking penicillin or amoxicillin for eradication of an infection. Clindamycin, azithromycin, or clarithromycin should be selected for prophylaxis if treatment is immediately necessary. Cephalosporins should be avoided due to cross resistance. Another approach is to wait for at least 10 days after the completion of antibiotic therapy before administration of prophylactic antibiotics.
  • 15. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter03: Hypertension Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. In prehypertension, diastolic pressure ranges from mm Hg. a. 80 to 89 b. 90 to 99 c. 100 to 109 d. 110 to 119 ANSWER: A In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained diastolic blood pressure of 90 mm Hg or greater is defined as hypertension. (Also see Table 3-1.) 2. Which of the following types of health professionals can make the diagnosis of hypertension and decide on its treatment? a. Physician b. Dentist c. Dental hygienist d. A, B, and C e. A and C only ANSWER: A Although only a physician can make the diagnosis of hypertension and decide on its treatment, Joint National ComG m R itA teD eE on SP MrO ev R eE nt. io C nO , D Metection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines specifically encourage the active participation of all health care professionals in the detection of hypertension and the surveillance of treatment compliance. Accordingly, the dental health professional can play a significant role in the detection and control of hypertension and may well be the first to detect a patient with an elevation in blood pressure or with symptoms of hypertensive disease. 3. Which of the following is true about hypertension in America? a. It is the second-most primary diagnosis behind congestive heart failure. b. Its prevalence has been steadily increasing 1990. c. Its prevalence is similar among all races and ethnicities. d. Its prevalence is similar among men and women. ANSWER: D According to National Health and Nutrition Examination Survey (NHANES) data for the period 2011 to 2012, at least 75 million adults in the United States have high blood pressure or are taking antihypertensive medication. This estimate equals about 29% of the U.S. population, compared with 24% when surveyed between 1988 and 1991. This marked increase is attributed to aging of the population and the epidemic increase in obesity. Accordingly, a typical practice population of 2000 patients will have about 580 patients who have hypertension.
  • 16. 4. It is estimated that about % of all blood pressure–related deaths from coronary heart disease occur in persons with blood pressure in the prehypertensive range.
  • 17. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM a. less than 1 b. 5 c. 15 d. 25 ANSWER: C About 15%. However, the higher the blood pressure, the greater the chances of heart attack, heart failure, stroke, and kidney disease. For every increase in blood pressure of 20 mm Hg systolic and 10 mm Hg diastolic, a doubling of mortality related to ischemic heart disease and stroke occurs. 5. Which of the following groups is most often the first-line drug category of choice if lifestyle modification is ineffective at lowering blood pressure? a. Beta-blockers (BBs), 1-adrenergic blockers, central 2 agonists, as well as other centrally acting drugs, and direct vasodilators b. Diuretics, thiazide diuretics, calcium channel blockers (CCBs), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors (ACEIs) c. Any of the above. d. None of the above; lifestyle modification should continue unless blood pressure is >140/90 mm Hg ANSWER: B Many drugs are currently available to treat hypertension. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) recommends diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) as first-line choices for the general non-Black population. For the general Black population, a thiazide diuretic or CCB is recommend G eR dA as DiE nS itiM al OtR he E r. ap C yO . O Mther drugs used as secondary choices include beta-blockers (BBs), 1-adrenergic blockers, central 2 agonists, as well as other centrally acting drugs and direct vasodilators. 6. Deferral of elective dental care and referral to a physician for evaluation and treatment within 1 week are indicated for patients found to have asymptomatic blood pressure of greater than or equal to mm Hg. a. 160/90 b. 160/11 0 c. 180/90 d. 180/11 0 ANSWER: D Patients with blood pressures less than 180/110 mm Hg can undergo any necessary dental treatment, both surgical and nonsurgical, with very little risk of an adverse outcome. For patients found to have asymptomatic blood pressure of 180/110 mm Hg or greater (uncontrolled hypertension), elective dental care should be deferred, and physician referral for evaluation and treatment within 1 week is indicated. Patients with uncontrolled blood pressure associated with symptoms such as headache, shortness of breath, or chest pain should be referred to a physician for immediate evaluation.
  • 18. 7. Which of the following is recommended for stress management for dental patients with hypertension? a. Afternoon appointments
  • 19. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM b. Premedication with a barbiturate c. Nitrous oxide plus oxygen for inhalation sedation d. Keeping the dental chair in an upright position during treatment ANSWER: C Nitrous oxide plus oxygen for inhalation sedation is an excellent intraoperative anxiolytic for use in patients with hypertension. Care is indicated to ensure adequate oxygenation at all times, avoiding postdiffusion hypoxia at the termination of administration. Short morning appointments seem best tolerated. Oral premedication with a short-acting benzodiazepine can reduce anxiety for many patients. Because many of the antihypertensive agents tend to produce orthostatic hypotension as a side effect, rapid changes in chair position during dental treatment should be avoided. 8. Why should rapid changes in chair position during dental treatment be avoided for patients under medication for hypertension? a. To lessen the chances of endogenous release of catecholamines. b. Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic hypotension as a side effect. c. Rapid chair position changes have nothing to do with antihypertensive medications and drugs used in dental practice. d. There is a high potential of triggering cardiovascular issues agents for hypertensive dental patients in moving chairs if local anesthetics are used. ANSWER: B Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic hypotension as a side effect, so rapid changes in chair position during dental treatment should be avoided. This effect can be potentiated by the actions of anxiolytic and sedative drugs. . 9. Use of how many cartridges of 2% lidocaine with 1:100,000 epinephrine at one time is considered to have little clinical risk for dental treatment of a patient with hypertension? a. 2 b. 4 c. 6 d. 8 ANSWER: A The existing evidence indicates that use of modest doses (one or two cartridges of 2% lidocaine with 1:100,000 epinephrine) carries little clinical risk in patients with hypertension, the benefits of its use far outweighing any potential problems. Use of more than this amount at one time may be tolerated well enough but with increasing risk for adverse hemodynamic changes. 10. Which of the following is an adverse drug interaction that may occur if a dental anesthetic containing a vasoconstrictor is administered to a patient being treated for hypertension with a nonselective -adrenergic blocking agent? a. Hypotension b. Hypertension c. Respiratory alkalosis
  • 21. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM The basis for concern with use of nonselective -adrenergic blocking agents (e.g., propranolol) is that the normal compensatory vasodilation of skeletal muscle vasculature mediated by beta 2 receptors is inhibited by these drugs, and injection of epinephrine, levonordefrin, or any other pressor agent may result in uncompensated peripheral vasoconstriction because of unopposed stimulation of alpha 1 receptors. This vasoconstrictive effect could potentially cause a significant elevation in blood pressure and a compensatory bradycardia. .
  • 22. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 04: Ischemic Heart Disease Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is true concerning the incidence and prevalence of ischemic heart disease in the United States? a. About 50% of the population is estimated to have some form of cardiovascular disease. b. Cardiovascular disease begins in middle life. c. The annual mortality rate for cardiovascular diseases has been declining since 1970. d. Cancer has replaced coronary heart disease as the leading cause of death in the United States after age 65. ANSWER: C More than 85 million Americans (about 25% of the population) have some form of cardiovascular disease, with about 15.5 million having coronary heart disease. Cardiovascular disease begins early in life, and autopsy studies have shown that one in six American teenagers already has pathologic intimal thickening of the coronary arteries. The annual mortality rate for cardiovascular diseases as a group has been declining since 1970. Despite this decline, cardiovascular diseases continue to be the leading cause of death in America, accounting for about 31% of all deaths. Coronary heart disease is the leading cause of death in the United States after age 65, and it is responsible for 735,000 new or recurrent heart attacks annually, of which more than 40% are fatal. . 2. Which of the following is the single MOST important modifiable risk factor for coronary heart disease? a. Diet high in cholesterol b. Failure to exercise c. Smoking cigarettes d. Smoking cigars ANSWER: C Cigarette smoking is the single most important modifiable risk factor for coronary heart disease. Multiple prospective studies have clearly documented that, compared with nonsmokers, persons who smoke 20 or more cigarettes daily have a two- to fourfold increase in coronary heart disease. This increased risk appears to be proportionate to the number of cigarettes smoked per day, and quitting has well documented benefits. Pipe and cigar smoking apparently convey minor risk for development of heart disease. 3. Which of the following is NOT true of the relationship between periodontal disease and cardiovascular disease? a. Studies report the possibility of an association between periodontal disease and cardiovascular disease. b. A single risk factor—dental caries—has been found to be responsible for the development of coronary atherosclerosis in patients over 50
  • 23. years old. c. Studies indicate a connection between tooth scaling and a decreased risk of cardiovascular disease outcomes.
