Cardiopulmonary Physical Therapy: Anatomy of the Cardiovascular and Pulmonary Systems, Exams of Cardiology

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Chapter 01: Anatomy of the Cardiovascular and Pulmonary Systems

Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition

MULTIPLE CHOICE

1. Which of the following chest wall structures is located level with the second costal cartilage anteriorly and thoracic vertebra T4 and T5 posteriorly? a. (^) Sternal angle b. (^) Jugular notch c. (^) Xiphoid process d. (^) Third costal cartilage ANS: A The sternal angle of the “angle of Louis” is level with the second costal cartilage anteriorly and thoracic vertebrae T4 and T5 posteriorly. PTS: 1
2. Pectus excavatum is BEST described as: a. (^) deformity of the sternum caused by trauma. b. (^) caved-in appearance of the chest. c. (^) diminished rib angle anteriorly. d. (^) conical shape of the thoracic cage. ANS: B Pectus excavatum is a common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally; it produces a caved-in or sunken appearance of the chest. PTS: 1
3. The true ribs are BEST defined by which of the following statements? a. (^) Vertebrochondral ribs b. (^) Vertebrosternal ribs c. (^) Ribs 11 and 12 d. (^) Ribs 8, 9, and 10 ANS: B The first seven ribs attach via their costal cartilages to the sternum and are called the true ribs (also known as the vertebrosternal ribs). PTS: 1
4. Which of the following interventions is MOST appropriate for a patient with lower rib fractures? a. (^) Short, shallow breaths b. (^) Pursed lip breathing c. (^) Deep breaths with splinting

d. (^) Breathing with arms raised ANS: C It is important for all therapists to recommend breathing (deep breathing), splinting (i.e., pillow), and coughing strategies for patients with rib fractures. PTS: 1

5. Which of the following positions facilitates greater excursion of both hemidiaphragms at rest? a. (^) Supine position b. (^) Side-lying position c. (^) Standing position d. (^) Sitting position ANS: A In the supine position, without the effects of gravity, the level of the diaphragm in the thoracic cavity rises. This allows for a relatively greater excursion. PTS: 1
6. Which of the following muscles help to achieve the active process of inspiration at rest in a normal, nonsmoking individual? a. (^) Sternocleidomastoid b. (^) Diaphragm c. (^) Abdominal muscles d. (^) Trapezius ANS: B The diaphragm and internal intercostals (intercartilaginous portion) are the essential muscles to achieve the active process of inspiration at rest. Abdominal muscles assist with expiration. The sternocleidomastoid and trapezius are accessory muscles and assist with a more forceful inspiration. PTS: 1
7. Which of the following accessory muscles of ventilation function to elevate and fix the first and second ribs? a. (^) Sternocleidomastoid muscle b. (^) Serratus anterior c. (^) Latissimus dorsi d. (^) Scalene muscle ANS: D The scalene muscles lie deep to the sternocleidomastoid, but may be palpated in the posterior triangle of the neck. These muscles function as a unit to elevate and fix the first and second ribs. The sternocleidomastoid muscle elevates the sternum. PTS: 1

8. When the arms and shoulders are fixed, by leaning on the elbows or grasping onto a table, this muscle can use its insertion as its origin and facilitate an increase in the A-P diameter of the thorax. a. (^) Upper trapezius b. (^) Pectoralis major c. (^) Sternocleidomastoid d. (^) Serratus anterior ANS: B When the insertion and origin of the pectoralis muscle are reversed by leaning on a table to fix the arms, the muscle will pull on the anterior chest wall, lifting the ribs and sternum to increase the A-P diameter of the thoracic cage. PTS: 1
9. The serous fluid within the pleural space serves to provide which of the following functions? a. (^) Create a constant negative pressure. b. (^) Assist with venous return of blood to the heart. c. (^) Reduce friction between the lungs and thoracic wall. d. (^) Serve to allow separation of the pleural layers. ANS: C The serous fluid within the pleural space serves to hold the pleural layers together during ventilation and reduce friction between the lungs and thoracic wall. The space creates a negative pressure to maintain lung inflation, not the fluid itself. PTS: 1
10. Irritation of the phrenic nerve supplied pleura results in which of the following pain referral patterns? a. (^) Thoracic wall b. (^) Abdominal wall c. (^) Mediasternal region d. (^) Lower neck and shoulder ANS: D Irritation of the phrenic nerve supplied pleura can result in referred pain in the lower neck and shoulder, whereas, irritation of the intercostally innervated pleura may result in referral of pain to the thoracic or abdominal wall. PTS: 1
11. An abnormal pleural friction rub on auscultation BEST indicates which of the following? a. (^) Infection with a resultant inflammatory response within the pleura b. (^) A buildup of fluid in the pleural space following cardiothoracic surgery c. (^) The presence of blood in the pleural space d. (^) A bacterial infection with resultant pus in the pleural space

ANS: A Infection with a resultant inflammatory response within the pleura is termed pleuritis or pleurisy and is best appreciated through the presence of pleural chest pain and an abnormal pleural friction rub on auscultation. A buildup of fluid, blood, or air in the space would result in diminished or absent breath sounds in the area. PTS: 1

