Nursing Exam Flashcards

ANS: a Correct: Acute or recent myocardial infarction (MI) within the preceding 3 to 6 months is a cardiovascular contraindication to dental treatment. Incorrect choices: Unstable or recent onset of angina pectoris, uncontrolled heart failure, uncontrolled arrhythmias, and significant, uncontrolled hypertension are all cardiovascular contraindications to dental treatment. Diabetes, hyperlipidemia, and gout are not absolute contraindications to treatment. REF: p. 187

ANS: a Correct: MI is an occlusion or blockage of arteries supplying the muscles of the heart, resulting in injury or necrosis of the heart muscle (heart attack). Incorrect choices: Transient lack of oxygen to the heart is myocardial ischemia. Myocardial infarction does not refer to CHF, which is a chronic condition, or abnormal sinus rhythm of the heart. REF: pp. 187, 194

ANS: b Correct: If not properly shielded, some electrical devices commonly used in dentistry may interfere with proper pacemaker activity. Incorrect choices: A cardiac pacemaker is implanted in a patient's chest to regulate heart rhythm. Patients with pacemakers do not require antibiotic prophylaxis. REF: p. 187

ANS: b Correct: Persons with untreated cardiovascular disease are at increased risk for severe periodontal disease, insulin-dependent diabetes mellitus, atherosclerosis, and emboli production. Incorrect choices: No correlation has been discovered between caries susceptibility and cardiovascular disease. Xerostomia is associated with caries but not with cardiovascular disease. Chronic impaction of the third molars may lead to infection, but this condition has not been associated with cardiovascular disease generally. REF: p. 187

ANS: b Correct: If the left side of the heart fails, the blood backs up into the pulmonary circulation. Pulmonary edema results, producing dyspnea and orthopnea. Incorrect choices: The left side usually fails first. If the right side of the heart fails, then the right ventricle is unable to remove all the blood from the right side of the heart. Right-sided heart failure causes systemic congestion. Symptoms include peripheral edema, with fluid accumulation evidenced by pitting edema. REF: pp. 187-188

ANS: c Correct: Full-reclining position may precipitate dyspnea or orthopnea (breathing difficulty experienced while lying flat). Incorrect choices: Elevation of one hip is indicated for some pregnant women requiring dental treatment during their third trimester. Lying in a flat position or with feet elevated above the head could precipitate orthopnea. REF: p. 187

ANS: d Correct: Digitalis glycosides increase the efficiency of the heart's contractions. Improved pumping action allows more circulation to the kidneys, which reduces edema. The drug does have a narrow therapeutic index. REF: p. 188

ANS: b Correct: Digoxin prolongs the refractory period of the AV node. By prolonging the refractory period of the AV node, fewer impulses will be transmitted to the ventricle, and the heart rate will fall. These effects are useful in the treatment of certain arrhythmias. Incorrect choices: Digoxin slows AV conduction and decreases the rate of the SA node. REF: p. 188

ANS: b Diuretics can produce hypokalemia, which can predispose a patient to serious arrhythmias. Digitalis is used to treat arrhythmias, and its toxicity can produce arrhythmias. REF: p. 188

ANS: b Correct: Early signs of digoxin toxicity include anorexia, nausea and vomiting, and copious salivation. A reduction in the dose level of digoxin usually alleviates these adverse reactions. Incorrect choices: None of the other choices cause hypersalivation as a sign of toxicity. Clonidine is most likely to cause xerostomia and enalapril the least likely (oral manifestations include dry cough and dysgeusia). Nifedipine and hydrochlorothiazide can produce mild to moderate xerostomia. REF: p. 188

ANS: d Erythromycin and tetracycline can increase the toxicity of digoxin in some patients. REF: pp. 188-189

ANS: b The intrinsic rhythm is called automaticity. "Pacemaker" cells spontaneously produce action potentials as they undergo slow spontaneous depolarization during diastole. If any heart muscle cell is left undisturbed and isolated from the rest of the heart with appropriate nutrients and oxygen, each cell will beat spontaneously at its own rate. REF: p. 189