  • 24. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM d. There is a hypothesis that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. ANSWER: B Numerous studies have reported an association between periodontal disease and cardiovascular disease, raising the question of whether periodontal disease is a risk factor for cardiovascular disease. Although the mechanism to explain this relationship is unclear, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. At present, despite studies showing that tooth scaling is associated with decreased risk of cardiovascular disease outcomes and improved endothelial function, a direct relationship (i.e., causation) between periodontal disease and cardiovascular disease has not been established. Additional studies are required to further elucidate this relationship. 4. Which of the following types of blood cells engulf lipid molecules to become foam cells? a. Red blood cells b. Macrophages c. Neutrophils d. Basophils ANSWER: B Atheroma formation is initiated by adherence of monocytes to an area of injured or altered endothelium. The attached monocytes then migrate into the intima of the vessel and become macrophages. Lipids derived from LDLs also enter through the injured or dysfunctional endothelium, forming extracellular deposits or small pools. Macrophages then engulf lipid molecules to become foam cells, which are characteristic features of the fatty streak. 5. Which of the following is the G im R p A or D ta E nS t s M y O m R pE to. m C o O fM coronary atherosclerotic heart disease? a. Pitting edema b. Dysphagia c. Dyspnea d. Chest pain ANSWER: D Chest pain is the most important symptom of coronary atherosclerotic heart disease. The pain may be brief, as in angina pectoris resulting from temporary ischemia of the myocardium, or it may be prolonged, as in unstable angina or acute MI. Ischemic myocardial pain results from an imbalance between the oxygen supply and the oxygen demand of the muscle. 6. New-onset chest pain that increases in frequency or intensity has a changing pattern, may possibly occur at rest, and is not readily relieved by nitroglycerin. This best defines . a. acute coronary syndrome b. Prinzmetal’s variant angina c. unstable angina
  • 26. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Unstable angina is defined as new-onset pain with increasing frequency or intensity, and that is precipitated by less effort than before or that occurs at rest. This pain is not readily relieved by nitroglycerin. Stable angina is pain that is predictably reproducible, unchanging, and consistent over time. This pain is typically precipitated by physical effort, such as walking or climbing stairs, but also may occur with eating or stress. Pain is relieved by cessation of the precipitating activity, by rest, or with the use of nitroglycerin. Acute coronary syndrome describes a continuum of myocardial ischemia, and Prinzmetal’s variant angina is a relatively uncommon form of angina. 7. Which of the following is the most common cause of sudden cardiac death? a. Ventricular fibrillation b. Myocardial infarction c. Coronary atherosclerosis d. Pulmonary embolism ANSWER: A The most common cause of sudden cardiac death is ventricular fibrillation, a form of abnormal electrical activity resulting from interruption of the heart’s electrical conduction system. 8. Which of the following is a serum enzyme determination used to establish the diagnosis of acute myocardial infarction (MI) and to determine the extent of infarction? a. Stress thallium-201 perfusion scintigraphy b. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA) c. Troponin I and troponin T d. Streptokinase (SK) ANSWER: C . Cardiac serum biomarkers of acute MI include troponin I, troponin T, creatine kinase isoenzyme (CK-MB), and myoglobin. The troponins and CK-MB are enzymes released only when cell death (infarction) or injury occurs. Troponins are proteins derived from the breakdown of myocardial sarcomeres. Troponin assays are the most sensitive and specific in differentiating cardiac muscle damage from trauma to skeletal muscle or other organs; and are virtually absent in the plasma of normal persons and are found only after cardiac injury. 9. Which of the following is true for an MI with ST segment elevation (STEMI)? a. It is due to partial blockage of coronary blood flow. b. It is due to complete blockage of coronary blood flow. c. Early fibrinolytic therapy will not improve the outcome for a patient with STEMI. d. Morphine use for pain relief is never recommended for STEMI patients. ANSWER: B An MI with ST segment elevation is due to complete blockage of coronary blood flow and more profound ischemia involving a relatively large area of myocardium. An MI without ST segment elevation (non-STEMI) is due to partial blockage of coronary blood flow. Early fibrinolytic therapy improves outcomes in STEMI but not in non- STEMI. Morphine use for pain relief is recommended for STEMI; however, use of
  • 27. morphine in non-STEMI patients is associated with increased mortality and should be avoided in these patients. 10. When planning dental treatment for a patient with stable angina or a past history of MI without ischemic symptoms, .
  • 28. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM a. administration of nitrous oxide should be avoided b. a pulse oximeter should be used c. nitroglycerin should be administered prophylactically d. NSAIDs should be avoided ANSWER: D In several studies, the use of NSAIDs in patients with previous MI has been shown to increase the risk for a subsequent myocardial infarction, even after only 7 days of NSAID administration. Only naproxen did not increase the risk. .
  • 29. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 05: Cardiac Arrhythmias Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is the most common type of persistent arrhythmia? a. Sinus arrhythmia b. Premature atrial complexes c. Atrial fibrillation d. Ventricular flutter and fibrillation ANSWER: C The most common type of persistent arrhythmia is atrial fibrillation (AF). AF affects more than 2.7 million people, and the majority is over age 60. In a dental practice of 2000 adults, one can expect about 300 patients to have some type of cardiac arrhythmia. 2. Which of the following sequences correctly depicts the normal pattern of sequential depolarization of the structures of the heart? (1) Right and left bundle branches, (2) sinoatrial (SA) node, (3) subendocardial Purkinje network, (4) bundle of His, (5) atrioventricular (AV) node. a. 5, 2, 4, 1, 3 b. 2, 5, 4, 1, 3 c. 2, 3, 4, 1, 5 d. 2, 5, 3, 1, 4 ANSWER: B . The normal pattern of sequential depolarization involves the structures of the heart in the following order: sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, subendocardial Purkinje network. 3. Tachycardia in an adult is defined as a heart rate greater then beats/min, with otherwise normal findings on the ECG. a. 100 b. 125 c. 150 d. 175 ANSWER: A Tachycardia in an adult is a heart rate greater than 100 beats/min. The rate usually is between 100 and 180 beats/min. This condition most often is a physiologic response to exercise, anxiety, stress, or emotion. Pathophysiologic causes include fever, hypertension, hypoxia, infection, anemia, hyperthyroidism, and heart failure. Drugs that may cause sinus tachycardia include atropine, epinephrine, alcohol, nicotine, and caffeine. 4. Which of the following is a disorder of repolarization? a. Mobitz type I (Wenckebach) b. Wolff-Parkinson-White syndrome c. Long QT syndrome
  • 30. d. Torsades de pointes
  • 31. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ANSWER: C Long QT syndrome is a disorder of the conduction system in which the recharging of the heart during repolarization (i.e., the QT interval) is delayed. It is caused by a genetic mutation in myocardial ion channels and by certain drugs, or may be the result of a stroke. Mobitz type I (Wenckebach) is a form of second-degree heart block. Wolff-Parkinson-White syndrome is tachycardia involving the AV junction. Torsades de pointes is a variant of ventricular tachycardia. 5. What is a specific advantage of implantable cardioverter-defibrillators (ICDs) in contrast to pacemakers? a. ICDs generally are smaller than pacemakers. b. ICDs are capable of providing antitachycardia pacing (ATP) and ventricular bradycardia pacing, while pacemakers are not capable of providing such pacing. c. ICDs have batteries that last much longer than pacemakers. d. ICDs do not require antibiotic prophylaxis prior to dental treatment whereas pacemakers do. ANSWER: B ICDs are capable not only of delivering a shock but of providing antitachycardia pacing (ATP) and ventricular bradycardia pacing. ICDs generally are larger than pacemakers, and their batteries do not last as long as those of a pacemaker. 6. Recent studies suggest dental devices do not cause significant with pacemakers and ICDs probably because of increased internal _ . a. interference; magnetic fields b. defibrillation; EMI c. cardiac arrhythmia; ATP . d. EMI; shielding ANSWER: D Recent studies performed in humans together with previous data suggest that most dental devices do not cause significant electromagnetic interference with the sensing and pacing of pacemakers and ICDs. This probably reflects the increased internal shielding provided in the newer pacemakers and ICDs. 7. Which of the following is classified as a significant arrhythmia according to American College of Cardiology and American Heart Association guidelines? a. Pathologic Q waves b. Left bundle branch block c. High-grade AV block d. ST-T wave abnormalities ANSWER: C Patients with high-grade AV block, symptomatic ventricular arrhythmias in the presence of cardiovascular disease, and supraventricular arrhythmias with an uncontrolled ventricular rate are at major risk for complications and are not candidates for elective dental care. The presence of pathologic Q waves is a clinical predictor of intermediate risk for perioperative complications. Left ventricular hypertrophy, left bundle branch block, and ST-T wave abnormalities are associated
  • 32. with minor perioperative risk. 8. The use of what drugs in local anesthetics can pose problems for patients with arrhythmias?
