Test Bank For Little and Falace's Dental Management of the Medically Compromised Patient, 9th Edition

Preview (16 of 71 Pages)

100%

Purchase to unlock

Loading page image...

1Chapter 01: Patient Evaluation and Risk AssessmentLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.Elective dental care should be deferred for patients with severe, uncontrolled hypertension, meaning that the blood pressure isgreater than or equal to ________ mm Hg.a.200/140b.180/140c.180/110d.160/110ANS:CElective dental care should be deferred for patients with severe, uncontrolled hypertension, which is blood pressure greater than orequal 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 cardiacconditions?a.Mitral valve prolapseb.Prosthetic heart valvec.Rheumatic heart diseased.Pacemakers for cardiac arrhythmiasANS:BPreviously, the American Heart Association (AHA) recommended antibiotic prophylaxis for many patients with heart murmurscaused 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 tocertain 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 to _________ certain drugs,including local anesthetics and analgesics.a.absorbb.distributec.metabolized.excreteANS:CPatients also may have chronic hepatitis (B or C) or cirrhosis, with impairment of liver function. This deficit may result inprolonged 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 palpitationsb.Itchingc.Vomitingd.FaintingANS:BSymptoms 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 anallergic 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 highincidence of tuberculosis.d.A diagnosis of active TB is made by a purified protein derivative (PPD) skin test.ANS:CThe potential coexistence of tuberculosis and acquired immunodeficiency syndrome (AIDS) should be explored because patientswith AIDS have a high incidence of tuberculosis. A positive result on skin testing means specifically that the person has at sometime been infected with TB, not necessarily that active disease is present. Most patients who become positive skin testers do notdevelop 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 hypotensionb.severe hypertensionc.respiratory depressiond.cessation of intestinal peristalsisANS:BVasoconstrictors should be avoided in patients who are cocaine or methamphetamine users because the combination mayprecipitate arrhythmias, MI, or severe hypertension.

Loading page image...

27.It has been shown that the risk for occurrence of a serious perioperative cardiovascular event (e.g., MI, heart failure) is increased inpatients who are unable to meet a __-MET (metabolic equivalent of task) demand during normal daily activity.a.4b.6c.8d.10ANS:ADaily activities requiring 4 METs include level walking at 4 miles/hour or climbing a flight of stairs. Activities requiring greaterthan 10 METs include swimming and singles tennis. An exercise capacity of 10 to 13 METs indicates excellent physicalconditioning.8.Which of the following alterations in the fingernails is associated with cirrhosis?a.Yellowingb.Clubbingc.White discolorationd.Splinter hemorrhagesANS:CAlterations 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 disappearsb.the radial pulse disappears and then inflated an additional 20 to 30 mm Hgc.two fingers cannot fit comfortably under the cuffd.the pulse no longer can be heard with the stethoscopeANS:BWhile the radial pulse is palpated, the cuff is inflated until the radial pulse disappears (approximate systolic pressure); it is theninflated 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.ANS:BPatient 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). Seriouslimitation of daily activity; likely major impact on anesthesia and surgery.

Loading page image...

1Chapter 02: Infective EndocarditisLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.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 havebeen virtually eliminated.c.IE is currently classified as acute or subacute, to reflect the rapidity of onset andduration.d.Accumulating evidence questions the validity of antibiotic prophylaxis in anattempt to prevent IE prior to certain invasive dental procedures.ANS:DAntibiotics 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 questionsthe validity of this practice.2.Which of the following is currently the most common underlying condition predisposing to infective endocarditis (IE)?a.Aortic valve diseaseb.Rheumatic heart disease (RHD)c.Mitral valve prolapse (MVP)d.Tetralogy of FallotANS:CMitral valve prolapse, which accounts for 25% to 30% of adult cases of native valve endocarditis (NVE), is now the most commonunderlying condition among patients who acquire IE. Previously, rheumatic heart disease (RHD) was the most common conditionpredisposing to endocarditis. In developed countries, however, the frequency of RHD has markedly declined over the past severaldecades.3.The leading cause of death due to infective endocarditis (IE) is __________.a.chronic obstructive pulmonary diseaseb.heart failurec.pulmonary embolid.atheromasANS:BThe most common complication of IE, and the leading cause of death, is heart failure, which results from severe valvulardysfunction. This pathologic process most commonly begins as a problem with aortic valve involvement, followed by mitral andthen 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 peripheralmetastatic abscesses.4.The interval between the presumed initiating bacteremia and the onset of symptoms of infective endocarditis (IE) is estimated to beless than __________ in more than 80% of patients with IE.a.1 weekb.2 weeksc.1 monthd.2 monthsANS:BIt 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 dentallyinduced 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 valveb.Palms of the hands and soles of the feetc.Pulp of the digitsd.Nail bedsANS:BJaneway lesions are small, nontender erythematous or hemorrhagic macular lesions on the palms and soles. Janeway lesions are oneof the peripheral manifestations of IE due to emboli and/or immunologic responses.