ANS: a The SA node has the fastest rate of depolarization and therefore directs all the other cells of the heart. It normally fires impulses approximately 80 times per minute. The SA node is innervated by both the parasympathetic nervous system and the sympathetic nervous system. The SA node sends a message to the AV node via the atrial muscle. REF: p. 189

ANS: b The direction of flow of the impulses to the excitable tissues of the heart is the SA node, AV node, bundle of His, Purkinje fibers, and cardiac muscle. REF: p. 189

ANS: c (**)The correct sequence of an action potential for cardiac muscle is: channels open/Na+ influx, Slow calcium influx/Na+ channels close, K+ influx, and K+ channels close. During each of these phases, a change occurs in the ion flow that results in certain effects. REF: p. 190

ANS: b Calcium channel blockers and quinidine are associated with gingival enlargement. Verapamil is the most reported calcium channel blocker associated with gingival enlargement. REF: p. 191

ANS: c Correct: Local anesthetic agents such as procainamide and lidocaine block Na+ channels in the heart and depress parts of the heart that are beating abnormally. Incorrect choices: Local anesthetic agents are not used in the treatment of coronary artery disease, hypertension, or angina pectoris. REF: p. 191

ANS: a At one time, the NTG-like compounds were the only class of drugs that could effectively relieve the symptoms of angina. More recently, the β-adrenergic blocking agents and the calcium channel blocking drugs have added a new dimension to drug therapy for angina. REF: p. 191

ANS: d Correct: NTG is a compound that releases nitrite and nitric oxide. These are very strong dilators to veins and arteries. This reduces workload to the heart and can reverse an anginal episode. Incorrect choices: NTG does not have utility in atherosclerosis, coronary artery disease, or arrhythmias. REF: p. 192

ANS: b Nitric oxide, an even more potent vasodilator than nitrite, activates guanylyl cyclase and increases cyclic guanosine monophosphate (cGMP), producing relaxation of vascular smooth muscle throughout the body. Indirectly, there is a reduction in work of the heart produced by the effect on both the venous and the arterial sides of the circulation. REF: p. 192

ANS: c Correct: Taking NTG within 24 hours of sildenafil is contraindicated. However, NTG is contraindicated because the combination can cause dangerously low blood pressure. REF: p. 193

ANS: d Correct: The dental team should be prepared to treat an acute anginal attack before treating any patient with a history of angina. The patient's personal NTG tablets or spray should be available and placed on the bracket table in case of an acute attack. The office should have some NTG in their emergency kit as well. Incorrect choices: NTG is degraded by heat and moisture, but not by light. It should be stored in its original brown glass container and tightly closed, because it can be adsorbed by plastic. It should not be refrigerated because condensation of the moisture in the air produces moisture that can reduce its effectiveness. In the case of an attack, NTG should be administered only three times within 15 minutes. If three tablets do not stop the anginal attack, the patient should be taken immediately to the emergency room with a member of the dental team or an emergency medical expert. REF: p. 193

ANS: c Prophylactic nitrates should be given with at least an 8- to 12- hour "vacation" every day. The mononitrate dose form requires a 7-hour "vacation" daily; the first dose is given in the morning and the second dose is given 7 hours later. With long-term regular use, tolerance develops to the effects of nitrates. In fact, no difference can be detected between a long-acting nitrate and placebo when taken without a daily "vacation". REF: p. 193

ANS: b Calcium channel blockers may be used for the treatment of angina, cardiac arrhythmias, and hypertension. Adverse effects include dizziness, weakness, constipation, and hypotension. REF: p. 194

ANS: d Correct: The net result of the use of β-adrenergic blocking agents for the treatment of angina pectoris is a reduced myocardial oxygen demand. Incorrect choices: β-Adrenergic blocking agents block the beta response to catecholamine stimulation, thereby reducing both the chronotropic and inotropic effects. β-Adrenergic blockers are effective in reducing both exercise- and stress-induced anginal episodes. Adverse effects of β-adrenergic blocking agents include bradycardia, heart failure, headache, dry mouth, blurred vision, and unpleasant dreams. REF: p. 194