  • 33. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM a. Digoxin b. Vasoconstrictors c. Beta-blockers d. NSAIDs ANSWER: B The use of vasoconstrictors in local anesthetics poses potential problems for patients with arrhythmias because of the possibility of precipitating cardiac tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor may be used as needed. They should also be avoided in patients taking digoxin because of the potential for inducing arrhythmias. 9. If a vasoconstrictor in local anesthetic is deemed necessary, patients in the low to intermediate risk category and those taking nonselective beta-blockers can safely be given up to cartridge(s) containing 1:100,000 epinephrine. a. one b. three c. two d. zero—epinephrine is an absolute contraindication ANSWER: C These patients can safely be given up to 0.036 mg epinephrine, which is the amount in two cartridges containing 1:100,000 epinephrine. Greater quantities of vasoconstrictor may well be tolerated, but increasing quantities are associated with increased risk for adverse cardiovascular effects. 10. Due to the rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects, the use of gingival retraction cord impregnated with epinephrineshouldbeavoidedGfR or Ap D aE tie SnM tsOaR t c Ea. rd C ia O cM risk. What might beusedasan alternative? a. Tetrahydrozoline b. Oxymetazoline c. Either A or B d. Neither A nor B ANSWER: C For patients at all levels of cardiac risk, the use of gingival retraction cord impregnated with epinephrine should be avoided because of the associated rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects. As an alternative, plain cord saturated with tetrahydrozoline HCl 0.05% or with oxymetazoline HCl 0.05% provides gingival effects equivalent to those of epinephrine without the adverse cardiovascular effects.
  • 34. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 06: Heart Failure (or Congestive Heart Failure) Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is the most common underlying cause of heart failure in the United States? a. Dilated cardiomyopathy b. Coronary heart disease c. Valvular heart disease d. Hypertension ANSWER: B The most common underlying cause of heart failure in the United States is coronary heart disease (secondary to atherosclerosis), accounting for 60% to 75% of cases, with cardiomyopathy, hypertension, and valvular heart disease also well- recognized contributory conditions. The second most common cause of heart failure, accounting for about one fourth of all cases, is dilated cardiomyopathy. 2. Most of the acquired disorders that lead to heart failure result in initial failure of the . a. bundle of His b. mitral valve c. right ventricle d. left ventricle ANSWER: D . Left ventricular heart failure (LVHF) often is followed by failure of the right ventricle. In adults, left ventricular involvement is almost always present, even if the clinical manifestations are primarily those of right ventricular dysfunction (fluid retention without dyspnea or rales). 3. The outstanding symptom of left ventricular heart failure is . a. dyspnea b. dysphagia c. cyanosis d. rales ANSWER: A The outstanding symptom is dyspnea, which results from the accumulation or congestion of blood in the pulmonary vessels—hence the designation congestive heart failure. Acute pulmonary edema is often the result of left ventricular failure. Left-sided heart failure leads to pulmonary hypertension, which increases the work of the right ventricle, pumping against increased pressure, often culminating in right-sided heart failure. 4. What is one reason the prognosis for patients with heart failure is poor? a. The symptoms reflect respective ventricular dysfunction. b. Because loss of life due to it cannot be modified by early identification and treatment.
  • 35. c. Primarily because auscultation often reveals a laterally displaced apical impulse
  • 36. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM caused by left ventricular hypertrophy. d. It is a progressive disease with symptoms that worsen over time. ANSWER: D Heart failure also predisposes the patient to ischemic stroke, the risk for which is twice as high as normal. The prognosis is better if the underlying cause can be treated. One year after the diagnosis of heart failure, 20% of patients will succumb to the disease. In people diagnosed with it, sudden death occurs six to nine times the rate for the general population. 5. Which of these symptoms and signs of heart failure worsens when the patient assumes a recumbent or semi-recumbent position? a. Orthopnea b. Paroxysmal nocturnal dyspnea (PND) c. Cheyne–Stokes respiration d. Tachycardia ANSWER: A Most patients with mild to moderate heart failure do not exhibit orthopnea when treated adequately. Paroxysmal nocturnal dyspnea (PND) is an attack of sudden, severe shortness of breath awakening the patient from sleep. PND is a common clinical feature associated with Cheyne–Stokes respiration in heart failure patients. With Cheyne–Stokes respiration, central regulation of respiration may be impaired, resulting in alternating cycles of hyperventilation with periods of central apnea. Tachycardia (increased pulse rate) indicates increased myocardial oxygen demand, coronary blood flow, and overall myocardial performance. 6. What is a primary reason outcomes in the care of patients with heart failure are not significantly improving? . a. Management of heart failure is complex and generally applied in a graduated approach. b. An algorithm for drug treatment of heart failure has not been found. c. Patient compliance with treatment recommendations is notoriously poor. d. Drugs that modulate or decrease neurohormonal activity have not yet become the foundation of treatment. ANSWER: C As with many conditions, a large degree of success of medical therapy depends upon patient compliance with treatment recommendations. Since many of these patients are treated with a plethora of drugs, it is important to monitor and/or encourage their compliance. However, a relatively recent study has demonstrated that even after telemonitoring and multiple verbal reminders, the overall impact on improving outcomes in heart failure was not significant. 7. Which of the following categories of drugs is considered to be first-line therapy for the treatment of heart failure? a. Digitalis glycosides b. -Adrenergic blockers c. Angiotensin-converting enzyme (ACE) inhibitors d. Angiotensin receptor blockers (ARBs)
  • 38. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ACE inhibition with enalapril has been shown to reduce mortality from heart failure by 20% to 40%. The ACE inhibitors are typically prescribed along with or following diuretic therapy and they decrease the need for large doses of diuretics as well as some of the adverse metabolic effects of the diuretics. 8. If drug therapy is found to be inadequate in controlling patients with severe, refractory heart failure . a. mechanical and/or surgical intervention may be introduced b. end-of-life care with hospice is the only remaining option c. medical therapy will depend solely upon patient compliance with experimental recommendations d. diuretic therapy becomes a patient’s “long shot” final attempt at improved health ANSWER: A Mechanical and surgical intervention may be provided. These measures may include intra-aortic balloon counterpulsation, left ventricular assist device (LVAD), and heart transplantation. Other therapies include implantable cardioverter-defibrillator (ICD), 9. Dental patients with a previous history of heart failure or who are asymptomatic have heart failure. a. decompensated b. compensated c. provisional d. orthopnea ANSWER: B With decreasing cardiac output, stimulation of the renin–angiotensin system and the sympathetic nervous system (n G eR ur A oD hu E m S o M ra O lR re E sp . o C nO seM s) occur in an attempt to compensate for the loss of function. The effects of these responses include increased heart rate and myocardial contractility, increased peripheral resistance, sodium and water retention, redistribution of blood flow to the heart and brain, and an increased efficiency of oxygen utilization by the tissues. If these responses result in improved cardiac output with an elimination of symptoms, the condition is termed compensated heart failure. Symptomatic heart failure is termed decompensated. 10. To what key information source must a dentist refer in determining the risk involved in treating a heart failure patient? a. The New York Heart Association’s classification system of heart failure b. Clinical manifestations of digitalis toxicity c. All details the patient included in the dental history d. The patient’s physician ANSWER: D In most cases, it will be necessary for the dentist to obtain a medical consultation with the patient’s cardiologist in order to determine physical status, laboratory test results, level of control, compliance with medications and recommendations, and overall stability. The American College of Cardiology and the American Heart Association have published guidelines which can help to make this determination.