12. The presence of four segments (anterior basal, superior basal, lateral basal, and posterior basal) BEST describes which of the following lobes? a. (^) Right upper lobe b. (^) Left upper lobe c. (^) Right middle lobe d. (^) Right lower lobe ANS: D The lowermost lobe, the right lower lobe, consist of four segments (anterior basal, superior basal, lateral basal, and posterior basal). PTS: 1
13. The physical therapist performs auscultation of the lateral portion of right middle lobe. Which of the following stethoscope locations BEST identifies this lung segment? a. (^) Adjacent to the fifth rib lateral right chest wall b. Adjacent to third to fifth rib posterior right chest wall c. (^) Adjacent to the fourth rib lateral right chest wall d. (^) Adjacent to the eighth thoracic vertebra lateral chest wall ANS: A The right middle lobe is subdivided into the lateral and medial lobes. This lobe is the smallest of the three lobes. Its inferior border is adjacent to the fifth rib laterally and sixth rib medially. PTS: 1
14. The BEST reason why a physical therapist should acquire an understanding of the various lobes and segments and their anatomical orientation is which of the following? a. (^) Provide tactile feedback for segmental breathing. b. (^) Placement of a stethoscope for auscultation. c. (^) Perform appropriate positioning during pulmonary hygiene. d. (^) Educate patients on best positioning during coughing. ANS: C An understanding of the various lobes and segments and their anatomical orientation is important for placement of a stethoscope during auscultation, but is more essential when the therapist is using positions to facilitate removal of secretions from various aspects of the lung during bronchopulmonary hygiene intervention.

PTS: 1

15. Which of the following upper respiratory structures provide humidification? a. (^) Nasopharynx b. (^) Pharynx c. (^) Larynx d. (^) Nasal cavity ANS: D The primary respiratory functions of the nasal cavity include air conduction, filtration, humidification, and temperature control. PTS: 1

16. During the administration of suctioning procedures, which of the following may cause an adverse response in the patient? a. (^) An elicited parasympathetic response b. (^) The catheter is inserted to the carina level c. (^) A cough is stimulated d. (^) The use of a nasal trumpet during suctioning ANS: A During suctioning procedures, the catheter is inserted to the level of the carina. When the catheter is in contact with the carina, a cough is ensued along with a strong parasympathetic response. The parasympathetic response may cause a decrease in heart rate and oxygen levels. PTS: 1

17. Which of the following lung architecture characteristics creates an increased susceptibility for aspiration in the lung? a. (^) A left mainstem angle of 40 to 60 degrees from the trachea b. (^) A right mainstem angle of 25 degrees from the trachea c. (^) A length of 2 inches from the trachea to the lung d. (^) A length of 1 inch from the trachea to the lung ANS: B The 25-degree angle of the right mainstem from the trachea predisposes foreign objects, food, and fluids to enter the right lung. Thus aspiration is relatively more common in the right lung as compared to the left lung. PTS: 1

18. Smoking specifically diminishes the function of which type of cells in the bronchial epithelium? a. (^) Goblet cells b. (^) Ciliated cells c. (^) Mucous cells d. (^) Serous cells

ANS: B Smoking paralyzes ciliated epithelial cells. These cilia will be paralyzed for 1 to 3 hours after smoking a cigarette, or in chronic smokers will be permanently paralyzed. PTS: 1

19. Which of the following functions does the myocardium layer of the heart serve? a. (^) Forms a continuous lining with the tissue of the valves. b. (^) Minimizes friction during cardiac contraction. c. (^) Provides a tough fibrous layer of dense irregular connective tissue. d. (^) Facilitates the pumping action of the heart. ANS: D The middle layer of the heart of myocardium facilitates the pumping action of the heart due to the presence of contractile elements. Myocardial cells are housed in this layer and are categorized as mechanical cells for conduction and conductive cells for electrical conduction. PTS: 1
20. The atrial kick created by the contractile ability of the pectinate muscles in the atria account for what percent of the cardiac output? a. (^) 15% to 20% b. (^) 5% to 10% c. 25% d. (^) Less than 5% ANS: A The effective contraction of the pectinate muscles of the atria accounts for approximately 15% to 20% of cardiac output—the atrial kick. PTS: 1
21. Regurgitation or insufficiency of the mitral valve causes blood to accumulate in which of the following heart chambers? a. (^) Right ventricle b. (^) Left ventricle c. (^) Right atrium d. (^) Left atrium ANS: D The mitral valve allows blood to be ejected from the left atrium to the left ventricle. If regurgitation of the mitral valve develops, blood will accumulate in the left atrium and elevate left atrial pressures. PTS: 1
22. Which of the following BEST describes the vagus nerve function in the heart? a. (^) Creates the impulses that pace the heart.

