Study Guide for Gould's Pathophysiology

for the Health Professions

SIXTH EDITION

Robert J. Hubert, BS
Laboratory Coordinator
Iowa State University
Department of Animal Sciences
Ames, Iowa

Karin C. VanMeter, PhD

Lecturer (retired)
Iowa State University
Department of Biomedical Sciences
College of Veterinary Medicine
Ames, Iowa
Table of Contents

Cover image

Title Page

Copyright

Section I Pathophysiology: Background and Overview

1 Introduction to Pathophysiology

2 Fluid, Electrolyte, and Acid-Base Imbalances

3 Introduction to Basic Pharmacology and Other Common Therapies

4 Pain

Section II Defense/Protective Mechanisms

5 Inflammation and Healing

6 Infection
7 Immunity

Section III Pathophysiology of Body Systems

8 Skin Disorders

9 Musculoskeletal System Disorders

Fractures

Bone Disease

Muscular Dystrophy

Primary Fibromyalgia Syndrome

Arthritis

Consolidation

10 Blood and Circulatory System Disorders

11 Lymphatic System Disorders

12 Cardiovascular System Disorders

Heart

Atherosclerosis

Angina Pectoris (Ap)

Myocardial Infarction

Cardiac Dysrhythmias (Arrhythmias)

 Heart Failure

Congenital Heart Defects

Rheumatic Fever, Rheumatic Heart Disease, and Infective Endocarditis

Hypertension

Antihypertensive Medications

Peripheral Vascular Disease (PVD)

Shock

Consolidation

13 Respiratory System Disorders

14 Nervous System Disorders

15 Disorders of the Eye, Ear, and Other Sensory Organs

16 Endocrine System Disorders

17 Digestive System Disorders

Ulcers

Cancer

Gallbladder Disease

Liver Disease

Pancreatitis

Intestinal Disorders
 Consolidation

18 Urinary System Disorders

19 Reproductive System Disorders

Male

Female

Endometriosis

Vaginal Candidiasis

Pelvic Inflammatory Disease (PID)

Breast Cancer

Cervical Cancer

Endometrial Cancer

Sexually Transmitted Diseases (STDs)

Section IV Factors Contributing to Pathophysiology

20 Neoplasms and Cancer

21 Congenital and Genetic Disorders

22 Complications of Pregnancy

23 Complications of Adolescence
24 Complications of Aging

Section V Environmental Factors and Pathophysiology

25 Immobility and Associated Problems

26 Stress and Associated Problems

27 Substance Abuse and Associated Problems

28 Environmental Hazards and Associated Problems

Answer Key
Copyright

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STUDY GUIDE FOR GOULD'S PATHOPHYSIOLOGY FOR THE

HEALTH PROFESSIONS, SIXTH EDITION ISBN: 978-0-323-41414-2

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SECTION I
Pathophysiology: Background and Overview
OUTLINE

1 Introduction to Pathophysiology
2 Fluid, Electrolyte, and Acid-Base Imbalances
3 Introduction to Basic Pharmacology and Other Common
Therapies
4 Pain
1

Introduction to Pathophysiology
1. Differentiate between an acute disease and a chronic disease.
2. What is the difference between an epidemic and a pandemic?
3. Cells adapt to environmental changes by changing their size, number,
and type. For each of the following scenarios, identify the appropriate
adaptive cellular change or changes that occur, using the following
terms:

atrophy metaplasia
hypertrophy dysplasia
hyperplasia neoplasia

i. a decrease in size of a leg after being in a cast for 6 weeks:

ii. breast enlargement at puberty:
iii. a dramatic increase in muscle mass in an Olympic weight lifter:
iv. a very aggressively growing cancer mass:
v. a benign tumor growing along the spine:
vi. the changes that occur in the lower extremities of someone paralyzed
below the waist:
vii. a pressure area under a poorly fitting denture:
viii. the changes that often occur over years in the respiratory tract of a
smoker:
ix. the changes responsible for an abnormal Pap smear:
x. the response of the skeletal system to excessive growth hormone:
xi. the thyroid gland's response to hypersecretion of thyroid-stimulating
hormone:
xii. the liver's response to prolonged drug intoxication (e.g., chronic
alcohol abuse):
xiii. the changes that occur in the gallbladder with the development of
gallstones:
xiv. the thyroid gland's response to decreased iodine intake:
 xv. the effect of decreased pituitary function on the adrenal glands:
xvi. the development of callus on the hands of an individual involved in
heavy physical labor:
4. Which of the cellular adaptations above is considered the most
dangerous? Explain why.
5. Explain the significance of anaplasia.
6. List eight causes of cellular damage.
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
7. Complete the following crossword puzzle:
Across
3. a tumor
7. number of new cases of a disease
8. worsening of disease
10. death rate
12. tissue enlargement caused by an increase in cell number
14. tissue death
18. development of a disease
20. the study of the cause of a disease
21. a specific local change in tissue
22. condition that continues for a prolonged period
23. originating inside the body
Down
1. condition in which cells fail to develop specialized features
2. condition with sudden onset and severe symptoms
4. subjective response to illness
5. tissue enlargement due to increased cell size
6. shoveling snow on a cold day (may cause heart problems)
7. unknown cause
9. condition resulting in atypical cervical cells
11. disease caused by a treatment procedure
13. contagious condition
15. objective indicator of disease
16. substitution of one mature cell type with a different cell type
17. originating outside the body
19. decreased O2
8. Identify the following cellular adaptations:
2

Fluid, Electrolyte, and Acid-Base

Imbalances

Edema
1. Define edema.
2. Identify the four general causes of edema, and explain how each
one results in accumulation of fluid in the extracellular
compartment.
3. For each of the following examples, state which of the causes
identified in the previous question is responsible for edema
formation:
i. a swollen arm following mastectomy (surgical removal of a
breast):
ii. the abdominal swelling that accompanies liver failure:
iii. the swelling that accompanies inflammation:
iv. the generalized edema that occurs in severe kidney disease:
v. swelling of the ankles that often happens at the end of the day
or after prolonged standing:
vi. swelling that occurs following multiple tooth extractions:
vii. edema that may accompany cancer:
viii. edema that accompanies burns:
ix. edematous hands and ankles that sometimes accompany
excessive ingestion of sodium:
x. the abdominal swelling that occurs with starvation:
xi. swelling of the ankles associated with heart problems:
xii. swelling associated with allergic reactions, such as hives:
4. Identify at least eight effects of edema.

Dehydration
5. List seven causes of dehydration.
6. Describe the manifestations of dehydration. What is the most
serious complication of dehydration?
7. Identify the compensatory mechanisms that are recruited during
dehydration.

Electrolyte Imbalances
8. Identify the electrolyte imbalance or imbalances that could
develop in each of the following situations:
i. renal failure:
ii. prolonged vomiting:
iii. insufficient secretion of antidiuretic hormone (ADH):
iv. prolonged use of corticosteroids:
v. hyperparathyroidism:
vi. excessive sweating:
vii. prolonged immobility:
viii. diuretic therapy:
ix. aldosterone insufficiency:
x. inadequate dietary intake of vitamin D:
xi. cancers involving bone:
xii. prolonged diarrhea:
9. Define tetany. Identify the electrolyte imbalance in which tetany
occurs.
10. Identify the electrolyte imbalances that affect normal cardiac
function.
11. What electrolyte excess may result in the formation of kidney
stones?
Acid-Base Imbalances
12. What is the pH range of normal human plasma? At what pH
levels does death usually result?
13. State the normal bicarbonate ion to carbonic acid ratio.
14. Identify the four major buffer systems.
15. An individual's bicarbonate ion to carbonic acid ratio is 5 : 1.
What acid-base imbalance is present? What effects would the
individual experience?
16. For each of the following scenarios, identify which acid-base
imbalance could potentially develop. Also identify the
compensatory mechanism(s) that might prevent this from
occurring:
i. chronic bronchitis:
ii. induced vomiting (e.g., bulimia):
iii. narcotic or barbiturate overdose resulting in respiratory
depression:
iv. extreme weight loss resulting in lipolysis:
v. panic attack with hyperventilation:
vi. pneumonia, with severe bronchial congestion:
vii. chronic diarrhea:
viii. renal failure:
3

Introduction to Basic Pharmacology and Other

Common Therapies
1. Describe the difference between dose and dosage.
2. Distinguish between the therapeutic effects and adverse or side effects of
a drug.
3. Briefly describe some specific forms of adverse drug reactions that may
affect your patients.
4. Medications may be administered by a number of different routes.
Describe what is meant by each of the following drug routes, and state
several examples of medications that are commonly taken this way:
i. topical:
ii. transdermal:
iii. oral:
iv. sublingual:
v. subcutaneous:
vi. intramuscular:
vii. intravenous:
viii. inhalation:
5. Drugs are used for both systemic and local effects. Which route of
administration is used to achieve a local effect?
6. Complete the following chart comparing and contrasting various routes
of drug administration:
7. Arrange the routes of drug administration according to rapidity of onset,
from the fastest to the slowest.
8. Describe what happens to a drug once it is absorbed into the blood.
9. Explain the manner in which many drugs exert their effects at a cellular
level.
10. Where are most drugs metabolized? How is this achieved?
11. How are most drugs or their metabolites excreted from the body?
12. Explain the ways in which liver or kidney disease could affect drug
activity.
13. Why are individuals with chronic lung disease considered to be at high
risk for complications when they receive a general anesthetic?
14. Explain how each of the following factors may influence drug action:
i. age:
ii. body weight:
iii. sex:
iv. psychological factors/emotional state:
v. presence of disease (e.g., heart disease, liver disease, kidney disease):
vi. time of administration (in relation to meals; time of day):
vii. route of administration:
viii. drug dosage:
ix. drug formulation (e.g., liquid, capsule, enteric coated):
x. patient compliance:
xi. environmental factors (e.g., temperature, odors, noise):
xii. drug interactions:
15. Define the following terms, and state an example for each:
i. hypersensitivity reaction:
ii. idiosyncratic reaction:
iii. potentiation:
iv. synergism:
v. antagonism:
vi. tolerance:
vii. placebo:
16. Differentiate between the generic and chemical names of a specific
drug.
17. Describe each of the following treatment modalities:
i. physiotherapy:
ii. speech therapy:
iii. occupational therapy:
iv. homeopathy:
 v. osteopathy:
vi. aromatherapy:
vii. chiropractic therapy:
viii. massage therapy:
18. Explain the basis of Asian concepts of healing such as acupuncture,
shiatsu, and yoga.
19. Which agency in the United States regulates the production, labeling,
distribution, and other aspects of drug control?
4

Pain
1. List the causes of pain.
2. Differentiate between somatic and visceral pain.
3. Name three chemical compounds produced by the body that will initiate
pain.
4. Describe the steps involved in the perception of pain, from the stimulus
to interpretation. Include all the anatomical structures that are involved
in the pathway.
5. Explain the mechanism by which endorphins can block pain impulses.
6. What is meant by referred pain? Explain how it occurs. Describe an
example of referred pain.
7. Differentiate between acute and chronic pain.
8. Outline measures used to control pain, including the rationale for each.
9. Identify factors that may influence an individual's response to pain.
10. Complete the following chart, which compares and contrasts non-
narcotic and narcotic analgesics:
11. Identify three general types of anesthesia, and state an example of how
each would be employed.
12. Identify the two different types of afferent fibers that conduct pain
impulses, and differentiate between the two based on structure and
function.
SECTION II
Defense/Protective Mechanisms
OUTLINE

5 Inflammation and Healing

6 Infection
7 Immunity
5

Inflammation and Healing

1. What is the body's first line of defense?
2. Identify the body's second and third lines of defense.
3. Which of the three lines of defense are specific? Explain what is meant
by “specific defense mechanism.”
4. Define phagocytosis. Identify types of cells that are phagocytic.
5. What is inflammation, and what is its basic function? Identify some
causes of inflammation.
6. Identify the two main events of the “vascular response” that occur
during an inflammatory response. Explain their function as part of
the response and the direct effects of each event.
7. Identify the four cardinal signs of an inflammatory response and the
cause of each.
8. Outline the sequence of events involved in the cellular response of
inflammation.
9. Match each of the following terms with the appropriate definition.

a. involved in cell-mediated immunity i. neutrophils

b. elevated during allergic responses ii. basophils
c. secrete histamine iii. eosinophils
d. the first cells to migrate to an injured area iv. macrophages
e. involved in antibody production v. mast cells
f. elevated during chronic inflammation vi. monocytes
g. a source of macrophages vii. T lymphocytes
h. phagocytize microorganisms viii. B lymphocytes
10. List the systemic effects of inflammation, and identify the reason that
each of these manifestations occurs.
11. List some potential complications that may develop as a result of
inflammation.
12. Compare and contrast acute and chronic inflammation, using the
following chart:
13. What is the four-letter acronym that lists the approach to first aid for
injury-related inflammation?
14. Identify the differences between nonsteroidal anti-inflammatory
drugs (NSAIDs) and glucocorticoids or steroidal anti-inflammatory
drugs.
15. Identify the differences between NSAIDs and acetaminophen.
16. Identify additional nonpharmacologic therapies/treatment that could
be used to treat inflammation, particularly conditions that are
chronic, such as arthritis.
17. Differentiate between the processes of resolution and regeneration.
18. Many factors influence tissue healing. Explain how the following
factors could complicate or delay healing, stating at least one
example to illustrate each one:

i. nature of the tissue/location of the wound:

ii. nutritional status of the injured individual:

 iii. condition of the wound:

iv. drugs being taken:

v. age of the individual:

vi. presence of foreign material in the wound:

vii. blood supply:

viii. presence of infection:

ix. degree of immobilization/irritation of the injured tissue:

x. preexisting disease/medical problems:

19. Identify potential complications that may occur during the healing
process with scar formation.
20. Describe the classifications of burns based on:

i. depth of tissue damage:

ii. body surface area involved:

21. Explain why full-thickness burns initially may be painless but later
become very painful.
22. Other than tissue destruction, what complications may arise from a
burn?
23. List some of the actions that may be taken to aid in the prevention of
infection in the healing of a burn.
24. Fill in values on the diagram used to assess burn area using the rule
of nines.
25. Explain the need for increased dietary intake of protein and
carbohydrates during healing of a burn injury.
6

Infection
1. Describe how a specific growth need of a bacterium may determine the
infection site in the host.
2. Explain the difference between infection and inflammation.

Bacteria
3. Identify the bacterial cellular morphology and arrangement using the
following terms:

bacillus spirilla spirochete

staph(ylo) diplo strep(to)
pleiomorphic coccus tetrad
palisade Vibrio

4. Describe the basic structure of a bacterium.

5. Explain the difference between gram-positive and gram-negative
bacteria.
6. Some bacteria secrete toxins. Explain the differences between exotoxins
and endotoxins.
7. What is an endospore or bacterial spore? Describe the process of spore
formation. Identify some genera of bacteria that produce spores.
8. Bacteria reproduce by a process called binary fission. Describe this
process.
9. Bacterial cells differ from human (eukaryotic) cells in a number of
significant ways. Compare and contrast bacterial and eukaryotic cells,
using the following chart:
Viruses
10. Why are viruses said to be “obligate intracellular parasites”?
11. Describe the structure of a viral particle or virion.
12. Outline the basic steps of viral infection/replication.

Fungi
13. Describe the basic structures of the single-cellular and multicellular
forms of a fungus.
14. Compare and contrast bacteria, fungi, and viruses, using the following
chart:

Other Microorganisms
15. List several pathologic conditions caused by each of the following types
of organisms:
i. chlamydiae:
ii. rickettsiae:
iii. mycoplasmas:
 iv. protozoa:
16. What is a helminth? Name an example of a helminth.
17. What is a prion? Name a human disease caused by a prion.
18. What is meant by the term normal flora or resident flora?
19. Identify areas of the body that lack resident flora and therefore should
be sterile.
20. Explain what is meant by an endemic infection.
21. Define the terms pathogenicity and virulence. Identify factors that
increase the virulence of microorganisms.

Consolidation of Microbiology
22. For each of the following infections, identify the causative agent or
agents, using the following terms:

bacteria chlamydia
fungi protozoa
rickettsiae viruses

i. Pneumocystis carinii pneumonia:

ii. candidiasis:
iii. syphilis:
iv. trichomoniasis:
v. tuberculosis:
vi. pneumonia:
vii. tetanus:
viii. Rocky Mountain spotted fever:
ix. tinea pedis:
x. herpes simplex:
xi. influenza:
xii. botulism:

Control of Transmission and Infection

23. What is the basic difference between a disinfectant and an antiseptic?
24. Identify the components in the infection chain and ways in which the
cycle can be broken.
25. Describe the methods for determining the effectiveness of an
antimicrobial agent as a possible treatment for a specific infection.
26. Define the following terms related to antibacterial drugs:
i. spectrum:
ii. bacterial resistance:
iii. bactericidal:
iv. bacteriostatic:
27. Explain what is meant by the term superinfection. What type of
microorganism often causes superinfections? Explain how this happens.
28. Describe some of the potential adverse effects associated with the use of
antibacterial drugs.
29. What is the difference between a superinfection and an opportunistic
infection?
30. When is it appropriate for a physician to prescribe a narrow-spectrum
antibacterial drug?
31. If an antibacterial drug is bacteriostatic rather than bactericidal, how
does the individual ever destroy the infecting microorganism?
32. When would the prescription of a bacteriostatic drug not be advisable?
33. Explain how the misuse or overuse of antibacterial agents could lead to
the development of bacterial resistance.
34. If antibacterial drugs are not effective in the treatment of viral
infections, why are they often prescribed for individuals with chronic
viral infections such as hepatitis B, hepatitis C, or HIV?
35. Identify guidelines that an individual should follow to maximize the
effects of antibacterial medications.
36. Explain why it has been difficult to develop antiviral drugs.
7

Immunity
1. State the three main components of the immune system, identify the
cells/tissues/organs in each of the components, and match the terms
with the structures/organs.

Bone marrow Lymphatic vessels

Lymph nodes (axillary) Palatine tonsil
Lymph nodes (cervical) Pharyngeal tonsil (adenoid)
Lymph nodes (inguinal) Spleen
Lymph nodes (intestinal) Thymus
2. What is a cell surface antigen? Why is it important?
3. What is the major histocompatibility complex (MHC), and how is it
related to the human leukocyte antigens (HLAs)?
4. Chemical mediators play an important role in both inflammation and
immunity. Identify the source and effects of the major chemical
mediators, using the following chart:
5. Several of the chemical mediators have overlapping effects. Identify all
of the chemical mediators that are responsible for each of the following
cellular or body responses:
i. vasodilation:
ii. increased capillary permeability:
iii. chemotaxis:
iv. pain:
v. contraction of bronchiolar walls/bronchospasm:
vi. proliferation of leukocytes:
vii. pruritus:
viii. fever:
6. All of the following cells are involved in immunity. Identify the role of
each:
7. Which cells participate in both cellular and humoral immunity?
8. Match the five classes of antibodies or immunoglobulins with their
chemical structure, and state the functions of each.
IgA

IgD
IgE

IgG

IgM
9. Explain how antibodies exert their effects and how the release of
complement contributes to these effects.
10. What is the approximate time frame between exposure to an antigen
and the appearance of immunoglobulins in the serum on the first
exposure to a specific antigen? On subsequent exposure to the antigen?
11. What is the average length of time required to acquire an effective
antibody titer following exposure to an antigen on first exposure and
subsequent exposures?
12. Explain the rationale for boosters.
13. Explain why individuals may contract infections such as colds,
influenza, and sexually transmitted diseases (STDs) repeatedly.
14. Compare and contrast active and passive immunity using the following
chart:
15. A serious complication of organ transplantation is organ rejection.
Identify measures that are taken in attempt to prevent this from
happening.
16. A common adverse effect of immunosuppressant drugs is the
development of opportunistic infections. What is meant by the term
opportunistic? Explain how this complication occurs.
17. What medications are often prescribed prophylactically for an
individual who is taking immunosuppressant drugs? Explain the
rationale.

Hypersensitivity
18. Compare and contrast the different types of hypersensitivity reactions,
using the following chart:
19. Hypovolemic shock is a potential complication of extensive burns (see
Chapter 12). Compare and contrast this type of shock with anaphylactic
shock using the following chart:

20. List the types of medications that might be prescribed in the treatment
of allergic conditions.
21. Identify and describe the type of reaction(s) involved in latex
hypersensitivity.
Autoimmunity
22. State the underlying mechanism responsible for autoimmune
disorders.
23. How is systemic lupus erythematosus diagnosed?
24. What types of medications and therapeutic interventions might be
prescribed in the treatment of the autoimmune disorder systemic lupus
erythematosus? Explain the rationale for each treatment.
25. Systemic lupus erythematosus has widespread effects virtually
throughout the body. Identify common manifestations under the
following headings:
i. skin:
ii. joints:
iii. heart:
iv. blood vessels:
v. blood/bone marrow:
vi. kidneys:
vii. lungs:
viii. central nervous system:

Immunodeficiency
26. List common causes of immunodeficiency.
27. Identify the general effects of immunodeficiency.
28. Identify the types of medications that are often prescribed for the
immunodeficient individual or immunocompromised host, and explain
the rationale for each drug group.