Loading page image...

26.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 tocause 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 lowinocula of bacteria in the bloodstream due to daily activities and not a dentalprocedure.c.The quality of oral hygiene has no appreciable effect on the magnitude ofbacteremia after toothbrushing.d.The magnitude of bacteremia resulting from dental procedures is greater than thatneeded to cause experimental bacterial endocarditis (BE) in animals.ANS:BAn assumption often made is that the magnitude of bacteremias resulting from dental procedures is more likely to cause IE thanthat seen with bacteremias resulting from normal daily activities. Published data do not support this contention. Furthermore, themagnitude of bacteremia resulting from dental procedures is relatively low (with bacterial counts of fewer than 104colony-formingunits/mL), is similar to that of bacteremia resulting from normal daily activities, and is far less than that (106to 108colony-formingunits/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 orless likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that caused by routine daily activitiessuch as chewing food, tooth brushing, or flossing.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.ANS:DIt has been shown that visible bleeding during a dental procedure is not a reliable predictor of bacteremia. Collective published datasuggest that the vast majority of dental office visits result in some degree of bacteremia, and that it is not clear which dentalprocedures are more or less likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that causedby 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 bacteriacaused by antibiotic therapy reduces the risk of or prevents IE.b.Antibiotics given to at-risk patients before a dental procedure will prevent orreduce a bacteremia.c.Prospective randomized, placebo-controlled trials have been conducted toexamine the efficacy of antibiotic prophylaxis for preventing IE in patients whoundergo a dental procedure.d.Investigators have concluded that dental or other procedures probably only causeda small fraction of cases of IE, and that prophylaxis would prevent only a smallnumber of cases, even if it were 100% effective.ANS:DThis conclusion came as the result of a study from the Netherlands by van der Meer and colleagues that investigated the efficacy ofantibiotic 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 forpatients with which of the following cardiac conditions?a.Mitral valve prolapse with regurgitationb.Rheumatic heart diseasec.Prosthetic cardiac valved.A, B, and Ce.A and CANS:CProphylaxis with antibiotics before a dental procedure is recommended for a prosthetic cardiac valve, previous infectiveendocarditis, 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 alreadytaking penicillin for eradication of an infection?a.Amoxicillinb.Clindamycinc.Cephalosporinsd.Keep the patient on the penicillin because the blood level has already beenachievedANS:BThe presence of viridians group streptococci that are relatively resistant to penicillin or amoxicillin is likely in pat ients alreadytaking penicillin or amoxicillin for eradication of an infection. Clindamycin, azithromycin, or clarithromycin should be selected forprophylaxis if treatment is immediately necessary. Cephalosporins should be avoided due to cross resistance. Another approach isto wait for at least 10 days after the completion of antibiotic therapy before administration of prophylactic antibiotics.

Loading page image...