b. (^) Creates an inhibitory effect decreasing the heart rate. c. (^) Stimulates the release of catecholamines. d. (^) Provides an excitatory effect on the heart for fight or flight. ANS: B The vagus nerve provides parasympathetic stimulation and is cardio inhibitory or slows the heart rate and contractility. PTS: 1

23. Occlusion of the circumflex artery MOST likely causes an infarction in which of the following regions within the heart? a. (^) SA node in the right atrium b. (^) Lateral aspect of the left ventricle c. (^) Anterior aspect of the left ventricle d. (^) Inferior portion of the left ventricle ANS: B The circumflex artery supplies blood to the lateral aspect of the left ventricle. PTS: 1
24. Which of the following veins empties into the left atrium? a. (^) Superior vena cava b. (^) Inferior vena cava c. (^) Pulmonary vein d. (^) Coronary sinus vein ANS: C The pulmonary veins, unlike the systemic veins, have no valves. They originate in the capillary networks and join together to ultimately form two veins—a superior and an inferior pulmonary vein—from each lung, which open separately into the left atrium. PTS: 1
25. Which of the following statements is true when describing characteristics of veins? a. (^) Veins have thin walls and small diameters. b. (^) Veins contain valves with bidirectional flow. c. (^) Venous elasticity promotes recoil of the wall. d. (^) Muscle pump activity has a milking effect on veins. ANS: D Veins have thin walls and large diameters, contain valves that create a unidirectional flow, and have less elastic tissue; venous blood flow back to the heart is facilitated by the milking effect of muscle pump activity. PTS: 1

26. Which of the following factors affecting the diaphragm MOST likely will cause an automatic firing of the accessory muscles to trigger inspiration? a. (^) Stomach fullness b. (^) Flat and rigid diaphragm c. (^) Obesity with the presence of pannus d. (^) Ascites due to liver disease ANS: B Patients with COPD tend to develop a flattening of the diaphragm due to the presence of hyperinflated lungs. A flat and rigid diaphragm cannot be strengthened and will cause an automatic firing of the accessory muscles to trigger inspiration. The other factors may affect normal excursion of the diaphragm, but still allow for the diaphragm to function. PTS: 1
27. The point at which the nerves, vessels, and primary bronchi penetrate the parenchyma of each lung is termed the: a. root. b. (^) fissure. c. (^) hilus. d. (^) segment. ANS: C The point at which the nerves, vessels, and primary bronchi penetrate the parenchyma of each lung is termed the hilus. PTS: 1
28. The right upper lobe bronchus divides into which of the following? a. (^) Lateral and medial segment b. (^) Superior segment to the upper portion c. (^) Apical, posterior, and anterior segments d. (^) Lower lobe bronchus to the medial basal segment ANS: C The right upper lobe bronchus divides into three segmental bronchi: apical segmental bronchus, posterior segmental bronchus, and anterior segmental bronchus. PTS: 1
29. Which of the following cells are involved in the production of surfactant? a. (^) Granular pneumocytes b. (^) Squamous pneumocytes c. (^) Endothelial cells d. (^) Serous cells ANS: A Granular pneumocyte (Type II) cells are thick, cuboidal shaped, cover 7% of the alveolar wall, and are involved in the production of surfactant.

PTS: 1

30. Which of the following anatomical landmarks coincides with the apex of the heart? a. (^) Left side at the third intercostal space b. (^) Left fifth intercostal space at the midclavicular line c. (^) Second intercostal space d. (^) Right fifth intercostal space at the midclavicular line ANS: B The apex of the heart is defined as the tip of the left ventricle and it projects into the fifth intercostal space on the left at the midclavicular line. PTS: 1

Chapter 02: Physiology of the Cardiovascular and Pulmonary Systems

Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition

MULTIPLE CHOICE

1. The primary function of the pulmonary system is which of the following? a. (^) Regulating acid–base balance and maintaining normal blood pH b. (^) Filtering and metabolizing toxic substances c. (^) Achieving temperature homeostasis through evaporative heat loss d. (^) Exchange of oxygen and carbon dioxide between environment, blood, and tissue ANS: D According to the author, the most important function of the pulmonary system is to exchange oxygen and carbon dioxide between the environment, blood, and tissue. PTS: 1
2. The total volume of air that is inhaled or exhaled in 1 minute is termed: a. (^) tidal volume. b. (^) minute ventilation. c. (^) inspiratory reserve volume. d. (^) inspiratory capacity. ANS: B The minute ventilation represents the total volume of air that is inhaled or exhaled in 1 minute. PTS: 1
3. The maximum amount of air that can be inhaled after a normal tidal exhalation is termed: a. (^) inspiratory reserve volume. b. (^) expiratory reserve volume. c. (^) inspiratory capacity. d. (^) vital capacity. ANS: C The inspiratory capacity (IC) is the sum of the tidal and inspiratory reserve volumes; it is the maximum amount of air that can be inhaled after a normal tidal exhalation. PTS: 1
4. Which of the following brain areas provides control for automatic breathing? a. (^) Medulla oblongata b. (^) Pons c. (^) Frontal lobe of the cerebrum d. (^) Hypothalamus ANS: A