  • 39. These guidelines can be applied to the provision of dental care and be of significant value to the dentist in making a determination of risk.
  • 40. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 07: Pulmonary Disease Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. The most important cause of chronic obstructive pulmonary disease (COPD) in the world is . a. occupational pollutants b. environment pollutants c. tobacco smoking d. allergy ANSWER: C Worldwide, tobacco smoking is the most important cause of COPD. Approximately 12.5% of current smokers, 9% of former smokers, and 8% of those exposed to passive smoke have COPD. Smoking also accounts for 85% to 90% of COPD-related deaths in both men and women. The risk for development of COPD is dose related and increases with the number of cigarettes smoked per day and duration of smoking. 2. Which of the following is true of the signs and symptoms associated with COPD for patients who were historically referred to as “blue bloaters” or “pink puffers”? a. Patients who had emphysema were traditionally known as “pink puffers” because they demonstrated enlarged chest walls, giving them a “barrel- chested” appearance. b. Currently, it is recognized that most patients with COPD may exhibit features of both diseases. . c. “Blue bloaters” demonstrated weight loss with progression of the disease and a lack of cyanosis. d. A and B e. B and C ANSWER: D “Blue bloaters” were presented as patients who had chronic bronchitis. They were described as sedentary, overweight, cyanotic, edematous, and breathless. Patients diagnosed with emphysema, “pink puffers,” exhibit weight loss with disease progression, severe exertional dyspnea with a mild, nonproductive cough, lack of cyanosis, and pursing of the lips with effort to forcibly exhale air from the lungs. Most patients with COPD may exhibit features of both diseases. 3. Which two of the following are true of the arterial blood gas measurement for a patient with emphysema? 1. Elevated partial pressure of carbon dioxide 2. Normal partial pressure of carbon dioxide 3. Decreased partial pressure of carbon dioxide 4. Decreased partial pressure of oxygen 5. Normal partial pressure of oxygen a. 1, 4 b. 2, 4
  • 42. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM d. 1, 5 e. 2, 5 ANSWER: B Patients with emphysema have a relatively normal partial pressure of carbon dioxide and a decreased partial pressure of oxygen. Patients with chronic bronchitis have an elevated partial pressure of carbon dioxide and a decreased partial pressure of oxygen. 4. Which of the following is true of dental management for a patient with COPD? a. The appointment should be rescheduled if pulse oximetry finds the oxygen saturation level to be less than 91%. b. The patient should be placed in a supine position for treatment in the dental chair. c. Prilocaine is the only local anesthetic that is recommended for use with this category of patient. d. Nitrous oxide is preferred over diazepam (Valium) for a patient with severe COPD. ANSWER: A A patient coming to the office for routine dental care who displays shortness of breath at rest, a productive cough, upper respiratory infection, or an oxygen saturation level less than 91% (as determined by pulse oximetry) is unstable, and the appointment should be rescheduled and an appropriate referral for medical attention should be made. Patients should be placed in a semisupine or upright chair position for treatment, rather than in the supine position, to prevent orthopnea and a feeling of respiratory discomfort. No contraindication to the use of local anesthetic has been identified. If sedative medication is required, low-dose oral diazepam may be used. Nitrous oxide–oxygen inhalation sedation should not be used in patients with severe COPD and emphysema because gas may accumulate in air spaces of the diseased lung. . 5. Which of the following chronic inflammatory diseases of the airways is characterized by reversible episodes of increased airway hyperresponsiveness? a. Emphysema b. Asthma c. Chronic bronchitis d. A and B e. B and C ANSWER: B Asthma is a chronic inflammatory disease of the airways characterized by reversible episodes of increased airway hyperresponsiveness resulting in dyspnea, coughing, and wheezing. Chronic bronchitis and emphysema are forms of chronic obstructive pulmonary disease (COPD), which is a general term for pulmonary disorders characterized by chronic airflow limitation from the lungs that is not fully reversible. 6. Which of the following medications is associated with “triad asthmaticus”? a. Methotrexate b. Nonspecific beta-blockers
  • 44. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Aspirin causes bronchoconstriction in about 10% of patients with asthma, and sensitivity to aspirin occurs in 30% to 40% of people with asthma who have pansinusitis and nasal polyps (the so-called triad asthmaticus). The ability of aspirin to block the cyclooxygenase pathway appears causative. 7. Which of the following agents is currently regarded as the first-line medication for long-term control of asthma? a. -Adrenergic agonist b. Corticosteroid c. Theophylline d. Cromolyn sodium ANSWER: B Current guidelines recommend a “stepwise” approach with the use of inhaled antiinflammatory agents as first-line drugs (the preferred inhalational agent is a corticosteroid preparation, with a leukotriene inhibitor as an alternative) for the long-term management and prophylaxis of persistent asthma. -Adrenergic agonists are recommended for intermittent asthma and are secondary agents that should be added (i.e., not to be used alone) for persistent asthma when antiinflammatory drugs are inadequate alone. 8. Which of the following is the drug of choice for relief of an acute asthma attack? a. Oral anticholinergic b. Inhalation corticosteroid c. Short-acting 2-adrenergic agonist d. Inhaled cromolyn sodium ANSWER: C . For relief of an acute asthma attack, inhaled short-acting 2-adrenergic agonists are the drugs of choice because of their fast and notable bronchodilatory and smooth muscle relaxation properties. Short-acting 2-adrenergic agonists produce bronchodilation by activating 2 receptors on airway smooth muscle cells, generally in 5 minutes or less. Inhalation corticosteroids, inhaled cromolyn sodium, and oral anticholinergics are not used for this purpose because of slow onset of action. 9. The use of local anesthetic without epinephrine or levonordefrin may be advisable for patients with moderate to severe asthma because preservatives are found in local anesthetic solutions that contain epinephrine or levonordefrin. a. alum b. sulfite c. methylparaben d. sodium chloride ANSWER: B In 1987, the U.S. Food and Drug Administration (FDA) warned that drugs containing sulfites were a cause of allergic-type reaction in susceptible individuals. Sulfite preservatives are found in local anesthetic solutions that contain epinephrine or levonordefrin, although the amount of sulfite in a local anesthetic cartridge is less than the amount commonly found in an average serving of certain foods.
  • 45. 10. According to the World Health Organization (WHO), approximately what percentage of the world’s population is infected with tuberculosis?
  • 46. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM a. One tenth b. One eighth c. One quarter d. One third ANSWER: D The World Health Organization (WHO) estimates that one third of the world’s population— representing 2 billion people—is infected. This disease kills more adults worldwide each year than does any other single pathogen. 11. Which of the following is true regarding laboratory tests for tuberculosis? a. A positive tuberculin (Mantoux) skin test (TST) means that the person has clinically active tuberculosis. b. The interferon-gamma release assay (IGRA) is administered by intradermal injection of 0.1 mL of purified protein derivative (PPD). c. All dentists should undergo annual tuberculin skin testing. d. The IGRA test can discriminate active from latent infection. ANSWER: C All persons who are at risk for development of TB—including dentists—should undergo tuberculin skin testing annually. Without treatment, approximately 5% of skin test converters develop TB within 2 years; another 5% develop it later. A positive result on a tuberculin (Mantoux) skin test (TST) presumptively means that the person has been infected. It does not mean that the person has clinically active TB. IGRAs (interferon-gamma release assays) are performed on fresh whole blood. Neither the TST nor the IGRA can discriminate active from latent infection. 12. For which of the following cat G eg R o A ri D es Eo S fM pO atR ieE nt. sC isO trM eatment in the dentaloffice contraindicated? 1. Patients with a positive tuberculin test 2. Patients with a history of tuberculosis 3. Patients with clinically active sputum-positive tuberculosis a. 1, 2, 3 b. 1, 2 c. 2, 3 d. 3 ANSWER: D Patients with recently diagnosed, clinically active TB and positive sputum cultures should not be treated on an outpatient basis. Treatment is best rendered in a hospital setting with appropriate isolation, sterilization (mask, gloves, gown), and special engineering control (ventilation) systems and filtration masks. The patient with a history of tuberculosis who is found to be free of active disease and is not immunosuppressed may be treated with the use of standard precautions. Patients with a positive tuberculin skin test may be treated in a normal manner with the use of standard precautions. 13. Any time a patient demonstrates unexplained, persistent signs or symptoms that may be suggestive of TB, or has a positive result on skin testing or IGRA, and has not been given follow-up medical care, .