HIV and AIDS

29. What is the causative agent responsible for AIDS? Describe its
properties.
30. Which cells are targeted by HIV? Identify the consequences of this.
31. List the routes of transmission of HIV.
32. Identify individuals who are at high risk for contracting HIV.
33. What is the average “window” or incubation period for HIV? State the
possible range.
34. How is a diagnosis of HIV infection confirmed?
35. What is the average length of time between infection with HIV and
development of full-blown AIDS?
36. How is a diagnosis of AIDS confirmed?
37. Identify possible manifestations of the initial phase of HIV infection.
38. As HIV progresses and the individual's immune system becomes more
compromised, literally every bodily system is affected. Describe these
complications under the following headings:
i. generalized effects:
ii. opportunistic infections:
iii. gastrointestinal manifestations:
iv. oral manifestations:
v. respiratory manifestations:
vi. nervous system manifestations:
vii. malignancies:
39. Identify medications that are used in the treatment of an individual
with HIV and AIDS, including those that are prescribed to prevent
potential complications.
40. What is the prognosis for an individual infected with HIV?
SECTION III
Pathophysiology of Body Systems
OUTLINE

8 Skin Disorders
9 Musculoskeletal System Disorders
10 Blood and Circulatory System Disorders
11 Lymphatic System Disorders
12 Cardiovascular System Disorders
13 Respiratory System Disorders
14 Nervous System Disorders
15 Disorders of the Eye, Ear, and Other Sensory Organs
16 Endocrine System Disorders
17 Digestive System Disorders
18 Urinary System Disorders
19 Reproductive System Disorders
8

Skin Disorders
1. Identify the five primary functions of skin.
2. Match structures of the skin with the terms provided.
Adipose tissue, Artery, Capillaries, Dermis, Eccrine gland, Epidermis,
Hair, Hair follicle, Melanocyte, Nerve fiber, Sebaceous gland, Sensory
receptor, Smooth muscle, Stratum basale, Stratum corneum,
Subcutaneous tissue, Vein

A. ____________________
B. ____________________
 C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
L. ____________________
M. ____________________
N. ____________________
O. ____________________
P. ____________________
Q. ____________________
3. State the etiology for each of the following skin conditions. Be as specific
as possible: If the cause is an infection, identify the causative organism.
Also identify the treatment for each condition.
4. Identify individuals who are at high risk for developing each of the
following malignancies:
 i. squamous cell carcinoma:
ii. malignant melanoma:
iii. Kaposi's sarcoma:
5. List the four warning signs of skin cancer.
6. Match the common skin lesions with the terms provided.
(Fissure, Macule, Nodule, Papule, Plaque, Pustule, Ulcer, Vesicle)
Consolidation
7. Identify the disease or diseases for which each of the following
statements or characteristics is true:
i. most commonly associated with HIV and AIDS:
ii. commonly known as hives:
iii. an autoimmune disorder that results in blister formation:
iv. caused by a mite:
v. commonly known as cold sores:
vi. caused by human papillomavirus:
vii. superficial fungal infection:
viii. commonly known as eczema:
9

Musculoskeletal System Disorders

Fractures
1. Match the parts of a long bone with the following terms.

Articular cartilage, Compact bone, Diaphysis, Endosteum, Epiphyseal

line, Epiphysis, Medullary cavity, Nutrient foramen, Periosteum,
Spongy bone

From Applegate EJ. The Anatomy and Physiology Learning System.

Philadelphia: WB Saunders; 2000.
2. Outline the distinguishing characteristics of the following types of
fractures, and match the type of fracture with the diagrams.

i. open:

ii. comminuted:

iii. compression:
 iv. greenstick:

v. impacted:

vi. oblique:

vii. pathologic:

viii. spiral:

ix. transverse:

x. Colles':

xi. segmental:

xii. Pott's:

3. Describe in detail the healing of a simple transverse fracture.

4. Identify the potential complications of fractures.
5. What is meant by reduction of a fracture? Differentiate between a
closed reduction and an open reduction.
6. Explain the difference between a joint dislocation and subluxation.
7. Differentiate between a sprain and an avulsion.

Bone Disease
8. List factors that predispose an individual to osteoporosis.
9. Identify common sites of osteoporosis.
10. Describe the pathophysiology of osteoporosis.
11. Outline the treatment of osteoporosis, including the rationale for each
therapeutic intervention.
12. Complete the following chart comparing and contrasting rickets,
osteomalacia, and Paget's disease:
 13. Identify a drug group that may cause osteomalacia with prolonged
use.
14. Differentiate between an osteosarcoma and a chondrosarcoma.

Muscular Dystrophy
15. Describe the basic pathophysiology involved in muscular dystrophy.
16. Complete the following chart comparing and contrasting the four
types of muscular dystrophy:
Primary Fibromyalgia Syndrome
17. Identify the manifestations of fibromyalgia.

Arthritis
18. Explain why osteoarthritis is often referred to as wear-and-tear
arthritis.
19. How is osteoarthritis diagnosed?
20. Complete the following chart comparing osteoarthritis and
rheumatoid arthritis:

21. Identify drug types that may be used in the treatment of rheumatoid
arthritis.
22. Outline how juvenile rheumatoid arthritis differs from the adult
form.
23. Identify the basic underlying problem with gout.
24. Outline how gout differs from other forms of arthritis.
25. Describe the pathologic changes that occur in ankylosing spondylitis.

Consolidation
26. Identify the disease or diseases for which each of the following
statements or characteristics is true:
i. loss of articular cartilage:

ii. development of tophi in soft tissue, bone, or both:

iii. possible presence of an antibody against IgG in the serum:

iv. classified as an autoimmune disease:

v. presence of extra-articular (i.e., systemic) manifestations:

vi. a sex-linked disorder:

vii. may be treated with bisphosphonates:

viii. most commonly affects weight-bearing joints:

ix. highest incidence in women between 20 and 50 years of age:

x. characterized by synovitis and pannus formation:

xi. treatment may involve intra-articular injections of glucocorticoids:

xii. may result in the development of kyphosis:

xiii. may be accompanied by ocular complications such as uveitis:

xiv. affects joints in hands and feet:

xv. characterized by elevated serum uric acid levels:

xvi. development of ankylosis or joint fusion over time:

xvii. treated with NSAIDs:

xviii. immunosuppressants sometimes prescribed during

exacerbations:

xix. characterized by the development of osteophytes:

xx. primary involvement occurs in the intervertebral joints:

xxi. characterized by compression fractures of the vertebral bodies:

xxii. crepitus often present:

xxiii. treated with additional vitamin D and calcium:

10

Blood and Circulatory System Disorders

Erythrocytes
1. Describe the normal life cycle of an erythrocyte, including where it is
produced, what its life span is, and where and how it is destroyed.
2. State the normal range for both red blood cell (RBC) count and
hemoglobin, differentiating between the values found in males and
females.
3. Define anemia.
4. List the general manifestations for all types of anemias.
5. Complete the following chart comparing and contrasting the different
types of anemias:
6. Sickle cell anemia is an inherited disorder. What is the pattern of
inheritance for this disorder? What is the genotype of an individual with
sickle cell anemia?
7. What is meant by the sickle cell trait? What is the genotype of an
individual who has this trait?
8. A woman with sickle cell trait is pregnant with the child of a man who
has sickle cell anemia. Draw a Punnett square to illustrate possible
outcomes.
i. What is the probability that the child will have sickle cell anemia?
ii. What is the probability that the child will have sickle cell trait?
iii. What is the probability that the child will have neither sickle cell trait
nor sickle cell anemia?
iv. What is the probability that any future child that this couple
conceives will have sickle cell anemia?
9. Describe the pathophysiology of sickle cell anemia.
10. What precipitates sickling?
11. What is meant by a crisis? Identify the potential complications of a
sickling crisis.
12. Explain why an individual with sickle cell anemia may experience the
following signs and symptoms:
i. jaundice:
ii. cerebrovascular accident:
iii. frequent infections:
iv. splenomegaly:
v. congestive heart failure:
13. Is there any means of preventing sickle cell anemia?
14. Define polycythemia.
15. Differentiate between primary and secondary polycythemia.
16. Describe the signs and symptoms and complications of polycythemia.
17. Identify three therapeutic interventions used in the treatment of
polycythemia.
Blood Clotting
18. Draw a flowchart representing the three steps involved in blood
coagulation.
19. List the warning signs of excessive bleeding.
20. Describe diagnostic tests that can be employed to identify and/or
monitor bleeding disorders.
21. Identify six causes of abnormal bleeding, and explain how each
interferes with normal hemostasis.
22. Describe how and explain why each of the following factors would
affect hemostasis (i.e., promote or delay blood clotting):
i. liver disease:
ii. ingestion of aspirin (ASA):
iii. prolonged antibiotic therapy:
iv. administration of heparin:
v. vitamin K deficiency:
vi. prolonged inactivity (e.g., postoperatively or sitting on a plane for
many hours):
vii. polycythemia:
viii. thrombocytopenia:
ix. increased hematocrit:
x. administration of warfarin (Coumadin):
23. Hemophilia A, or classic hemophilia, is an inherited disorder. What is
the pattern of inheritance for this disorder? What is the genotype of an
individual with hemophilia A?
24. A woman is a carrier for hemophilia A. She is pregnant with the child
of a man who does not have hemophilia. What is her genotype for this
disorder? Draw a Punnett square to show possible outcomes.
i. What is the probability that the child she is carrying will have
hemophilia A? Would a child with hemophilia be a male or female?
ii. What is the probability that the child will be a carrier of hemophilia?
What would be the sex of a child who is a carrier?
iii. What is the probability that the child will neither have hemophilia
nor be a carrier of the disease?
 iv. What is the probability that any future sons whom this couple
conceives will have hemophilia?
v. What is the probability that any future daughters whom this couple
conceives will be carriers of hemophilia?
25. A man with hemophilia A marries a woman whose father has
hemophilia A.
i. What is the man's genotype?
ii. What is the woman's genotype?
Draw a Punnett square to illustrate the genotypes of possible children.
i. What is the probability that any children whom this couple conceives
will have hemophilia?
ii. What is the probability that any children whom this couple conceives
will be carriers of hemophilia?
iii. What will be the sex of a child who is a carrier?
26. Describe the pathophysiology and manifestations of disseminated
intravascular coagulation (DIC).

Leukocytes
27. Define leukemia.
28. What is a blast cell? Describe its characteristics.
29. Explain the two major classifications of leukemia.
30. Identify individuals who are considered at high risk for the
development of leukemia.
31. What test could be used to confirm a diagnosis of leukemia?
32. The signs and symptoms of leukemia are diverse and widespread
throughout the body. Explain why each of the signs and symptoms
occurs:
i. Weight loss and fatigue:
ii. Anemia:
iii. Thrombocytopenia:
iv. Multiple infections, including those caused by microorganisms of low
virulence:
 v. Increased bleeding and even severe hemorrhage:
vi. Kidney stones:
vii. Fever:
viii. Lymphadenopathy:
ix. Splenomegaly and hepatomegaly:
x. Bone pain:
33. Describe the treatments used for the patient with leukemia, including
the adverse effects or complications of each.
34. Describe the different prognoses for the types of leukemia.
35. Complete the following chart comparing and contrasting acute and
chronic leukemia:

Consolidation
36. For each of the following characteristics, identify the blood disorder or
disorders in which they occur:
i. involves both excessive bleeding and clotting:
ii. decreased or lack of intrinsic factor production:
iii. characterized by primitive blast cells:
iv. sex-linked bleeding disorder:
v. increased production of erythrocytes:
vi. frequent adverse effect of chemotherapy:
vii. may result in impaired growth and development:
viii. common in individuals from the Mediterranean area:
ix. may be accompanied by jaundice:
x. may be accompanied by loss of coordination:
xi. a neoplastic disorder involving the red blood cells:
xii. more prevalent in individuals with Down syndrome:
xiii. predisposes individuals to infections:
11

Lymphatic System Disorders

Lymphatic System Structures

1. Match the terms with the structures/organs of the lymphatic system in
the figure.
Arteriole, Axillary lymph nodes, Blood capillary, Bone marrow, Inguinal
lymph nodes, Left subclavian vein, Lymph capillaries, Right
lymphatic duct, Right subclavian vein, Spleen, Thoracic duct,
Thymus, Tissue cells, Tonsil, Venule
 From VanMeter K, Hubert R. Microbiology for the Healthcare Professional.
St. Louis: Elsevier; 2010.

A. ____________________
B. ____________________
C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
 J. ____________________
K. ____________________
L. ____________________
M. ____________________
N. ____________________
O. ____________________

Lymphatic System Disorders

2. What type of cell forms the diagnosis for Hodgkin disease? Describe this
cell.
3. Outline the basis for the staging of Hodgkin disease.
4. Describe the signs and symptoms of Hodgkin disease, through the four
stages.
5. Identify treatments for Hodgkin disease.
6. Explain how non-Hodgkin lymphoma differs from Hodgkin disease.
7. Define multiple myeloma.
8. Describe the signs and symptoms of multiple myeloma, including the
reason that each occurs.
12

Cardiovascular System Disorders

Heart
1. Identify the structures of the heart using the following labels:

From VanMeter K, Hubert R. Microbiology for the Healthcare Professional.

St. Louis: Elsevier, 2010.

aorta mitral (bicuspid) valve

aortic semilunar valve papillary muscle
chordae tendineae pericardium
inferior vena cava right atrium
interventricular septum right ventricle
left atrium superior vena cava
left ventricle tricuspid valve

Atherosclerosis
 2. Describe four general treatment measures for cardiac disorders.
3. Identify ten risk factors for developing atherosclerosis. Indicate which
ones are modifiable and which ones are not. Note that these are the
same risk factors for heart disease.
4. Describe the process of atheroma formation, from the initial fatty
streaks in the arterial wall intima to a complicated plaque.
5. Describe the significance of plaque formation, including five potential
complications of atherosclerosis.
6. Which vessels are affected by atherosclerosis?
7. Describe common therapeutic interventions, to include lifestyle
changes, used in the treatment of atherosclerosis.
8. Explain the rationale for prescribing the following drugs:

i. antilipidemics or lipid-lowering drugs:

ii. platelet inhibitors:

iii. anticoagulants:

iv. antihypertensives:

9. What type of surgical interventions can be used in advanced

atheromas?

Angina Pectoris (Ap)

10. Define angina pectoris.
11. What is the underlying pathology involved in angina pectoris?
12. Identify disorders that may cause or predispose an individual to
angina.
13. What is the most serious complication of angina pectoris?
14. The factors listed below often precipitate an attack (i.e., pain) in an
individual with a history of angina. Explain the mechanism involved
for each of them:

i. smoking a cigarette or being exposed to secondhand smoke:

ii. going from a warm environment into the cold:

iii. engaging in an argument or other stressful behavior:

 iv. exercise, such as climbing a flight of stairs or rushing to catch a
bus:

15. Describe the classic manifestations of an anginal attack. What is the

usual duration of an anginal attack?
16. What type of drug is used to treat an acute anginal attack? Explain
how these drugs relieve chest pain.
17. In an emergency anginal attack, how would you administer
nitroglycerin?
18. Outline the management of an anginal attack.
19. When should emergency medical services (EMS) be requested?
20. The drug groups identified in the accompanying chart are often
prescribed alone or in combination to control angina and prevent
periods of myocardial hypoxia. Explain the action of each type and
how each would prevent anginal pain. Also identify adverse effects
and one example for each group.

21. List other types of medication that might be prescribed for an

individual with angina, and explain the rationale for each.
22. Identify surgical interventions that might be used in the treatment of
angina.
23. Describe nonpharmacologic interventions that could help to control
angina.
24. A patient states that he has angina pectoris. Identify additional
information that should be obtained from this individual.
 25. Identify measures that would help decrease the chance of an
individual experiencing an anginal attack.

Myocardial Infarction
26. Define myocardial infarction (MI).
27. State three causes of MI, and indicate which one occurs most
frequently.
28. List the warning signs of an MI.
29. Differentiate between a transmural and intramural infarction.
30. What is the most common site of an MI?
31. Describe the pathophysiology of an MI.
32. Describe the manifestations of an MI.
33. How could a diagnosis of MI be confirmed?
34. What are serum enzymes? What is their significance in someone who
has suffered an MI? Differentiate between enzymes and isoenzymes.
35. Explain why the electrocardiogram (ECG) would change after an MI.
36. What complication of MI is responsible for the greatest number of
deaths? Why is this complication so serious?
37. Briefly describe other complications that may accompany an MI.
38. Identify the treatments for an MI, and include the rationale for each.
39. Identify at least four differences between angina pectoris and MI.

Cardiac Dysrhythmias (Arrhythmias)

40. Locate and label the components of the cardiac conduction system on
the following diagram:
Structures
atrioventricular (AV) bundle (Bundle of His) Purkinje fibers
atrioventricular (AV) node right bundle branch
left bundle branch sinoatrial (SA) node
41. Describe the pathway of impulses in the cardiac conduction system,
starting at the pacemaker of the heart.
42. Label the following diagram of an electrocardiogram (ECG):

43. Explain what is represented by each segment of the ECG tracing:

i. P wave:

ii. QRS complex:

 iii. T wave:

44. Define dysrhythmia.

45. List several conditions in which cardiac arrhythmias occur.
46. Match the following definitions with the correct term:

a. heart rate greater than 350 beats per i. cardioversion

minute
b. extra heartbeat arising in the ventricles ii. bradycardia
c. heart rate less than 60 beats per minute iii. ectopic beat
d. slowing or no transmission of impulses iv. flutter
between atria and ventricles
e. additional heartbeat originating in atria v. fibrillation
f. restoration of normal cardiac rhythm by vi. heart block
electrical shock
g. heart rate between 160 and 350 vii. premature atrial
beats/minute contraction (PAC)
h. extra beat originating outside the SA viii. premature ventricular
node contraction (PVC)
i. heart rate between 100 and 160 beats per ix. tachycardia
minute
47. Why is a rapid (resting) heart rate undesirable?
48. Why is an excessively slow heart rate undesirable?
49. The drug groups identified in the accompanying chart are often
prescribed alone or in combination to control dysrhythmias. Explain
the action of each and how they would control or prevent
arrhythmias. Also identify adverse effects and one example for each
group.
 50. An individual who has been diagnosed with cardiac arrhythmias
may have a history of atherosclerosis and other heart-related
conditions, such as angina or a previous MI. Identify other
medications that such an individual may be taking to control these
conditions.
51. What type of pacemaker can be used by paramedics as an immediate
lifesaving treatment of an MI?
52. Why is it important to know whether a patient has a pacemaker?
53. Define cardiac arrest.

Heart Failure
54. Identify causes of congestive heart failure.
55. Describe the compensatory mechanisms that are recruited in early
heart failure to maintain cardiac output.
56. The consequences of heart failure are often referred to as the backup
and forward effects. Explain what is meant by these terms.
57. One side of the heart usually fails first, depending on the specific
cause. Complete the following chart comparing and contrasting
right-sided and left-sided heart failure:
58. Explain why each of the following manifestations occurs with
congestive heart failure:

i. splenomegaly:

ii. ascites:

iii. orthopnea:

iv. cough:

v. hemoptysis:

vi. distended neck veins:

vii. decreased urine output:

viii. nocturia:

ix. polycythemia:

59. Many different therapeutic interventions are used in the treatment of

congestive heart failure. Explain the rationale for each of the
following treatment measures:

i. low-sodium diet:
 ii. low-cholesterol diet:

iii. compression stockings:

iv. continuous oxygen therapy:

v. diuretics:

vi. potassium supplement:

vii. angiotensin-converting enzyme (ACE) inhibitors:

viii. digoxin:

ix. platelet inhibitor or anticoagulant:

x. sedative or antianxiety agent:

Congenital Heart Defects

60. List factors that may contribute to the development of congenital
heart defects.
61. Define the following terms:

i. septal defect:

ii. valvular incompetence:

iii. regurgitation:

iv. prolapse:

v. stenosis:

vi. heart murmur:

62. How are most congenital heart defects detected?

63. Distinguish between a “left-to-right shunt” and a “right-to-left
shunt.” Describe the composition of systemic blood, and explain the
implications in each case.
64. Outline the signs and symptoms of large congenital heart defects.
65. Explain the consequences of a large ventricular septal defect,
including the complications that develop if the defect is not
surgically corrected.
66. To understand the consequences of a heart valve defect, it is
important to consider what is happening “behind” the valve (the
“backup” effect), as well as what is happening “in front” of it (the
“forward” effect). Complete the following chart comparing and
contrasting selected valve defects:

67. Name two conditions that are usually associated with heart
murmurs.
68. Describe the four defects that are present in tetralogy of Fallot.
Outline the direction of blood flow, or draw a diagram to illustrate
blood direction. Describe the implications of altered blood flow.
69. Describe therapeutic interventions used in the treatment of heart
defects.
70. A patient states that he previously had a heart murmur but the
defective valve was replaced with a prosthetic valve.
 i. What medication will he be taking? Explain the rationale for this
drug.

ii. What medications will he require if he is undergoing an invasive

procedure such as dental surgery? Explain why this is necessary.