1Chapter 03: HypertensionLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.In prehypertension, diastolic pressure ranges from ________ mm Hg.a.80 to 89b.90 to 99c.100 to 109d.110 to 119ANS:AIn adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained diastolic blood pressure of 90 mm Hg orgreater 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.Physicianb.Dentistc.Dental hygienistd.A, B, and Ce.A and C onlyANS:AAlthough only a physician can make the diagnosis of hypertension and decide on its treatment, Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines specifically encourage the activeparticipation 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 bethe 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.ANS:DAccording to National Health and Nutrition Examination Survey (NHANES) data for the period 2011 to 2012, at least 75 millionadults in the United States have high blood pressure or are taking antihypertensive medication. This estimate equals about 29% ofthe U.S. population, compared with 24% when surveyed between 1988 and 1991. This marked increase is attributed to aging of thepopulation and the epidemic increase in obesity. Accordingly, a typical practice population of 2000 patients will have about 580patients who have hypertension.4.It is estimated that about __% of all blood pressure–related deaths from coronary heart disease occur in persons with blood pressurein the prehypertensive range.a.less than 1b.5c.15d.25ANS:CAbout 15%. However, the higher the blood pressure, the greater the chances of heart attack, heart failure, stroke, and kidneydisease. For every increase in blood pressure of 20 mm Hg systolic and 10 mm Hg diastolic, a doubling of mortality related toischemic 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 loweringblood pressure?a.Beta-blockers (BBs),α1-adrenergic blockers, centralα2agonists, as well as othercentrally acting drugs, and direct vasodilatorsb.Diuretics, thiazide diuretics, calcium channel blockers (CCBs), angiotensinreceptor 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 HgANS:BMany 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 enzymeinhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) as first-line choices for thegeneral non-Black population. For the general Black population, a thiazide diuretic or CCB is recommended as initial therapy.Other drugs used as secondary choices include beta-blockers (BBs),α1-adrenergic blockers, centralα2agonists, as well as othercentrally acting drugs and direct vasodilators.

Loading page image...

26.Deferral of elective dental care and referral to a physician for evaluation and treatment within 1 week are indicated for patientsfound to have asymptomatic blood pressure of greater than or equal to ________ mm Hg.a.160/90b.160/110c.180/90d.180/110ANS:DPatients 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 1week is indicated. Patients with uncontrolled blood pressure associated with symptoms such as headache, shortness of breath, orchest 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 appointmentsb.Premedication with a barbituratec.Nitrous oxide plus oxygen for inhalation sedationd.Keeping the dental chair in an upright position during treatmentANS:CNitrous 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 formany patients. Because many of the antihypertensive agents tend to produce orthostatic hypotension as a side effect, rapid changesin 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 orthostatichypotension as a side effect.c.Rapid chair position changes have nothing to do with antihypertensivemedications and drugs used in dental practice.d.There is a high potential of triggering cardiovascular issues agents forhypertensive dental patients in moving chairs if local anesthetics are used.ANS:BAlpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic hypotension as a side effect, so rapid changes inchair position during dental treatment should be avoided. This effect can be potentiated by the actions of anxiolytic and sedativedrugs.9.Use of how many cartridges of 2% lidocaine with 1:100,000 epinephrine at one time is considered to have little clinical risk fordental treatment of a patient with hypertension?a.2b.4c.6d.8ANS:AThe existing evidence indicates that use of modest doses (one or two cartridges of 2% lidocaine with 1:100,000 epinephrine) carrieslittle clinical risk in patients with hypertension, the benefits of its use far outweighing any potential problems. Use of more than thisamount 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 isadministered to a patient being treated for hypertension with a nonselectiveβ-adrenergic blocking agent?a.Hypotensionb.Hypertensionc.Respiratory alkalosisd.Respiratory acidosisANS:BThe basis for concern with use of nonselectiveβ-adrenergic blocking agents (e.g., propranolol) is that the normal compensatoryvasodilation 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 unopposedstimulation of alpha 1 receptors. This vasoconstrictive effect could potentially cause a significant elevation in blood pressure and acompensatory bradycardia.

Loading page image...

