1.
Skeletal muscle breakdown produces predominantly liberation of which of the following
two amino acids?
A. Lysine and tyrosine.
B. Tyrosine and alanine.
C. Alanine and glutamine.
D. Glutamine and arginine.
E. Arginine and tyrosine.
answer: C
Alanine is released from skeletal muscle and extracted by the liver, where it is converted to new
glucose. Glutamine is also released from muscle and participates in renal acid-base homeostasis and
serves as fuel for rapidly growing cells such as enterocytes, stimulated macrophages, and fibroblasts.
Together, these two amino acids account for approximately two thirds of the nitrogen released from
skeletal muscle.
-------------------------------------------------------------------------------------------------------- -------------------2. glucose produced by gluconeogenesis post operation or post trauma is consumed by all of
the following tissues except?
A. Central nervous system.
B. Skeletal muscle.
C. Kidney.
D. Tissue in the healing wound.
Answer: B
Glucose is produced in increased amounts to satisfy the fuel requirements of the healing wound. In
addition, nerve tissue and the renal medulla also utilize this substrate. Skeletal muscle primarily
utilizes fatty acids, and bone utilizes mineral substrate.
---------------------------------------------------------------------------------------------------------------------------3. Shock can be best defined as:
A. Hypotension.
B. Hypoperfusion of tissues.
C. Hypoxemia.
D. All of the above.
Answer: B
Shock, no matter what the cause, is a syndrome associated with tissue hypoperfusion. Tissue
hypoperfusion leads to tissue hypoxia, which may or may not be due to hypoxemia. Hypotension is a
late sign of shock and, therefore, is not a good clinical indicator of the presence of tissue
hypoperfusion.
--------------------------------------------------------------------------------------------------------------------------4. All of the following are true about neurogenic shock except:
A. There is a decrease in systemic vascular resistance and an increase in venous capacitance.
B. Tachycardia or bradycardia may be observed, along with hypotension.
C. The use of an alpha agonist such as phenylephrine is the mainstay of treatment.
D. Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic
shock.
Answer: C
Neurogenic shock occurs when severe head injury, spinal cord injury, or pharmacologic sympathetic
blockade leads to sympathetic denervation and loss of vasomotor tone. Both arteriolar and venous
vessels dilate, causing reduced systemic vascular resistance and a great increase in venous
capacitance. The patient's extremities appear warm and dry, in contrast to those of a patient in
cardiogenic or hypovolemic shock. Tachycardia is frequently observed, though the classic
description of neurogenic shock includes bradycardia and hypotension. Volume administration to
fill the expanded intravascular compartment is the mainstay of treatment. The use of alphaadrenergic agonist is infrequently necessary to treat neurogenic shock.
5. all of the following may be useful in the treatment of cardiogenic shock except:
A. Dobutamine.
B. Sodium nitroprusside.
C. Pneumatic antishock garment.
D. Intra-aortic balloon pump.
Answer: C
Cardiogenic shock occurs when the heart fails to generate adequate cardiac output to maintain
tissue perfusion. Intrinsic causes such as myocardial dysfunction secondary to coronary artery
disease, or extrinsic causes such as pulmonary embolism, tension pneumothorax, and pericardial
tamponade, may produce cardiogenic shock. Principles of treatment of cardiogenic shock are aimed
at optimizing preload, cardiac contractility, and afterload. Preload is usually adequate or high in
cardiogenic shock. Dobutamine is a useful inotropic agent, particularly when filling pressures are
high, because of its mild vasodilatory effect, as well as its effect to enhance cardiac contractility.
Afterload-reducing agents, such as sodium nitroprusside, may be beneficial in cardiogenic shock in
the setting of elevated filling pressures, low cardiac output, and elevated systemic vascular
resistance. Cardiac output may improve with use of afterload-reducing agents by decreasing
myocardial wall tension and optimizing the myocardial oxygen supply-demand ratio. The intraaortic balloon pump (IABP), by providing diastolic augmentation, reducing left ventricular
afterload, and reducing myocardial oxygen consumption, is sometimes useful in the treatment of
cardiogenic shock. The IABP is especially useful in low–cardiac output postcardiotomy patients, in
patients awaiting revascularization, and in patients with acute myocardial infarction complicated by
mitral insufficiency or ventricular septal defect. The pneumatic antishock garment (PASG), which
causes an increase in systemic vascular resistance, is contraindicated in cardiogenic shock.