The medulla oblongata contains inspiratory neurons that produce inspiration and expiratory neurons that are triggered with force expiration. These neurons control automatic breathing. PTS: 1

5. Which of the following statements BEST explains why increasing administered oxygen should be done cautiously in a patient with severe chronic obstructive pulmonary disease (COPD) AT REST? a. (^) The body may rely on hypoxic drive to breathe (oxygen receptors) and increasing administered oxygen at rest leads to hyperoxemia suppressing the hypoxic drive. b. (^) The body needs additional time to allow the peripheral chemoreceptors to cause an increase of ventilatory rate to improve oxygenation. c. (^) The body is relying on carbon dioxide to regulate the respiratory cycle, and increasing administered oxygen at rest leads to inhibition of the carbon dioxide receptors. d. (^) Increasing administered oxygen to the body oversaturates the system leading to toxicity. ANS: A A patient with severe COPD who develops high CO 2 blood levels subsequently leads to the body relying more on oxygen receptors instead of carbon dioxide receptors. This is termed hypoxic drive to breathe. If administered oxygen is too high and causes hyperoxemia (increased oxygen in the blood), the oxygen receptors may be suppressed, which reduces the drive to breathe. PTS: 1
6. Which of the following lung tissue receptors are located along the smooth muscles lining the airways are sensitive to increasing size and volume within the lung, termed the Hering–Breuer reflex? a. (^) Irritant receptors b. (^) Stretch receptors c. (^) Chemoreceptors d. (^) Juxtapulmonary receptors ANS: B Stretch receptors are located along smooth muscles lining the airways and are sensitive to increasing size and volume within the lung. The Hering–Breuer reflex is active with large increases in the tidal volume, especially seen during exercise, and protects the lung from excessive inflation. PTS: 1
7. Which of the following lung receptors are stimulated in a patient with left-sided congestive heart failure who develops pulmonary edema causing the patient to breathe in a SHALLOW, tachypneic pattern. a. (^) Irritant receptors

b. (^) Stretch receptors c. (^) Chemoreceptors d. (^) Juxtapulmonary receptors ANS: D The juxtapulmonary receptors (J receptor) are located near the pulmonary capillaries and are sensitive to increased pulmonary capillary pressures. On stimulation, these receptors initiate a rapid, shallow breathing pattern. In a patient with congestive heart failure, pulmonary edema would stimulate the interstitial J receptors. PTS: 1

8. Which of the following events occur as a result of the diaphragm and external intercostals contracting to facilitate inspiration? a. (^) An increase in the volume of the thoracic cavity and lung reducing the intrapulmonary pressure b. (^) An increase in the pressure within the lung occurring due to Boyle’s law c. A decrease in the volume of the thoracic cavity and lung increasing the intrapulmonary pressure d. (^) A change in the thoracic cavity and lung volume leading to an intrapulmonary pressure that exceeds the atmospheric pressure ANS: A When the diaphragm and external intercostals contract to facilitate inspiration, it causes an increase in the volume of the thoracic cavity and lung, which reduces the intrapulmonary pressure. The intrapulmonary pressure is decreased below the atmospheric levels facilitating the flow of air into the lungs to normalize pressure differences. PTS: 1
9. Which of the following BEST describes the intrapleural pressure compared to the intrapulmonary pressure? a. (^) Intrapleural pressure is less than intrapulmonary pressure. b. (^) Intrapleural pressure is the same as intrapulmonary pressure. c. (^) Intrapleural pressure is greater than intrapulmonary pressure. d. (^) Intrapleural pressure is not related to the intrapulmonary pressure. ANS: A The intrapleural pressure is normally lower than the intrapulmonary pressure developed during both inspiration and expiration. This difference in pressures helps to maintain the lung near the chest wall. PTS: 1
10. Compliance is BEST explained by which of the following statements. a. (^) The tendency of a structure to return to its initial size after being distended b. (^) The pressure that acts to collapse the alveolus and increase the pressure of air within the structure

c. (^) The tendency of a force that exists to collapse or recoil the structure while inflated d. (^) The pressure that allows changes in lung volume to parallel changes in thoracic excursion during breathing ANS: C Compliance of lung tissue is likened to a balloon during inspiration, where there exists a tendency to collapse or recoil while inflated. A = elasticity; B = surface tension; D = transmural pressure. PTS: 1