1Chapter 04: Ischemic Heart DiseaseLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.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 cardiovasculardisease.b.Cardiovascular disease begins in middle life.c.The annual mortality rate for cardiovascular diseases has been declining since1970.d.Cancer has replaced coronary heart disease as the leading cause of death in theUnited States after age 65.ANS:CMore than 85 million Americans (about 25% of the population) have some form of cardiovascular disease, with about 15.5 millionhaving coronary heart disease. Cardiovascular disease begins early in life, and autopsy studies have shown that one in six Americanteenagers already has pathologic intimal thickening of the coronary arteries. The annual mortality rate for cardiovascular diseasesas a group has been declining since 1970. Despite this decline, cardiovascular diseases continue to be the leading cause of death inAmerica, accounting for about 31% of all deaths. Coronary heart disease is the leading cause of death in the United States after age65, 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 cholesterolb.Failure to exercisec.Smoking cigarettesd.Smoking cigarsANS:CCigarette smoking is the single most important modifiable risk factor for coronary heart disease. Multiple prospective studies haveclearly documented that, compared with nonsmokers, persons who smoke 20 or more cigarettes daily have a two- to fourfoldincrease in coronary heart disease. This increased risk appears to be proportionate to the number of cigarettes smoked per day, andquitting 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 andcardiovascular disease.b.A single risk factor—dental caries—has been found to be responsible for thedevelopment of coronary atherosclerosis in patients over 50 years old.c.Studies indicate a connection between tooth scaling and a decreased risk ofcardiovascular disease outcomes.d.There is a hypothesis that the chronic inflammatory burden of periodontal diseasemay lead to impaired functioning of the vascular endothelium.ANS:BNumerous studies have reported an association between periodontal disease and cardiovascular disease, raising the question ofwhether periodontal disease is a risk factor for cardiovascular disease.Although the mechanism to explain this relationship isunclear, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of thevascular endothelium. At present, despite studies showing that tooth scaling is associated with decreased risk of cardiovasculardisease outcomes and improved endothelial function, a direct relationship (i.e., causation) between periodontal disease andcardiovascular 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 cellsb.Macrophagesc.Neutrophilsd.BasophilsANS:BAtheroma formation is initiated by adherence of monocytes to an area of injured or altered endothelium. The attached monocytesthen migrate into the intima of the vessel and become macrophages. Lipids derived from LDLs also enter through the injured ordysfunctional endothelium, forming extracellular deposits or small pools. Macrophages then engulf lipid molecules to becomefoam cells, which are characteristic features of the fatty streak.5.Which of the following is the important symptom of coronary atherosclerotic heart disease?a.Pitting edemab.Dysphagiac.Dyspnead.Chest painANS:DChest pain is the most important symptom of coronary atherosclerotic heart disease. The pain may be brief, as in angina pectorisresulting from temporary ischemia of the myocardium, or it may be prolonged, as in unstable angina or acute MI. Ischemicmyocardial pain results from an imbalance between the oxygen supply and the oxygen demand of the muscle.

Loading page image...

26.New-onset chest pain that increases in frequency or intensity has a changing pattern, may possibly occur at rest, and is not readilyrelieved by nitroglycerin. This best defines _________.a.acute coronary syndromeb.Prinzmetal’s variant anginac.unstable anginad.stable anginaANS:CUnstable angina is defined as new-onset pain with increasing frequency or intensity, and that is precipitated by less effort thanbefore 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, butalso may occur with eating or stress. Pain is relieved by cessation of the precipitating activity, by rest, or with the use ofnitroglycerin. Acute coronary syndrome describes a continuum of myocardial ischemia, and Prinzmetal’s variant angina is arelatively uncommon form of angina.7.Which of the following is the most common cause of sudden cardiac death?a.Ventricular fibrillationb.Myocardial infarctionc.Coronary atherosclerosisd.Pulmonary embolismANS:AThe most common cause of sudden cardiac death is ventricular fibrillation, a form of abnormal electrical activity resulting frominterruption 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 todetermine the extent of infarction?a.Stress thallium-201 perfusion scintigraphyb.3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA)c.Troponin I and troponin Td.Streptokinase (SK)ANS:CCardiac serum biomarkers of acute MI include troponin I, troponin T, creatine kinase isoenzyme (CK-MB), and myoglobin. Thetroponins and CK-MB are enzymes released only when cell death (infarction) or injury occurs. Troponins are proteins derived fromthe breakdown of myocardial sarcomeres. Troponin assays are the most sensitive and specific in differentiating cardiac muscledamage from trauma to skeletal muscle or other organs; and are virtually absent in the plasma of normal persons and are found onlyafter 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.ANS:BAn MI with ST segment elevation is due to complete blockage of coronary blood flow and more profound ischemia involving arelatively large area of myocardium. An MI without ST segment elevation (non-STEMI) is due to partial blockage of coronaryblood flow. Early fibrinolytic therapy improves outcomes in STEMI but not in non-STEMI. Morphine use for pain relief isrecommended for STEMI; however, use of morphine in non-STEMI patients is associated with increased mortality and should beavoided in these patients.10.When planning dental treatment for a patient with stable angina or a past history of MI without ischemic symptoms, _________.a.administration of nitrous oxide should be avoidedb.a pulse oximeter should be usedc.nitroglycerin should be administered prophylacticallyd.NSAIDs should be avoidedANS:DIn several studies, the use of NSAIDs in patients with previous MI has been shown to increase the risk for a subsequent myocardialinfarction, even after only 7 days of NSAID administration. Only naproxen did not increase the risk.