Rheumatic Fever, Rheumatic Heart Disease, and

Infective Endocarditis
71. Which microorganism generally causes rheumatic fever?
72. Identify individuals who are at high risk for developing rheumatic
fever.
73. Describe the pathophysiology of rheumatic fever.
74. Describe the manifestations of rheumatic fever under the following
headings:

i. general indication of systemic inflammation:

ii. pericarditis:

iii. myocarditis:

iv. endocarditis:

v. polyarthritis:

vi. skin manifestations:

vii. subcutaneous nodules:

viii. Sydenham's chorea:

75. Endocarditis is the most common pathophysiologic change

associated with rheumatic fever and may be the most serious
problem. Explain the statement.
76. Identify measures used to diagnose rheumatic fever.
77. The treatment of rheumatic fever involves the use of several different
types of drugs. Complete the following chart, identifying the effects
of each type of medication as well as providing an example:
78. Distinguish between rheumatic fever and rheumatic heart disease.
79. Which heart valve is most commonly affected by rheumatic heart
disease?
80. Why is ASA (aspirin) often prescribed for individuals with a history
of rheumatic heart disease?
81. Why are individuals with a history of rheumatic heart disease at an
increased risk for developing infective endocarditis?
82. Explain why individuals with a history of rheumatic heart disease
require prophylactic antibiotic coverage before any invasive
procedure, such as dental surgery.
83. Severely damaged heart valves may be surgically replaced with
prosthetic valves. Explain why someone with a prosthetic heart valve
will still be required to take ASA (or some other platelet inhibitor or
anticoagulant) for the rest of his or her life and why such a patient
will still require antibiotic coverage before invasive procedures.
84. Differentiate between subacute and acute infective endocarditis
(formerly known as bacterial endocarditis). Identify the microbial
agents involved in each type.
 85. Identify individuals who are at high risk for developing each type of
infective endocarditis.
86. Outline the pathophysiology of infective endocarditis.
87. Describe the manifestations and complications of infective
endocarditis.
88. How is a diagnosis of infective endocarditis confirmed?
89. Describe the treatment for infective endocarditis.
90. Complete the following chart comparing and contrasting rheumatic
fever and infective endocarditis:

91. Name the possible causes of acute pericarditis.

Hypertension
92. Define hypertension. Include numerical values for blood pressure in
your definition. How does age affect the criteria for hypertension?
93. Differentiate between essential and secondary hypertension.
94. What is meant by the term malignant hypertension?
95. Identify predisposing factors for hypertension, indicating those that
are modifiable. Note that these parallel the risk factors for
atherosclerosis and heart disease.
 96. Describe the pathophysiology and complications of undiagnosed or
uncontrolled hypertension.
97. Explain why hypertension is often referred to as “the silent killer.”
98. Describe lifestyle and behavioral changes that are recommended in
the treatment of hypertension. Explain the rationale for each
modification.
99. What is the greatest problem in the treatment of hypertension?

Antihypertensive Medications
100. Individuals with hypertension are often prescribed one or more
antihypertensive medications, as well as other medications.
Complete the following chart comparing and contrasting the most
commonly prescribed types of antihypertensive agents:

101. Identify adverse effects that are common to all antihypertensive

medications.
102. List other medications that might be prescribed, and state the
rationale for each.

Peripheral Vascular Disease (PVD)

103. Describe the general manifestations of peripheral vascular disease.
104. Outline the various treatments used in treating peripheral vascular
disease.
105. Define aortic aneurysm.
106. Identify the causes of aneurysms.
107. Describe the complications of aneurysms.
108. Identify factors that contribute to the development of varicose veins.
109. Describe the signs and symptoms of varicosities.
110. Differentiate between thrombophlebitis and phlebothrombosis.
111. Identify three factors that contribute to the development of
thrombophlebitis.
112. Outline measures that could decrease the risk for developing
thrombophlebitis.
113. What is a pulmonary embolus? Where did the blood clot probably
originate?

Shock
114. Define shock.
115. Outline the compensatory mechanisms that are recruited as the
blood pressure decreases.
116. Describe the general manifestations of shock, including the cause of
each.
117. Identify the potential complications of shock, and explain why each
one occurs.
118. Outline general measures used in the treatment of shock.
119. Complete the following chart comparing and contrasting the
different types of shock:
Consolidation
120. Identify the cardiovascular condition or conditions in which the
following manifestations would be present:

i. ascites:

ii. positive Homan sign:

iii. ECG changes:

iv. positive blood cultures:

v. claudication:

vi. hemoptysis:

vii. heart murmur:

viii. elevated cardiac enzymes:

ix. subcutaneous nodules:

 x. pulmonary edema:

121. Identify the use or uses of the following drugs:

i. calcium channel blockers:

ii. nitroglycerine:

iii. penicillin:

iv. β-adrenergic blockers:

v. digoxin:

vi. diuretics:

vii. antidysrhythmics:

viii. ACE inhibitors:

13

Respiratory System Disorders

1. Match the anatomic terms with the diagram of the respiratory system.
Alveoli, Bronchiole, Diaphragm, Epiglottis, Heart, Larynx (voice box),
Left lung, Left main bronchus, Lower respiratory system, Nasal
cavity, Oral cavity, Pharynx, Pleura, Right lung, Right main bronchus,
Tongue, Trachea, Upper respiratory system
 From VanMeter K, Hubert R. Microbiology for the Healthcare Professional.
St. Louis: Elsevier; 2010.

A. ____________________
B. ____________________
C. ____________________
D. ____________________
 E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
L. ____________________
M. ____________________
N. ____________________
O. ____________________
P. ____________________
Q. ____________________
R. ____________________
2. Match the pattern of breathing with the general manifestations of
respiratory disease.
 From Phipps WJ, Monahan FD, Sands JK, et al. Medical-Surgical Nursing:
Health and Illness Perspectives. 7th ed. St. Louis: Mosby; 2003.

Apnea Eupnea
Apneusis Hyperpnea
Ataxic breathing Kussmaul's respiration
Bradypnea Obstructed breathing
Cheyne-Stokes respiration Tachypnea

3. Describe the common complications of viral infections of the respiratory

tract.
4. Complete the following chart comparing and contrasting common
childhood respiratory infections:
5. Complete the following chart comparing and contrasting selected types
of pneumonia:
6. Briefly describe Pneumocystis carinii pneumonia (PCP). Identify
individuals who are at high risk for contracting this type of pneumonia.
7. Name the microbial agent responsible for severe acute respiratory
syndrome (SARS), and identify its mode of transmission.
8. Outline the pathophysiology of SARS.
9. Describe the signs and symptoms of SARS, including its effects on both
blood gases and acid-base balance.
10. Identify the therapeutic interventions used in the treatment of SARS.
11. Discuss the difficulties involved in controlling the spread of infection
when the causative agent is unidentified.

Tuberculosis
12. Describe the characteristics of Mycobacterium tuberculosis.
13. Explain why it is difficult for host defensive cells to eradicate
tuberculosis (TB) bacilli.
14. Identify individuals who are at high risk for contracting tuberculosis.
15. Describe the pathophysiology of tuberculosis, distinguishing between
primary and secondary infection.
16. Describe the specific type of lesion that is associated with TB.
17. Outline the signs and symptoms of tuberculosis, distinguishing
between those that occur with primary infection and those that develop
with secondary infection or reinfection.
18. Briefly describe miliary tuberculosis.
19. How is a diagnosis of active (i.e., infectious) tuberculosis confirmed?
20. What is a Mantoux test? What does a positive test indicate?
21. List medications used in the treatment of tuberculosis. Why is it
necessary to take several different medications? What is the usual
duration of drug therapy?
22. When will an individual who is taking TB medications become
noncontagious? Explain why the drugs are prescribed for a longer
period.
23. Individuals who are considered to be at high risk for contracting TB are
routinely prescribed TB prophylaxis. Identify individuals who may
require TB prophylaxis.
24. Identify the medications that are used for TB prophylaxis and the usual
duration of treatment.
25. Describe measures that a health care professional should take to protect
himself or herself against TB.
26. A patient states that his last TB skin test was swollen and red. What
additional information should be obtained from this individual?
27. An individual states that he had TB a number of years ago. What
additional information should be obtained from this individual?

Cystic Fibrosis
28. What type of disorder is cystic fibrosis (CF)?
29. A baby is diagnosed with CF. Neither parent has this disorder. What
are the genotypes of the parents? What is the probability that any of the
baby's siblings will also have this disorder?
30. If an individual with CF had a child with an individual who was a
carrier of CF, what is the probability that the child will have CF? What is
the probability that he or she will be a carrier of CF?
31. Describe the pathophysiology of CF.
32. Outline the manifestations of CF.
33. Identify tools used in the diagnosis of CF.
34. Outline the treatments for CF.
35. What is the life expectancy of an individual with CF? What is the usual
cause of death?

Lung Cancer
36. Explain why the lungs are a frequent site of metastatic tumors.
37. List the risk factors for bronchogenic cancer.
38. Describe the effects of lung cancer.
39. Describe the signs and symptoms of lung cancer.
40. List treatments for lung cancer.

Aspiration
41. Define aspiration.
42. Identify individuals who are at high risk for aspiration.
43. Describe the effects of aspiration.
44. Identify common signs and symptoms of aspiration.
45. Describe the Heimlich maneuver.

Asthma
46. Define asthma.
47. Compare and contrast the two types of asthma (extrinsic and intrinsic).
48. Describe the pathophysiology of an asthmatic attack, identifying the
three factors that interfere with normal ventilation.
49. Outline the potential complications of poorly controlled asthma.
50. Describe the progression of an asthmatic attack.
51. Identify nonpharmacologic measures used in the treatment of asthma.
52. Four types of medications are used in the control and treatment of
asthma. Complete the following chart comparing and contrasting these
drugs:

53. Identify which drug group can be used during an acute asthmatic
attack.
54. An individual states he has asthma. What additional information
should be obtained from this individual?

Chronic Obstructive Pulmonary Disease (COPD)

55. What is the leading causative factor for both emphysema and chronic
bronchitis? Identify other contributing factors in the development of
chronic obstructive pulmonary disease.
56. Explain why polycythemia may develop in both advanced emphysema
and chronic bronchitis.
57. Identify the underlying pathology involved in emphysema.
58. Loss of alveolar walls characteristically occurs with emphysema.
Explain the consequences of this change.
59. Explain why individuals with emphysema are sometimes referred to as
pink puffers.
60. Outline the complications that develop with the progression of
emphysema.
61. What impact does increased residual volume have on blood gases in
advanced emphysema? How could this affect blood pH?
62. Explain how respiratory control mechanisms change as emphysema
progresses.
63. What is meant by the term barrel chest? Explain why this condition
develops in individuals with emphysema.
64. Outline the treatments for emphysema.
65. Describe the pathophysiology of chronic bronchitis.
66. Identify the most significant symptom of chronic bronchitis.
67. Explain why individuals with chronic bronchitis are sometimes
referred to as blue bloaters.
68. Describe the treatments for chronic bronchitis.
69. Complete the following chart comparing and contrasting selected
chronic obstructive lung disorders:
70. Define bronchiectasis, and list two primary conditions/diseases that
may cause it.
71. Define pneumoconiosis, and state the usual treatment.

Pulmonary Edema
72. Identify the causes of pulmonary edema.
73. Describe the pathophysiology of pulmonary edema.
74. Describe the signs and symptoms of pulmonary edema.
75. Explain why the sputum of an individual with pulmonary edema
might be frothy and possibly pink in color.
76. Explain why an individual with mild pulmonary edema will
experience dyspnea when placed in a supine position (e.g., for dental
treatment). What is the term used to describe this condition?
77. Outline the treatment of pulmonary edema, including medications that
might be used.
Pulmonary Embolus
78. Define pulmonary embolus.
79. Where do most pulmonary emboli originate? Identify other potential
sources of pulmonary emboli.
80. Identify individuals who are at high risk for developing pulmonary
emboli.
81. Describe the pathophysiology of a pulmonary embolus.
82. Identify the signs and symptoms of a pulmonary embolus.
83. What drugs may be used to treat pulmonary emboli?

Expansion Disorders
84. Explain the differences between atelectasis and bronchiectasis,
including the etiologies, complications, and signs and symptoms.
85. Explain the differences between a pleural effusion and pneumothorax,
including etiologies and signs and symptoms.
86. Explain what is meant by a flail chest injury.
87. Identify causes of acute respiratory failure.
88. Complete the following chart comparing and contrasting infant
respiratory distress syndrome and adult respiratory distress syndrome:
89. Match each of the following definitions with the correct terms.

a. air in the pleural cavity i. pleural effusion

b. abnormal widening of the bronchi ii. atelectasis
c. excessive fluid in the pleural cavity iii. pneumothorax
d. chronic disorder resulting from continued exposure to irritating iv. bronchiectasis
particles
e. fungal infection of the lungs v. histoplasmosis
f. collapse of a portion of the lung vi.
pneumoconiosis

Consolidation
90. For each of the following characteristics or definitions, identify the
appropriate respiratory disorder or disorders in which they occur:
i. characterized by episodic bronchospasm:
ii. causes orthopnea:
iii. sputum often frothy and pink or blood-tinged:
iv. loss of alveolar walls and lung elasticity:
v. caused by an acid-fast bacillus:
vi. acute manifestations usually relieved by adrenergic agonists:
vii. occurs most commonly in immunosuppressed individuals:
viii. deficit of pancreatic digestive enzymes:
ix. collapse of a lung or portion of a lung:
x. characterized by a constant productive cough:
xi. a potential complication of thrombophlebitis in leg veins:
xii. inadequate production of surfactant:
xiii. results from rib fractures:
xiv. defect in chloride ion transport in cell membranes:
xv. causes malabsorption of nutrients:
xvi. may cause cavitation within lungs:
xvii. abnormal dilation of the bronchi:
xviii. accumulation of fluid in the pleural cavity:
xix. characterized by caseation necrosis:
xx. treated with leukotriene receptor antagonists:
14

Nervous System Disorders

Acute Disorders
1. Match terms with the anatomic parts of the brain and functional areas.
The functional areas are indicated with a bold blank line on the figure.
Central sulcus, Cerebellum, Frontal lobe, Lateral sulcus, Medulla, Motor
cortex, Occipital lobe, Parietal lobe, Pons, Premotor cortex, Sensory
cortex, Temporal lobe, Visual area, Visual association, Intellect
personality, Broca's speech area, Wernicke's area, Auditory area,
Memory, Balance equilibrium coordination, RAS, Vital centers
Anatomic Features
A. ____________________
B. ____________________
C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
 J. ____________________
K. ____________________
L. ____________________
M. ____________________
Functional Features
N. ____________________
O. ____________________
P. ____________________
Q. ____________________
R. ____________________
S. ____________________
T. ____________________
U. ____________________
V. ____________________
2. Name the meninges and the spaces between the layers.
3. What is the main function of the cerebrospinal fluid (CSF), and which
structure forms the CSF?
4. Name the neurotransmitter that is acting at:
i. the neuromuscular junction but also in the central nervous system:
ii. preganglionic synapse of the autonomic nervous system:
iii. postsynaptic synapses of the parasympathetic and sympathetic
systems:
5. Name/identify the action of the sympathetic branch of the autonomic
nervous system on the following:
i. heart:
ii. adrenal medulla:
iii. respiratory system:
iv. eye:
v. digestive system function:
6. One of the early notable changes in individuals with acute brain
disorders is a decreasing level of consciousness or responsiveness.
 Which areas of the brain are involved in the maintenance of
consciousness?
7. Name criteria that are generally used in the diagnosis of brain death,
and explain how this diagnosis is made.
8. Define aphasia, and briefly describe the three main types, including
areas of the brain affected.
9. Identify conditions in which increased intracranial pressure may
develop.
10. Describe the consequences of increased intracranial pressure.
11. Identify the manifestations of increased intracranial pressure,
explaining why each one occurs.

Tumors
12. Manifestations of brain tumors, whether they originate in the brain or
are metastatic tumors, are primarily caused by their space-occupying
effect and the replacement of normal tissue by tumor cells. Summarize
the potential generalized manifestations of brain tumors (i.e., nonfocal).

TIAs and CVAs

13. Define transient ischemic attack (TIA).
14. Describe the manifestations of a TIA.
15. Explain the significance of TIAs.
16. Differentiate between a TIA and a stroke (cerebrovascular accident
[CVA]).
17. Identify individuals who are considered to be at high risk for
experiencing a CVA or stroke.
18. Describe the warning signs of a stroke. Notice that they are the same as
the manifestations of a TIA.
19. Identify the three common categories of CVA or stroke, indicating
which one occurs most commonly.
20. Describe the pathophysiology of a stroke (CVA).
21. Complete the following chart comparing and contrasting the three
most common types of cerebrovascular accidents:

22. Identify the possible origins of cerebral emboli.

23. Explain why the prognosis for a hemorrhagic type stroke is worse than
for other types.
24. Describe the possible manifestations of a stroke under the following
headings:
i. motor deficits:
ii. sensory deficits:
iii. speech deficits:
iv. cognitive and emotional manifestations:
25. Describe the therapeutic interventions used in the long-term treatment
of an individual who has experienced a stroke (CVA), including
medications.
26. An individual suffers a massive thrombus-type CVA involving the left
frontal and parietal lobes. Describe the manifestations that he or she
would probably experience.
Cerebral Aneurysms
27. Describe cerebral aneurysm.
28. Identify the most common factor that precipitates rupture of an
aneurysm.
29. Describe manifestations of both an enlarging and a ruptured aneurysm.

Infections
30. Complete the following chart comparing and contrasting meningitis
and encephalitis:

31. Identify the causative agent of shingles and when the condition usually
manifests itself.
32. Describe the pathophysiology associated with Reye syndrome.

Injuries
33. Briefly describe the following types of head injuries:
i. concussion:
ii. contusion:
iii. linear fracture:
 iv. compound fracture:
v. basilar fracture:
vi. contrecoup injury
34. Identify the location of the following hematomas:
i. epidural:
ii. subdural:
iii. subarachnoid:
iv. intracerebral:
35. Describe the consequences and potential complications of a head
injury.
36. Describe the general manifestations of head injuries.
37. Identify therapeutic interventions employed in the treatment of a head
injury.
38. Identify the common causes of spinal cord injuries.
39. Outline the consequences and potential complications of a spinal cord
injury.
40. Describe the potential manifestations of a spinal cord injury.
41. Identify the therapeutic interventions used in treatment of spinal cord
injuries.
42. Complete the following crossword puzzle:
Across
5. drooping eyelid
9. inability to recognize everyday objects
10. opposite side
11. difficulty pronouncing words
12. paralysis of lower half of body
13. inability to express or comprehend speech
Down
1. increased sensitivity to light
2. paralysis of all four limbs
3. same side
4. paralysis of one side of the body
6. loss of vision from the medial side of one eye and the lateral side of the
other eye
7. brain tumor originating in neuroglial cells
8. bruising of the brain

Congenital Neurologic Disorders

Hydrocephalus
43. Define hydrocephalus.
44. State the causes of hydrocephalus.
45. Outline the pathophysiology of hydrocephalus.
46. Distinguish between noncommunicating (obstructive) and
communicating hydrocephalus.
47. Describe the signs and symptoms of hydrocephalus.
48. What is the treatment for hydrocephalus?

Spina Bifida
49. Identify the basic defect involved in spina bifida.
50. Describe the three types of spina bifida, and match types to the
diagrams.

51. How is spina bifida diagnosed prenatally?

52. List the possible causes of spina bifida.
53. Describe the signs and symptoms of spina bifida.
54. Outline the treatment of spina bifida.

Cerebral Palsy
55. List the causes of cerebral palsy.
56. Describe the pathophysiology of cerebral palsy.
57. Describe the three major classifications of motor disabilities that occur
with cerebral palsy.
58. Identify other possible manifestations of cerebral palsy.
59. Outline the treatment of cerebral palsy.

Seizure Disorders
60. Define seizure.
61. Describe the pathophysiology of a seizure disorder.
62. Distinguish between primary and secondary (acquired) seizures.
63. List causes of acquired seizures.
64. Differentiate between a generalized seizure and a partial seizure.
65. Describe an absence, or petit mal, seizure. What is the usual duration of
this type of seizure?
66. What is meant by prodromal signs?
67. What is an aura? Give several examples of typical auras. What is the
significance of an aura?
68. Identify factors that might precipitate a seizure in an individual who
suffers from epilepsy.
69. Describe a tonic-clonic seizure. What is the typical duration of this type
of seizure?
70. What are the potential complications of a seizure?
71. Outline the emergency treatment of a seizure.
72. When is it necessary to seek medical assistance?
73. Differentiate between a simple partial and a complex partial seizure.
74. Identify two types of medications prescribed to prevent seizures.
75. Describe the adverse effects of these drugs.
76. What is status epilepticus? What drugs are used to treat this condition?
77. An individual states that he suffers from epilepsy. What additional
information should you obtain before initiating treatment?
78. What measures should be taken to decrease the possibility of
precipitating a seizure?
79. What diagnostic tests are used to determine the following?
i. type and location of seizure:
ii. structural abnormalities in the brain:

Chronic Degenerative Disorders

Multiple Sclerosis (MS)
80. Describe pathologic changes associated with multiple sclerosis (MS).
81. What is known about the etiology of MS?
82. Identify individuals who are at high risk for developing MS.
83. Describe how the characteristic lesions of MS affect nerve conduction.
84. What type of neurons are affected by MS?
85. How is MS diagnosed?
86. Describe the manifestations of MS, distinguishing between early and
late symptoms.
87. Outline the therapeutic interventions used in the treatment of MS.
88. Explain the rationale for the use of corticosteroids and interferon in the
treatment of MS.