6.
An 18-year-old man shot in the left chest has a blood pressure of 80/50 mm. Hg, a heart
rate of 130 beats per minute, and distended neck veins. Immediate treatment include:
A. Administration of one liter of Ringer's lactate solution.
B. Subxiphoid pericardiotomy.
C. Needle decompression of the left chest in the 6th intercostal space.
D. Emergency thoracotomy to cross-clamp the aorta.
Answer: A
The finding of distended neck veins in conjunction with hypotension should suggest tension
pneumothorax or pericardial tamponade. Absent ipsilateral breath sounds and a trachea deviated to
the contralateral side may provide additional evidence for a tension pneumothorax, the immediate
treatment of which is needle decompression of the chest in the second or third intercostal space in
the midclavicular line. Pericardial tamponade may initially respond to volume administration by
enhancing preload. Pericardiocentesis may need to be performed emergently if hemodynamic
instability persists after an initial fluid bolus when signs of compressive cardiogenic shock are
present. Subxiphoid pericardiotomy should be performed only in the operating room by experienced
persons who are trained to deal with penetrating cardiac injuries. There is no role for aortic crossclamping in this scenario of cardiogenic shock.
---------------------------------------------------------------------------------------------------------------------------7. All of the following statements about hemorrhagic shock are true except:
A. Following hemorrhagic shock, there is an initial interstitial fluid volume contraction.
B. Dopamine, or a similar inotropic agent, should not be given immediately for resuscitation from
hemorrhagic shock.
C. The use of colloid solutions or hypertonic saline solutions is contraindicated for treatment of
hemorrhagic shock.
D. In hemorrhagic shock, a narrowed pulse pressure is commonly seen before a fall in systolic
blood pressure.
Answer: C
Hemorrhagic shock is associated with a contraction of the interstitial fluid compartment because of
precapillary vasoconstriction and reabsorption of interstitial fluid into the vascular compartment
along hydrostatic pressure gradients. Systolic hypotension may not be evident in hemorrhagic shock
until at least 30% or more of blood volume is exsanguinated. A decrease in the pulse pressure (the
difference between systolic and diastolic pressures) may be observed with losses of 15% to 30% of
blood volume. Treatment of hemorrhagic shock includes intravascular fluid administration and
definitive control of the source of the hemorrhage. Inotropic agents should not be started before
volume resuscitation but may be added to improve oxygen delivery to hypoxic tissues if volume
administration alone does not produce resuscitative goals. Colloid or hypertonic saline solutions are
not contraindicated in the treatment of hemorrhagic shock; however, definitive evidence that such
solutions are better than standard crystalloid solutions is lacking.
8. Which of the following statements about the role of the gut in shock and sepsis is not true?
A. Selective decontamination of the digestive tract with the use of oral antibiotics has been shown to
reduce nosocomial pneumonias and to improve mortality rates.
B. Enteral nutrition, as compared with parenteral nutrition, preserves the villus architecture of the
gut.
C. Gut dysfunction may be an effect of shock, but it may also contribute to the development of
MODS by the mechanism of bacterial translocation.
D. As compared with parenteral nutrition, enteral nutrition is associated with a reduction in septic
morbidity.
Answer: A
The gut has a vital role in the pathophysiology of shock. The splanchnic circulation is very
vulnerable to the circulatory redistribution that occurs in shock, thus, gut ischemia may occur early
in the various shock syndromes. Gut injury, as a result of ischemia or reperfusion injury, leads to
disruption in the intestinal mucosal barrier and increased gut permeability. Translocation of enteric
flora or bacterial toxins across the gut wall may then occur, resulting in amplification of the
systemic inflammatory response and the development of multiple organ dysfunction. Gut
dysfunction, therefore, may perpetuate the inflammatory process. Various methods have been tried
to modulate the deleterious effects of gut dysfunction. Selective decontamination of the digestive
tract by oral antibiotics has been shown to reduce the incidence of nosocomial pneumonias, but no
improvement in mortality has been demonstrated thus far with this controversial technique. Early
enteral nutrition probably has the biggest impact on the preservation of gut architecture and
function. When compared to parenteral nutrition, enteral feeding is more cost effective and is
associated with a lower rate of septic morbidity.