ANS: b The dental team should make sure that the patient has not used a phosphodiesterase 5 (PDE5) inhibitor within the past 24 hours. The administration of any of these drugs with either daily or intermittent doses of any nitrate is contraindicated. If the patient has used one of these drugs, then NTG cannot be given. REF: p. 194

ANS: c The dental office should have a supply of sublingual NTG for acute emergencies. One tablet can be administered at once, followed in 5 minutes by another, and in another 5 minutes by a third tablet. If these tablets do not stop the anginal attack, the patient should be taken to the emergency room. REF: p. 194

ANS: d Hypertension is the most common cardiovascular disease, affecting some 50 million Americans and 1 billion individuals worldwide. The prevalence of hypertension increases with age and is higher among women than men. REF: p. 194

ANS: b Normal blood pressure is defined as a systolic pressure of less than 120 mm Hg and a diastolic pressure of less than 80 mm Hg. Prehypertension is 120 to 139 mm Hg systolic, and 80 to 89 mm Hg diastolic. People in the range of 130/80 to 139/89 mm Hg are at twice the risk of developing hypertension compared with those with lower values. REF: p. 195

ANS: a Correct: High blood pressure occurs without regard to stress or tension and complications of hypertension are greatly increased with concomitant smoking. Incorrect choices: In approximately 10% of hypertensive patients, the cause can be identified and associated with a specific disease process involving the endocrine or renal systems. REF: p. 195

ANS: c Only approximately 50% of those with known hypertension are properly treated. If hypertensive patients are properly treated, meaning their blood pressure is normalized, their risk of complications is equal to that of the patient without hypertension. REF: p. 195

ANS: a Correct: Approximately 85% to 90% of patients diagnosed with hypertension have essential, idiopathic, or primary hypertension. These terms all stand for hypertension from an unknown cause. Incorrect choices: Iatrogenic hypertension would be hypertension caused as a consequence of treatment. Hypertension precipitated by another disorder would be secondary hypertension. A rapidly developing hypertension is malignant hypertension. REF: p. 195

ANS: c Common adverse reactions associated with thiazides include hypokalemia secondary to sodium-potassium exchange and hyperuricemia due to inhibition of uric acid secretion. Hyperglycemia, hyperlipidemia, and hypercalcemia and anorexia are other side effects. REF: pp. 199-200

ANS: b The most important dental drug interaction with the thiazides is interaction with the NSAIDs. NSAIDs can reduce the antihypertensive effect of the thiazide diuretics. This interaction takes a few days to develop, and therefore a few doses of an NSAID can safely be used for acute pain control. REF: p. 200

ANS: c Correct: A characteristic adverse effect of thiazide diuretics is the loss of potassium and potential hypokalemia. Bananas are rich in potassium and are effective at replenishing the ion. Incorrect choices: Bananas do not deplete calcium, prevent diuresis, or inhibit the metabolism of thiazide diuretics. REF: p. 200

ANS: c Correct: Furosemide is considered a "loop diuretic" because it works at the ascending loop of Henle. It acts before the other diuretics listed and can cause a more rapid and pronounced diuresis. Incorrect choices: Hydrochlorothiazide primarily works in the distal convoluted tubule, whereas triamterine and spironolactone have their site of action in the late distal convoluted tubule and collecting duct. REF: p. 200

ANS: c Potassium-sparing diuretics are "puny" diuretics with "potassium-catching" ability. Individual members of this group have different mechanisms of action, but all have weak diuretic action. REF: p. 200

ANS: c ACEIs should not be given to persons taking potassium supplements. Patients taking potassium supplements should be questioned about their use of diuretics, and the possibility of cardiovascular disease should be explored when a drug history is taken. REF: p. 200

ANS: d β1-Receptor stimulation is associated with an increase in heart rate, cardiac contractility, and AV conduction. Stimulation of β2-receptors produces vasodilation in skeletal muscles and bronchodilation in the pulmonary tissues. REF: p. 201