Loading page image...

1Chapter 05: Cardiac ArrhythmiasLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.Which of the following is the most common type of persistent arrhythmia?a.Sinus arrhythmiab.Premature atrial complexesc.Atrial fibrillationd.Ventricular flutter and fibrillationANS:CThe most common type of persistent arrhythmia is atrial fibrillation (AF). AF affects more than 2.7 million people, and the majorityis 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, 3b.2, 5, 4, 1, 3c.2, 3, 4, 1, 5d.2, 5, 3, 1, 4ANS:BThe 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.100b.125c.150d.175ANS:ATachycardia in an adult is a heart rate greater than 100 beats/min. The rate usually is between 100 and 180 beats/min. Thiscondition 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 includeatropine, epinephrine, alcohol, nicotine, and caffeine.4.Which of the following is a disorder of repolarization?a.Mobitz type I (Wenckebach)b.Wolff-Parkinson-White syndromec.Long QT syndromed.Torsades de pointesANS:CLong QT syndrome is a disorder of the conduction system in which the recharging of the heart during repolarization (i.e., the QTinterval) is delayed. It is caused by a genetic mutation in myocardial ion channels and by certain drugs, or may be the result of astroke. Mobitz type I (Wenckebach) is a form of second-degree heart block. Wolff-Parkinson-White syndrome is tachycardiainvolving 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 ventricularbradycardia 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 whereaspacemakers do.ANS:BICDs 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 ofincreased internal _________.a.interference; magnetic fieldsb.defibrillation; EMIc.cardiac arrhythmia; ATPd.EMI; shieldingANS:DRecent studies performed in humans together with previous data suggest that most dental devices do not cause significantelectromagnetic interference with the sensing and pacing of pacemakers and ICDs. This probably reflects the increased internalshielding provided in the newer pacemakers and ICDs.

Loading page image...

27.Which of the following is classified as asignificantarrhythmia according to American College of Cardiology and American HeartAssociation guidelines?a.Pathologic Q wavesb.Left bundle branch blockc.High-grade AV blockd.ST-T wave abnormalitiesANS:CPatients with high-grade AV block, symptomatic ventricular arrhythmias in the presence of cardiovascular disease, andsupraventricular arrhythmias with an uncontrolled ventricular rate are at major risk for complications and are not candidates forelective 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?a.Digoxinb.Vasoconstrictorsc.Beta-blockersd.NSAIDsANS:BThe use of vasoconstrictors in local anesthetics poses potential problems for patients with arrhythmias because of the possibility ofprecipitating cardiac tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor may be used as needed. Theyshould 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 takingnonselective beta-blockers can safely be given up to ____ cartridge(s) containing 1:100,000 epinephrine.a.oneb.threec.twod.zero—epinephrine is an absolute contraindicationANS:CThese patients can safely be given up to 0.036 mg epinephrine, which is the amount in two cartridges containing 1:100,000epinephrine. Greater quantities of vasoconstrictor may well be tolerated, but increasing quantities are associated with increased riskfor adverse cardiovascular effects.10.Due to the rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects, the use ofgingival retraction cord impregnated with epinephrine should be avoided for patients at cardiac risk. What might be used as analternative?a.Tetrahydrozolineb.Oxymetazolinec.Either A or Bd.Neither A nor BANS:CFor patients at all levels of cardiac risk, the use of gingival retraction cord impregnated with epinephrine should be avoided becauseof the associated rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects. As analternative, plain cord saturated with tetrahydrozoline HCl 0.05% or with oxymetazoline HCl 0.05% provides gingival effectsequivalent to those of epinephrine without the adverse cardiovascular effects.