---------------------------------------------------------------------------------------------------------------------------9. Which of the following statements about CNS injury because of severe hyponatremia are
true?
A. There are no primary alterations in cardiovascular signs.
B. Signs of increased intracranial pressure may be masked by the hyponatremia.
C. Oliguric renal failure is an unlikely complication.
D. Rapid correction of the hyponatremia may prevent central pontine injury.
E. This patient is best treated by restriction of water intake.
Answer: A
Acute symptomatic hyponatremia is characterized by central nervous system signs of increased
intracranial pressure. Changes in blood pressure and pulse are secondary to increased intracranial
pressure. In the absence of hypovolemia, asymptomatic patients may be treated by restriction of
water intake; however, in such patients, hyponatremia should be partially corrected by parenteral
sodium administration. Rapid correction, particularly to hypernatremia, may lead to central pontine
myelinolysis. Oliguric renal failure may rapidly develop in severe hyponatremia.
10. Which of the following statements about extracellular fluid is true?
A. The total extracellular fluid volume represents 40% of the body weight.
B. The plasma volume constitutes one fourth of the total extracellular fluid volume.
C. Potassium is the principal cation in extracellular fluid.
D. The protein content of the plasma produces a lower concentration of cations than in the
interstitial fluid.
E. The interstitial fluid equilibrates slowly with the other body compartments.
Answer: B
The total extracellular fluid volume represents 20% of body weight. The plasma volume is
approximately 5% of body weight. Sodium is the principal cation. The Gibbs-Donan equilibrium
equation explains the higher total concentration of cations in plasma. Except for joint fluid and
cerebrospinal fluid, the majority of the interstitial fluid exists as a rapidly equilibrating component.
11. Which of the statements listed below about bleeding disorders is false?
A. Acquired bleeding disorders are more common than congenital defects.
B. Deficiencies of vitamin K decrease production of factors II, VII, IX, and X, protein C, protein S.
C. Hypothermia below 32‫؛‬C rarely causes a bleeding disorder.
D. Von Willebrand's disease is a relatively common congenital bleeding disorder.
Answer: C
Acquired bleeding disorders are significantly more common than congenital bleeding defects.
Vitamin K deficiency may be related to malnutrition or competitive inhibition of the production of
the vitamin K–dependent factors II, VII, IX, X, protein C, and protein S by warfarin (Coumadin).
Hypothermia causes significant platelet dysfunction with a significant bleeding disorder in many
patients. It is among the least recognized causes of altered coagulation in surgical patients. Von
Willebrand's disease is a relatively common disorder of bleeding and is generally undetectable by
routine screening methods.
------------------------------------------------------------------------------------------------------------------------12. The evaluation of a healthy middle aged patient scheduled for elective surgery should
always include which of the following as tests of hemostasis and coagulation:
A. History and physical examination.
B. Complete blood count (CBC), including platelet count.
C. Prothrombin time (PT) and activated partial thromboplastin time (APTT).
D. Studies of platelet aggregation with adenosine diphosphate (ADP) and epinephrine.
Answer: A
The evaluation of most patients scheduled for elective surgery who do not have a history of
significant bleeding disorders is somewhat controversial. An adequate history and physical
examination screen out most patients with bleeding problems. For patients who are scheduled to
undergo a major surgical procedure, it is advisable to obtain a CBC and platelet count, as well as a
PT and APTT level. This detects a large number of bleeding disorders but does not rule out all
possible causes of perioperative bleeding. Studies of platelet aggregation are indicated only for
patients who are suspected of having qualitative defects of platelet function (e.g., von Willebrand's
disease).
13. Which of the following statements regarding the transmission of infectious agents through
blood transfusions is false?
A. The transmission rates for human immunodeficiency virus (HIV) have been decreasing
progressively since the early 1980s.
B. The transmission rates of hepatitis have been decreasing steadily since the 1980s.
C. HIV is the infectious agent most commonly transmitted in blood.
D. Severely immunocompromised patients (such as patients undergoing transplantation) should
receive specially screened blood products.