Parkinson Disease
89. What is Parkinson disease?
90. State the underlying pathologic change that occurs in Parkinson
disease. Describe the consequences of this change.
91. Describe the manifestations of Parkinson disease, distinguishing
between early and late symptoms.
92. What drug group may cause drug-induced Parkinsonism?
93. List drug groups that are used in the treatment of Parkinson disease.

ALS, Myasthenia Gravis, and Huntington Disease

94. Amyotrophic lateral sclerosis (ALS), myasthenia gravis, and
Huntington disease are all progressive neurologic disorders that cause
motor deficits. Complete the following chart comparing and contrasting
these three conditions:

Dementia
95. State several causes of dementia.
96. Outline the typical changes that occur in the brains of individuals with
Alzheimer disease.
97. List the causes of Alzheimer disease.
98. Identify the signs and symptoms of Alzheimer disease.

Mental Illness
99. Summarize the types of behavior exhibited by individuals with
schizophrenia.
100. Describe the adverse effects of antipsychotic medications.
101. Identify types of antidepressant drugs, and state an example of each.
Panic Disorder
102. Describe the signs and symptoms of panic disorder.

Spinal Cord Disorder

Herniated Disk
103. Describe the anatomic changes that occur in a herniated intervertebral
disk.
104. What is the most serious complication of a herniated disk?
105. Identify the most common site of a herniated disk, and describe the
resulting manifestations.
106. Outline the treatment of a herniated lumbar disk.

Consolidation
107. A patient has a history of cognitive impairment. What additional
information should you try to obtain?
108. Identify how treatment should be modified for an individual with a
history of cognitive impairment.
109. For each of the following pathologic findings/characteristics, identify
the condition or conditions in which they occur:
i. loss of myelin in the CNS:
ii. impairment of receptors at neuromuscular junctions:
iii. reduced function of the basal ganglia (nuclei):
iv. development of neurofibrillary tangles:
v. decreased dopamine synthesis:
vi. depletion of GABA:
vii. degeneration of both upper and lower motor neurons:
viii. an autosomal dominant disorder:
ix. an autoimmune disorder:
x. rigidity and difficulty initiating movements:
xi. development of plaques in the brain:
xii. decreased levels of acetylcholine (ACh) in the CNS:
xiii. treated with levodopa:
xiv. treated with donepezil:
xv. caused by infection by a prion:
15

Disorders of the Eye, Ear, and Other Sensory

Organs

Eye
1. Match the structures of the eye with the terms.
Anterior chamber, Canal of Schlemm, Central retinal artery and vein,
Choroid, Ciliary muscle, Conjunctiva, Cornea, Fovea centralis, Iris,
Lateral rectus muscle, Lens, Medial rectus muscle, Meninges, Optic
disc (“blind spot”), Optic nerve, Posterior cavity (vitreous humor),
Posterior chamber, Pupil, Retina, Retinal artery, Retinal vein, Sclera,
Suspensory ligament
A. ____________________
B. ____________________
C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
L. ____________________
M. ____________________
 N. ____________________
O. ____________________
P. ____________________
Q. ____________________
R. ____________________
S. ____________________
T. ____________________
U. ____________________
V. ____________________
W. ____________________
2. Explain the use of the following basic diagnostic tests:
i. Snellen chart:
ii. visual field test:
iii. tonometry:
iv. ophthalmoscope:
v. gonioscopy:
3. Define the following functional defects associated with the eye:
i. myopia:
ii. hyperopia:
iii. presbyopia:
iv. astigmatism:
v. diplopia:
4. Describe the following eye infections, including the causative agent(s):
i. stye:
ii. conjunctivitis:
iii. trachoma:
iv. keratitis:
5. State the basic pathology involved in glaucoma.
6. Differentiate between narrow-angle and wide-angle glaucoma.
7. Identify individuals who are at increased risk for developing glaucoma.
8. List the manifestations of glaucoma.
9. Outline the therapeutic interventions used in the treatment of glaucoma.
10. Complete the following chart comparing common ocular problems:

11. List and briefly describe the treatments for both types of age-related
macular degeneration.
12. For each of the following pathologic findings/characteristics, identify
the condition(s) in which they occur:
i. characterized by clouding of the ocular lens:
ii. characterized by degeneration of the fovea centralis:
iii. treated with cholinergic eye drops:
iv. characterized by loss of central vision:
v. appearances of “halos” around lights:
vi. increased intraocular pressure:

Ear
13. Match the terms with the structures of the ear shown in the diagram.
Auditory (eustachian) tube, Auditory nerve (VIII), Auditory ossicles,
Cochlea containing organ of Corti, Cochlear nerve, External auditory
canal, External ear, Incus, Inner ear, Malleus, Middle ear, Oval
window, Pinna, Semicircular canals, Stapes, Temporal bone,
Tympanic membrane, Vestibular nerve, Vestibule
A. ____________________
B. ____________________
C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
L. ____________________
M. ____________________
N. ____________________
O. ____________________
P. ____________________
Q. ____________________
 R. ____________________
S. ____________________
14. Differentiate between conduction deafness and sensorineural deafness,
and state several examples of each type.
15. Define otitis media and common microorganisms causing the infection.
16. Discuss the treatment options for otitis media.
17. Name the structures involved in otitis externa and the possible
causative agents.
18. Briefly outline the pathophysiology and describe the manifestations of
Ménière's syndrome.
19. Identify individuals who are at high risk for developing the following
conditions:
i. otitis media:
ii. otitis externa:
iii. Ménière's syndrome:
16

Endocrine System Disorders

1. Match the terms with the endocrine glands depicted in the diagram.
Adrenal gland, Kidney, Ovary in female, Pancreas, Parathyroid glands
on posterior thyroid, Pineal gland, Pituitary gland, Testis in male,
Thymus, Thyroid gland
2. Define hormones and their classification; give an example of each type.
3. What is the major mechanism that controls hormone levels in the blood?
4. What are the two categories of endocrine problems?
5. What tests are commonly used to check the serum level of a hormone?

Diabetes Mellitus
6. List the predisposing factors for developing diabetes mellitus.
7. Describe the etiology of diabetes mellitus, comparing type 1 and type 2.
8. Describe the pathophysiology of type 1 and type 2 diabetes mellitus.
9. Explain why ketoacidosis develops in untreated or uncontrolled type 1
diabetes mellitus.
10. Identify the warning signs of diabetes mellitus, explaining the
pathologic basis for each manifestation.
11. How is a diagnosis of diabetes mellitus established?
12. Outline the dietary modifications that are required in the successful
treatment of diabetes mellitus.
13. How do oral hypoglycemic or antidiabetic agents lower blood sugar?
14. List the adverse effects of oral antidiabetic agents.
15. What are the differences among the various forms of insulin?
16. How is insulin administered?
17. Identify factors that could precipitate a hypoglycemic or insulin
reaction.
18. Identify measures that could minimize the chances of a diabetic
individual experiencing a hypoglycemic reaction.
19. Distinguish between microangiopathy and macroangiopathy, including
the consequences of each.
20. Explain what is meant by peripheral neuropathy caused by diabetes.
Identify the cause and complications of diabetic neuropathy.
21. Explain why individuals with diabetes are considered to be at high risk
for developing serious tissue trauma and infections.
22. Identify the types of infections that commonly occur in individuals
with poorly regulated diabetes mellitus.
23. Explain why there may be delayed healing in an individual with
diabetes mellitus.
24. What is gestational diabetes?
25. Complete the following chart comparing and contrasting the two acute
complications that may occur in an individual who has diabetes:

26. Complete the following chart comparing and contrasting type 1 and
type 2 diabetes mellitus:
Parathyroid Disorders
27. Identify the causes of hypoparathyroidism and hyperparathyroidism.
28. Identify the consequences of hypoparathyroidism.
29. Identify the consequences of hyperparathyroidism.
Acromegaly
30. State the etiology of acromegaly.
31. Outline the manifestations and complications of acromegaly.

Antidiuretic Hormone
32. Differentiate between diabetes insipidus and diabetes mellitus.

Thyroid Disorders
33. What is a goiter? State the etiology of a goiter.
34. Complete the following chart comparing and contrasting
hyperthyroidism and hypothyroidism:
Adrenal Disorders
35. Complete the following chart comparing and contrasting Cushing
syndrome and Addison disease:
36. Individuals with Cushing syndrome may be prescribed prophylactic
antibacterial drugs before invasive procedures such as dental surgery.
Explain the rationale for this.

Consolidation
37. For each of the following disorders, identify the etiology (i.e.,
hyposecretion or hypersecretion of a specific hormone):
i. Graves disease:
ii. gigantism:
iii. myxedema:
 iv. diabetes insipidus:
v. acromegaly:
vi. Cushing syndrome:
vii. dwarfism:
viii. diabetes mellitus:
ix. Addison disease:
x. cretinism:
38. For each of the following characteristics, identify the endocrine
disorder or disorders in which it occurs:
i. hyperglycemia:
ii. increased basal metabolic rate:
iii. increased susceptibility to infection:
iv. intolerance to cold:
v. development of osteoporosis or decreased bone density:
vi. mental retardation:
vii. predisposition to renal calculi:
viii. hypotension:
ix. impaired physical growth:
x. hyperpigmentation of the skin and oral mucosa:
xi. autoimmunity:
xii. development of peripheral edema:
xiii. development of exophthalmos:
xiv. bradycardia:
xv. delayed clotting:
xvi. poor healing:
xvii. poor response to stress:
xviii. development or exacerbation of hypertension:
xix. weight loss:
xx. presence of a goiter:
xxi. enlarged hands and feet:
xxii. tachycardia and palpitations:
xxiii. hyponatremia:
xxiv. hypocalcemia:
17

Digestive System Disorders

1. Match the terms with the organs/structures of the digestive system
depicted in the diagram.

Anus, Appendix, Ascending colon, Cardiac sphincter, Cecum, Common

bile duct, Descending colon, Diaphragm, Duodenal papilla,
Duodenum, Esophagus, Gallbladder, Hard palate, Ileocecal valve,
Ileum, Jejunum, Large intestine, Liver, Mouth, Oropharynx, Pancreas,
Parotid salivary gland, Pyloric sphincter, Rectum, Sigmoid colon,
Stomach, Sublingual salivary gland, Submandibular salivary gland,
Tongue, Tooth, Trachea, Transverse colon
2. Match the following definitions with the correct term:
 a. drug used to decrease nausea and vomiting i. steatorrhea
b. formation of gallstones ii. melena
c. greasy, loose stools iii. dysphagia
d. loss of appetite iv. antiemetic
e. opportunistic oral fungal infection v. anorexia
f. outpouching of the mucosa in colon vi. hematemesis
g. tarry stools caused by bleeding vii. impaction
h. difficulty swallowing viii. candidiasis
i. inflammation of tissue surrounding the teeth ix. gingivitis
j. retention of feces x. cholelithiasis
k. vomit containing blood xi. diverticulum
3. Identify six causes of vomiting, and state an example of each.
4. Outline measures that are used to decrease vomiting.
5. Identify nine causes of constipation.
6. What dietary modifications could help prevent chronic constipation?
7. Identify the causes of dysphagia depicted in the diagrams.

(Achalasia, Compression, Congenital atresia, Congenital

tracheoesophageal, Diverticulum, Fibrosis, Neurologic damage to
cranial nerves V, VII, IX, X, and XII)
 8. Describe a hiatal hernia.
9. Describe the signs and symptoms of a hiatal hernia.
10. Outline helpful measures to reduce the discomfort of hiatal hernias
by decreasing lower esophageal sphincter pressure.
11. What is GERD? Describe the etiology of GERD.
 12. What types of medications are used in the treatment of GERD?
13. Distinguish between acute gastritis and acute gastroenteritis.
14. Differentiate between acute gastritis and chronic gastritis in relation
to etiology and signs and symptoms.
15. Complete the following chart comparing and contrasting selected
types of food poisoning:

16. List and briefly describe the 5 forms of intestinal disease caused by an
E. coli infection.

Ulcers
17. State the locations where peptic ulcers occur.
18. Identify factors that contribute to the development of peptic ulcers.
19. Describe the pathophysiology of peptic ulcers.
20. Outline the potential complications that may occur with peptic
ulcers.
21. Describe the signs and symptoms of peptic ulcers.
22. Identify the treatment for simple peptic ulcers.

Cancer
23. Complete the following chart comparing and contrasting cancer of
the gastrointestinal tract and accessory organs:
Gallbladder Disease
24. Identify individuals who are considered high risk for developing
gallstones.
25. Describe the signs and symptoms of gallstones.

Liver Disease
26. State the three groups of disorders that may cause jaundice, and state
examples of each.
27. Identify causes of nonviral hepatitis.
28. Complete the following chart comparing and contrasting the most
common types of viral hepatitis:
29. Explain what is meant by the “fecal-oral” route of transmission. State
several examples of how infections can be spread this way.
30. Hepatitis D occurs only in individuals who also have hepatitis B.
Explain why.
 31. How can hepatitis D infection be detected if the individual also has
hepatitis B?
32. How is hepatitis E contracted?
33. The signs and symptoms of all types of hepatitis are remarkably
similar. What varies is the onset, severity, and duration of symptoms.
Describe the general signs and symptoms of hepatitis.
34. Explain why it is often very difficult to track infection sources for
those individuals with Hepatitis B.
35. Define cirrhosis.
36. Identify causes of cirrhosis.
37. Describe the pathophysiology of cirrhosis.
38. Identify the liver functions that are lost or impaired with cirrhosis.
39. Describe the signs and symptoms that are a consequence of the losses
identified in the previous question.
40. Explain what is meant by portal hypertension and how it develops.
41. Describe the complications that develop as a consequence of portal
hypertension.
42. Outline the interventions for cirrhosis.

Pancreatitis
43. Identify the causes of acute pancreatitis.
44. Describe the pathophysiology of acute pancreatitis.
45. Identify the signs and symptoms of pancreatitis.
46. Outline the treatment of pancreatitis.

Intestinal Disorders
47. What is celiac disease?
48. Briefly describe the pathophysiology of celiac disease.
49. What are the characteristic signs and symptoms of malabsorption
syndromes?
50. Outline the treatment of celiac disease.
51. Explain what is meant by chronic inflammatory bowel disease.
52. Complete the following chart comparing and contrasting Crohn
disease and ulcerative colitis:
53. Describe the treatment for inflammatory bowel disease.
54. Describe the pathophysiology of appendicitis.
55. Outline the signs and symptoms of acute appendicitis.
56. Briefly describe the pathophysiology and a complication of
diverticulitis.
57. List the warning signs of colorectal cancer.
58. Identify the causes of intestinal obstruction depicted in the diagrams.
 59. Outline the pathophysiology and complications of intestinal
obstruction.
60. Describe the signs and symptoms of intestinal obstruction.
61. Define peritonitis.
62. Identify the causes of peritonitis.
63. Outline the pathophysiology and complications of peritonitis.
64. Describe the signs and symptoms of peritonitis.
65. Identify the treatment of peritonitis.

Consolidation
66. Identify the classification of the following medications, and state at
least one condition for which each would be prescribed:

i. prednisone:

ii. dimenhydrinate:

iii. clarithromycin:

iv. ranitidine:

v. loperamide:

vi. psyllium:

vii. sucralfate:
18

Urinary System Disorders

1. Match the terms with the organs/structures of the urinary system
depicted in the diagram.
Adrenal gland, Aorta, Hilum, Interior vena cava, Kidney (left),
Pelvis, Penis, Prostate gland, Rectum, Renal artery, Renal vein,
Ribs, Trigone, Ureter, Ureteral opening, Urethra, Urinary
bladder

A. ____________________
B. ____________________
C. ____________________
D. ____________________
 E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
L. ____________________
M. ____________________
N. ____________________
O. ____________________
P. ____________________
Q. ____________________
2. Match the terms with the structures of a complete nephron
depicted in the diagram.
Afferent arteriole, Arcuate artery, Arcuate vein, Collecting duct,
Distal convoluted tubules, Efferent arteriole, Glomerular
capillaries, Loop of Henle, Peritubular capillaries, Proximal
convoluted tubule, Urine flow
 A. ____________________
B. ____________________
C. ____________________
D. ____________________
E. ____________________
F. ____________________
G. ____________________
H. ____________________
I. ____________________
J. ____________________
K. ____________________
3. Urine normally is clear and straw-colored with a mild odor. What
are the possible implications of the following?
i. cloudy urine:
ii. dark-colored urine:
 iii. urine with an unpleasant or unusual odor:
4. Name abnormal constituents that may be present in urine.
5. Explain the significance of diuretics, and give examples of
commonly used diuretics.
6. Explain the difference between hemodialysis and peritoneal
dialysis.
7. Identify potential complications of hemodialysis.
8. Explain why individuals receiving hemodialysis are at an
increased risk for developing HIV and hepatitis B and C.
9. Explain why individuals who require dialysis are usually required
to take prophylactic antibiotics before dental surgery or other
invasive procedures.
10. Identify factors that predispose an individual to the development
of a urinary tract infection. Explain why women are more prone to
urinary tract infections than are men.
11. Distinguish between the manifestations of cystitis and
pyelonephritis.
12. Describe the pathophysiology of glomerulonephritis.
13. Outline the signs and symptoms of glomerulonephritis.
14. Identify tests used to diagnose glomerulonephritis.
15. Outline the treatment of glomerulonephritis.
16. Describe the pathophysiology of nephrotic syndrome.
17. Identify the most significant sign of nephrotic syndrome, and
outline the potential consequences.
18. List the medications used in the treatment of nephrotic
syndrome.
19. Identify causative factors in the development of renal calculi.
20. Individuals with renal calculi are routinely instructed to strain
their urine. Explain the rationale for this procedure.
21. Identify the characteristic signs and symptoms of renal calculi.
22. Define hydronephrosis.
23. Identify causes of hydronephrosis.
24. What is a major predisposing factor for the development of
malignant tumors in the urinary system?
25. Define nephrosclerosis.
26. List the causes of nephrosclerosis.
27. Name and briefly describe some congenital disorders of the
urinary system.

Renal Failure
28. Identify causes of acute renal failure.
29. Outline the treatment of acute renal failure.
30. Identify causes of chronic renal failure.
31. Distinguish between renal insufficiency and end-stage renal
failure.
32. Describe the manifestations of end-stage renal failure under the
following headings:
i. fluid and electrolyte balance:
ii. cardiovascular system:
iii. central nervous system:
iv. musculoskeletal system:
v. endocrine system:
vi. skin and mucosa:
33. Explain why each of the following manifestations occurs in end-
stage renal failure:
 i. metabolic acidosis:
ii. hyperkalemia:
iii. hypocalcemia:
iv. increased BUN and serum creatinine:
v. anemia:
vi. delayed clotting:
vii. edema:
viii. increased blood pressure:
ix. cardiac dysrhythmias:
x. congestive heart failure:
xi. pulmonary edema:
xii. lethargy, confusion:
xiii. muscle weakness:
xiv. bone pain:
xv. amenorrhea:
xvi. severe pruritus:
xvii. ammonia odor on breath:
xviii. hypoplasia of tooth enamel:
34. Explain why individuals with renal failure have an increased
chance of having an exaggerated or prolonged response to many
medications.
35. Complete the following crossword puzzle:
Across
1. presence of pus in the urine
3. medication that promotes urination
4. sudden, extreme urge to void
9. inability to control urination
10. scanty urine output
Down
2. no urine output
3. painful urination
5. kidney stones
6. blood in the urine
7. inability to empty bladder
8. presence of nitrogenous wastes in blood
19

Reproductive System Disorders

1. Identify causes of infertility for both males and females.

Male
2. Match the terms with the organs/structures of the male reproductive
system depicted in the diagram.

Ampulla, Bulbourethral gland, Ductus deferens, Ejaculatory duct,

Epididymis, Glans penis, Membranous urethra, Parietal peritoneal
membrane, Penis, Prepuce (foreskin), Prostate gland, Prostatic
urethra, Rectum, Scrotum, Seminal vesicle, Seminiferous tubules,
Spongy urethra, Surface of urinary bladder, Testis, Ureter, Urethra,
Urinary bladder opened
A. ____________________

B. ____________________

C. ____________________

D. ____________________

E. ____________________

F. ____________________

G. ____________________

H. ____________________

I. ____________________

J. ____________________

K. ____________________

L. ____________________

M. ____________________

N. ____________________

O. ____________________

P. ____________________

Q. ____________________

R. ____________________

S. ____________________

T. ____________________

U. ____________________
 V. ____________________

3. Define the following terms:

i. hypospadias:

ii. epispadias:

iii. cryptorchidism:

iv. hydrocele:

v. spermatocele:

vi. varicocele:

4. State factors that predispose a man to the development of prostatitis.

5. What is the most common causative agent in bacterial prostatitis?
6. Outline the manifestations of prostatitis.
7. Describe benign prostatic hypertrophy.
8. Explain how benign prostatic hypertrophy could lead to cystitis and
kidney damage.
9. Identify the manifestations of benign prostatic hypertrophy.
10. What are the risk factors associated with the development of prostatic
cancer?
11. What are the warning or early signs of prostatic cancer?
12. Prostatic cancer often metastasizes. Identify common sites of
metastases.
13. What screening tools are useful in the early detection of prostatic
cancer?
14. Why are testosterone blocking agents sometimes useful in the
treatment of prostatic cancer?
15. List known risk factors for testicular cancer.
16. Describe the manifestations of testicular cancer.
17. Outline therapeutic interventions used in the treatment of testicular
cancer.