ANS: b Correct: Pindolol and acebutolol have partial agonist activity and cause some -stimulation while blocking catecholamine action. Pindolol is nonselective, whereas acebutolol is beta-1 selective. Incorrect choices: Atenolol and metoprolol are 1-selective full antagonists. Carvedilol is a nonspecific -blocker with -blocking activity as well. REF: p. 201

ANS: a Correct: Propranolol is a nonselective -adrenergic antagonist. It can inhibit lung -receptors, which are involved in bronchodilation. REF: p. 201

ANS: b Correct: -Adrenergic blockers lower blood pressure primarily by decreasing cardiac output. Incorrect choices: Other effects that may contribute to their antihypertensive effect include a lowering of plasma renin levels, a reduction in plasma volume and venous return, a decrease in sympathetic outflow from the central nervous system (CNS), and a reduction in peripheral resistance. REF: p. 201

ANS: c In patients with cardiovascular disease or higher blood pressure, the amount of epinephrine given to patients taking nonspecific -blockers should be limited to the cardiac dose unless careful blood-pressure monitoring accompanies the use of larger doses. Neither gingival re-traction cord containing epinephrine nor 1:50,000 epinephrine should be used. REF: p. 201

ANS: b Correct: Labetalol and Carvedilol are both β-blockers with α-blocking activity. Incorrect choices: Atenolol is a β-adrenergic blocker. Doxazosin is an α-adrenergic blocker. Minoxidil is a vasodilator. REF: pp. 196, 201

ANS: c Many calcium channel blockers end in the suffix -dipine. These agents are used to treat hypertension and other cardiac conditions such as arrhythmias and angina. Common calcium channel blockers include the drugs Verapamil, nifedipine, and diltiazem. REF: p. 201

ANS: d Correct: Orthostatic hypotension is an uncommon effect of calcium channel blocker treatment. Incorrect choices: Calcium channel blockers dilate coronary and peripheral arteries and arterioles, thereby reducing afterload on the heart. They act by blocking L-type calcium channels. Their effect on the heart leads to a decrease in cardiac contractility. The decreased contractility and increased arteriolar dilation can result in peripheral edema. REF: pp. 201-202

ANS: c Many ACEIs end in the suffix -pril. ACEIs prevent the conversion of angiotensin I to angiotensin II. ACEIs are commonly used as antihypertensives. Examples include captopril, enalapril, and lisinopril. REF: p. 202

ANS: c Correct: ACEIs retard the progression of diabetic nephropathy whether hypertension is present or not. REF: p. 202

ANS: d Correct: ARBs end with the suffix -artan. The ARBs act by attaching to the angiotensin II receptor and blocking the effect of angiotensin II. Losartan is the prototype. Incorrect choices: Many β-adrenergic blockers end in -olol. Many calcium channel blockers end in -dipine. ACEIs end in pril. REF: pp. 201-203

ANS: a Correct: The antihypertensive effectiveness of ACEIs is reduced by administration of the NSAIDs, which is a result of the blockage of bradykinin-mediated vasodilation, which is at least in part prostaglandin-mediated. A few doses of an NSAID are of little concern, but chronic administration for several days might result in an increase in the patient's blood pressure. Incorrect choices: NSAIDs do not antagonize the antihypertensive actions of -adrenergic antagonists, calcium channel blockers, loop diuretics, or centrally acting hypertensive agents. REF: p. 203

ANS: d Correct: 1-Adrenergic blocking agents end in -zosin. REF: p. 204

ANS: c α1-Adrenergic blocking agents result in reduction of urethral resistance and pressure, bladder outlet resistance, and urinary symptoms. This effect accounts for their use in management of older males who have an enlarged prostate gland. Surgery can often be avoided in those patients who are managed by drug therapy. If a man has both hypertension and benign prostatic hypertrophy (BPH), then one can "kill two birds with one stone." REF: p. 204