  • 47. a. it is appropriate to treat the patient using standard precautions b. respiratory equipment should be used during provision of dental care
  • 48. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM c. only treatment that utilizes a rubber dam should be provided d. dental care should not be rendered, and the patient should be referred to a physician for evaluation ANSWER: D Dental care should not be rendered. If a health care provider is exposed to TB, the provider should be evaluated for skin test conversion. Converters should be treated promptly with isoniazid. .
  • 49. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 08: Smoking and Tobacco Use Cessation Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following causes the most preventable deaths in the United States? a. Motor vehicle crashes b. Acquired immunodeficiency syndrome (AIDS) c. Smoking d. Alcohol abuse and illicit drug use ANSWER: C Smoking is the leading cause of preventable death and disease in the United States, resulting in nearly half a million premature deaths per year and over $200 billion in direct health care costs and lost productivity. Smoking causes more than twice as many deaths as human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), alcohol abuse, motor vehicle crashes, illicit drug use, and suicide combined. 2. The nicotine in tobacco products contains complex addictive and behavioral effects that are known to primarily affect what within the brain? a. Neuroreceptors b. Dopaminergic pathways c. Centers of logic d. It affects many other parts of the body, but not the brain in particular. ANSWER: B . Nicotine is a highly addictive drug that has been equated with heroin, cocaine, and amphetamine in terms of addiction potential and its effects on brain neurochemistry. The addictive and behavioral effects of nicotine are complex and are due primarily to its effects on dopaminergic pathways. 3. How long does it take nicotine to reach the brain following inhalation of cigarette smoke? a. 10 seconds b. 60 seconds c. 5 minutes d. 15 minutes ANSWER: A A cigarette is a very efficient delivery system for the inhalation of nicotine. Nicotine is rapidly distributed throughout the body after inhalation, reaching the brain in as little as 10 seconds. A person who smokes about 30 cigarettes a day gets 300 hits of nicotine to the brain every day, each one within 10 seconds after a puff. 4. Which of the following is true concerning the benefits of quitting smoking? a. The risk of dying of lung cancer is double among smokers than in those who have never smoked. b. Persons who quit smoking before the age of 50 have half of the risk of dying in the next 15 years compared with those who continue to smoke. c. The risk of dying of coronary heart disease for smokers is double that for
  • 50. lifetime nonsmokers, as is the risk of dying from a stroke.
  • 51. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM d. A and B e. B and C ANSWER: E Data show that persons who quit smoking before the age of 50 have half the risk of dying in the next 15 years compared with those who continue smoking. Risks of dying of lung cancer are 22 times higher among male smokers and 12 times higher among female smokers than in those who have never smoked. Smokers have twice the risk of dying of coronary heart disease compared with lifetime nonsmokers. 5. Which of the following is true about interventions for smoking cessation? a. Patients need to be “badgered” about quitting smoking. b. The highest success rates are achieved by stopping “cold turkey.” c. The chance for success increases when more than one option is used. d. Use of telephone quit lines does not increase the chances of success. ANSWER: C In general, the chance for success increases when more than one option is used, and counseling combined with nicotine replacement therapy (NRT) or medication significantly improves outcomes. “Badgering” the patient is not advised. The 1-year success rate with stopping cold turkey is about 5%. The use of telephone quit lines or brief counseling roughly doubles the chance of success, as does the use of any of the NRT products. 6. If a patient does not desire to stop smoking, what is a health care provider encouraged to do? a. Prescribe smoking cessation medications for the patient. b. Since it relates to a health issue, not to give up and to gently push the patient. c. Refuse to offer services and refer the patient to another practitioner. d. Point out the benefits of qu G it R tiA ng Da E sS aM pO ot R eE nt. iaC l m Oe Mt hod of motivating the patient. ANSWER: D The patient should be made aware that you support and encourage quitting to improve overall health and that you will assist in an effort to quit. If the patient does not wish to quit, the provider is encouraged to point out the benefits of doing so as a method of motivating the patient. If there is still, the topic should be dropped and the patient not badgered. It is generally counterproductive to pursue the issue; however, the patient can be told that if at any time they would like to quit, you would be happy to speak with them about it. 7. Evidence has shown that the more intensive the counseling, the better the success rate. Counseling typically consists of both and therapies. a. smoking; addictive b. pharmacological; psychological c. Cessation; NRT d. cognitive; behavioral ANSWER: D Counseling typically consists of both cognitive and behavioral therapies. Cognitive therapy attempts to change the way a patient thinks about smoking, while behavioral therapy attempts to help smokers avoid situations that might trigger the
  • 52. desire to smoke. Evidence has shown that the more intensive the counseling, the better the success rate, and that when counseling is combined with other forms of therapy, such as nicotine replacement therapy or pharmacotherapy, it is even more effective.
  • 53. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM 8. How long does it take nicotine blood levels to return to baseline after smoking a cigarette? a. 1 minute b. 25 to 30 minutes c. 3 to 5 hours d. 1 day ANSWER: B Smoking one cigarette rapidly increases nicotine blood levels to 35 to 40 ng/mL, producing the “hit” or “rush” experienced with smoking; this level then gradually returns to baseline within about 25 to 30 minutes. To prevent withdrawal symptoms, a smoker must maintain a baseline level of nicotine of about 15 to 18 ng/mL. 9. Why are e-cigarettes subject to government (FA) regulation? a. Because they are designed to simulate the act of tobacco smoking b. Because they contain nicotine derived from tobacco c. Because little is known about their health risks d. Because they are often promoted as safer alternatives to traditional cigarettes ANSWER: B In an effort to help protect the public from the dangers of tobacco use, the U.S. Food and Drug Administration (FDA) has established a new rule for e-cigarettes and their liquid solutions. Because e-cigarettes contain nicotine derived from tobacco, they are now subject to government regulation as tobacco products, including the requirement that both in- store and online purchasers are at least 18 years of age. 10. Which pair of FDA-approved non-NRT pharmacotherapeutic smoking cessation agents has proven more effective than anG y R of A tD he Eo S th M eO r R p aE ir. s?COM a. Bupropion SR and varenicline b. Monoamine oxidase inhibitors and opioid receptor antagonists c. Bromocriptine and glucose tablets d. Partial nicotine agonists and nicotine vaccines ANSWER: A Bupropion SR is a first-line, FDA-approved, non-NRT pharmacotherapeutic cessation agent. It is an atypical antidepressant thought to affect the dopaminergic and/or noradrenergic pathways involved in nicotine addiction. It is effective when used alone or in combination with an NRT product and/or counseling. Another FDA-approved agent is varenicline, an alpha4beta2 nicotinic receptor partial agonist that stimulates dopamine and blocks nicotinic receptors, thus preventing the reward and reinforcement associated with smoking. Other treatment strategies have less- proven efficacy and there are various other approaches currently under investigation.