Loading page image...

1Chapter 06: Heart Failure (or Congestive Heart Failure)Little: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.Which of the following is the most common underlying cause of heart failure in the United States?a.Dilated cardiomyopathyb.Coronary heart diseasec.Valvular heart diseased.HypertensionANS:BThe 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-recognizedcontributory conditions. The second most common cause of heart failure, accounting for about one fourth of all cases, is dilatedcardiomyopathy.2.Most of the acquired disorders that lead to heart failure result in initial failure of the ________.a.bundle of Hisb.mitral valvec.right ventricled.left ventricleANS:DLeft ventricular heart failure (LVHF) often is followed by failure of the right ventricle. In adults, left ventricular involvement isalmost always present, even if the clinical manifestations are primarily those of right ventricular dysfunction (fluid retentionwithout dyspnea or rales).3.The outstanding symptom of left ventricular heart failure is ________.a.dyspneab.dysphagiac.cyanosisd.ralesANS:AThe outstanding symptom is dyspnea, which results from the accumulation or congestion of blood in the pulmonary vessels—hencethe designationcongestiveheart failure. Acute pulmonary edema is often the result of left ventricular failure. Left-sided heartfailure leads to pulmonary hypertension, which increases the work of the right ventricle, pumping against increased pressure, oftenculminating 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 andtreatment.c.Primarily because auscultation often reveals a laterally displaced apical impulsecaused by left ventricular hypertrophy.d.It is a progressive disease with symptoms that worsen over time.ANS:DHeart failure also predisposes the patient to ischemic stroke, the risk for which is twice as high as normal.The prognosis is better ifthe underlying cause can be treated. One year after the diagnosis of heart failure, 20% of patients will succumb to the disease. Inpeople 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.Orthopneab.Paroxysmal nocturnal dyspnea (PND)c.Cheyne–Stokes respirationd.TachycardiaANS:AMost 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 featureassociated with Cheyne–Stokes respiration in heart failure patients. With Cheyne–Stokes respiration, central regulation ofrespiration 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 graduatedapproach.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 thefoundation of treatment.ANS:CAs with many conditions, a large degree of success of medical therapy depends upon patient compliance with treatmentrecommendations. Since many of these patients are treated with a plethora of drugs, it is important to monitor and/or encouragetheir 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.

Loading page image...

27.Which of the following categories of drugs is considered to be first-line therapy for the treatment of heart failure?a.Digitalis glycosidesb.β-Adrenergic blockersc.Angiotensin-converting enzyme (ACE) inhibitorsd.Angiotensin receptor blockers (ARBs)ANS:CACE inhibition with enalapril has been shown to reduce mortality from heart failure by 20% to 40%. The ACE inhibitors aretypically prescribed along with or following diuretic therapy and they decrease the need for large doses of diuretics as well as someof 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 introducedb.end-of-life care with hospice is the only remaining optionc.medical therapy will depend solely upon patient compliance with experimentalrecommendationsd.diuretic therapy becomes a patient’s “long shot” final attempt at improved healthANS:AMechanical and surgical intervention may be provided. These measures may include intra-aortic balloon counterpulsation, leftventricular 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 areasymptomatichave ________ heart failure.a.decompensatedb.compensatedc.provisionald.orthopneaANS:BWith decreasing cardiac output, stimulation of the renin–angiotensin system and the sympathetic nervous system (neurohumoralresponses) occur in an attempt to compensate for the loss of function.The effects of these responses include increased heart rateand myocardial contractility, increased peripheral resistance, sodium and water retention, redistribution of blood flow to the heartand brain, and an increased efficiency of oxygen utilization by the tissues. If these responses result in improved cardiac output withan elimination of symptoms, the condition is termedcompensatedheart failure. Symptomatic heart failure is termeddecompensated.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 failureb.Clinical manifestations of digitalis toxicityc.All details the patient included in the dental historyd.The patient’s physicianANS:DIn most cases, it will be necessary for the dentist to obtain a medical consultation with the patient’s cardiologist in order todetermine physical status, laboratory test results, level of control, compliance with medications and recommendations, and overallstability. The American College of Cardiology and the American Heart Association have published guidelines which can help tomake this determination. These guidelines can be applied to the provision of dental care and be of significant value to the dentist inmaking a determination of risk.