11. Which of the following statements is MOST correct about surfactant? a. (^) Diminishes the overall surface tension of the alveoli to keep air in smaller alveoli. b. (^) Pulmonary surfactant is composed of a single class of molecules. c. (^) Compression of the surfactant molecules decreases their density. d. (^) Surfactant develops early in fetal life. ANS: A Surfactant is a surface-active agent that is needed to decrease the overall surface tension of alveoli in order to lower wall tension in proportion to the radius of the alveolus. Pressure within the alveolus is directly proportional to the surface tension and inversely proportional to the radius of the alveolus. The availability of surfactant assists in keeping air in alveoli of varying sizes. PTS: 1
12. Which of the following factors act to decrease airway resistance? a. (^) The presence of mucus and edema b. (^) Smaller airway diameter c. (^) Parasympathetic nervous system d. (^) Sympathetic nervous system ANS: D Sympathetic nervous system influence decreases airway resistance, which would be congruent with the need to improve airflow in order to keep up with the body’s demand for oxygen during exercise. Poiseuille’s law states that the flow through a vessel or airway is directly proportional to the pressure difference and radius and inversely proportional to the length of the airway and viscosity of the gas. Small changes in radius account for large changes in airflow. PTS: 1
13. Which of the following physical properties of lungs facilitates passive expiration? a. (^) Compliance b. (^) Elasticity c. (^) Surface tension d. (^) Resistance to airflow ANS: B

Elasticity refers to the tendency of a structure to return to its initial size after being distended. This elastic recoil of the lung allows passive expiration to occur. PTS: 1

14. To facilitate the diffusion of oxygen from alveoli to pulmonary capillary, which of the following must occur? a. (^) The alveolar walls become thicker. b. (^) Concentration of oxygen is high in the pulmonary artery. c. (^) Concentration of oxygen is high in the alveoli. d. (^) Partial pressure of oxygen must equal 20.93%. ANS: C For gas exchange to occur, a pressure gradient must be created across the alveolar capillary interface. This gradient will enable gases to diffuse from an area of high concentration to areas of low concentration across the semipermeable respiratory membrane. PTS: 1
15. Which of the following improves gas exchange in the base of the lungs? a. (^) Gas ventilation is greater than blood perfusion. b. (^) Patient is positioned in prone. c. (^) Patient is positioned in upright sitting. d. (^) Blood perfusion amount is greater than gas ventilation. ANS: C A change in the position of the patient changes areas of ventilation and perfusion. Generally, greater ventilation and perfusion occur in gravity-dependent areas, thereby allowing better respiration to occur in the dependent lung. The upright sitting position would facilitate better ventilation/perfusion matching in the base of the lungs due to gravity dependency. PTS: 1
16. Which of the following forms of hemoglobin molecules refers to the binding of heme to carbon monoxide instead of oxygen? a. (^) Oxyhemoglobin b. (^) Deoxyhemoglobin c. (^) Methemoglobin d. (^) Carboxyhemoglobin ANS: D Carboxyhemoglobin is another form of hemoglobin that involves the binding of heme to carbon monoxide instead of oxygen. The bond with carbon monoxide is 210 times stronger than oxygen, and therefore displaces oxygen and inhibits its binding capacity. PTS: 1

17. In the systemic arteries, at a partial pressure of 100 mm Hg, the percent of hemoglobin should be: a. (^) 85%. b. (^) 97%. c. (^) 74%. d. (^) 21%. ANS: B In the systemic arteries, at a partial pressure of 100 mm Hg, the percent of hemoglobin is 97% indicating that 97% of hemoglobin molecules in blood are bound to oxygen. The remaining 3% reflects deoxyhemoglobin, methemoglobin, and carboxyhemoglobin concentrations. PTS: 1
18. Which of the following is the BEST way to measure oxyhemoglobin saturation? a. (^) Pulse oximeter b. Hemoglobin blood test c. (^) Arterial blood gas d. (^) Pulmonary function test ANS: C The gold standard or best test for measuring oxyhemoglobin saturation is through an analysis of arterial blood gases. Pulse oximeter can also be utilized to obtain this number, but is less accurate due to it being an estimation and not a direct measure. PTS: 1
19. Which of the following changes in the system would cause a shift in the oxyhemoglobin dissociation curve to the left? a. (^) An increase in the pH b. (^) A decrease in the pH c. (^) Increase in tissue temperature d. (^) Prolonged hypoxemia ANS: A An increase in pH or alkalemia would shift the curve to the left. Answer choices B, C, and D all shift the curve to the right. PTS: 1
20. Which of the following factors will potentially diminish cardiac output? a. (^) Medications that have a positive ionotropic effect b. (^) Beta-blocker effect on beta-receptors c. (^) Release of epinephrine and norepinephrine d. (^) An increase in blood volume ANS: B

Beta-blocker medications blunt heart rate response during exercise by making the beta- receptors on the myocardial wall unresponsive to sympathetic stimulation and appropriately increase heart rate. A lack of heart rate response would potentially diminish cardiac output. PTS: 1