  • 54. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter09: Sleep-Related Breathing Disorders Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is true about primary snoring? a. Primary snoring is associated with fragmentation of sleep architecture. b. Primary snoring is not associated with disrupted sleep or complaints of daytime sleepiness. c. Primary snoring is also known as upper airway resistance syndrome (UARS). d. Primary snoring is characterized by episodes of complete cessation of breathing due to airway obstruction during sleep. ANSWER: B Primary snoring is sometimes referred to as simple snoring or benign snoring. It occurs as an independent entity and is not associated with disrupted sleep or complaints of daytime sleepiness and occurs without abnormal ventilation. Findings on an overnight sleep study, or polysomnogram (PSG), are normal. UARS is a clinical entity midway between primary snoring and OSA that is characterized by snoring, variable complaints of daytime sleepiness, and fragmentation of sleep. 2. Which of the following are the most common sites of airway narrowing or closure during sleep for a patient with obstructive sleep apnea (OSA)? a. The retropalatal and retroglossal regions b. Septal deviation and enlarged turbinates c. Hypertrophic adenoids and GtR on As D ilE s SMORE.COM d. Redundant parapharyngeal folds ANSWER: A The most common sites of airway narrowing or closure during sleep are the retropalatal and retroglossal regions. Most patients with OSA have more than one site of narrowing. 3. Which of the following is characteristic of REM sleep? a. Synchronous brain waves b. Low-voltage EEG waves c. Mental inactivity d. Physiologic stability ANSWER: B A key feature of REM sleep is the presence of periodic rapid movement of the eyes with low-voltage EEG waves resembling those typical of wakefulness. REM sleep is characterized by asynchronous brain waves, an active brain, physiologic instability, and muscular inactivity. The REM sleep state often is described as “an active brain in a paralyzed body.” Dreaming occurs during REM sleep. 4. Most people who snore do not have OSA, but almost all patients with OSA snore. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false.
  • 55. d. The first statement is false, the second statement is true.
  • 56. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ANSWER: A In the Wisconsin Sleep Cohort Study of subjects aged 30 to 60 years, 44% of men and 28% of women were habitual snorers, but only 4% of the men and 2% of the women had OSA. 5. Which of the following components of a polysomnogram (PSG) is used to monitor eye movements? a. ECG b. EEG c. EMG d. EOG ANSWER: D The electrooculogram (EOG) is used to monitor eye movements. The electrocardiogram (ECG) monitors heart rate and rhythm, the electroencephalogram (EEG) is used to monitor brain waves, and the electromyogram (EMG) is used to monitor jaw muscular activity. 6. Approximately what percentage of patients who try positive airway pressure (PAP) for treatment of obstructive sleep apnea (OSA) are able to tolerate it? a. 100 b. 75 c. 50 d. 25 ANSWER: C Compliance with PAP has long been a problem, with only about 50% of patients who try it able to tolerate it. Of those who do use PAP, the average patient uses it for only about 4 to 5 hours per night and for onlyab G o R uA t 5 Dn E ig Sh M ts Op R eE r w .e CeO k.MAdverse effects with PAP are common and include mask leaks, skin ulceration or irritation under the mask, epistaxis, rhinorrhea, nasal congestion, sinus congestion, dry eyes, conjunctivitis, ear pain, and claustrophobia. 7. Which of the following is true of tongue-retaining devices (TRDs) used to treat patients with sleep-related breathing disorders? a. They typically are made of acrylic resin and are composed of two pieces that cover the upper and lower dental arches. b. Over 70 different types of TRDs have been approved by the FDA for treatment of obstructive sleep apnea (OSA). c. TRDs are capable of providing continuous positive airway pressure (CPAP). d. TRDs generally are made of silicone in the shape of a bulb or cavity. ANSWER: D The tongue is stuck into the bulb, which is then squeezed and released, producing a suction that holds the tongue forward in the bulb. Mandibular advancement devices (MADs) typically are made of acrylic resin and cover the upper and lower dental arches. Only one design of tongue-retaining device has been approved by the FDA for treatment of OSA. 8. Of the surgical procedures advocated to treat OSA (to varying degrees of success),
  • 57. which is almost uniformly effective in curing OSA? a. Laser-assisted uvulopalatoplasty (LAUP) b. Tracheostomy c. Maxillary and mandibular advancement osteotomy (MMO)
  • 58. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM d. Nasopharyngoscopy ANSWER: B Tracheostomy, which bypasses all obstruction in the entire upper airway, is almost uniformly effective in curing OSA. Its use is limited, however, in that it is unacceptable to most patients but may be used for the occasional patient with very severe OSA who is intolerant of CPAP and who requires urgent treatment. 9. Which of the following is the most successful surgical treatment for OSA in children? a. Uvulopalatopharyngoplasty (UPPP) b. Radiofrequency volumetric tissue reduction (RVTR) c. Adenotonsillectomy d. Laser-assisted uvulopalatoplasty (LAUP) ANSWER: C Adenotonsillar hypertrophy is the most common cause of upper airway obstruction in children; adenotonsillectomy is curative in 75% to 100% of such cases. 10. Which of the following statements regarding mandibular advancement devises (MADs) and tongue-retaining devices (TRDs) is NOT true? a. Both are associated with increased airway size in both the retropalatal and retroglossal regions. b. Both provide similar treatment effects; however, TRDs are not tolerated by users as well as MADs. c. Both offer attractive for patients unable to tolerate positive airway pressure (PAP) devices. d. Both are oral appliances that directly engage the tongue and hold it in a forward position. . ANSWER: D The two basic types of oral appliances are MADs, which engage the mandible and reposition it (and indirectly, the tongue) in an anterior or forward position, and TRDs, which directly engage the tongue and hold it in a forward position. Oral appliances offer an alternative treatment option for patients unable to tolerate or refuse to use a PAP. Oral appliances exert their effects by mechanically increasing the volume of the upper airway in the retropalatal and retroglossal areas.
  • 59. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 10: Liver Disease Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which of the following is a form of infectious (rather than serum) hepatitis? a. Hepatitis a b. Hepatitis b c. Hepatitis c d. Hepatitis d ANSWER: A Hepatitis A and hepatitis E are forms of infectious hepatitis; they are spread largely by the fecal–oral route, are associated with poor sanitary conditions, are highly contagious, occur in outbreaks as well as sporadically, and cause self-limited hepatitis only. Hepatitis B, hepatitis C, and hepatitis D are forms of serum hepatitis, are spread largely by parenteral routes and less commonly by intimate or sexual exposure, and are not highly contagious but instead occur sporadically and rarely cause outbreaks. 2. Which of the following is thought to be the major factor in the pathogenesis of liver injury? a. Antibody-dependent cellular cytotoxicity b. Proinflammatory cytokines c. Cytotoxic T cell responses d. Natural killer cell activity ANSWER: C . The timing and histologic appearance of hepatocyte injury in viral hepatitis suggest that immune responses, particularly cytotoxic T cell responses to viral antigens expressed on hepatocyte cell membranes, may be the major effectors of injury. Other proinflammatory cytokines, natural killer cell activity, and antibody- dependent cellular cytotoxicity also may play modulating roles in cell injury and inflammation during acute viral hepatitis infection. 3. Which of the following is the most reliable prognostic factor in acute hepatic failure due to hepatitis? a. Changes in personality b. The degree of prolongation of prothrombin time c. Serum aminotransferase levels d. Viral titers ANSWER: B The most reliable prognostic factor in acute hepatic failure is the degree of prolongation of the prothrombin time; other signs of poor prognosis are persistently worsening jaundice, ascites, and decreases in liver size. Serum aminotransferase levels and viral titers have little prognostic value and often decrease with worsening hepatic failure. 4. (A/An) _ syndrome develops during the preicteric phase in approximately 10% to 20% of patients with acute hepatitis.