Loading page image...

1Chapter 07: Pulmonary DiseaseLittle: Dental Management of the Medically Compromised Patient, 9th EditionMULTIPLE CHOICE1.The most important cause of chronic obstructive pulmonary disease (COPD) in the world is ________.a.occupational pollutantsb.environment pollutantsc.tobacco smokingd.allergyANS:CWorldwide, tobacco smoking is the most important cause of COPD. Approximately 12.5% of current smokers, 9% of formersmokers, and 8% of those exposed to passive smoke have COPD. Smoking also accounts for 85% to 90% of COPD-related deathsin both men and women. The risk for development of COPD is dose related and increases with the number of cigarettes smoked perday 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” becausethey demonstrated enlarged chest walls, giving them a “barrel-chested”appearance.b.Currently, it is recognized that most patients with COPD may exhibit features ofboth diseases.c.“Blue bloaters” demonstrated weight loss with progression of the disease and alack of cyanosis.d.A and Be.B and CANS: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 exhaleair 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 dioxide2. Normal partial pressure of carbon dioxide3. Decreased partial pressure of carbon dioxide4. Decreased partial pressure of oxygen5. Normal partial pressure of oxygena.1, 4b.2, 4c.3, 4d.1, 5e.2, 5ANS:BPatients 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 oxygensaturation 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 thiscategory of patient.d.Nitrous oxide is preferred over diazepam (Valium) for a patient with severeCOPD.ANS:AA patient coming to the office for routine dental care who displays shortness of breath at rest, a productive cough, upper respiratoryinfection, or an oxygen saturation level less than 91% (as determined by pulse oximetry) is unstable, and the appointment should berescheduled and an appropriate referral for medical attention should be made. Patients should be placed in a semisupine or uprightchair position for treatment, rather than in the supine position, to prevent orthopnea and a feeling of respiratory discomfort. Nocontraindication to the use of local anesthetic has been identified. If sedative medication is required, low-dose oral diazepam maybe used. Nitrous oxide–oxygen inhalation sedation should not be used in patients with severe COPD and emphysema because gasmay accumulate in air spaces of the diseased lung.

Loading page image...