21. In patients with congestive heart failure, which of the following positions should be avoided to minimize the preload on a failing heart? a. (^) Sitting up in a bedside chair b. (^) Standing at a support surface c. (^) Semireclined on an exercise mat d. (^) Supine with lower extremities elevated ANS: D In patients with congestive heart failure, the Frank–Starling mechanism does not apply. An increase in preload puts additional stress on the failing heart. These patients will not tolerate supine (flat) or supine with legs elevated due to the effects of gravity and a resultant increase of blood volume return to the heart. PTS: 1
22. The positive ionotropic effect on myocardial contractility produced by the release of norepinephrine from sympathetic nerve endings is an example of: a. (^) intrinsic control factor. b. (^) extrinsic control factor. c. (^) Frank–Starling mechanism. d. (^) parasympathetic stimulus. ANS: B The extrinsic control of contractility depends on the activity of the sympathoadrenal system. Epinephrine from the adrenal medulla and norepinephrine from the sympathetic nerve endings produce a positive ionotropic effect, or increase myocardial contractility by promoting an influx of calcium available to the sarcomeres of the myocardial cells. PTS: 1
23. Afterload is BEST defined by which of the following statements? a. (^) A reflection of the pressure against which the heart has to contract b. (^) The amount of load (stretch) on the myocardial wall prior to contraction c. (^) The maximum amount of blood that can be filled in the ventricles d. (^) The pressure within the arterial system during the diastolic phase of the cardiac cycle ANS: A The afterload is a reflection of the pressure against which the heart has to contract to pump blood into the aorta. The pressure within the arterial system during the diastolic phase of the cardiac cycle is a function of total peripheral resistance.

PTS: 1

24. The BEST indicator of cardiac function is: a. (^) stroke volume. b. (^) end-diastolic volume. c. (^) ejection fraction. d. (^) end-systolic volume. ANS: C The ejection fraction represents a ratio or percentage of the volume of blood ejected out of the ventricles relative to the volume of blood received by the ventricles before contraction and is the best indicator of cardiac function. PTS: 1
25. In a patient with systolic heart failure, the compromised ejection fraction is commonly reflected as: a. (^) 70%. b. (^) 60%. c. (^) 50%. d. (^) 35%. ANS: D In patients with systolic heart failure, the ejection fraction is compromised as evidenced by a ratio less than 40%. For every 100 mL of blood brought into the ventricles, less than 40 mL of blood is ejected per contraction due to a failing heart. PTS: 1
26. Peripheral muscle contraction and deep diaphragmatic inspiratory maneuvers directly enhance which of the following influences on cardiac function? a. (^) Venous return b. (^) Myocardial contractility c. (^) Afterload d. (^) End-systolic volume ANS: A Venous return represents the return of blood to the right side of the heart via the veins. Factors that directly influence venous return include the pressure gradient in the venous system, peripheral muscle activity, deep diaphragmatic inspiratory maneuvers, and sympathetic nerve fiber stimulation on smooth muscle cell contraction in veins. PTS: 1
27. Myocardial tissue requires constant aerobic metabolism both at rest and during heavy exercise. Which of the following attributes of myocardial tissue BEST facilitates the supply of oxygen during systole (myocardium contraction)? a. (^) High capillary density b. (^) Myoglobin

c. (^) Coronary perfusion d. (^) Hemoglobin ANS: B The myocardium contains large amounts of myoglobin. These structures have the ability to store oxygen during diastole and release the stored oxygen during systole to myocardial cells. Systole involves myocardial contraction, which squeezes coronary arteries reducing the perfusion of blood. Capillary density is helpful, but its influence does not change as related to diastole and systole phases. PTS: 1

28. The rate pressure product is a clinically useful tool to estimate the myocardial oxygen demand and is calculated using which of the following variables? a. (^) Respiratory rate × systolic blood pressure b. (^) Respiratory rate × diastolic blood pressure c. (^) Heart rate × systolic blood pressure d. Heart rate × diastolic blood pressure ANS: C The rate pressure product is a clinically useful tool to estimate the myocardial oxygen demand and is calculated by using heart rate × systolic blood pressure. During exercise, alterations in autonomic nervous system stimulation also influence coronary blood flow by directly affecting heart rate and force of contraction—the two primary determinants of the myocardium’s metabolic rate. PTS: 1
29. Which of the following age-related cardiovascular physiological changes MOST likely leads to increased ventricular wall thickness? a. (^) Increased body weight b. (^) Decreased maximal heart rate c. (^) Reduced arteriovenous oxygen uptake d. (^) Increased collagen presence ANS: D With increasing age, left-ventricular wall thickness increases due to increased collagen and the enhanced size of myocardial cells. Increased body weight, decreased maximal heart rate, and reduced arteriovenous oxygen uptake contribute to a decline in maximal oxygen uptake. PTS: 1
30. Which of the following age-related cardiovascular physiological changes is considered a peripheral factor? a. (^) Compromised arteriovenous oxygen uptake b. (^) Reduced stroke volume c. (^) Decreased maximal heart rate d. (^) Low stroke volume values

ANS: A Arteriovenous oxygen uptake is considered a peripheral factor (not specific to heart) whereas reduced stroke volume, decreased maximal heart rate, and low stroke volume values all reflect specific heart (central) factors. PTS: 1