Answer: C
The incidence of both HIV and hepatitis transmitted via blood transfusions has been steadily
decreasing since the 1980s. This is related to improved methods for detection and increased
awareness of surrogate markers of disease. The currently available techniques for the detection of
HIV are highly effective, provided the donor is not in the “window” before the formation of specific
antibody. The surrogate markers for hepatitis C, as well as the specific assays for the organism, are
now sufficiently refined to allow the detection of a large percentage of hepatitis C infection in
donated blood. Screening for hepatitis B surface antigen has effectively eliminated the transmission
of hepatitis B through blood products in most cases. CMV is the most commonly transmitted
infectious agent in blood. Since a large percentage of the population carry the virus, routine
screening is not performed for this organism; however, severely compromised patients such as those
undergoing transplantation should receive CMV-negative blood products.
-----------------------------------------------------------------------------------------------------------------------14. The most common cause of fatal transfusion reactions is:
A. An allergic reaction.
B. An anaphylactoid reaction.
C. A clerical error.
D. An acute bacterial infection transmitted in blood.
Answer: C
The most common cause of fatalities related to transfusion reactions result from ABO-incompatible
transfusion related to clerical error. Most such reactions occur if a type O person receives type A red
cells owing to a clerical error that occurs either at the time the blood sample was drawn, during
processing in the laboratory, or at the time a unit is administered. The importance of extremely
careful labeling, transfer, and handling of specimens and of cross-matched blood products cannot
be overemphasized. Allergic and other reactions are common but rarely fatal. The transmission of
bacterial organisms (e.g., Staphylococcus aureus) has been reported especially with platelet
concentrates maintained at or near room temperature. Fortunately, such reactions are rare.
-------------------------------------------------------------------------------------------------------------------------
15. A major problem in nutritional support is identifying patients at risk. Recent studies suggest
that these patients can be identified. all of the following findings identify the patient at risk except?
A. Weight loss of 5% over 6 months.
B. Serum albumin of less than 3 gm. per 100 ml. in the hydrated state.
C. Malnutrition as identified by global assessment.
D. Serum transferrin of less than 220 mg. per 100 ml.
E. Functional impairment by history.
Answer: A
All of these are at least partially correct. It is not clear whether weight loss of 10% or 15% is the
required threshold, but it certainly is close. Serum albumin of less than 3 gm per 100 ml. remains
the most constant identifier of patients at risk in the literature and has been so for years. Global
assessment in the hands of an experienced investigator is quite efficacious at identifying persons at
risk. Serum transferrin is certainly a confirmatory identifier of patients with malnutrition—and may
be even a primary one. Graham Hill and his co-workers have pioneered the concept of global
assessment using functional parameters, and in the hands of an experienced observer is quite a
reasonable way of approaching and identifying patients at risk.
---------------------------------------------------------------------------------------------------------------------------16. It is stated that enteral nutrition is safer than parenteral nutrition. Which of the following is
not a complications of enteral nutrition?
A. Hypoosmolar, nonketotic coma.
B. Vomiting and aspiration.
C. Pneumatosis cystoides intestinalis.
D. Perforation and peritonitis.
Answer: A
It is not necessarily true that enteral nutrition is safer than parenteral nutrition, and it may in fact
be associated with a higher risk of death than parenteral nutrition. Specifically, a well-run
parenteral nutrition service should not be associated with significant mortality, except for the
occasional death due to undetected yeast infection. On the other hand, enteral nutrition, especially if
not carried out safely, can result in significant mortality. The most common of the severe
complications of enteral nutrition result from the gastrostomy, or tube feedings into the stomach.
Sudden changes in gastric motility, such as those associated with sepsis, may result in aspiration.
Nasoenteric or nasoduodenal tubes help prevent this complication, as does shutting off enteral
feedings between the hours of 11 P.M. and 7 A.M. It is also essential to keep the patient's head
elevated 30 degrees. Also necessary is the use of extreme care when initiating enteral nutrition. If
hypertonic material is given into the stomach, one can increase osmolality followed by an increase in
volume. If, however, the material is given into the small bowel, volume must be increased first and
then tonicity, with the expectation that osmolality greater than 400 or 500 mOsm per liter may never
be achieved without provoking severe diarrhea. If care is not taken with the initiation of enteral
nutrition, massive diarrhea may result, including fluid loss, the absorption of enormous amounts of
carbohydrate into the circulation with inadequate fluid to support it, and the development of
hyperosmolar, nonketotic coma. Alternatively, severe unremitting diarrhea may result in necrosis of
the intestinal wall, the appearance of pneumatosis cystoides intestinalis, and, finally, perforation and
death. All of these complications may be prevented by judicious use of enteral nutrition with the
same care one uses for parenteral nutrition.