25.Which of the following chronic inflammatory diseases of the airways is characterized by reversible episodes of increased airwayhyperresponsiveness?a.Emphysemab.Asthmac.Chronic bronchitisd.A and Be.B and CANS:BAsthma is a chronic inflammatory disease of the airways characterized by reversible episodes of increased airwayhyperresponsiveness resulting in dyspnea, coughing, and wheezing. Chronic bronchitis and emphysema are forms of chronicobstructive pulmonary disease (COPD), which is a general term for pulmonary disorders characterized by chronic airflowlimitation from the lungs that is not fully reversible.6.Which of the following medications is associated with “triad asthmaticus”?a.Methotrexateb.Nonspecific beta-blockersc.Aspirind.PenicillinANS:CAspirin causes bronchoconstriction in about 10% of patients with asthma, and sensitivity to aspirin occurs in 30% to 40% of peoplewith asthma who have pansinusitis and nasal polyps (the so-called triad asthmaticus). The ability of aspirin to block thecyclooxygenase pathway appears causative.7.Which of the following agents is currently regarded as the first-line medication for long-term control of asthma?a.β-Adrenergic agonistb.Corticosteroidc.Theophyllined.Cromolyn sodiumANS:BCurrent guidelines recommend a “stepwise” approach with the use of inhaled antiinflammatory agents as first-line drugs (thepreferred inhalational agent is a corticosteroid preparation, with a leukotriene inhibitor as an alternative) for the lo ng-termmanagement and prophylaxis of persistent asthma.β-Adrenergic agonists are recommended for intermittent asthma and aresecondary agents that should be added (i.e., not to be used alone) for persistent asthma when antiinflammatory drugs are inadequatealone.8.Which of the following is the drug of choice for relief of an acute asthma attack?a.Oral anticholinergicb.Inhalation corticosteroidc.Short-actingβ2-adrenergic agonistd.Inhaled cromolyn sodiumANS:CFor relief of an acute asthma attack, inhaled short-actingβ2-adrenergic agonists are the drugs of choice because of their fast andnotable bronchodilatory and smooth muscle relaxation properties. Short-actingβ2-adrenergic agonists produce bronchodilation byactivatingβ2receptors on airway smooth muscle cells, generally in 5 minutes or less. Inhalation corticosteroids, inhaled cromolynsodium, 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 asthmabecause _________ preservatives are found in local anesthetic solutions that contain epinephrine or levonordefrin.a.alumb.sulfitec.methylparabend.sodium chlorideANS:BIn 1987, the U.S. Food and Drug Administration (FDA) warned that drugs containing sulfites were a cause of allergic-type reactionin 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 ofcertain foods.10.According to the World Health Organization (WHO), approximately what percentage of the world’s population is infected withtuberculosis?a.One tenthb.One eighthc.One quarterd.One thirdANS:DThe World Health Organization (WHO) estimates that one third of the world’s population—representing 2 billion people—isinfected. This disease kills more adults worldwide each year than does any other single pathogen.

Loading page image...

311.Which of the following is true regarding laboratory tests for tuberculosis?a.A positive tuberculin (Mantoux) skin test (TST) means that the person hasclinically active tuberculosis.b.The interferon-gamma release assay (IGRA) is administered by intradermalinjection 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.ANS:CAll persons who are at risk for development of TB—including dentists—should undergo tuberculin skin testing annually. Withouttreatment, approximately 5% of skin test converters develop TB within 2 years; another 5% develop it later. A positive result on atuberculin (Mantoux) skin test (TST) presumptively means that the person has been infected. It does not mean that the person hasclinically active TB. IGRAs (interferon-gamma release assays) are performed on fresh whole blood. Neither the TST nor the IGRAcan discriminate active from latent infection.12.For which of the following categories of patients is treatment in the dental office contraindicated?1. Patients with a positive tuberculin test2. Patients with a history of tuberculosis3. Patients with clinically active sputum-positive tuberculosisa.1, 2, 3b.1, 2c.2, 3d.3ANS:DPatients 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 specialengineering control (ventilation) systems and filtration masks. The patient with a history of tuberculosis who is found to be free ofactive disease and is not immunosuppressed may be treated with the use of standard precautions. Patients with a positive tuberculinskin 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 resulton skin testing or IGRA, and has not been given follow-up medical care, _________.a.it is appropriate to treat the patient using standard precautionsb.respiratory equipment should be used during provision of dental carec.only treatment that utilizes a rubber dam should be providedd.dental care should not be rendered, and the patient should be referred to aphysician for evaluationANS:DDental care should not be rendered. If a health care provider is exposed to TB, the provider should be evaluated for skin testconversion. Converters should be treated promptly with isoniazid.

Preview Mode

This document has 71 pages. Sign in to access the full document!

Report

Study Now!

Document Details

Related Documents

PETH 410 Midterm

EPI Notes

Understanding Hemodialysis Patient Guide and Meal

Newborn Assessment Critical Thinking Map

Maternal Health Theory and Applications

Gynecological Exam

Navigating the Difficulties of Addressing Intricat

Cardiovascular 2 Handout

NCLEX Key Concepts

Understanding EKG Rhythms and Pacemaker Care NCLEX

Company

Explore

Study Tools