Chapter 03: Ischemic Cardiovascular Conditions and Other Vascular Pathologies

Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition

MULTIPLE CHOICE

1. The presence of an obstruction that causes permanent damage to heart muscle fibers downstream, thus inhibiting heart muscle function, is BEST termed which of the following? a. (^) Angina pectoris b. (^) Coronary artery disease c. (^) Coronary heart disease d. (^) Atherosclerosis ANS: C As a direct result of the work of Enos and coworkers, the medical community now distinguishes coronary artery disease (CAD––the presence of an obstruction that limits coronary blood flow but does not significantly inhibit heart muscle function) from coronary heart disease (CHD––the presence of an obstruction that causes permanent damage to heart muscle fibers downstream, thus inhibiting heart muscle function). PTS: 1
2. Which of the following layers of the coronary arteries is responsible for making adjustments to the luminal diameter? a. (^) Adventitia b. (^) Media c. (^) Intima d. All of the above ANS: B In the middle layer (media), through alterations in vasomotor tome, as demands for changes in blood flow to the myocardium are perceived, this muscular layer (multiple layers of smooth muscle cells) is responsible for making adjustments to the luminal diameter. PTS: 1
3. Which of the following layers of the coronary arteries is selectively permeable to low- density lipoprotein (LDL) leading to the possible development of myocardial ischemia? a. (^) Adventitia b. (^) Media c. (^) Intima d. (^) None of the above ANS: C The arterial endothelium is selectively permeable to macromolecules of the size of a low- density lipoprotein (LDL). This permeability may lead to the development of processes associated with myocardial ischemia.

PTS: 1

4. Which of the following statements BEST explains how myocardium tissue perfusion occurs primarily during periods of muscle relaxation (diastole)? a. (^) All fluids follow the path of least resistance and flow from higher to lower pressure. b. (^) The right ventricle has a lower pressure than the left ventricle during systole resulting in less difference in blood flow in the right coronary artery between systole and diastole. c. (^) During diastole, full coronary arteries create high pressures, driving blood into the myocardium when intramyocardial pressure drops. d. (^) When the aortic valve closes, pressure is transmitted through dilated Valsalva sinuses to openings of coronary arteries. ANS: C Statements A, B, and D all relate to preliminary processes that lead to coronary artery filling, but statement C discusses specifically how a high- to low-pressure gradient is created during diastole leading to enhanced blood flow into the myocardium tissue. PTS: 1
5. In a patient with coronary artery disease, beta-blocking medications may be prescribed. Which of the following statements BEST describes the reasoning? a. (^) Beta-blockers lower resting heart rate, increasing diastolic filling time. b. (^) Beta-blockers lower the intramyocardial pressures, increasing muscle relaxation. c. (^) Beta-blockers lower the vasomotor tone in the media, increasing the diameter of the artery. d. (^) Beta-blockers lower the aortic pressure during systole, increasing blood flow to coronary arteries. ANS: A Beta-blocking medications may optimize the filling of the coronary arteries in individuals with disease by lowering the resting and exercise heart rates, therefore increasing diastolic filling time. PTS: 1
6. Which of the following determinants of myocardial blood flow will cause restriction to flow into restriction to flow into the capillary beds of the endocardium if elevated? a. (^) Diastolic blood pressure b. (^) Vasomotor tone c. (^) Resistance to flow d. (^) Left-ventricular end-diastolic pressure ANS: D LVEDP is the pressure within the ventricle at the end of diastole; it causes an occlusive force on the capillary beds of the muscle closest to the pumping chamber, the endocardium.

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7. Which of the following determinants of myocardial blood flow will inhibit flow of blood to the myocardium? a. (^) Increased diastolic blood pressure b. (^) Increased vasomotor tone c. (^) Decreased vasomotor tone d. (^) Lower left-ventricular end-diastolic pressure ANS: B Increased vasomotor tone will cause constriction, which will inhibit blood flow. Increased diastolic blood pressure, decreased vasomotor tone, and lower left-ventricular end-diastolic pressure all enhance blood flow. PTS: 1
8. The processes of atherosclerosis development occur in which of the following arterial layers? a. (^) Adventitia b. (^) Media c. (^) Intima d. (^) All of the above ANS: C Atherosclerosis consists of two processes, atherosis and sclerosis, that occur within the intima and endothelium of arterial walls. PTS: 1
9. The accumulation of lipids by monocytes between endothelial cells is termed: a. (^) foam cells. b. (^) fibrous cap. c. (^) thrombus. d. (^) Sclerosis. ANS: A Clusters of monocytes have been found in junctional areas, between endothelial cells, where they accumulate lipid and are known as foam cells. PTS: 1
10. Which of the following is characteristic of the “sclerotic” phase of atherosclerosis? a. (^) Fatty streaks in the artery b. (^) Accumulation of lipid by monocytes c. (^) Stretched endothelium by enlarging foam cells d. (^) Aggregation of platelets forming a thrombus ANS: D

When the endothelium is overstretched enough to cause an intima-based lesion, exposing the underlying connective tissue to the circulation, platelets aggregate forming a thrombus. The formation of a thrombus is characteristic of the “sclerotic” phase. Answers A, B, and C describe processes occurring in the “atherosis” phase. PTS: 1

