Unit 3 Clinical Questions

1.Timothy has been having difficulty breathing since he had pneumonia last month. Recently he had severe pain in his chest and back, and his breathing was extremely irregular. The doctor at the emergency room told him that one of the lobes of his lung had collapsed. How could this happen? Page Ref: 715
1.Timothy suffered a pneumothorax, or lung collapse, most likely caused by a rupture of the visceral pleura as a result of coughing during his bout with pneumonia. The pneumothorax was large enough to cause atelectasis, or collapse, of one of his lobes, but not the remainder of his lung.

2.While having a physical examination, a young male informed his doctor that at age 8 he had lobar pneumonia and pleurisy in his left lung. The physician decided to measure his VC. Describe the apparatus and method used for taking this measurement. Define the following terms used in the description of lung volumes: TV, IRV, ERV, RV, and VC. Page Ref: 719-720
2.His vital capacity (VC) was measured using a spirometer. As he breathed into a handheld device, the speed and volume of air flow was calculated from the output of a pressure transducer. Tidal volume (TV) is the amount of air that moves into and out of the lungs with normal breathing. Inspiratory reserve volume (IRV) is the amount of air that can be forcibly inhaled beyond the tidal volume. The expiratory reserve volume (ERV) is the amount of air that can be evacuated from the lungs over and above a tidal expiration. Residual volume (RV) is the amount of air that remains in the lungs even after the most strenuous expiration. Vital capacity (VC) is the total amount of exchangeable air.

3.Jane had been suffering through a severe cold and was complaining of a frontal headache and a dull, aching pain at the side of her face. What regions are likely to become sites of secondary infection following nasal infection? Page Ref: 704
3.Following nasal infection, the paranasal sinuses can become infected.

4.A smoker sees his doctor because he had a persistent cough for months and is short of breath after very little exertion. What diagnosis will the doctor make and what can the person expect if he does not quit smoking? Page Ref: 736-738
4.The person is suffering from chronic bronchitis, which causes the dyspnea and coughing. If he does not stop smoking, he can expect frequent pulmonary infections, more coughing, and progressively worse dyspnea (all symptoms of chronic obstructive pulmonary disease). Ultimately, he can expect to develop hypoxemia, CO2 retention, and respiratory acidosis. He may develop emphysema or lung cancer.

5.After a long scuba diving session on a Caribbean reef, Carl boards a plane to Dallas. He begins to feel pain in his elbow on the flight back to Dallas. What is happening to him? Page Ref: 715, 722
5.Carl is experiencing the bends due to several problems: (1) Applying Boyle’s law, a lot of gas was forced into Carl’s bloodstream during the dive and there was not sufficient time to decompress the excess before he boarded the plane. (2) The plane is not pressurized to sea level, which further reduced atmospheric pressure holding the gases in suspension (Henry’s law). Carl should be to be transported to a hyperbaric chamber to be repressurized. This will reduce the volume of the gas bubbles in his arm so that normal circulation can resume.

6.A patient was admitted to the hospital with chronic obstructive pulmonary disease. His PO2 was 55 and PCO2 was 65. A new resident orders 54% oxygen via the venturi mask. One hour later, after the oxygen was placed, the nurse finds the patient with no respiration or pulse. She calls for a Code Blue and begins cardiopulmonary resuscitation (CPR). Explain why the patient stopped breathing. Page Ref: 737
6.In people who retain carbon dioxide because of pulmonary disease, arterial PCO2 is chronically elevated and chemoreceptors become unresponsive to this chemical stimulus. In such cases, declining PO2 levels act on the oxygen-sensitive peripheral chemoreceptors and provide the principle respiratory stimulus, or the so-called hypoxic drive. At atmospheric PO2 (21% O2) the patients arterial PO2 was 55, 54% O2 would raise his arterial PO2 high enough to remove his respiratory stimulus (low PO2 levels).

7.While dining out in a restaurant a man suddenly chokes on a piece of meat. The waitress is also a student nurse and comes to the man’s aid. She asks him if he can talk. The man responds by shaking his head no and grabbing at his neck. What is the significance of the man’s inability to talk? Page Ref: 705-706
7.Speech involves the intermittent release of expired air and opening and closing of the glottis. Because the man is unable to speak, this indicates that he is choking on a piece of food that suddenly closed off air at or below the glottis.

8.A patient with tuberculosis is often noncompliant with treatment. Explain why this may happen. Page Ref: 737-738
8.Noncompliance may occur because of the length of treatment. Treatment entails a 12-month course of antibiotics. Once the patient begins to feel better and the clinical symptoms dissipate, the patient may stop taking the medication.