  • 60. a. chronic fatigue b. irritable bowel c. serum sickness–like
  • 61. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM d. aspirin triad syndrome ANSWER: C In 10% to 20% of patients with acute hepatitis, a serum sickness–like syndrome marked by variable combinations of rash, arthralgias, and fever develops during the preicteric phase. This immune complex-like syndrome often is mistakenly attributed to other illnesses until the onset of jaundice, at which time the fever, hives, and arthralgias quickly resolve. 5. Which of the following is true regarding the diagnosis of acute viral hepatitis? a. Acute viral hepatitis is marked by a prominent fibrosis observed during histologic evaluation. b. Immunohistochemical stains for hepatitis antigens are positive during the acute disease. c. There are reliably distinctive features in the liver that separate the five viral forms of acute hepatitis from one another. d. Serologic tests are adequate for the diagnosis of acute viral hepatitis, so liver biopsy is not recommended unless the diagnosis remains unclear and a therapeutic decision is needed. ANSWER: D Serologic tests are adequate for diagnosis. If biopsy is required, the histologic pattern in acute viral hepatitis is characterized by widespread parenchymal inflammation and spotty necrosis. Inflammatory cells are predominantly lymphocytes, macrophages, and histiocytes. Fibrosis is absent. Immunohistochemical stains for hepatitis antigens generally are negative during the acute disease, and there are no reliably distinctive anatomic features in the liver that separate the five viral forms of acute hepatitis from each other. 6. Which of the following is the G mR os A tD co E m Sm Mo O nR m Ee . an CsO bM y which hepatitis A is spread? a. Consumption of shellfish from contaminated waterways b. Fecal contamination of food or water c. Direct person-to-person exposure d. Blood transfusions ANSWER: C Investigation of the sources of infection for hepatitis A reveals that most cases are due to direct person-to-person exposure and, to a lesser extent, to direct fecal contamination of food or water. Consumption of shellfish from contaminated waterways is a well-known but quite uncommon means of acquiring hepatitis A. Rare instances of hepatitis A being spread by blood transfusions and administration of pooled plasma products have been described. 7. Which of the following is associated with immunity to hepatitis B? a. HBsAg b. HBcAg c. HBeAg d. Anti-HBs e. Anti-HBe ANSWER: D
  • 62. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Anti-HBs is a long-lasting antibody that is associated with immunity. Generally, HBV DNA, and HBeAg begin to fall at the onset of illness and may be undetectable at the time of peak clinical illness. HBsAg becomes undetectable and anti-HBs appears during recovery, several weeks to months after loss of HBsAg. 8. Which of the following is true regarding prevaccination screening and booster doses of hepatitis B vaccine? a. Prevaccination screening and booster doses are recommended for all persons receiving the hepatitis B vaccination. b. Prevaccination screening is not recommended; however, booster doses are recommended for all persons receiving the hepatitis B vaccination. c. Prevaccination screening is not recommended except for adults in high- risk groups. Booster doses are not routinely recommended but may be appropriate for persons at high risk if titers of anti-HBs fall below what is considered protective. d. Neither prevaccination screening, nor booster doses of hepatitis B vaccine are recommended for anyone. ANSWER: C Prevaccination screening for anti-HBs is not recommended except in adults in high- risk groups. Postvaccination testing for anti-HBs to document seroconversion is not recommended routinely except in persons whose subsequent clinical management depends on knowledge of their immune status, particularly health care and public safety workers. At present, booster doses are not recommended but may be appropriate for persons at high risk if titers of anti-HBs fall below what is considered protective (10 IU/mL). Current guidelines published by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices recommend booster doses only for persons who did not respond to the primary vaccine series. . 9. Which of the following is the most common means of transmission of hepatitis C? a. Maternal-infant b. Sexual exposure c. Injection drug use d. Needlestick accidents ANSWER: C Current studies of acute hepatitis C indicate that more than 60% of cases are attributable to injection drug use; 15% to 20% to sexual exposure; and only a small proportion to maternal-infant spread, needlestick accidents, and iatrogenic causes. Approximately 10% of cases are not associated with any history of potential exposure and remain unexplained. 10. Which of the following hepatitis viruses is second most likely (following hepatitis B) to be transmitted occupationally to a dental healthcare worker? a. HAV b. HCV c. HEV
  • 64. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Little to no risk exists for transmission of HAV, HEV, and non-A-E hepatitis viruses from occupational exposure of dental health care workers to persons infected with these viruses. Risk for transmission of HBV is well recognized, and a lesser risk is present for HCV infection after occupational exposure to infected blood or body fluids containing infected blood. After percutaneous or other sharps injury in health care workers involving exposure to contaminated blood, the risk of contracting HBV infection is reported to range from 6% to 30%. The seroconversion rate for accidental blood exposure to HCV is between 2% and 8%. 11. Chronic active hepatitis B is diagnosed by the presence of in blood serum. a. HBsAg b. HBcAg c. HBeAg d. A, B, and C e. A and C ANSWER: E Chronic active hepatitis B is characterized by HBsAg and HBeAg in the serum, signs and symptoms of chronic liver disease, persistent hepatic cellular necrosis, and elevation of liver enzymes for longer than 6 months. 12. According to CDC guidelines, what should be done first if a vaccinated health care worker sustains a needlestick or puncture wound involving exposure to blood from a patient known to be HBsAg-positive? a. Nothing, because the health care worker has already been vaccinated. b. The health care worker should be tested for an adequate titer of anti-HBs if those levels are unknown. c. The health care worker sho G u R ld AiD m E m S eM diO atR elE y. re C ce O iM ve an injection of HBIG. d. The health care worker should immediately receive an injection of the hepatitis B vaccine as a booster dose. ANSWER: B The health care worker should be tested for an adequate titer of anti-HBs. If the levels are inadequate, the worker should immediately receive an injection of HBIG and a vaccine booster dose. If the antibody titer is adequate, however, nothing further is required. 13. Which of the following is true of the pathophysiology of alcoholic liver disease? a. Fatty liver is not reversible. b. Alcoholic hepatitis may be fatal if damage is widespread. c. In some patients with cirrhosis, blood from bleeding ulcers and esophageal varices is incompletely metabolized to ammonia. d. A and B e. B and C ANSWER: E Fatty liver is considered completely reversible. For the most part, alcoholic hepatitis is considered a reversible condition; however, it can be fatal if damage is widespread. In some patients with cirrhosis, blood is metabolized to ammonia, which travels to the brain and contributes to encephalopathy.
  • 65. 14. Which of the following tests is the best way to screen for problems before dental treatment of an alcoholic patient?
  • 66. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM a. Bilirubin total b. Alkaline phosphatase total c. LDH total d. A complete blood count (CBC) ANSWER: D A CBC with differential and determinations of AST and ALT, bleeding time, thrombin time, and prothrombin time are sufficient to screen for potential problems. Abnormal laboratory values, on a background of suggestive findings on the clinical examination or a positive history, constitute the basis for referral to a physician for definitive diagnosis and treatment. 15. Which of the following types of breath odor is associated with liver failure? a. Sweet, musty b. Breadlike c. Ammonia d. Garlic ANSWER: A A sweet, musty odor to the breath is associated with liver failure, as is jaundiced mucosal tissue. .