Female
18. Match the terms with the organs/structures of the female
reproductive system depicted in the diagram.

Anus, Cervix, Clitoris, Coccyx, Fallopian tube, Fimbriae, Labium

majus, Labium minus, Ovary, Peritoneal membrane, Posterior
fornix, Rectum, Symphysis pubis, Urethra, Urinary bladder,
Uterus, Vagina, Vaginal orifice

A. ____________________

B. ____________________

C. ____________________

D. ____________________

E. ____________________

F. ____________________
 G. ____________________

H. ____________________

I. ____________________

J. ____________________

K. ____________________

L. ____________________

M. ____________________

N. ____________________

O. ____________________

P. ____________________

Q. ____________________

R. ____________________

19. Define the following terms:

i. dysmenorrhea:

ii. amenorrhea:

iii. dyspareunia:

20. Match the terms with the diagrams depicting structural abnormalities
of the uterus.

Anteflexion, Cystocele, Rectocele, Retrocession, Retroflexion-flexion

posteriorly, Retroversion, Uterine prolapse
 21. Briefly list six steps in the menstrual cycle.

Endometriosis
22. Define endometriosis.
23. Describe the pathophysiology of endometriosis.
24. Identify the primary manifestation with endometriosis.
25. Outline the treatment of endometriosis.

Vaginal Candidiasis
26. Identify predisposing factors for the development of vaginal
candidiasis. Note that these are exactly the same factors that
predispose an individual to oral candidiasis.
27. Outline the manifestations of vaginal candidiasis.
Pelvic Inflammatory Disease (PID)
28. Define pelvic inflammatory disease (PID).
29. Identify predisposing factors for the development of PID.
30. Describe the pathophysiology of PID.
31. Outline the manifestations of PID.
32. Identify the potential complications of untreated PID.
33. What is the treatment for PID?

Breast Cancer
34. Identify risk factors for breast cancer.
35. Outline the development of breast cancer, including the metastatic
pattern.
36. Identify the manifestations of breast cancer.
37. Outline the therapeutic interventions used in the treatment of breast
cancer.
38. Discuss measures that can be used to detect early signs of breast
cancer.

Cervical Cancer
39. Explain why the number of deaths from cervical cancer has declined.
Why has the incidence of new cases not decreased?
40. Identify individuals who are considered at high risk for developing
cervical cancer.
41. Describe the progression of undiagnosed or untreated cervical
cancer.
42. List the signs and symptoms of cervical cancer.
43. Outline the treatment for cervical cancer.

Endometrial Cancer
44. Identify individuals who are considered at high risk for developing
endometrial cancer.
45. Describe the progression of undiagnosed or untreated endometrial
cancer.
46. List the manifestations of endometrial cancer.
47. Outline the treatment of endometrial cancer.
Sexually Transmitted Diseases (STDs)
48. Complete the following chart comparing and contrasting different
sexually transmitted diseases:
SECTION IV
Factors Contributing to Pathophysiology
OUTLINE

20 Neoplasms and Cancer

21 Congenital and Genetic Disorders
22 Complications of Pregnancy
23 Complications of Adolescence
24 Complications of Aging
20

Neoplasms and Cancer

1. Define the following terms:
i. neoplasm:
ii. benign:
iii. malignant:
iv. carcinoma:
v. sarcoma:
vi. anaplasia:
2. Name three specific pathophysiologic changes that occur in the
formation of malignant tumors.
3. Identify the correct nomenclature for both benign and malignant tumors
in the following tissues/organs:

4. Compare and contrast benign and malignant tumors using the following
chart:
5. Identify the warning signs of cancer.
6. A tumor is a space-occupying mass that produces predictable local
effects as it enlarges. Describe the consequences that could result from
the following effects:
i. compression of blood vessels:
ii. compression or obstruction of a tube or duct:
iii. compression of nerves:
iv. erosion of blood vessels and other structures:
v. invasion and replacement of normal tissue:
7. Malignant tumors also have generalized systemic effects. Outline the
factors that contribute to the development of the following systemic
manifestations:
i. weight loss and cachexia:
ii. anemia:
iii. systemic infections:
iv. bleeding:
8. Define and describe paraneoplastic syndrome.
9. Explain how the following diagnostic tools can assist in the detection
and diagnosis of cancer:
 i. blood tests:
ii. tumor markers:
iii. x-ray, ultrasound, magnetic resonance imaging (MRI), and computed
tomography (CT or CAT scan):
iv. biopsy and histologic and cytologic examinations:
10. Describe how malignant cells spread from the original tumor to distant
sites in the body. What is this called?
11. Distinguish between the grading and staging of neoplasms.
12. Differentiate between an initiating factor and a promoter in relation to
carcinogenesis.
13. Identify eight risk factors for developing cancer, and include at least
one example of each.
14. Explain why individuals who have incompetent immune systems are at
a higher risk for developing malignancies.
15. Identify the four conventional treatment measures employed in the
treatment of cancer. Why are they often used in combination rather than
singly?
16. Treatment for cancer may be curative, palliative, or prophylactic.
Explain the circumstances when each of these treatments may be used.
17. Explain how radiotherapy is effective in treating some types of cancer.
18. Identify the mechanisms of action of antineoplastic medications.
19. Identify adverse effects that commonly occur during both radiotherapy
and chemotherapy, and explain why they happen.
20. What is a biologic response modifier? How are these agents useful in
the treatment of some types of cancer?
21. Explain the three potential goals of gene therapy in the treatment of
cancer.
22. Identify other types of drugs that may be used in the treatment of
cancer, including the rationale for each.
23. What is the most common form of skin cancer?
24. Complete the following crossword puzzle:
Across
2. severe tissue wasting
4. malignant tumor arising from connective tissue
6. spread of cancer to a distant site
8. transformation of normal cells into cancer cells
9. confined to the site of origin (hyphenated)
10. degree of differentiation of malignant cells
12. cancer-causing agent
13. malignant tumor arising in epithelial tissue
14. invasion
Down
1. agents capable of causing alterations in DNA
3. failure of cells to develop specialized features
5. spread of cancer via body secretions
7. conversion of normal cells to cancerous cells
11. the study of cancer
21

Congenital and Genetic Disorders

1. Define congenital defects/anomalies.
2. Outline the etiology of chromosomal disorders.
3. Define teratogenic agents.
4. Differentiate between an inherited disorder and a chromosomal
disorder.
5. Name and briefly describe single-gene disorders.
6. Define each of the following terms:
i. monosomy:
ii. trisomy:
7. Explain what is meant by a multifactorial disorder. Identify several
examples.
8. Explain how maternal substance abuse might cause
developmental disorders, and identify the most critical time of
embryonic development for such effects.
9. Explain how a congenital disorder might occur as a result of
factors during labor and delivery.
10. What is a significant risk factor for chromosomal disorders?
11. Explain the difference between the carrier of an infectious disease
such as hepatitis B and the carrier of a genetic disorder.
12. In what type or types of inherited disorders is there a carrier
state?
13. Is the genotype of a carrier heterozygous or homozygous? Does a
carrier of a genetic disorder usually become symptomatic?
14. Let “H” represent an autosomal dominant disorder. Complete the
following Punnett square, and then answer the accompanying
questions:

i. Which parent is affected by this disorder: the father or mother?

ii. What is the probability that this couple will produce a child
with the disorder?
iii. What is the probability that this couple will produce a child
who is a carrier of the disease? Explain.
15. Let “H” represent an autosomal dominant disorder. Complete the
following Punnett square, and then answer the accompanying
questions:

i. Which parent is affected by this disorder?

ii. What is the probability that this couple will produce a child
with the disease?
16. Let “t” represent an autosomal recessive disorder. Complete the
following Punnett square, and then answer the accompanying
questions:
 i. Which parent is:
a. affected by this disorder?
b. a carrier of this disorder?
c. asymptomatic in relation to this disorder?
ii. What is the probability that this couple will produce a child:
a. with the disorder?
b. who is a carrier of the disorder?
c. who is phenotypically normal?
d. who is not a carrier?
17. Let “t” represent an autosomal recessive disorder. Complete the
following Punnett square, and then answer the accompanying
questions:

i. Which parent is:

a. affected by this disorder?
b. a carrier of this disorder?
c. asymptomatic in relation to this disorder?
ii. What is the probability that this couple will produce a child:
a. with the disorder?
 b. who is a carrier of the disorder?
c. who is phenotypically normal?
d. who is not a carrier?
18. Let “t” represent an autosomal recessive disorder. Complete the
following Punnett square, and then answer the accompanying
questions:

i. Which parent is:

a. affected by this disorder?
b. a carrier of this disorder?
c. asymptomatic in relation to this disorder?
ii. What is the probability that this couple will produce a child:
a. with the disorder?
b. who is a carrier of the disorder?
c. who is phenotypically normal?
d. who is not a carrier?
19. A newborn is diagnosed with phenylketonuria (PKU), an
autosomal recessive disorder. Neither of his parents have this
disease.
i. What is the baby's genotype?
ii. Which parent is a carrier of PKU?
iii. If this couple has a second child, what is the probability that he
or she will also have phenylketonuria?
iv. What is the probability that any of the baby's siblings will be
carriers of phenylketonuria?
20. Let “t” represent an autosomal recessive disorder. Complete the
following Punnett square, and then answer the accompanying
questions:

i. Which parent is:

a. affected by this disorder?
b. a carrier of this disorder?
c. asymptomatic in relation to this disorder?
ii. What is the probability that this couple will produce a child:
a. with the disorder?
b. who is a carrier of the disorder?
c. who is phenotypically normal?
d. who is not a carrier?
21. Sex-linked disorders are often referred to as “X-linked” because
the abnormal gene is usually carried on the X chromosome. Let
“H” represent the normal gene and “h” the abnormal one.
Complete the following Punnett squares, and then answer the
accompanying questions:
Referring to Square A:
i. Which parent is:
a. affected by this disorder?
b. a carrier of this disorder?
ii. What is the probability that this couple will produce a child
with the disorder?
iii. What would be the sex of that child?
iv. What is the probability that this couple will produce a child
who is a carrier of this disorder? What would be the sex of that
child?
v. What is the probability of producing a genotypically and
phenotypically normal:
a. son?
b. daughter?

Referring to Square B:
i. Which parent is:
a. affected by this disorder?
b. a carrier of this disorder?
c. genotypically and phenotypically normal?
ii. What is the probability that this couple's:
a. daughters will be carriers of this disorder?
b. daughters will be affected by this disorder?
 c. sons will be carriers of this disorder?
d. sons will be affected by this disorder?
22. How could a female individual have a sex-linked disorder? Draw
a Punnett square to illustrate this scenario.
23. A boy is diagnosed with Duchenne's muscular dystrophy, a sex-
linked disorder. Neither of his parents have this disease.
i. What is the child's genotype?
ii. Which parent is a carrier?
iii. If this couple has a second child, what is the probability that he
or she will also have cystic fibrosis?
iv. If the child does have a sibling with muscular dystrophy, will it
be a brother or sister? Explain.
v. What is the probability that any of the child's siblings will be
carriers of cystic fibrosis? Will the carriers be male or female?
Explain.
24. List the genetic disorders under the appropriate classification.
i. fragile X syndrome
ii. cystic fibrosis
iii. adult polycystic kidney disease
iv. familial hypercholesterolemia
v. Duchenne muscular dystrophy
vi. sickle cell anemia
vii. hemophilia A
viii. Klinefelter syndrome
ix. phenylketonuria
x. Huntington disease
xi. Tay-Sachs disease
xii. schizophrenia
xiii. cleft lip and palate
xiv. Turner syndrome
 Chromosomal Autosomal Autosomal X-linked X-linked multifactorial
dominant recessive dominant recessive

25. What type of disorder is Down syndrome? How can it be

diagnosed prenatally? What is the karyotype of an individual with
Down syndrome?
26. Outline the abnormalities or problems associated with Down
syndrome.
27. Describe the characteristic appearance of an individual with
Down syndrome.
22

Complications of Pregnancy
1. Which time during a pregnancy is referred to as the embryonic
stage? At what time during the pregnancy is the term fetus used?
During what period does organogenesis occur?
2. Discuss the risk to a developing fetus if the mother smokes during
the pregnancy.
3. What is the hormone (substance) used as the basis for laboratory
diagnosis of pregnancy, and how accurate is the test in each of the
trimesters?
4. Match the following definitions with the correct terms:

a. milk production i. gestation

b. pregnancy ii. gravidity
c. inflammation of uterine lining iii. parity
d. number of pregnancies iv. lactation
e. number of viable pregnancies v. endometritis

5. Briefly describe the following complications of pregnancy:

i. ectopic pregnancy
ii. preeclampsia and eclampsia
iii. gestational diabetes mellitus
iv. placenta previa
v. abruptio placentae
vi. thromboembolism and thrombophlebitis
vii. disseminated intravascular coagulation (DIC)
viii. Rh incompatibility
ix. infections
x. adolescent pregnancy
6. Explain why Rh incompatibility occurs. Describe the
manifestations and complications of Rh incompatibility.
7. What is RhoGAM? Explain how its administration prevents Rh
incompatibility.
8. Name and explain risks that can occur during adolescent
pregnancies.
23

Complications of Adolescence
1. Define the period of adolescence.
2. Using the body mass index (BMI) charts inside the back cover of the text,
calculate the BMI for the individuals listed in the following chart. In
addition, determine if the BMI of the individual is normal (N),
overweight (Ov), or obese (Ob).

3. Name the pathophysiologic problems associated with obesity in children

and teens.
4. Name the three factors that are common in definitions for metabolic
syndrome.
5. Match the following definitions with the correct terms:
 a. condition characterized by alternating “binge and purge” i. osteoporosis
behavior
b. extreme weight loss caused by self-starvation ii. osteomyelitis
c. demineralization of bone iii. anorexia
nervosa
d. bone infection iv. bulimia nervosa

6. Match terms with abnormal curvature of the spine depicted in the

diagrams.
Kyphosis, Lordosis, Scoliosis

From Patton KT, Thibodeau GA. Anatomy & Physiology. 8th ed. St. Louis:
Mosby; 2013.

7. Identify risk factors for the development of osteomyelitis.

8. Outline the pathophysiology of osteomyelitis.
9. Juvenile rheumatoid arthritis (JRA), an autoimmune disease, is
somewhat similar in pathology to adult rheumatoid arthritis. What are
the distinctive characteristics of JRA?
10. Distinguish between anorexia nervosa and bulimia nervosa.
11. What two organisms are most often associated with acne vulgaris?
12. What is the causative agent of mononucleosis?
13. List the manifestations and potential complications of mononucleosis.
14. Which chromosomal disorder in females is caused by lack of an X
chromosome, and how does this affect sexual development?
15. What is the definition of dysmenorrhea?
24

Complications of Aging
1. Several different theories of aging are discussed in the
literature, and most likely many factors contribute to the aging
process. Name three theories/factors discussed in the text.
2. Describe the effects of aging on the following body systems:

i. Endocrine:

ii. Reproductive, both female and male:

iii. Skin and mucosa:

iv. Cardiovascular:

v. Musculoskeletal:

vi. Respiratory:

vii. Nervous:

viii. Gastrointestinal:

ix. Urinary:

3. Explain why elderly individuals are at a higher risk for both

infections and cancer than are younger individuals.
4. Match the following definitions with the correct terms:
a. inability to control urination i. atherosclerosis
b. farsightedness ii. cataract
c. predetermined cell death iii. apoptosis
d. excessive urination at night iv. glaucoma
e. opacity of the ocular lens v. incontinence
f. deposition of fat in arterial walls vi. nocturia
g. dry mouth vii. presbyopia
h. increased intraocular pressure viii. xerostomia
SECTION V
Environmental Factors and Pathophysiology
OUTLINE

25 Immobility and Associated Problems

26 Stress and Associated Problems
27 Substance Abuse and Associated Problems
28 Environmental Hazards and Associated Problems
25

Immobility and Associated Problems

1. Summarize the effects of immobility throughout the body systems.
2. Match the following definitions with the correct terms:

a. stationary blood clot i. atelectasis

b. collapse of lung tissue ii. contracture
c. sudden drop in blood pressure when change in position iii. decubitus ulcer
occurs
d. breakaway thrombus iv. embolus
e. pressure sore or bedsore v. hemiplegia
f. paralysis below the waist vi. orthostatic
hypotension
g. joint deformity caused by excessive scarring vii. paraplegia
h. paralysis of one side of the body viii. thrombus
i. loss of bone mass ix. flaccidity
j. loss of muscle tone x. osteoporosis

3. Name two classes of drugs that may lead to slowed, shallow

respiration, especially in immobilized individuals.
26

Stress and Associated Problems

1. Define the term stressor.
2. Each individual may perceive stress differently. Some factors
can occur that may interfere with an individual's ability to
respond adequately to a stressor. Name two of these.
3. Identify the hormones that are secreted during stress, including
the source and effects of each.
4. Summarize the effects of the sympathetic nervous system
during stress.
5. Explain why prolonged stress, such as that associated with
divorce or professional difficulties, can be detrimental to health.
6. Name three strategies/support systems that may play a role in
minimizing the risk for development of stress-related
pathologies.
27

Substance Abuse and Associated Problems

1. What is the basic difference between the terms physiologic
dependence, psychological dependence, and addiction?
2. According to present theories, what are the five causes of
substance abuse?
3. Describe the three stages of liver damage that may be caused by
excessive alcohol intake (Laënnec's cirrhosis).
4. Name medications used to treat heroin addiction and alcohol
addiction.
5. Match each of the following street drug names with the drug
clinical name.

a. Speed i. methamphetamine
b. Ecstasy ii. phencyclidine
c. Blow iii. nicotine
d. Angel dust iv. amphetamines
e. Ice v. MDMA
f. Snow vi. marijuana
g. Special K vii. cocaine
h. Weed viii. heroin
28

Environmental Hazards and Associated

Problems
1. Identify three ways that chemicals can damage cells in the body.
2. List four toxic effects of the heavy metal, lead.
3. What are the two classifications of inhalants? Give an example
of each.
4. What is hyperthermia? List three syndromes associated with
hyperthermia.
5. Describe some of the differences between local and systemic
hypothermia.
6. What types of body cells does radiation primarily affect?
7. List three ways in which a bite or sting may cause disease.
Answer Key

Chapter 1
Introduction to Pathophysiology
1. (p. 6) acute disease: a short-term illness that develops quickly;
chronic disease: a milder condition that develops gradually but
persists for a long time and usually causes more permanent tissue
damage
2. (p. 7) epidemic: higher than expected number of cases of an
infectious disease within a given area; pandemic: higher number of
cases in many regions of the globe
3. (pp. 8–9)
i. atrophy
ii. hyperplasia
iii. hypertrophy
iv. neoplasia
v. neoplasia
vi. atrophy
vii. atrophy
viii. metaplasia
ix. dysplasia
x. hyperplasia
xi. metaplasia; dysplasia; neoplasia
xii. hyperplasia
xiii. hypertrophy
xiv. hyperplasia
 xv. atrophy
xvi. hyperplasia
4. (pp. 8–9) dysplasia; may be the forerunner of neoplasia
5. (p. 9) failure of cells to differentiate or develop specialized features;
term applied to grading malignant tumors
6. (p. 9)
i. ischemia
ii. physical agents (e.g., excessive temperature, radiation)
iii. mechanical damage
iv. chemical toxins or foreign substances
v. pathogens
vi. abnormal metabolites
vii. nutritional deficits
viii. fluid or electrolyte imbalances
7. answer to crossword puzzle (see next page)
8. a. atrophy
b. normal cells
c. hyperplasia
d. neoplasia (malignancy)
e. dysplasia
f. metaplasia
g. hypertrophy
Chapter 2
Fluid, Electrolyte, and Acid-Base Imbalances
Edema
1. (p. 17) excess fluid in the interstitial compartment
2. (Fig. 2.2, pp. 17–18)
i. increased capillary hydrostatic pressure, forcing excessive
amounts of fluid out and preventing return of fluid from the
 interstitial compartment
ii. loss of plasma proteins, reducing plasma osmotic pressure
iii. obstruction of lymphatic circulation, restricting the return of
excess fluid and protein to the general circulation
iv. increased capillary permeability—as in inflammation, resulting
in fluid and protein movement into the interstitial compartment
3. (pp. 18–20)
i. obstruction of lymphatic circulation due to removal of lymphatic
vessels; increased capillary permeability, and increased capillary
hydrostatic pressure immediately following surgery
ii. loss of plasma proteins due to decreased production of plasma
proteins
iii. increased capillary hydrostatic pressure and increased capillary
permeability
iv. increased capillary hydrostatic pressure caused by/due to
increased blood volume; possibly caused by/due to decreased
capillary osmotic pressure due to protein-wasting kidney
disease
v. increased capillary hydrostatic pressure caused by/due to the
effects of gravity
vi. increased capillary hydrostatic pressure and increased capillary
permeability caused by/due to inflammation
vii. obstruction of lymphatic circulation or increased capillary
hydrostatic pressure if blood vessels are compressed
viii. increased capillary permeability and loss of plasma proteins
ix. increased capillary hydrostatic pressure caused by/due to
increased water retention
x. loss of plasma proteins caused by/due to decreased synthesis of
plasma proteins
xi. increased capillary hydrostatic pressure
xii. increased capillary hydrostatic pressure and increased capillary
permeability caused by/due to inflammation
4. (Table 2.3, pp. 19–20) local swelling; pale, gray, or red skin color;
pitting edema; slow, bounding pulse with high blood pressure;
lethargy, possible seizures; pulmonary congestion, cough, rales;
weight gain; functional impairment of joints or movement of
organs such as the heart and lungs; pain; impairment of arterial
circulation; tissue breakdown from pressure, abrasion, and
external chemicals; infection of gingival tissue