9.John has undergone surgery and has developed pneumonia. He also has a history of emphysema. Which symptoms and signs would the nurse expect to find? Page Ref: 736-737
a.The patient may have dyspnea.
b.The patient may have hypoxemia because of increased secretions in the lungs.
c.The patient may use his accessory muscles to assist breathing.
d.The patient may have a productive cough.
e.The patient’s breath sounds may have rales (crackles).

10.Mrs. Wong goes to the emergency room with the following symptoms: severe pain in the umbilical region, loss of appetite, nausea, and vomiting. While she was waiting to see a doctor, the pain moved to the lower right abdominal quadrant. What is the likely diagnosis and treatment? Page Ref: 778
10.The most likely diagnosis is appendicitis. The accepted treatment is immediate surgical removal of the appendix.

11.Jose is brought to the emergency room complaining of a burning sensation in his chest, increased salivation, and difficulty in swallowing. He is having difficulty breathing and feels the presence of a “lump in his throat.” The diagnosis is gastroesophageal reflux disease. Explain. Page Ref: 753
11.Gastroesophageal reflux disease is a disorder in which the rate of reflux is greater than in normal individuals and causes clinical symptoms and/or histological changes. Reflux and regurgitation may result in aspiration of gastric contents into the air passages, causing respiratory distress such as hoarseness, asthma, and pneumonia. The sensation of a lump in his throat may be due to esophageal muscle spasm from irritation or even worse, that he has developed a stricture (narrowing) or cancer from prolonged neglect.

12.Sami has been hospitalized with acute gastritis. Her symptoms were epigastric pressure (just above the stomach), headache, nausea, and vomiting with traces of old dark blood. She revealed that she had been suffering back pain and drank four shots of gin and took three aspirin to “kill the pain.” What led the physician to make this diagnosis, and what may have caused the sudden attack? Page Ref: 759
12.Gastritis is an inflammation of the mucosal lining of the stomach and is suspected because of the pain location, accompanying symptoms, and ingestin of likely causative agents. He would likely confirm the diagnosis by doing an upper GI endoscopy. The probable reason for the abrupt onset of symptoms is due to rapid and heavy ingestion of alcohol and aspirin. Acute gastritis is often due to chemical irritants that destroy the alkaline mucus barrier, particularly alcohol or salicylate.

13.A woman is brought to an emergency room complaining of severe pain in her left iliac region. She claims previous episodes and says that the condition is worse when she is constipated, and is relieved by defecation. A large, tender mass is palpated in the left iliac fossa and a barium study reveals a large number of diverticula in her descending and sigmoid colon. What are diverticula, and what is believed to promote their formation? Does this woman have diverticulitis or diverticulosis? Explain. Page Ref: 782
13.Diverticula are small herniations of the mucosa through the colon walls, a condition called diverticulosis. They are believed to form when the diet lacks bulk and the volume of residue in the colon is small. The colon narrows contractions of its circular muscles and they become more powerful, increasing the pressure on its walls. Diverticulitis is a condition in which the diverticula become inflamed. This woman has diverticulitis due to the inflammation of her diverticula, as evidenced by the pain and mass.

14.A patient is 67 years old and has had a hiatal hernia for three years. In the last year, she has complained of worsening heartburn, especially at night. What are the characteristic symptoms of a hiatal hernia and which of these symptoms did the patient have? Page Ref: 753
14.Heartburn and regurgitation from gastroesophageal reflux are the most common clinical manifestations of hiatal hernia. This patient complained of heartburn.

15.A patient was admitted to the hospital because of severe epigastric pain. He has noted that his stools were darker than the usual brown color. He appears pale and very anxious. The history reports that he drinks 2-3 beers per day and smokes 2 packs of cigarettes a day. Based on the assessment data, what condition might the nurse determine this patient has? Explain why. Page Ref: 759
15.The patient most likely has a gastric ulcer. The most distressing symptom of a gastric ulcer is gnawing epigastric pain that seems to bore through to the back. The danger posed by ulcers is perforation of the stomach wall followed by peritonitis and massive hemorrhage. Because the patient’s stools are darker than usual and he is pale and anxious, the nurse suspects a bleeding ulcer. Factors such as smoking and alcohol increase hypersecretion of hydrochloric acid and low secretion of mucus.

16.A patient has esophageal cancer and must have a feeding tube inserted. The nurse tells the patient that the tube will be inserted surgically into the duodenum. The patient’s wife asks why the tube will not be inserted into the stomach. What should the nurse say? Page Ref: 767
16.The duodenum is part of the small intestine, which is the body’s major digestive organ. Digestion is completed and absorption is best in the small intestine. There is also less risk for vomiting, which may cause complications.