  • 67. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 11: Gastrointestinal Disease Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. Which is the most common location for peptic ulcers in Western populations? a. Stomach b. Duodenum c. Jejunum d. Ileum ANSWER: B The first portion of the duodenum is the location of most ulcers in Western populations, whereas gastric ulcers are more frequent in Asia. The upper jejunum rarely is involved. Peptic ulcers develop principally in regions of the gastrointestinal tract that are proximal to acid and pepsin secretions. 2. Which of the following is the most common cause of peptic ulcer disease? a. Cytomegalovirus infection b. Acid hypersecretion c. H. pylori infection d. Use of nonsteroidal anti-inflammatory medication ANSWER: C The primary etiologic factor is H. pylori. This organism is present in 80% of duodenal ulcers. Use of NSAIDs is the second most common cause of peptic ulcer disease. Other risk factors include advanced age, psycholG oR giA ca D l E an S dM p O hR ys E ic . al Cs O trM ess, acid hypersecretion, cigarette smoking, use of certain drugs, and major comorbid disease. Cystic fibrosis also predisposes to ulcers. Cytomegalovirus infection is a rare cause noted in human immunodeficiency virus (HIV)–positive patients. 3. Which of the following is characteristic of gastric peptic ulcers rather than duodenal peptic ulcers? a. Epigastric pain that is long-standing b. Diffuse rather than localized epigastric pain c. Symptoms rapidly relieved in most cases by ingestion of food, milk, or antacids d. Pain that most commonly manifests 90 minutes to 3 hours after eating ANSWER: A Many patients with an active peptic ulcer report no ulcer symptoms; however, most experience epigastric pain that is long-standing, sharply localized, and recurrent. The pain is described as “burning” or “gnawing,” but may be “ill-defined” or “aching.” The discomfort of a duodenal ulcer manifests most commonly on an empty stomach, and frequently awakens the patient in the middle of the night. Ingestion of food, milk, or antacids provides rapid relief in most cases. In contrast, patients with gastric ulcers are unpredictable in their response to food; in fact, eating may precipitate abdominal pain. 4. Which of the following is/are components of currently recommended therapy
  • 68. when a peptic ulcer is confirmed and H. pylori is present? a. Inhibitors of gastric acid secretion
  • 69. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM b. Dissection of the vagus nerves from the gastric fundus c. Antimicrobial agents d. A, B, and C e. A and C ANSWER: E Combination therapy is recommended because antisecretory drugs, such as histamine H2 receptor antagonists and PPIs, provide rapid relief of pain and accelerate healing, and antibiotics are effective in eradicating H. pylori. Elective surgical intervention largely has been abandoned in the management of peptic ulcer disease. Today, surgery is reserved primarily for complications of peptic ulcer disease, such as significant bleeding, perforation, and gastric outlet obstruction. 5. Which of the following is true of Crohn’s disease? a. Crohn’s disease is limited to the large intestine and the rectum. b. Crohn’s disease affects men and women equally. c. Crohn’s disease occurs more often in smokers. d. Most patients who have Crohn’s disease require at least one operation for their condition. ANSWER: D Most patients with Crohn’s disease require at least one operation. Crohn’s disease is a transmural process that may produce “patchy” ulcerations at any point along the alimentary canal, from the mouth to the anus, but most commonly involves the terminal ileum. Ulcerative colitis affects men and women equally, whereas Crohn’s disease is slightly more common among women. Crohn’s disease occurs more often in nonsmokers, whereas smoking protects against ulcerative colitis. . 6. Patients with inflammatory bowel disease (IBD) who have fewer than bowel movements per day with little or no blood, no fever, few symptoms, and a sedimentation rate below 20 mm/hour are considered to have mild disease and can receive dental care in the dentist’s office. a. two b. four c. six d. eight ANSWER: B Patients with fewer than four bowel movements per day can receive dental care in the dentist’s office. Patients with moderate disease or severe disease—the latter defined as having siz or more bowel movements per day with blood, fever, anemia, and a sedimentation rate higher than 30 mm/hour—are poor candidates for dental care and should be referred to their physician. 7. Which of the following is the most common oral complication associated with inflammatory bowel disease (IBD)? a. Petechiae b. Vascular pools c. Sialadenitis d. Aphthous-like lesions
  • 70. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM ANSWER: D Aphthous-like lesions occur in up to 20% of patients with ulcerative colitis. They typically are located on the alveolar, labial, and buccal mucosa, as well as the soft palate, uvula, and retromolar trigone, and they may be difficult to distinguish from aphthous lesions. Pyostomatitis vegetans also can affect patients with ulcerative colitis and may aid in the diagnosis. Unique oral manifestations of Crohn’s disease occur in approximately 20% of patients and may precede the diagnosis of gastrointestinal disease by several years. Features include atypical mucosal ulcerations and diffuse swelling of the lips and cheeks. 8. Which of the following organisms is the causative agent in 90% to 99% of cases of pseudomembranous colitis? a. H. pylori b. C. difficile c. S. aureus d. C. albicans ANSWER: B Pseudomembranous colitis is a severe and sometimes fatal form of colitis that results from the overgrowth of Clostridium difficile in the large colon. C. difficile is a gram- positive, spore-forming anaerobic rod that has been found in sand, soil, and feces. C. difficile produces and releases potent enterotoxins that induce colitis and diarrhea. 9. Which of the following is the most common presenting manifestation of pseudomembranous colitis? a. “Red man” syndrome b. Diarrhea c. Peptic ulcer . d. Acute hypertension ANSWER: B Diarrhea is the most common presenting manifestation of pseudomembranous colitis. In mild cases, the stool is watery and loose. In severe cases, bloody diarrhea is accompanied by abdominal cramps, tenderness, and fever. Severe dehydration, metabolic acidosis, hypotension, peritonitis, and toxic megacolon are serious complications of untreated disease. 10. What is the recommendation to dental practitioners regarding patients with pseudomembranous colitis desiring elective dental care? a. It does not have to be delayed until the condition has resolved. b. It should be delayed until after the condition has resolved. c. It should proceed ONLY after the use of certain systemic antibiotics. d. It does not have to be delayed except in the cases of elderly or debilitated patients. ANSWER: B Elective dental care should be delayed until after pseudomembranous colitis has resolved. The practitioner should be cognizant that the use of certain systemic
  • 71. antibiotics—especially clindamycin, ampicillin, and cephalosporins—is associated with a higher risk of pseudomembranous colitis in elderly, debilitated patients, and in those with a previous history of pseudomembranous colitis. Use of these drugs with pseudomembranous colitis patients can result in fungal overgrowth (candidiasis) in the oral cavity.
  • 72. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM Chapter 12: Chronic Kidney Disease and Dialysis Little: Dental Management of the Medically Compromised Patient, 10th Edition MULTIPLE CHOICE 1. According to the National Kidney Foundation, which stage of chronic kidney disease (CKD) is characterized by a loss of 50% or more of normal renal function? a. Stage 2 b. Stage 3 c. Stage 4 d. Stage 5 ANSWER: B Stage 3 is evidenced as a moderately decreased glomerular filtration rate (GFR), with loss of 50% or more of normal renal function. Stage 4 is defined by a severely decreased GFR. Stage 5 is reflected by renal failure, wherein 75% or more of the approximately 2 million nephrons have lost function. 2. In which of the following populations is end-stage renal disease (ESRD) increasing most rapidly? a. Polycystic kidney disease b. Patients over age and in those with diabetes mellitus and hypertension c. Hypertension d. Chronic glomerulonephritis ANSWER: B . The prevalence of CKD is increasing by approximately 4% per year, most rapidly in patients over age 65 and in those who have diabetes and hypertension. CKD occurs more commonly in men; African, Native, and Asian Americans; and those between the ages of 45 and 64 years. 24.5% of people 60 years and older have CKD, and more than 90% of patients with kidney failure are older than 18 years of age. 3. Failing kidneys are unable to concentrate and filter the intake of . a. sodium b. potassium c. iron d. phosphate ANSWER: A Failing kidneys are unable to concentrate and filter the intake of sodium, which contributes to the drop in urine output, development of fluid overload, hypertension, and risk for severe electrolyte disturbances and cardiac disease. 4. Which of the following sequences correctly depicts the sequence of osseous changes observed in the patient with renal osteodystrophy? 1. Osteosclerosis 2. Osteomalacia 3. Osteitis fibrosa
  • 73. a. 1, 2, 3 b. 1, 3, 2
  • 74. WWW.GRADESMORE.COM Stuvia.com - The Marketplace to Buy and Sell your Study Material Page 1 of 74 WWW.NURSYLAB.COM GRADESMORE.COM c. 2, 3, 1 d. 2, 1, 3 ANSWER: C The progression of osseous changes is (increased unmineralized bone matrix), followed by osteitis fibrosa (bone resorption with lytic lesions and marrow fibrosis) and then osteosclerosis of variable degree (enhanced bone density). 5. Which of the following tests is a measure of muscle breakdown and filtration capacity of the nephron? a. Glomerular filtration rate (GFR) b. Blood urea nitrogen (BUN) c. Serum creatinine d. Creatinine clearance ANSWER: C The serum creatinine level is a measure of muscle breakdown and filtration capacity of the nephron. The creatinine concentration is proportional to the glomerular filtration and tubular excretion rates, and this ratio commonly is used as the index of creatinine clearance in a 24-hour urine collection. BUN is a commonly used indicator of kidney function, but the BUN level is not as specific as creatinine clearance or serum creatinine level. 6. How do most dialysis patients in the United States receive hemodialysis? a. Continuous cyclic peritoneal dialysis (CCPD) b. Chronic ambulatory peritoneal dialysis (CAPD) c. Through an arteriovenous graft, usually placed in the forearm d. Through a central catheter . ANSWER: C More than 80% of the people who receive hemodialysis in the United States do so through a permanent and surgically created arteriovenous graft or fistula, usually placed in the forearm. Approximately 18% of patients receive dialysis through a temporary or permanent central catheter, while the permanent access site is healing or when all other access options have been exhausted. The principal use of peritoneal dialysis is in patients in acute renal failure or in those who require only occasional dialysis. 7. Which of the following viruses has been reported to be transmitted nosocomially in dialysis centers in the United States? 1. Hepatitis B 2. Hepatitis C 3. Human immunodeficiency virus (HIV) a. 1, 2, 3 b. 1, 2 c. 2, 3 d. 1 only ANSWER: B