11. Which of the following risk factors is considered nonmodifiable? a. (^) Cigarette smoking b. (^) High blood pressure c. (^) Increased age d. (^) Physical inactivity ANS: C Modifiable risk factors include cigarette/tobacco smoking, high blood pressure, high blood cholesterol levels, and physical inactivity. Nonmodifiable risk factors include heredity, male sex, and increased age. PTS: 1
12. Which of the following risk factors has been shown to be associated with leukocytosis, lower serum high-density lipoprotein, elevated fibrinogen and plasma catecholamine levels, and increased blood pressure? a. (^) Elevated cholesterol b. (^) Physical inactivity c. (^) Diabetes d. (^) Cigarette smoking ANS: D In comparison to nonsmokers, smokers have been shown to manifest leukocytosis, lower serum high-density lipoprotein levels, elevated fibrinogen and plasma catecholamine levels, and increased blood pressure. PTS: 1
13. Which of the following blood pressure recordings would be considered hypertensive? a. (^) 132/85 b. (^) 142/95 c. (^) 119/78 d. (^) 128/88 ANS: B Hypertension, both systolic (over 140 mm Hg) and diastolic (over 90 mm Hg), is believed to be an independent risk factor for development of CAD and peripheral and cerebral vascular disease. Some new standards report systolic pressure of 120 or higher and diastolic of 80 or higher as prehypertension, but this question asked about hypertension. PTS: 1

14. Which of the following ratios is the BEST predictor for developing cholesterol-related blockages in an artery? a. (^) Total cholesterol/high-density lipoproteins b. (^) Total cholesterol/low-density lipoproteins c. (^) Triglycerides/high-density lipoproteins d. (^) Gram level of saturated fat/mg level of cholesterol ANS: A The best predictor of risk for developing cholesterol-related blockages in an artery is the ration of total cholesterol to HDL; a ratio of greater than 4.5 increases an individual’s risk of developing atherosclerosis. PTS: 1
15. In a patient with diabetes, which of the following physiological changes is a result of increased glycosylation? a. (^) Increase sensitivity to enzymes b. (^) Elevated high-density lipoprotein c. (^) Enhanced fibrin degrading by fibrinogen d. (^) Enhanced thrombus formation ANS: D Nonenzymatic glycosylation, or the chemical attachment of glucose to proteins without the involvement of enzymes, is known to affect fibrogen, collagen, antithrombin III, HDL, and LDL, all of which are involved in the evolution of CAD. The attachment of glucose to these molecules renders them less sensitive to the enzymes and other substances with which they interact. Thrombus formation enhanced via antithrombin III activity is decreased and fibrinogen is less likely to perform its function of degrading fibrin. PTS: 1
16. In an older adult aged 70 years without known disease, which of the following interventions would have the HIGHEST impact on reducing the risk for coronary heart disease similar to younger subjects? a. (^) Age is too strong of a risk factor; therefore, overall risk could not be altered. b. (^) Have the older adult follow a low carbohydrate diet. c. (^) Encourage the older adult to walk daily for a minimum of 30 minutes. d. (^) Have the older adult consume a low dose of aspirin daily. ANS: C Studies have shown that interventions on other risk factors have proved to be beneficial in older subsets of patients and have resulted in the reduction of clinical end points, for example, myocardial infarction and symptoms. Age is not a strong enough factor to be an independent predictor of heart disease risk. A low carbohydrate diet potentially will increase saturated fats. Increasing physical activity would have a greater impact on risk factors than taking a low dose of aspirin.

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17. Which of the following factors is defined as a type of amino acid found in blood that when elevated has been linked to increased risk for development of cardiovascular diseases? a. (^) C-reactive protein b. (^) Homocysteine c. Factor VII d. (^) Lipoprotein a (Lpa) ANS: B Homocysteine, which is a type of amino acid found in the blood, has been linked to an increased risk for the development of cardiovascular diseases when the levels in the blood are elevated. PTS: 1
18. Which of the following interventions would result in the highest survival rate from ventricular fibrillation sudden cardiac arrest? a. (^) Entry into emergency medical system within 15 minutes b. (^) Administration of CPR within 10 minutes c. (^) Immediate CPR and AED shock within 3 to 5 minutes d. (^) AED shock within 15 minutes ANS: C Early CPR and rapid defibrillation combined with early advanced care can produce high long-term survival rates for witnessed cardiac arrest. If bystanders provide immediate CPR and the first shock is delivered within 3 to 5 minutes, the reported survival rates from ventricular fibrillation cardiac arrest are as high as 48% to 74%. PTS: 1
19. Which of the following monitoring tools is MOST useful to the clinician when attempting to correlate functional activities and myocardial capabilities in a patient diagnosed with chronic stable angina? a. (^) Product of exercise HR and systolic BP b. (^) Maximum heart rate during specific activity c. (^) Systolic blood pressure at end of activity d. (^) Highest rating of perceived exertion (RPE) ANS: A The double product or rate pressure product (HR × Systolic BP) is an index that is useful in correlating functional activities with myocardial capabilities. Rate pressure product is closely related to myocardial oxygen demand and chronic stable angina results from an imbalance in supply and demand of myocardial oxygen. PTS: 1