17. which is true about Intensive insulin therapy:
A. Prevents the aggressive development of atherosclerosis in diabetic patients.
B. Is not associated with unawareness of hypoglycemia.
C. Improves peripheral neuropathy.
D. Improves established retinopathy and nephropathy.
E. Is indicated in all patients with non–insulin-dependent diabetes mellitus (NIDDM).
Answer: C
Intensive insulin therapy is indicated in patients with IDDM who can actively participate in their
own management and the attainment of the goals set for their blood glucose and glycosylated
hemoglobin (HgA1 c) levels. Because the main complication of intensive therapy is iatrogenic
hypoglycemia, this mode of treatment is not indicated for patients with NIDDM, who often have
coexisting medical conditions such as coronary artery disease and who tolerate hypoglycemia poorly.
There is little or no evidence that macrovascular disease is affected by intensive insulin therapy, and
the added weight gain and hyperinsulinemia associated with the therapy may worsen
atherosclerosis. Unawareness of hypoglycemia is directly related to a recent hypoglycemia episode,
so patients treated intensively are often unaware of the problem. Intensive therapy does not improve
established retinopathy or nephropathy but slows or prevents progression of these complications;
however, better glucose control may improve peripheral neuropathy.
---------------------------------------------------------------------------------------------------------------------------18.What is the major determinant in an individual patient's risk for perioperative complications?
A. The surgical procedure.
B. The length of the surgical procedure.
C. The anesthetic technique (e.g., general, regional).
D. The length of anesthesia.
.answer: A
The planned surgical procedure is the major determining factor in assessing an individual patient's
risk for perioperative complications and in deciding which anesthetic technique will be most
appropriate. Good communication between the surgeon and the anesthesiologist is vital, as the
surgeon knows better than anyone else the extent of the operation and the length of time it will
require.
---------------------------------------------------------------------------------------------------------------------------19. about Local anesthetics all true except:
A. Inhibit transmission of nerve impulses by reducing sodium membrane permeability and the
displacement of ionized calcium.
B. Are classified as amides or esters.
C. Produce peripheral vasodilation.
D. Are weak acids.
Answer: D
Local anesthetics act within the nerve membrane, where they inhibit transmission of nerve impulses
by reducing sodium membrane permeability and the displacement of ionized calcium. All local
anesthetics consist of a hydrophilic region and a hydrophobic region separated by an alkyl chain.
The bond of the alkyl chain is either an ester or an amide, and these drugs are classified based on
this bond. All local anesthetics except cocaine produce vasodilatation and are weak bases.
---------------------------------------------------------------------------------------- -----------------------------------20. Discharge criteria following ambulatory surgery ( day surgery) include all except:
A. Ability to eat solid food.
B. Stable vital signs.
C. Ability to ambulate.
D. Ability to have protective airway reflexes.
Answer: A
Discharge criteria following ambulatory surgery include the patient's being fully awake and
oriented, the ability to have protective airway reflexes, stable vital signs, adequate hydration with the
ability to hold down oral intake, the ability to ambulate, and adequate pain control. All patients must
have a competent person with them to transport them—and ideally to stay with them on the first
postoperative night.
------------------------------------------------------------------------------------- --------------------------------------21. Advantages of patient-controlled analgesia (PCA) include all except:
A. Immediate medication delivery.
B. Less contact with nursing staff.
C. Rapid onset of analgesia.
D. Patient control over pain medication.
Answer: B
Advantages of PCA are immediate medication delivery, rapid onset of analgesia, and patient control
over pain medication. Disadvantages of PCA are less contact with nursing staff and patients' fears
that they could inadvertently administer an overdose or possibly become addicted to the opioid.