ANS: d -Adrenergic blockers can cause postural or orthostatic hypotension, so the dental chair must be moved slowly to prevent syncope. They antagonize the vasoconstrictive actions of epinephrine. Because vasoconstrictors are contraindicated, caution and local measures are needed to manage excessive bleeding. REF: p. 204

ANS: b Correct: The incidence of xerostomia is highest with clonidine. Incorrect choices: Losartan, enalapril, and atenolol are not known to cause excessive xerostomia. REF: p. 204

ANS: b Correct: The sympathomimetics can increase the antihypertensive effects of doxazosin. The 1-blockers prevent the 1-agonist effects (vasoconstriction) of epinephrine, leaving the β1- and β2-agonist effects (vasodilation) to predominate. The combined vasodilation can result in severe hypotension and reflex tachycardia. Incorrect choices: No clinically relevant drug interactions have been found between sympathomimetics and calcium channel blockers, ARBs, or potassium-sparing diuretics. REF: p. 204

ANS: c Correct: Gingival hypertrophy is not an adverse effect produced by clonidine administration. Incorrect choices: Phenytoin is an anticonvulsant well known for its hypotrophic effect on the gingiva. Verapamil and felodipine are calcium channel blockers, another drug class known for high incidence of gingival hypertrophy. REF: p. 205

ANS: b Correct: Hydralazine is known to cause a serious toxic reaction producing symptoms such as those of systemic lupus erythematosus. Incorrect choices: Therapy with clonidine, isosorbide dinitrate, or spironolactone is not associated with a lupus-like reaction. REF: p. 205

ANS: a Correct: Many antihypertensive drugs cause orthostatic hypotension to some extent or another. Getting up quickly can lead to pooling of blood in the extremities and lightheadedness. This can be prevented by getting one's circulation moving and getting up slowly. REF: p. 205

ANS: d Hyperlipidemia includes elevations in cholesterol and/or triglycerides and are associated with the development of arteriosclerosis, although the exact correlation is unknown. HDLs are known as good cholesterol because they have the lowest cholesterol content and are considered to be beneficial. REF: p. 205

ANS: c Correct: Of the drugs used to treat hyperlipidemia, the statins are very effective, but have a pregnancy factor X. Women wishing to conceive should not take statins. Incorrect choices: A medication change to any statin would be contraindicated in women wishing to conceive. Gemfibrozil and niacin have a pregnancy risk factor C. Candesartan is not used to treat hyperlipidemia. REF: pp. 206-207

ANS: a Correct: Statins such as pravastatin are HMG CoA reductase inhibitors. They lower serum cholesterol. Incorrect choices: Ramipril is an ACEI, Nifedipine is a calcium channel blocker, and ezetimibe (Zetia) is a cholesterol-lowering agent that acts by inhibiting cholesterol absorption from the small intestine. REF: p. 206

ANS: c Correct: The ENHANCE trial has shown that little difference exists in the cholesterol lowering abilities of Vytorin (ezetimibe/simvastatin) and simvastatin alone. Incorrect choices: Ezetimibe (Zetia) works by inhibiting the intestinal absorption of cholesterol. This drug decreases total cholesterol, LDL cholesterol, and increases HDL cholesterol levels. Vytorin (ezetimibe/simvastatin) has been found to lower LDL cholesterol, but it had little effect on plaque buildup in the arteries. REF: p. 206

ANS: c Correct: Niacin inhibits the secretion of VLDLs without accumulation of triglycerides in the liver. This reduces LDL synthesis. Incorrect choices: The statins lower cholesterol levels by inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis. Ezetimibe works by inhibiting the intestinal absorption of cholesterol. Gemfibrozil works by increasing lipolysis of triglycerides, decreasing lipolysis in adipose tissue, and inhibiting secretion of VLDLs from the liver. REF: pp. 206-207