Dehydration
5. (p. 21) vomiting, diarrhea, excessive sweating, diabetic
ketoacidosis, insufficient water intake, drainage or suction, use of
concentrated infant formula
6. (Table 2.3, p. 21) Signs and symptoms include sunken, soft eyes;
decreased skin turgor; thirst, weight loss; rapid, weak pulse and
low blood pressure; fatigue, weakness, dizziness, and possible
stupor; and increased body temperature. The most serious
problems are decreased blood pressure and potential shock.
7. (p. 21) increasing thirst, falling blood pressure, increasing heart
rate, constricting cutaneous blood vessels, and decreasing urinary
output

Electrolyte Imbalances
8. (pp. 21–29)
i. hyponatremia, hyperkalemia, hypocalcemia, hypermagnesemia,
hyperphosphatemia
ii. hyponatremia, hypochloremia
iii. hypernatremia, hyperchloremia
iv. hypernatremia, hypokalemia, hyperchloremia
v. hypercalcemia, hypophosphatemia, hypomagnesemia
vi. hyponatremia, hypochloremia
vii. hypercalcemia
viii. hyponatremia, hypokalemia, hypomagnesemia (with
potassium-sparing diuretics: hyperkalemia)
 ix. hyponatremia, hyperkalemia, hypochloremia
x. hypocalcemia
xi. hypercalcemia
xii. hyponatremia, hypokalemia, hypophosphatemia
9. (p. 27) skeletal muscle spasm due to hypocalcemia
10. (Table 2.6, p. 26) hypokalemia and hyperkalemia; (Table 2.7, p. 27)
hypocalcemia and hypercalcemia
11. (Table 2.7, p. 27) hypercalcemia

Acid-Base Imbalances
12. (p. 29) Normal serum pH range is 7.35 to 7.45; pH less than 6.8
and greater than 7.8 usually results in death.
13. (p. 30) 20 : 1
14. (p. 30) sodium bicarbonate–carbonic acid system; phosphate
system; hemoglobin system; protein system
15. (Table 2.9, p. 30) The imbalance is metabolic acidosis. The
individual would experience the following manifestations: rapid,
deep respirations; lethargy, weakness, confusion; coma; and
decreased pH of urine.
16. (Table 2.9, pp. 32–33, and Fig. 2.12)
i. respiratory acidosis—more acidic urine
ii. metabolic alkalosis—slow, shallow respirations and increased
pH of urine
iii. respiratory acidosis—more acidic urine
iv. metabolic acidosis—increased renal excretion of acids and
conservation of bicarbonate
v. respiratory alkalosis—less acidic urine
vi. respiratory acidosis—more acidic urine and increased rate and
depth of respiration (if possible)
 vii. metabolic acidosis—increased rate and depth of respirations,
more acidic urine
viii. metabolic acidosis—increased rate and depth of respiration

Chapter 3
Introduction to Basic Pharmacology and Other Common
Therapies
1. (p. 42) Dose is the amount of drug administered at a single time,
dosage is the total amount of the drug given over a period of time.
2. (p. 41) Therapeutic effect is the desired action; adverse (severe) or
side (mild) effects are the unwanted or undesirable effects.
3. (p. 46) hypersensitivity (allergic reactions; see Chapter 7, Type I
allergic reactions); idiosyncratic reactions: unexpected or unusual
responses to drugs; iatrogenic reactions: negative effect due to
medication error, drug overdose, unusual response;
teratogenic/harmful effects on the fetus; drug interactions: effect of
drug is modified when combined with another drug, food, herbal
compounds, or other materials
4. (pp. 43–44, Table 3.1)
i. applied to the skin or mucous membranes (e.g., steroid cream,
local anesthetics, antimicrobials, eye drops)
ii. patch applied to the skin for absorption into the blood (e.g.,
long-term continuous administration of nitroglycerin, nicotine
patch, scopolamine patch, estradiol)
iii. by mouth (e.g., aspirin, vitamins, cough syrup, antibiotics)
iv. under the tongue (e.g., nitroglycerin, loperamide, testosterone)
v. injection beneath the epidermis and dermis, into the
subcutaneous layer of the skin (e.g., insulin, heparin, interferon)
vi. injection into the muscle (e.g., penicillin, meperidine, tetanus
and diphtheria toxoid, vitamin B12)
 vii. injection into a vein, into the bloodstream (e.g., general
anesthetic like sodium pentothal, morphine, diazepam,
vincristine)
viii. into the respiratory tract (e.g., bronchodilator medication,
glucocorticoid inhaler, anesthetics such as nitrous oxide)
5. (pp. 42–44, Table 3.1) topical
6. (p. 44, Table 3.1)
 Onset of
Advantages Disadvantages
Action
Topical Rapid Easy to apply Can be messy, smelly,
or unpleasant
Transdermal Rapid; long- Easy to apply for Action may continue
term, long-term, after desired effect
continuous continuous achieved
administration
Oral Long time to Tablets, capsules, Taste and swallowing
onset (30–60 stable, variable cost problems; gastric
min) but relatively irritation; uncertain
inexpensive; self- absorption due to food
administered interactions
Sublingual Immediate Rapid and Tablets are soft and
prolonged effect; can unstable over time
be administered to
unconscious patient
Subcutaneous Slow Simplest injection; Requires training,
absorption; only small doses asepsis, and equipment;
some drug may be given may be irritating
loss
Intramuscular Good Rapid, prolonged Requires training,
absorption effect; can be used asepsis, and equipment;
into blood, when patient short shelf-life; some
sometimes lag unconscious or injection discomfort
and drug loss nauseated
Intravenous Immediate Immediate effect; Costly; injection skill
and no drug predictable drug required; drug irritation
loss levels; can be used at IV site
when patient
unconscious
Inhalation Rapid; little Local effect or Requires training in
drug loss absorbed into effective technique
alveolar capillaries;
rapid; good for
anesthesia

7. (p. 44, Table 3.1)

intravenous
sublingual
 g
inhalation and topical
subcutaneous
intramuscular
oral
8. (pp. 42–44, Fig. 3.2) Once in the bloodstream, drugs are transported
by the circulating blood through various pathways, branching off
into different organs or tissues. Depending on the specific
characteristics of a drug, some may be lost temporarily in storage
areas such as fatty tissue (e.g., anesthetics) or may be quickly
metabolized. Eventually, the drug reaches the target organ or
tissue, moves into the interstitial fluid, and exerts its effect. Most
drugs are gradually metabolized and inactivated in the liver and
then excreted in the kidneys—a few in the bile or feces.
9. (p. 44, Fig. 3.3) Drugs interact with natural specific tissue receptors
and act by either (a) stimulating the receptors, increasing biologic
activity; or (b) blocking the receptor sites, decreasing activity.
10. (pp. 44–45) Drugs are removed from the circulation in the liver,
where they are absorbed by the cells whose various metabolic
pathways catabolize them.
11. (p. 45) by the kidneys
12. (p. 46) Disease of the liver could impair or slow drug metabolism;
therefore, the drug is active longer. This prolongs the drug's
effects. If the individual is taking the drug regularly, blood levels
will gradually increase, possibly resulting in toxic effects. Liver
disease may result in decreased production of plasma proteins.
This results in decreased protein binding, resulting in increased
free drug in circulation and therefore increased drug effects.
Kidney disease may interfere with drug excretion—the drug and
its metabolites could accumulate, resulting in increased and
prolonged drug effects.
13. Inhalation anesthetics are generally excreted via the lungs; it
would be difficult to predict the individual's response. There
would be problems assessing both the dosage and the rate of drug
 removal. Intravenous anesthetics depress the respiratory center.
This could cause additional hypoxia and increase the risk for
developing acidosis.
14. i. (p. 42) newborns and babies: immature liver and drug effects
more difficult to predict; also have much smaller body mass;
elderly: may have diseases that interfere with drug metabolism
and excretion; also more likely to be taking more than one
medication, increasing the possibility of drug interactions
ii. Smaller individuals require less medication—for children,
generally the dosage is calculated according to body weight. (p.
42)
iii. Pregnant women should avoid drug usage whenever possible
because many drugs cross the placenta and may cause
teratogenic effects. (p. 42)
Breastfeeding women should also avoid drug use because many
drugs are excreted, to some degree, in milk and can affect the
child.
Gender differences—metabolism, percentage body fat,
percentage body fluids
iv. If an individual believes a drug is going to be effective, this will
likely have a positive effect; the converse is true.
positive suggestion or reinforcement therefore often useful
“placebo” effect (p. 47)
v. Heart disease may impair circulation, resulting in decreased
distribution, metabolism, and excretion of drugs.
Liver disease could impair or slow drug metabolism. Therefore,
the drug is active longer—this prolongs the drug's effects. If
the individual is taking the drug regularly, blood levels will
gradually increase, possibly resulting in toxic effects.
Liver disease may result in decreased production of plasma
proteins. This results in decreased protein binding, resulting
in increased free drug in circulation and therefore increased
drug effects.
 Kidney disease may interfere with drug excretion. Therefore, the
drug and its metabolites could accumulate, resulting in
increased and prolonged drug effects.
vi. (p. 42) Some medications should be taken with food, whereas
others must be taken on an empty stomach to prevent food
interactions. Therefore, it is important to always confirm with a
pharmacist, nurse, or physician.
Certain drugs should not be taken at bedtime, e.g., diuretics
(water pills, stimulants).
Antibiotics should be evenly spaced throughout the day.
vii. (p. 44, Table 3.1) determines onset of action; also determines
whether there may be drug destruction (e.g., oral route—drug
may be destroyed by gastric pH or by food)
viii. (pp. 42–44) Generally, the higher the dosage is, the greater the
therapeutic effect will be. Unfortunately, as dosage increases, so
do the incidence and severity of adverse and even toxic effects.
ix. (p. 44, Table 3.1) This will determine onset and duration of
action (e.g., liquids are absorbed faster than pills; enteric coating
delays onset and may prolong duration of action).
x. (p. 44) Is the patient taking the drug at the prescribed times, with
or without food?
xi. A quiet, stress-free environment enhances the effectiveness of
analgesics by helping the individual relax.
If someone has just vomited, removing the emesis and opening
the window to improve ventilation will enhance the
effectiveness of the antiemetic.
xii. (p. 42) These may enhance or decrease drug action (e.g.,
ingestion of alcohol potentiates narcotics, hypnotics, and
sedatives, and caffeine antagonizes hypnotics and sedatives.
15. (pp. 41–42, 47)
i. allergic, immunologic reaction (e.g., penicillin allergy)
ii. unexpected or unusual responses to drugs (e.g., excessive
excitement after administration of a sedative)
 iii. in which one drug enhances the action of another (e.g.,
epinephrine enhances the effects of local anesthetic without
increasing the dose)
iv. the effect of a combination of drugs is much greater than
expected (e.g., combination of drugs to treat pain)
v. the effects of a combination of drugs are greatly decreased (e.g.,
antidotes for poisoning)
vi. when the body adapts to a drug, over time, resulting in a higher
dosage to achieve the desired effect (Chapter 27, e.g., use of
narcotic analgesia)
vii. therapeutic effects after administration of a substance that does
not have the pharmacologic effects of the drug being studied (p.
47) (e.g., use in research study)
16. (p. 46) Generic names are unique, official, simple names for
specific drugs; chemical names reflect the often-complex chemical
structure of the drug.
17. (pp. 48–49)
i. individualized treatment and rehabilitation to restore function as
well as reduce pain, involving various modalities including
exercises, ultrasound, and transcutaneous electrical nerve
stimulation (TENS)
ii. assessment and treatment of communication or swallowing
disorders
iii. functional assessment and treatments to restore activities of
daily living (ADLs)
iv. use of plant, animal, and mineral products to stimulate the
immune system and natural healing power of the body
v. medical practice using surgery and drugs in addition to
manipulations of the musculoskeletal system to promote healing
vi. use of essential oils from plants that have therapeutic effects
when applied topically or inhaled
vii. therapy that frequently involves manipulation of the vertebral
column—no drugs or surgery
 viii. use of techniques to increase circulation, reduce pain, increase
flexibility, and reduce muscle spasm
18. (p. 50) Acupuncture involves the use of needles inserted into
acupoints on the body; it is designed to balance the life energy in
the body. Imbalances of these life energies are thought to be
responsible for disease. Shiatsu is a massage therapy designed to
apply pressure to acupoints, rather than inserting needles into
acupoints, in an effort to bring balance to the life energies. Yoga
involves the combining of physical activity in the form of
stretching postures with meditation to improve the flow of life
energy throughout the body.
19. (p. 47) U.S. Food and Drug Administration

Chapter 4
Pain
1. (pp. 53–54) inflammation, infection, ischemia, tissue necrosis,
stretching of tissue, chemicals, burns
2. (p. 54) Somatic pain arises from skin or deeper structures (i.e., bone
or muscle); visceral pain originates in the organs.
3. (p. 54) Bradykinin, histamine, prostaglandin
4. (Fig. 4.1; p. 54)
• Stimulation of pain receptors (nociceptors) by thermal, chemical,
or physical stimuli
• If the stimulus exceeds the threshold of the receptors, the
associated nerve fibers transmit a “pain” signal to the spinal
cord and brain.
• Myelinated A delta fibers (acute pain) or unmyelinated C fibers
(chronic pain) transmit the afferent pain impulse to the dorsal
root ganglia and then to the spinal cord.
• Sensory impulse reaches the spinal cord synapse and from there
crosses over to the opposite spinothalamic tract
(neospinothalamic tract for acute sharp pain;
 paleospinothalamic tract for chronic or dull pain). Reflex
response to sudden pain at the spinal cord level results in
involuntary muscle contraction to move the body part away
from the source of pain.
• The impulse moves up the lateral spinothalamic tract to the
reticular formation (influencing brain awareness) in the
brainstem, the hypothalamus (stress response), the thalamus,
and other structures (limbic system; emotional response) as they
ascend to the somatic sensory area of the cerebral cortex and the
parietal lobe of the brain, where the location and character of the
pain are perceived.
5. (pp. 54–57, Fig. 4.2) Endorphins (enkephalins, dynorphin, beta-
lipotropins) are released by interneurons of the spinal cord; they
then attach to opiate receptors and block the release of substance P.
6. (p. 57, Fig. 4.3) Referred pain occurs when pain is perceived at a
site distant from the source. It is due to multiple sensory fibers
from different sources connecting at a single level of the spinal
cord, making it difficult for the brain to discern the actual origin of
the pain. An example is the pain of a heart attack, which is
experienced in the left neck and/or arm. Pain in the shoulder may
also occur.
7. (p. 59) Acute pain is generally sudden, severe, and short term.
Chronic (long-term) pain is more difficult to treat, and prognosis
may be less certain.
8. (pp. 61–63, Tables 4.2 and 4.3) Pain can be managed in a number of
ways. The most common method of management is use of
analgesic medications to relieve pain. Sedatives and antianxiety
drugs are often used to promote rest and relaxation. Using them in
conjunction with analgesics may reduce the dosage of pain
medication required. Severe pain may be self-managed by the
patient through use of patient-controlled analgesia (PCA). A small
pump attached to a vascular access site allows the patient to
medicate as needed and reduces the overall amount of narcotic
needed. Other methods for managing pain include stress reduction
 and relaxation, distractors, heat and cold applications, massage,
physiotherapy, exercise, therapeutic touch, hypnosis imaging, and
acupuncture, which may modify the brain's pain perception and
response. Finally, surgical intervention may be necessary to sever
the sensory nerve pathway. Injections may be used to achieve
similar effects.
9. (pp. 58–59) age, culture, family traditions, and prior experience
10. (Table 4.2, p. 62)

Non-Narcotic Analgesics Narcotic Analgesics

Action Decrease pain at peripheral 1. Codeine and oxycodone: act on
site; all are antipyretic; ASA opiate receptors in the CNS and
affect pain perception
and NSAIDs are also
2. Morphine and meperidine: act on
antiinflammatory
CNS, producing euphoria and
sedation; block pain pathways in
the spinal cord and brain
Adverse Nausea, gastric ulcers, 1. Nausea, constipation, and, at higher
effects bleeding, allergies doses, respiratory depression
2. Addiction
Uses For mild pain, especially 1. Moderate pain
when inflammation is present 2. Severe pain
Examples Tylenol, ibuprofen, naproxen, 1. Codeine, alone or in combination
aspirin with acetaminophen); oxycodone
2. Morphine; meperidine
ASA, acetylsalicylic acid (aspirin); CNS, central nervous system; NSAIDs, nonsteroidal
antiinflammatory drugs.

11. (pp. 62–63, Table 4.3)

Local anesthesia: injected or topical; lidocaine, blocks nerve
conduction; removal of skin lesion, tooth extraction
Spinal or regional anesthesia: local anesthetic into subarachnoid or
epidural space; blocks nerve conduction (sensation) below the
level of injection; labor and delivery
General anesthesia: intravenous (thiopental) or inhalation (nitrous
oxide); loss of consciousness; general surgery
12. (pp. 54–55) myelinated A delta fibers: fibers are wrapped in
myelin sheath and transmit impulses very rapidly. Associated
with the acute pain.
Unmyelinated C fibers: no myelin sheath, transmit impulses slowly.
Associated with chronic pain.