---------------------------------------------------------------------------------------------------------------------------22. Factors that decrease collagen synthesis include all of the following except:
A. Protein depletion.
B. Infection.
C. Anemia.
D. Advanced age.
E. Hypoxia.
Answer: C
Collagen synthesis, an integral part of wound healing, is affected by many local and systemic
factors. Protein depletion impairs fibroplasia. Hypoproteinemia leads to diminution of fibroblast
proliferation, proteoglycan and collagen synthesis, angiogenesis, and wound remodeling. Although
anemia was once believed to be a significant cause of wound disruption, studies have shown that, in
the absence of malnutrition or hypovolemia, anemia with a hematocrit greater than 15% does not
interfere with wound healing. In contrast, molecular oxygen is critical for collagen synthesis
because it is one of the factors required for the hydroxylation of lysine and proline. Also, hypoxia
favors wound infection. The role of age in collagen synthesis is not clear, but the incidence of wound
failure and incisional hernias is greater in patients older than 60. Fibroplasia occurs at a slower rate
in older animals. Perhaps more than any other factor, wound infection is associated with the risk of
wound failure.
---------------------------------------------------------------------------------------------------------------------------23. In contrast to adult wound healing with scar formation, which of the following are
characteristic of scarless fetal skin healing?
A. Matrix rich in hyaluronic acid.
B. Increased inflammatory response.
C. Increased production of TGF-b.
D. No collagen deposition.
Answer: A
The ability of a fetus to heal without scar formation depends on its gestational age at the time of
injury and the size of the wound defect. In general, linear incisions heal without scar until late in
gestation, whereas excisional wounds heal with scar at an earlier gestational age. The profiles of
fetal proteoglycans, collagens, and growth factors are different from those in adult wounds. The less
differentiated state of fetal skin is probably an important characteristic responsible for scarless
repair. There is minimal inflammation and angiogenesis in fetal wounds. Fetal wounds are
characterized by high levels of hyaluronic acid and its stimulator(s) with more rapid, highly
organized collagen deposition. The roles of peptide growth factors such as TGF-b and basic
fibroblast growth factor are less prominent in fetal than in adult wound healing. An understanding
of scarless tissue repair has possible clinical applications in the modulation of adult fibrotic diseases
and abnormal scar-forming conditions.
---------------------------------------------------------------------------------------------------------------------------24. Which of the following cell types are not crucial for healing of a clean, incisional wound?
A. Macrophage.
B. Platelet.
C. Fibroblast.
D. Myofibroblast.
Answer: D
Experimental studies have shown that healing may progress normally in the absence of
polymorphonuclear leukocytes in an uninfected wound. In contrast, depletion of monocytes and
macrophages causes a severe alteration in wound healing with poor débridement, delayed fibroblast
proliferation, and inadequate angiogenesis. Platelets carry a cadre of biologically active substances
that are important for wound repair, including peptide growth factors like platelet-derived growth
factor (PDGF) and TGF-b. Fibroblasts are the principal cell for matrix synthesis and deposition.
Myofibroblasts are important for wound contraction in open defects but have little if any role in
clean, incisional wounds.
---------------------------------------------------------------------------------------------------------------------25.Which of the following statement(s) is true concerning nutritional support of the injured patient?
a. The goal of nutritional support is maintenance of body cell mass and limitation of weight
loss to less than 25% of preinjury weight
b. Under-nutrition may compromise the patient’s available defense mechanisms
c. Nutritional support is an immediate priority for the trauma patient
d. Fifty percent of non-nitrogen caloric requirements should be provided in the form of fat.
Answer: b
Metabolic response to injury results in increased energy expenditure. If energy intake is less than
expenditure, oxidation of body fat stores and erosion of lean body mass will occur with resultant loss
of weight. When weight loss exceeds 10–15% of body weight, the complications of malnutrition
interact with disease processes, with increased morbidity and mortality rates. The goal of nutritional
support is maintenance of body cell mass and limitation of weight loss to less than 10% preinjury.
The major impact of nutritional support in the trauma patient is to aid host defense. Under-nutrition
may compromise the available host defense mechanism and may thus increase the likelihood of
invasive sepsis, multiple organ system failure, and death. Resuscitation, oxygenation and arrest of
hemorrhage are immediate priorities for survival. Nutritional support is an essential part of the
metabolic care of the critically ill patient and should be instituted after resuscitation before
significant weight loss occurs. The nutritional requirements of a trauma patient can be determined
by determining basal metabolic rate with appropriate increases based on extent of injury and
hospital activity. After initial determination of nitrogen requirements, caloric requirements should
be distributed at a ratio of 70% as glucose and 30% as fat.