17.A 45-year-old patient was admitted to the hospital with a diagnosis of cirrhosis of the liver. He is thin and malnourished. His abdomen is very large due to an accumulation of fluid in the abdominal cavity. His lower extremities are very swollen. Explain why these changes have occurred. Page Ref: 773
17.Cirrhosis is a diffuse and progressive chronic scarring of the liver that typically results from chronic alcoholism or severe chronic hepatitis. Cirrhosis is characterized by extensive degeneration and destruction of the liver parenchymal cells. Edema and ascites (accumulation of fluid in the peritoneal cavity) Occur because the portal blood cannot flow as easily through narrowed, scarred canaliculi, leading to a backup of pressure (portal hypertension) that causes increased filtration loss of fluid through intestinal capillary walls.

18.A 45-year-old patient was admitted to the hospital with a diagnosis of cirrhosis of the liver. The nurse is observing him closely for the possibility of gastrointestinal bleeding. Why is this considered a possible complication? Page Ref: 773
18.As scar tissue eventually shrinks, it obstructs blood flow throughout the hepatic portal system, causing portal hypertension. Some veins of the portal system anastomose with veins that drain into the venae cavae. However, these connecting veins are small, include submucosal veins in the lower esophagus and gastric cardia, and tend to burst when forced to carry large volumes of blood. Signs of their failure include vomiting blood.

19.After chopping wood for about 2 hours, on a hot but breezy afternoon, John stumbled into the house and immediately fainted. His T-shirt was wringing wet with perspiration, and his pulse was faint and rapid. What is your tentative diagnosis? Explain your reasoning and note what you should do to help John’s recovery. Page Ref: 831
19.John was suffering from heat exhaustion due to excessive loss of body fluids (indicated by his wet T-shirt); his low blood pressure; and cool, clammy skin. To help his recovery, he should be given fluid and electrolyte replacement therapy and should be cooled down.

20.Harry is hospitalized with bacterial pneumonia. When you visit him, his teeth are chattering, his skin is cool and clammy to the touch, and he complains of feeling cold, even though the room is quite warm. Explain his symptoms. Page Ref: 831-832
20.Harry’s symptoms indicate a fever caused by his bacterial pneumonia. The white cells battling the pneumonia release pyrogens that act directly on the hypothalamus, causing its neurons to release prostaglandins. The prostaglandins reset the hypothalamic thermostat to a higher temperature, causing the body to initiate heat-promoting mechanisms including shivering and vasoconstriction that causes a decline of heat loss from the body surface, cooling of the skin, and shivering.

21.Hank, a 17-year-old high school student, suffered a heart attack during a recreational swim. An autopsy revealed that he had had atherosclerosis and that his death had been caused by coronary artery disease. What might have been the cause of this disease that usually strikes a person much older than Hank? Page Ref: 824
21.Hank suffered from a genetic disorder known as “familial hypercholesterolemia,” a condition in which the LDL receptors are absent or abnormal, the uptake of cholesterol by tissue cells is blocked, and the total concentration of cholesterol and LDLs in the blood is enormously elevated. Victims of the disease usually die in adolescence of coronary artery disease.

22.The patient is a 28-year-old female with insulin-dependent diabetes. She developed viral gastroenteritis with nausea and vomiting. She did not take her insulin and she became increasingly nonresponsive. Her husband called 911 and she was taken to the emergency room. Her pulse rate was 128 and her respiratory rate was 28, deep, and smelled fruity (Kussmaul breathing). Her urinary glucose and ketone levels were both 4+. Her pH was dangerously low. Explain how the body attempted to compensate for the low serum pH. Page Ref: 812
22.The deep, rapid respirations were the body’s attempt to compensate for the extremely low pH by blowing off CO2, resulting in less carbonic acid that in turn caused pH to rise.

The patient is 52 years old and has a history of hypertension. His cholesterol level is 245. He states his job is very stressful and he is recently going through a divorce. He admits to being overweight and has an inactive lifestyle. His father died of a stroke at age 60. He is worried about having a heart attack and/or stroke and wishes to change his lifestyle. The nurse encourages the patient to eat more fish. Explain why eating more fish would be of benefit for this patient. Page Ref: 824
The omega-3 fatty acids in cold-water fish have a powerful antiarrhythmic effect on the heart and also make blood platelets less sticky, thus helping to prevent spontaneous clotting that can block blood vessels, lowering blood pressure.

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