ANS: d Correct: Cholestyramine is a bile acid-binding resin that inhibits the reabsorption of bile acids from the jejunum and ileum back into the circulation. The body needs to replace these lost bile acids and increases its utilization of cholesterol for this purpose. Incorrect choices: Niacin lowers cholesterol levels by inhibiting the secretion of VLDLs without accumulation of triglycerides in the liver. Atorvastatin is an HMG CoA reductase inhibitor, gemfibrozil increases the lipolysis of triglycerides and is a <chck> (PPAR-α) inhibitor. Clopidogrel is not a cholesterol-lowering agent. REF: p. 207

ANS: d Gemfibrozil causes fewer gastrointestinal complaints than the bile-acid-binding drugs, but it can promote gallstone formation (cholelithiasis). An altered sense of taste and hyperglycemia have been reported. REF: p. 207

ANS: a A danger of embolism exists if the dose is too small. Hemorrhage may occur if the dose of the anticoagulant is too large. REF: p. 208

ANS: b Correct: Endogenous clotting factors II, VII, IX, and X have half-lives that are 60, 6, 24, and 40 hours, respectively. Factor VIII has a half-life of 10 to 12 hours. It is not a vitamin K-dependent clotting factor. REF: p. 208

ANS: d Correct: Warfarin is notorious for interacting with other drugs. Incorrect choices: Phenobarbital induces its metabolism and decreases circulating warfarin levels. Erythromycin inhibits its metabolism and increases the risk of bleeding crises. Aspirin can displace warfarin from plasma protein sites and increase warfarin's free serum levels. Aspirin's antithrombotic action is also additive with warfarin's anticoagulant action. REF: pp. 208-209

ANS: b The therapeutic target INR for most indications, such as thrombophlebitis, or atrial fibrillation is between 2 and 3. For patients with a prosthetic heart valve, the target INR is between 2.5 and 3.5. The INR can range from 1 to 4, although it can reach higher levels with overdose. REF: p. 208

ANS: b The most common adverse effects associated with the oral anticoagulants are various forms of bleeding, including hemorrhage. One should look for petechial hemorrhages in the oral cavity. Ecchymoses can occur, even without concomitant trauma. REF: p. 208

ANS: b Patients taking warfarin should not be given aspirin or aspirin-containing products because bleeding episodes or fatal hemorrhages can occur. Aspirin causes hypoprothrombinemia and alters platelet adhesiveness. REF: p. 208

ANS: b Correct: Dipyridamole is used to prolong the life of platelets in patients with prosthetic heart valves. Incorrect choices: Clopidogrel, ticlopidine, and aspirin all inhibit adenine dinucleotide phosphate-induced platelet aggregation. . REF: pp. 210-211 TRUE/FALSE

ANS: False Dental treatment can be given to a patient 6 months after a myocardial infarction. REF: p. 187

ANS: True Several studies correlate the patient's periodontal condition to cardiovascular disease over time. REF: p. 187

ANS: True Blood goes from the peripheral circulation to the right atrium, to the right ventricle, to the lungs for oxygenation, to the left atrium, to the left ventricle, and is then pumped at high pressure into the arteries. If the left side of the heart fails, the blood backs up into the pulmonary circulation (lungs). REF: p. 187

ANS: True ACEIs are now considered first-line therapy and are the cornerstone of CHF therapy. REF: p. 188

ANS: False Preload refers to the blood that is coming to the heart from the general circulation (i.e., from the veins). Afterload refers to the resistance that the heart needs to work against (i.e., from the arteries, "downstream" from the heart). REF: p. 189

ANS: True Nitrous oxide can reduce anxiety, which is commonly a precipitating factor in angina pectoris. Nitrous oxide also produces vasodilation. REF: p. 194

ANS: False Correct: -Methyldopa and clonidine act in the CNS as -adrenergic agonists. REF: p. 199

ANS: True ACEIs produce nonproductive cough because of their ability to raise the levels of bradykinin. ARBs do not alter the levels of bradykinin. REF: p. 202

ANS: False Hydralazine is the drug of choice for the treatment of a pregnant hypertensive woman (it is pregnancy risk factor C). REF: p. 205

ANS: True Many surgical procedures can be carried out on a patient receiving therapeutic doses of anticoagulants (see Table 15-13). REF: pp. 209-210