Chapter 5
Inflammation and Healing
1. (p. 66) mechanical barrier such as intact skin and mucous
membrane
2. (pp. 66–67) second: processes of phagocytosis and inflammation;
third: the immune system response
3. (p. 67) The immune system is the specific defense mechanism of
the body. It provides protection by stimulating a unique response
following exposure to foreign substances. (review of the immune
system in Chapter 7)
4. (p. 67 and Fig. 5.2) process by which neutrophils, monocytes, and
macrophages engulf and destroy bacteria, cellular debris, or
foreign material
5. (p. 67) Inflammation is the body's nonspecific response to injury
that involves increased blood flow to the area to localize and
remove an injurious agent. Inflammation can cause redness,
swelling, warmth, and pain; loss of function is also possible. It may
be caused by direct physical damage such as cuts or sprains,
caustic chemicals such as acids or drain cleaners, ischemia or
infarction, allergic reactions, extremes of heat or cold, foreign
bodies such as splinters or glass, and infection.
6. (p. 69) The two main events are vasodilation, and increased
capillary permeability in response to a chemical mediator (e.g.,
histamine, serotonin) released at the site of injury. This allows for
the accumulation in the area of fluid (to dilute any toxic
substances) and specific plasma proteins such as globulins or
 antibodies (to react with specific antigens) and fibrinogen (to form
a fibrin mesh to localize the problem).
7. (p. 70)
• Redness (rubor or erythema)
• Due to increased blood flow to the damaged area
• Heat
• Also due to increased blood flow
• Swelling (edema)
• Caused by the shift of protein and fluid into the interstitial
space
• Pain
• Due to increased pressureof fluid on the nerves
8. (pp. 69–70) Events of the cellular response:
• chemotaxis
• margination
• emigration (diapedesis)
• phagocytosis and subsequent release of lysosomal enzymes
9. (Table 5.2, p. 70)
a. vii
b. iii
c. ii, v
d. i
e. vii and viii
f. vi
g. vi
h. i, iv, vi
10. (p. 71) fever due to the release of pyrogens by leukocytes and
macrophages; malaise, fatigue, headache, and anorexia
11. (p. 72) infection in inflamed tissue, deep ulcers (from severe or
prolonged inflammation), skeletal muscle spasms or strong muscle
contractions, local complications such as tissue destruction and
scarring, immobility due to pain or edema (edema compresses
organs such as blood vessels and airways)
12. (pp. 67–77 and Fig. 5.5)

Characteristic Acute Inflammation Chronic Inflammation

Causative Direct damage (trauma) When the cause persists
agents Chemicals and is not removed or
Ischemia eradicated
Cell necrosis or infarction
Allergic reactions
Physical agents (burns)
Foreign bodies (splinters or
dirt)
Infection
Signs and Immediate or occurring within Delayed and prolonged
symptoms a few hours (e.g., sunburn) over a significant period of
Severity varies with the time. May be intermittent
situation or cause Severity varies depending
on the cause and
pathophysiology and
duration
Cells Neutrophils and macrophages; Lymphocytes,
involved lymphocytes if an immune macrophages, fibroblasts
response is involved
Treatment Acetaminophen, glucocorticoids Acetaminophen, NSAIDs
and NSAIDs, RICE (rest, ice, and ACTH, exercise,
compression, elevation) physiotherapy and pain
modification
Results Healing unless it becomes Scarring and/or granuloma
chronic due to persistence of Tissue breakdown may
causative agent; regeneration or occur with bleeding and
resolution loss of function

13. (p. 75)

 R = Rest allows time for healing, minimizing further pain and
irritation to the injured area.
I = Early application of cold causes vasoconstriction, decreasing
pain and edema.
C = Compression reduces edema and pain by activating alternate
sensory pathways.
E = Elevation improves fluid flow away from the damaged area.
14. (pp. 74–75) NSAIDs are analgesic and antipyretic. They may
cause allergic reactions, slow blood clotting, and cause nausea
and/or stomach ulceration. Steroids decrease immune responses
and increase the risk for infection, hypertension, and edema. They
may also cause osteoporosis and skeletal muscle wasting.
15. (p. 74) NSAIDs are antiinflammatory. They may cause allergic
reactions and slow blood clotting. Acetaminophen has no
antiinflammatory action. Overuse at higher dosages than
recommended may cause kidney and liver damage.
16. (pp. 75–76) heat, physiotherapy, adequate nutrition and
hydration, mild to moderate exercise, elastic stockings to reduce
fluid accumulation
17. (p. 75) Resolution occurs when there is minimal tissue damage,
the damage is repaired, and cells recover and resume normal
function in a short time. Regeneration is the healing process that
occurs in tissues whose cells are capable of mitosis (e.g., epithelial
cells of the skin, gastrointestinal tract). The damaged cells are
replaced by the proliferation of nearby undamaged cells.
18. (pp. 76–77, Boxes 5.1 and 5.2)
i. Inoperable bullet wound to the brain may be inaccessible without
further tissue damage and loss of function.
ii. Malnutrition, especially deficiencies in vitamins such as C, E,
and K, would impair the blood-clotting capability of the
individual, impairing wound closure and delaying repair of
damaged tissues.
 iii. Large, deep cuts, for example, especially if untreated, or
presenting difficult suture closure would facilitate extensive scar
formation (e.g., cuts due to broken glass or power tools).
iv. Anticlotting medications would limit or impair clotting and
hence wound closure (e.g., aspirin and other blood-thinning
drugs prior to surgery).
v. Nutritional status is often inadequate in the very old, and the
aging process itself slows down normal healing responses at
many levels.
vi. Foreign bodies, if not removed, impair wound closure and
promote scarring as well as predispose to infection (e.g., a large
splinter).
vii. If the blood supply is limited or is absent from the damaged
tissue, then most of the cellular and blood factors necessary for
healing will not reach the affected area.
viii. Infection requires its own cure, before healing can occur;
removal of the infectious agent, if impaired or delayed, would
prolong the healing process, leading to more extensive scarring
and, if untreated, perhaps systemic infection. A puncture
wound, like a rusty nail, could bring infection to the damaged
tissue. Another example is a bite from a rabid animal.
ix. Broken bones, if not immobilized, do not heal properly. (See
Chapter 9 for further discussion on fracture healing.)
x. Disease, if chronic and with systemic effects, could impair
immune and other normal healing tissue responses. Diabetes,
for example, may result in impaired circulation to the damaged
area.
19. (p. 78) loss of function; contractures and obstructions; adhesions;
hypertrophic scar tissue; ulceration
20. (pp. 79–80; Figs. 5.10, 5.11, and 5.12)
i. Partial-thickness burns involve the epidermis and part of the
dermis; deep partial-thickness burns involve destruction of the
epidermis and part of the dermis; full-thickness burns result in
 destruction of all skin layers and often underlying subcutaneous
tissues as well.
ii. The percentage of body surface area (BSA) burned uses the “rule
of nines” for calculation to determine extent of injury and fluid
replacement needs.
21. (p. 79) Nerves in the burned area have been destroyed.
22. (pp. 82–83) shock, respiratory problems, pain, infection
23. (p. 83) excision/removal of damaged tissue, antibiotics, covering
of wound
24. See Fig. 5.12, p. 82 Assessment of burn area using the rule of nines
Total head: 9%
Two arms: 18%
Trunk: 36%
Perineum: 1%
Two legs: 36%
25. (p. 83) There is an ongoing need to produce more body heat and
replace damaged/destroyed tissue (especially the skin and
erythrocytes), which means higher nutrient demands.

Chapter 6
Infection
1. (p. 90) Growth factors such as pH, temperature, carbohydrates,
and oxygen requirements can determine the site of infection.
Example: Clostridium tetani is anaerobic and therefore favors deep
tissue infections.
2. (Chapter 5, Chapter 6, p. 100) Inflammation is a normal body
response to anything that results in tissue damage. Infection is
when microorganisms reproduce in or on body tissues.

Bacteria
3. (p. 89, Fig. 6.1): A: coccus, B: bacillus, C: Vibrio, D: spirilla, E:
pleiomorphic, F: spirochete, G: diplo-, H: staph(ylo)-, I: strep(to)-, J:
palisade, K: tetrad
4. (pp. 89–90, Fig. 6.3): The basic structure of a bacterium consists of
an outer rigid cell wall, a cell membrane, a DNA strand, and
cytoplasm. In addition, some species contain an external capsule or
slime layer, specialized structures such as flagella, and pili or
fimbriae.
5. (pp. 90–91) Gram-positive bacteria have a thick peptidoglycan
layer in the cell wall, and they stain purple with the standard
Gram stain process. Gram-negative bacteria have a very thin
peptidoglycan layer, and they stain red/pink in the Gram stain
process.
6. (p. 91) Exotoxins are produced/secreted by gram-positive bacteria.
Endotoxins are components of the cell wall of gram-negative
organisms.
7. (pp. 91–92, Figs. 6.1 and 6.4) Endospores are latent forms of some
bacterial species with an outer coat that is resistant to heat and
other environmental conditions. The process of spore formation is
illustrated in Fig. 6.4, p. 92. Examples of spore-producing bacteria
include tetanus (C. tetani) and botulism (C. botulinum).
8. (p. 92, Fig. 6.6) Binary fission is simply dividing in half, forming
two daughter cells identical to the parent bacterium.
9. (p. 93, Table 6.2)
 Bacterial Cells Human Cells
Cell wall Present Not present
Cell membrane Present—selectively Present—
permeable; site of selectively
metabolic processes permeable
Capsule or slime coat Present in some Not present
Flagella Present Sperm only
Pili or fimbriae Present in some Not present
Cilia Not present Present in
some
Membrane-bound organelles Not present Present
(mitochondria, lysosomes,
endoplasmic reticulum)
Ribosomes Present Present—
larger
Nucleus Not present Present
Number of chromosomes Single; circular 46; paired
(except sex
cells)
Method of reproduction Binary fission Mitosis

Viruses
10. (p. 93) They require a living host cell for replication.
11. (p. 93) The virion consists of a protein coat or capsid and a DNA
or RNA nucleic acid core.
12. (pp. 92–93, Fig. 6.7B) Virus attaches to the host cell and penetrates.
It uncoats and takes over the host cell DNA. The host cell
synthesizes viral components. The components assemble and are
released by host cell lysis. Sometimes the virus may remain
inactive in the host cell or activate at a later time.

Fungi
13. (p. 95) Fungi are classified as eukaryotic. They consist of cells or
chains of cells and may have long filaments called hyphae that
intertwine to form a mass called the mycelium, which is large
enough to be visible.
14. (pp. 90, 93, 94)

Bacteria Fungi Viruses

Basic Cell wall, cell Cell wall, Capsid, nucleic acid
structure membrane, hyphae core of either RNA or
cytoplasm, DNA Eukaryotic DNA
Method of Binary fission Budding, spores, Use host cell to
reproduction extending replicate and assemble
hyphae components
Method of Various culture Culture media Living host cells
culturing media (simple
glucose/agar)
Drugs used Antimicrobials Antifungal Antiviral drugs
to treat agents

Other Microorganisms
15. (p. 94)
i. chlamydiae: pelvic inflammatory disease; eye infections in
newborn of infected mothers
ii. rickettsiae: typhus; Rocky Mountain spotted fever
iii. mycoplasmas: pneumonia
iv. protozoa: Trichomonas vaginalis; malaria; amebic dysentery
16. (p. 99) Helminths are round or flat worms. Examples includes
tapeworm and hookworm.
17. (p. 99) Prions are proteinaceous agents that are transmitted by the
consumption of contaminated tissue. They cause Creutzfeldt-Jakob
disease in humans.
18. (pp. 99–100) microorganisms that normally inhabit various areas
of the body, such as the skin and gastrointestinal tract
19. (p. 99, Table 6.3) Brain, blood, kidneys, bladder
20. (p. 100) Endemic infections are those that consistently occur in a
population.
21. (p. 102) Pathogenicity is the capacity of a microbe to cause
disease. Virulence is the degree of pathogenicity of a microbe or
pathogen. It can be enhanced by production of exotoxins or
endotoxins, destructive enzymes, spore formation, and presence of
bacterial capsules. Immunodeficiency or immunodepression can
result in opportunistic infections; relocation of normal flora to
another body site can also result in the production of disease.

Consolidation of Microbiology
22. (pp. 93–106)
i. fungi
ii. fungi
iii. bacteria
iv. protozoa
v. bacteria
vi. bacteria; viruses; fungi
vii. bacteria
viii. rickettsiae
ix. fungi
x. viruses
xi. viruses
xii. bacteria

Control of Transmission and Infection

23. (pp. 103–104) Disinfectants are designed for use on nonliving
surfaces; antiseptics are designed to be used on living tissue.
24. (pp. 103–104, Fig. 6.13) The components and means to break the
cycle include locating and removing the reservoir or sources of
infection; blocking the exit from the source; providing or
cleaning/sterilizing barriers; maintaining immunizations; and
treating or quarantining infection or carrier.
25. (pp. 107–108, Fig. 6.17) The disk diffusion method involves
plating a small amount of the specimen to produce a bacterial
colony and placing paper disks impregnated with an antibiotic on
the inoculated plate. After a 24-hour incubation, if there is a clear
zone of inhibition surrounding the disk, the zone will be measured
to determine the effectiveness of the agent. If there is no zone, the
bacteria are resistant to the antibiotic. The Minimum Inhibitory
Concentration method uses a series of dilutions of an antimicrobial
agent applied against a known pathogen to determine the
minimum concentration of a specific agent that is effective against
the organism.
26. (pp. 107–108)
i. (p. 107) the range of bacteria for which the drug is effective:
narrow, either gram-positive or gram-negative; broad, both
gram-positive and gram-negative bacteria
ii. (p. 107) bacteria that develop or adapt so as to lose their
sensitivity to a drug, such as altering their metabolism to block
the drug's effects, producing enzymes that inactivate the drug,
or altering their cell membranes
iii. (p. 107) drugs that kill microorganisms
iv. (p. 107) drugs that inhibit bacterial reproduction
27. (p. 108) a secondary or new infection by pathogens that results
from disruption or reduction of the normal resident flora by
antimicrobial drugs
28. (p. 109) allergic reactions, anaphylaxis, disruption of resident
flora, secondary infections
29. (p. 108) A superinfection occurs only during treatment with
antimicrobial agents. An opportunistic infection occurs in an
individual with decreased immunity. Both are usually caused by
fungi or by bacteria that are part of the normal resident flora or
when resident flora from one area of the body are introduced to
another area causing an infection there.
30. (p. 108) when the identity of the bacterium is known; after culture
and sensitivity have been completed
31. (p. 108) The drug prevents replication of the bacteria, thereby
keeping the number of bacteria constant—the body's own
defensive cells will destroy the organism.
32. (p. 108) if the individual was immunosuppressed (e.g., organ
transplant recipient) or immunodeficient (e.g., someone with
AIDS)
33. (pp. 108–109) Bacteria adapt and/or mutate to develop various
means of losing drug sensitivity; excessive or unnecessary use of
drugs provides a stimulus for such adaptation.
34. (p. 109) because they may reduce the risk for secondary bacterial
infection
35. (p. 107) The drug should be taken regularly according to the
prescription. The drug should be taken until the prescription is
completely used. Follow instructions regarding food or fluid
intake. Provide a good medical history, including known drug
allergies.
36. (p. 92) Because viruses are obligate intracellular parasites, a drug
that destroys viruses would also destroy the host cell.

Chapter 7
Immunity
1. The three main components of the immune system are: lymphoid
tissue, immune cells, and tissues concerned with immune cell
development. Lymphoid tissue: lymph nodes, spleen, tonsils,
intestinal lymphoid tissue, lymphatic circulation. Immune cells:
lymphocytes, macrophages. Cell development: bone marrow,
thymus gland.
(pp. 114–115, Fig. 7.1)
A. Pharyngeal tonsil (adenoid)
B. Palatine tonsil
 C. Lymph nodes (cervical)
D. Lymphatic vessels
E. Lymph nodes (axillary)
F. Spleen
G. Lymph nodes (intestinal)
H. Lymph nodes (inguinal)
I. Bone marrow
J. Thymus
2. (p. 115) A cell surface antigen is a unique protein or glycoprotein
configuration that is a distinctive marker for the recognition of a
cell by the immune system. It provides the means by which the
immune system distinguishes self from nonself. It is important
because it provides for the detection and identification of
“nonself” by the immune system. This differentiation underlies the
host defense against infection and other foreign antigens, and it
forms the basis for selection of compatible organs and tissues for
transplantation.
3. (p. 115) The major histocompatibility complex (MHC) cell
membrane antigens are molecules that are specific for each
individual. The HLA is the human MHC on human leukocytes
that determine “self” and serve as the basis for identifying
histocompatible cells and tissues for transplantation, including
blood transfusion. These antigens representing “self” are present
on an individual's cell membranes.
4. (Table 7.1, p. 115, Table 5.1, p. 67)
 Chemical
Source Effects
Mediator
Histamine Mast cells and Vasodilation and increased vascular
basophils permeability, contraction of bronchiolar
smooth muscle; pruritus
Prostaglandins Group of lipids Various effects from causing
synthesized in inflammation, vasodilation, increased
mast cells capillary permeability, muscle spasm,
and pain
Cytokines T lymphocytes and Increase in plasma proteins, Erythrocyte
(lymphokines, macrophages Sedimentation Rate (ESR); stimulate
monokines, activation and proliferation of B and T
interleukins, cells and communication between cells
interferon) (messengers); induce fever, leukocytosis,
and chemotaxis
Leukotrienes Group of lipids Contraction of bronchiolar smooth
derived from mast muscle; vasodilation and increased
cells and basophils capillary permeability; chemotaxis
Kinins Activation of Vasodilation, edema, and pain
(bradykinin) plasma protein
(kinogen; e.g.,
bradykinin)
Complement Group of proteins Release of chemical mediators,
circulating in the promoting inflammation, chemotaxis,
bloodstream; phagocytosis, cell membrane damage
activated by (e.g., hemolysis)
antigen-antibody
reactions on cell
surface

5. (Table 7.1, p. 115, Table 5.1)

i. histamine, prostaglandins, kinins, leukotrienes
ii. histamine, prostaglandins, leukotrienes
iii. cytokines, leukotrienes, complement
iv. prostaglandins, kinins
v. histamine, leukotrienes
vi. cytokines
vii. histamine
 viii. tumor necrosis factor (TNF), cytokines
6. (p. 115, Table 7.1)
Macrophages: phagocytosis; foreign antigen recognition
Natural killer (NK) cells: destroy foreign cells, virus-infected cells,
and cancer cells
T lymphocytes: stimulated by particular antigen to initiate cell-
mediated immune response
Cytotoxic or killer T cells: destroy antigens and cancer and virus-
infected cells
Helper T cells (T4 or CD4 lymphocytes): activate B and T cells;
limit immune response
Memory T cells: remember antigen and stimulate immune
response upon subsequent exposure (secondary response)
Suppressor T cells (T8): limit immune response
B lymphocytes: stimulated by particular antigen cloning becoming
plasma cells producing antibodies. A population of cells remains
as memory cells following simulation by the antigen.
Plasma cells: produce specific antibody
B memory cells: secondary antibody response
7. (p. 117, Fig. 7.2) helper T cells
8. (p. 119, Table 7.2) A, B, C: IgG, IgD, IgE (in any order), D: IgA, E:
IgM
IgG: primary and secondary antibody responses; activates
complement; includes antibacterials, antivirals, and antitoxins;
crosses placenta, creates passive immunity in newborns
IgM: primary antibody responses; activates complement; forms
natural antibodies; is involved in blood ABO incompatibility
reactions
IgA: found in secretions such as tears and saliva, in mucous
membranes, and in colostrum to provide protection for
newborns
 IgE: binds to mast cells in skin and mucous membranes; when
linked to allergen, causes release of histamine and other
chemicals, resulting in inflammation
IgD: attached to B cells; activates B cells
9. (p. 118) Antibodies exert their effects by binding to the specific
antigen that elicited their production, usually on a cell or bacterial
surface, resulting in antigen destruction, cell membrane damage
(especially in the presence of complement), and, in the case of red
blood cells, cell lysis. Some antigen-antibody-complement
complexes are also chemotactic, attracting phagocytes and other
cells to the site.
10. (p. 120) Primary response on initial antigen exposure may range
from days to weeks. Secondary response is almost immediate.
11. (p. 120, Fig. 7.3) Primary response is approximately 3 to 4 weeks.
Secondary response is quicker, with much higher titer within 1 or
2 weeks.
12. (p. 121) to promote a stronger, faster secondary immune response
by “reminding” the immune system of the previously encountered
antigen
13. (p. 121) There are many strains of a virus or bacteria that cause a
disease, and they may mutate readily, causing new strains; then,
because the immune response is specific, infection with one strain
does not create immunity to subsequent exposures to new,
different strains.
14. (p. 120, Table 7.3)
 Characteristic Active Immunity Passive Immunity
Method of Exposure to Receiving specific antibody passively (i.e.,
acquisition antigen and produced by others who have been
production of exposed to the antigens) via either milk
specific antibodies (newborn infants) or injection of pooled
IgG fractions
Onset of Several weeks for Immediate upon receipt of the antibodies
immunity a primary
after response
exposure to
antigen
Duration of Depending on the Months
effectiveness nature of the
antigen, usually
lasts for years
(memory T cells)
Examples Polio, measles, Breast milk, rabies immune globulin, and
diphtheria, snake antivenom serum
vaccines,
chickenpox

15. (pp. 121–122) A close match of HLAs between donor and host
tissues reduces the risk for rejection. The common treatment
involves immunosuppressive drugs, such as cyclosporine,
azathioprine (Imuran), and prednisone. The use of tissues that lack
a blood supply decreases the potential for rejection.
16. (p. 122) The term opportunistic describes microorganisms that are
usually harmless in healthy individuals unless conditions occur
that favor the growth of the organism over the normal flora.
Patients taking immunosuppressant drugs have limited body
defenses that are not prepared for an infection by normally
harmless organisms.
17. (p. 122) Preventive (prophylactic) antibiotics are usually
administered because opportunistic infections are common, can be
difficult to treat, and are best prevented.

Hypersensitivity
18. (pp. 122–128, Table 7.5 and pp. 122–127)

Type Mechanism Effects Example

I IgE bound to mast cells; Immediate Hay fever, seasonal
release of histamine and inflammation allergies; anaphylaxis
chemical mediators and pruritus
II IgG or IgM reacts with Cell lysis and ABO blood
antigen on cell— phagocytosis incompatibility
complement activated
III Antigen-antibody complex Inflammation; Autoimmune disorders:
deposits in tissue— vasculitis systemic lupus
complement activated erythematosus (SLE);
glomerulonephritis
IV Antigen binds to T Delayed Contact dermatitis;
lymphocyte; sensitizing inflammation transplant rejection
lymphocytes that release
lymphokines

19. (Table 12.4 chapter 12)

 Hypovolemic Shock Anaphylactic Shock
Etiology Hemorrhage, severe Severe, life-threatening, systemic
burns, dehydration, hypersensitivity (allergic) reaction
peritonitis, pancreatitis caused by insect stings, ingestion
of nuts or shellfish, penicillin, or
local anesthetics
Distinguishing Anxiety, restlessness, Very rapid onset of decreased
features thirst (early sign); blood pressure, weakness,
tachycardia; cool, pale, fainting; itching; airway
moist skin; oliguria; obstruction, cough, dyspnea;
hyperventilation during edema around the face, hands,
compensation and feet; hives, urticaria, fear, and
Progressive: lethargy, panic. If untreated, collapse and
weakness, faintness; loss of consciousness ensue.
metabolic acidosis; CNS
depression; organ
damage
Specific Put patient in supine Epinephrine injection
treatment position; cover to keep immediately; oxygen
warm; call for help or administration; antihistamine
transport to hospital. injection; treatment for shock;
Administer oxygen, summon help/transport to
whole blood, plasma, or hospital; CPR, if necessary
fluids with electrolytes, if
available and ordered.

20. (p. 125) antihistamine drugs for early signs and symptoms;
glucocorticoids for severe or prolonged reactions
21. (pp. 125–126) Latex sensitivity may result from a type I or type IV
reaction. Type IV is the most common reaction, with a rash
developing 48 to 96 hours after contact. Type I is rare but more
serious, with possible asthma, hives, or anaphylaxis.

Autoimmunity
22. (p. 128, Fig. 7.8, p. 129) when individuals develop antibodies to
their own cells or cellular material
23. (p. 129) Systemic lupus erythematosus (SLE) is diagnosed by the
presence of numerous antinuclear antibodies (ANAs), especially
 anti-DNA, as well as other antibodies. Lupus erythematous (LE)
cells are mature neutrophils containing nuclear material found in
the circulating blood and are a positive sign.
24. (pp. 129–131) prednisone (glucocorticoid) to reduce the immune
response and subsequent inflammation; hydroxychloroquine
(antimalarial) may be used to reduce exacerbations; nonsteroidal
antiinflammatory drugs
25. (p. 130, Table 7.7)
i. skin: butterfly rash
ii. joints: polyarthritis
iii. heart: carditis and pericarditis
iv. blood vessels: Raynaud phenomenon
v. blood: anemia, leukopenia, thrombocytopenia
vi. kidneys: glomerulonephritis, with marked proteinuria and
progressive damage
vii. lungs: pleurisy
viii. central nervous system: psychosis, depression, mood changes,
seizures

Immunodeficiency
26. (p. 131, Table 7.8)
primary: hypogammaglobulinemia; thymic aplasia, DiGeorge
syndrome, combined immunodeficiency syndrome (CIDS),
inherited deficits in any one or more of the components
secondary: kidney disease, Hodgkin disease, AIDS, radiation,
immunosuppressive drugs, immunosuppression, malnutrition,
loss or removal of the spleen, liver disease
27. (p. 132) predisposition to opportunistic infections and an
increased risk for cancer
28. (p. 132) prophylactic antimicrobials to reduce incidence of
opportunistic infections; gamma globulin replacement therapy to
provide passive immunity (antibodies)
Hiv and Aids
29. (p. 132) Human immunodeficiency virus (HIV) is the causative
agent for AIDS. It is a “slow-acting” retrovirus containing two
strands of RNA and the enzyme reverse transcriptase. Its envelope
is characterized by spikes of glycoprotein. The virus is inactivated
by many disinfectants and high temperatures.
30. (p. 132) CD4 T-helper lymphocytes are the major target and, when
destroyed, their function in the initiation of both humoral and
cellular immunity is reduced or absent.
31. (p. 135) HIV must enter the bloodstream of the recipient through
transmission of body fluids such as blood, semen, and vaginal
secretions. Transmission most often occurs through unprotected
sexual intercourse with an HIV-positive partner, intravenous
injection with contaminated needles, maternal-fetal transmission,
or blood transfusion.
32. (p. 134) At the highest risk are intravenous drug users,
individuals with multiple sexual partners (particularly those
having unprotected sex), and the unborn fetuses of HIV-positive
mothers.
33. (p. 134, Fig. 7.13) Infected individuals usually become HIV
positive within 2 to 10 weeks, but the “window” may be as long as
6 months. Full-blown AIDS may not occur for many years. After
an initial infection, mild flulike symptoms appear in 3 to 6 weeks,
followed by an asymptomatic latent period that may last for years
before phase 3, acute onset of signs and symptoms, including
multiple severe opportunistic infections and rare cancers such as
Kaposi sarcoma.
34. (p. 136) A blood test is performed for HIV antibodies using HIV
antigen from recombinant HIV or ELISA for the primary test. The
three-stage process involves determining: 1. Presence of HIV-
1/HIV-2 antigens/antibodies, differentiation/identification between
HIV-1 and HIV 2 antibodies, and a nucleic acid test to confirm
HIV-1 positivity and eliminate a false negative.
35. (pp. 133–134, Figs. 7.12 and 7.13) Full-blown AIDS may not occur
for 6 to 7 years on average.
36. (p. 136) AIDS is diagnosed by a major decrease in the CD4 T-
helper lymphocyte count and a change in the CD4+-to-CD8+ ratio
in the presence of opportunistic infection or certain cancers.
37. (p. 136, Fig. 7.13) mild, self-limited nonspecific flulike symptoms:
low fever, fatigue, joint pain, and sore throat
38. (pp. 136–137, Fig. 7.15)
i. generalized effects: lymphadenopathy, fatigue and weakness,
headache, and arthralgia
ii. opportunistic infections (see also gastrointestinal
manifestations): Pneumocystis carinii in the lungs, causing severe
pneumonia; herpes simplex, causing cold sores; and Candida, a
fungal infection of the mouth and esophagus
iii. gastrointestinal manifestations, including parasitic infections:
chronic severe diarrhea, vomiting, and ulcers; necrotizing
periodontal disease; severe weight loss, malnutrition, and
wasting
iv. oral manifestations: cold sores (herpes simplex) and Candida
v. respiratory manifestations: Pneumocystis carinii, causing
pneumonia
vi. nervous system manifestations: HIV encephalopathy (AIDS
dementia), aggravated by lymphomas, causing confusion,
progressive cognitive impairment, memory loss, loss of
coordination and balance, and depression; seizures
vii. malignancies: Kaposi sarcoma and non-Hodgkin lymphomas
39. (pp. 137–138) HIV drugs are grouped into six classes according to
how they fight against HIV:
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• Nucleoside reverse transcriptase inhibitors (NRTIs)
• Protease inhibitors (PIs)
• Fusion inhibitors
 • CCR5 antagonists (CCR5s) (also called entry inhibitors)
• Integrase strand transfer inhibitors (INSTIs)

antiviral drugs such as AZT; protease inhibitors such as indinavir;

viral integrase inhibitors such as saquinavir and ritonavir; reverse
transcriptase inhibitors such as zidovudine and lamivudine; and
various drug combinations known as cocktails, which can be made
of combinations of three to five drugs; a “one pill daily”
combination of three drugs (Atripla) is available to improve patient
adherence to their drug protocol. Currently highly active
antiretrovirus (HAART) therapy has been very effective at
controlling the virus, reducing the viral load in the blood, and
returning CD4 cell counts to near-normal levels; prophylactic
medications, including antibacterial, antifungal, and
antituberculosis drugs; other drugs such as antidiarrheals (e.g.,
Imodium); and vitamin and mineral supplements may be
required.
40. (p. 138) Prognosis is much improved because of earlier detection
and newer drug and nutritional therapies. Without treatment,
death occurs within several years of diagnosis.

Chapter 8
Skin Disorders
1. (p. 143) provides the first line of defense against invasion by
microorganisms and other foreign material; prevents excessive
fluid loss, important in controlling body temperature; provides
sensory perception; involved in synthesis and activation of vitamin
D
2. See Fig. 8.1, p. 142 of text.
A. Hair, B. Capillaries, C. Sebaceous gland, D. Smooth muscle, E.
Vein, F. Artery, G. Nerve fiber, H. Hair follicle, I. Adipose tissue,
J. Subcutaneous tissue, K. Eccrine gland, L. Sensory receptor, M.
 Dermis, N. Stratum basale, O. Epidermis, P. Stratum corneum,
Q. Melanocyte
3. (pp. 146–157)
Condition Etiology Treatment
Scleroderma Unknown; may be local or NSAIDs and glucocorticoids
systemic
Kaposi Rare skin cancer that occurs in Radiation and chemotherapy
sarcoma immunosuppressed patients
(especially patients with
AIDS)
Tinea Fungal infections of various Oral antifungal agents such as
parts of the body caused by griseofulvin
various species of Trichophyton Topical antifungal agents:
griseofulvin, tolnaftate, or
ketoconazole
Atopic Type 1 hypersensitivity, with Topical glucocorticoids
dermatitis inherited tendency or genetic
component
Pemphigus Autoimmune disorder Systemic glucocorticoids
Herpes Varicella zoster virus Antiviral medications for
zoster symptoms (e.g., acyclovir)
Herpes HSV-1 Topical acyclovir
simplex
Verrucae Human papillomaviruses Topical medications; laser and
cryotherapy
Urticaria Type 1 hypersensitivity to Topical antihistamines or
certain ingested substances topical glucocorticoids
(e.g., shellfish)
Psoriasis Unknown; familial tendency Glucocorticoids; tar
preparations, and methotrexate
when severe
Scabies Mite infection by Sarcoptes Topical treatment with lindane
scabiei
Lichen Unknown inflammatory Topical glucocorticoids
planus condition of skin and mucous
membranes
Impetigo Staphylococcus aureus Topical and systemic
antimicrobials
Cellulitis Infection of dermis and Systemic antimicrobials; local
subcutaneous tissue, compression and analgesics
secondary to an injury; S.
aureus
 Condition Etiology Treatment
Necrotizing Group A β-hemolytic Antimicrobials, fluid
fasciitis Streptococcus replacement, excision of all
infected tissue, and amputation
if necessary

4. (pp. 157–159)
i. those with excessive, cumulative sun (UV) exposure, smokers,
individuals with scar tissue (particularly African Americans)
ii. genetic predisposition; hormonal factors; UV radiation
(sunlight)
iii. immunosuppressed patients (e.g., individuals with AIDS)
5. (p. 157) a sore that does not heal; change in the shape, size, color,
or texture of a lesion; new moles or the development of odd-
shaped lesions; a skin lesion that bleeds repeatedly, oozes fluid, or
itches

Consolidation
6. See Fig. 8.2 of the text.
A. Macule, B. Nodule, C. Papule, D. Pustule, E. Vesicle, F. Plaque,
G. Ulcer, H. Fissure
7. (pp. 145–156)
i. Kaposi sarcoma
ii. urticaria
iii. pemphigus
iv. scabies
v. herpes simplex 1
vi. verrucae
vii. mycoses
viii. atopic dermatitis

Chapter 9
Musculoskeletal System Disorders
Fractures
1. (p. 162, Fig. 9.1B)
A. Articular cartilage, B. Epiphyseal line, C. Spongy bone, D.
Compact bone, E. Medullary cavity, F. Nutrient foramen, G.
Endosteum, H. Periosteum, I. Articular cartilage, J. Epiphysis, K.
Diaphysis, L. Epiphysis
2. (pp. 167–169, Fig. 9.4)
i. C: when the skin is broken; more damage to soft tissue (Open)
ii. B: multiple fracture lines and bone fragments (Comminuted)
iii. L: when a bone is crushed or collapses into small pieces
(Compression)
iv. H: bone is only partially broken, shaft is bent, tearing the
cortical bone on one side (Greenstick)
v. I: one end of the bone is forced or telescoped into the adjacent
bone (Impacted)
vi. A: fracture at an angle to the diaphysis of the bone (Oblique)
vii. D: fracture results from a weakness in bone structure; due to
tumor or osteoporosis (Pathologic)
viii. F: a break that angles around the bone; usually due to a
twisting injury (Spiral)
ix. G: a fracture across the bone (Transverse)
x. J: break in the distal radius at the wrist (Colles')
xi. E: segmental is a break in which several large bone fragments
separate from the main body of a fractured bone.
xii. K: fracture of the lower fibula at the ankle (Pott)
3. (pp. 167–169; Fig. 9.5) Bleeding occurs and inflammation develops
around the bone as a result of the soft-tissue damage. A hematoma
or clot forms in the medullary canal, under the periosteum.
Necrosis occurs at the ends of the broken bone. The hematoma
serves as a basis for fibrin network into which granulation tissue
 grows. Capillaries extend into tissue; phagocytic cells clean up
debris. Fibroblasts (collagen) and chondroblasts (cartilage) migrate
to the fibrin network. Bone ends become splinted by a procallus or
fibrocartilaginous collar. Osteoblasts generate new bone, and
callus is replaced, forming a bony callus. New bone is remodeled
by osteoblastic and osteoclastic activity.
4. (pp. 169–170) Complications include muscle spasm causing
abnormalities in the bone during the healing process, infections,
ischemia, compartment syndrome, fat emboli, nerve damage,
nonunion (failure to heal) or malunion (deformity), and residual
effects of fractures near a joint (osteoarthritis); stunted growth in
children.
5. (p. 170) Reduction of a fracture is the manipulation of the fracture
to restore bones to their normal position and alignment. A closed
reduction is done by exerting pressure and traction. An open
reduction requires surgery; devices may be placed to fix the
fragments.
6. (p. 170, Fig. 9.6) Dislocation is the separation of two bones at a joint
with loss of contact between the articular surfaces. Subluxation is
the partial displacement of bone with partial loss of contact
between surfaces.
7. (p. 170) A sprain is a tear in a ligament. An avulsion occurs when a
tendon or ligament is completely separated from its bony
attachment.

Bone Disease
8. (p. 172)
• aging
• decreased mobility or sedentary lifestyle
• hormonal factors such as hyperparathyroidism, Cushing
syndrome
• deficits of calcium, vitamin D, or history of childhood deficits or
malabsorption disorders
 • cigarette smoking
• small, light bone structure
• excessive caffeine intake
9. (p. 172) bones consisting of higher proportions of cancellous bone,
such as vertebrae and the femoral neck
10. (p. 172) Bone resorption exceeds bone formation during the
continuous process of bone remodeling, leading to thin, fragile
bones.
11. (p. 172) Treatment includes dietary supplements, fluoride
supplements, bisphosphonates, calcitonin, and human parathyroid
hormone, weight-bearing exercises, raloxifene, and possibly newer
medications under investigation such as strontium ranelate;
antibody that binds to osteoclasts.
12. (p. 173)

Rickets Osteomalacia Paget Disease

Etiology Vitamin D deficiency in Vitamin D or Idiopathic
children due to diet or calcium Unknown virus
malabsorption deficiency in Genetic factors
adults
Manifestations Deformities—“bow Soft bones Pathologic
legs” Compression fractures
Decreased height fractures Compression
fractures of
vertebrae;
kyphosis
Compression of
cranial nerves
Cardiovascular
disease and heart
failure
Treatment Supplements Supplements Supportive
Treat malabsorption

13. (p. 174) long-term use of phenobarbital (e.g., in treatment of

seizures)
14. (p. 174) Osteosarcoma is a primary malignant neoplasm that
usually develops in the metaphysis of the femur, tibia, or fibula in
children or young adults, particularly males (Fig. 9.8).
Chondrosarcomas are malignant tumors arising from cartilage and
are more common in adults.

Muscular Dystrophy
15. (p. 175) The basic pathophysiology is the same in all types of
muscular dystrophy. A metabolic defect, a deficit of dystrophin (a
muscle cell membrane protein) leads to degeneration and necrosis
of the cell. Skeletal muscle fibers are replaced by fat and fibrous
connective tissue, leading to the hypertrophic appearance of the
muscle.
16. (p. 175, Table 9.1)

Primarily Fibromyalgia Syndrome

17. (p. 176) pain and stiffness affecting muscles, tendons, and
surrounding soft tissues (not joints); other manifestations: sleep
disturbances, depression, possibly irritable bowel syndrome,
urinary symptoms

Arthritis
18. (p. 176) It is a degenerative process. There is an increased
incidence with age and excessive mechanical stress such as sports
injuries or repetitive strain injury (RSI).
19. (p. 176) diagnosed by exclusion of other disorders and
radiographic evidence of joint changes consistent with the clinical
signs
20. (pp. 176–179, Figs. 9.10 to 9.14)
 Osteoarthritis Rheumatoid Arthritis
Etiology Degenerative Autoimmune
Primary: idiopathic Genetic factor
Secondary: injury
Genetic factor
Predisposing Age Familial
factors Obesity predisposition
Any joint injury Females
Familial tendency
Joints involved Weight-bearing and those Symmetrical
frequently injured—hips and involvement
knees, cervical and lumbar spine, Small joints of hands
distal interphalangeal, and feet
temporomandibular Wrists and ankles
Temporomandibular
Pathophysiology Damage of articular cartilage leads Synovitis leads to
to interference with movement, pannus formation,
resulting in further damage, resulting in cartilage
exposure of endochondral bone, erosion, fibrosis, and
and development of cysts and finally ankylosis
osteophytes that causes joint space Muscle atrophy
narrowing Development of
Inflammation in surrounding soft malalignments,
tissue contractures, and
deformities
Signs and Pain with use Aching and stiffness
symptoms Limited movement Impaired mobility
Enlarged, hard joints Deformities,
Crepitus functional losses
No systematic manifestations
Systemic effects None Rheumatoid factor
(RF) in blood
Elevated ESR
Low-grade fever,
malaise, fatigue
Subcutaneous
nodules: pleura,
heart valves, eyes
 Osteoarthritis Rheumatoid Arthritis
Treatment NSAIDs Physiotherapy;
Minimize stress on joint ambulatory aids
Ambulatory aids Occupational
Orthotic devices therapy: assistive
Arthroplasty devices
Joint replacement NSAIDs, COX-2
inhibitors
Glucocorticoids
Immunosuppressants
Gold salts
Arthroplasty
Joint replacement

21. (p. 180)

• NSAIDs, COX-2 inhibitors
• glucocorticoids
• immunosuppressants
• gold salts
• Beta cell–depleting agents (rituximab)
• Interleukin-1 antagonists (anakinra)
22. (p. 180) The onset is usually more acute. Systemic effects are more
marked, but rheumatoid nodules are absent. Large joints are
frequently affected. Rheumatoid factor is not usually present.
Other abnormal antibodies (e.g., ANA) may be present. The
systemic form, Still disease, develops with fever, rash,
lymphadenopathy, and hepatomegaly, as well as joint
involvement.
23. (pp. 180–181, Fig. 9.15) deposits of uric acid and urate crystals in
the joint that cause an acute inflammatory response
24. (pp. 180–181) Gout is usually due to a metabolic abnormality,
resulting in hyperuricemia. It often affects only a single joint. It is
more common in men older than 40 years of age. There are tophi
formation and urate crystal deposits.
25. (p. 181) Pathologic changes include inflammation of the vertebral
joints, fibrosis, and calcification or fusion of the joints,
inflammation that begins in the lower back at sacroiliac joints and
progresses up the spine, kyphosis, and osteoporosis; lung
expansion may be limited at the late stage due to calcification of
the costovertebral joints.

Consolidation
26. (pp. 169–178)
i. osteoarthritis, rheumatoid arthritis
ii. gout
iii. rheumatoid arthritis
iv. rheumatoid arthritis
v. rheumatoid arthritis, gout, ankylosing spondylitis
vi. Duchenne muscular dystrophy
vii. osteoporosis
viii. osteoarthritis
ix. fibromyalgia
x. rheumatoid arthritis
xi. rheumatoid arthritis
xii. osteoporosis, ankylosing spondylitis
xiii. rheumatoid arthritis, ankylosing spondylitis
xiv. rheumatoid arthritis
xv. gout
xvi. rheumatoid arthritis, ankylosing spondylitis
xvii. osteoarthritis, rheumatoid arthritis, gout, ankylosing
spondylitis
xviii. rheumatoid arthritis
xix. osteoarthritis
xx. ankylosing spondylitis
xxi. osteoporosis
 xxii. osteoarthritis
xxiii. osteoporosis

Chapter 10
Blood and Circulatory System Disorders

Erythrocytes
1. (Fig. 10.5, pp. 187–191, Fig. 10.7) All blood cells originate in the red
bone marrow from pluripotential hematopoietic stem cells during
hemopoiesis. The life span is approximately 120 days. As the cell
ages, it becomes rigid and fragile and finally is phagocytosed in
the spleen or liver and broken down into globin and heme. Globin
is broken down into amino acids and, along with the iron, is
recycled to the liver to be used in hemoglobin synthesis. The heme
is processed to release iron for recycling, and bilirubin, which is
transported to the liver, where it is conjugated with glucuronide
and then excreted in the bile.
2. (Handy Tables [inside front cover])
males: RBC: 4.9–5.9 × 106/mm3 (4.9–5.9 × 1012/L)
hemoglobin: 13.5–18 g/100 mL (135–180 g/L)
females: RBC: 4.2–5.2 × 106/mm3 (4.2–5.2 × 1012/L)
hemoglobin: 12–16 g/100 mL (120–160 g/L)
3. (p. 195) below normal concentrations of red blood cells and
hemoglobin in the blood
4. (p. 195) fatigue, pallor, dyspnea, and tachycardia
5. (pp. 195–203, Table 10.2)
Type of Specific Signs and Specific
Etiology
Anemia Symptoms Treatment
Iron Malnutrition Pallor Identify and
deficiency Chronic blood loss Fatigue, lethargy, treat the
anemia (p. Malabsorption and cold underlying
196, Fig. Severe liver disease intolerance cause
10.13, p. Underutilization of iron Irritability Iron
194) in some infections and Degenerative supplements
cancers changes (e.g., brittle
hair, rigid nails)
Stomatitis and
glossitis
Menstrual
irregularities
Delayed healing
Tachycardia, heart
palpitations,
dyspnea, and
possible syncope
Pernicious Dietary insufficiency Basic signs of Vitamin B12
anemia— (rare) anemia injection
Vitamin Malabsorption resulting Enlarged, red, sore
B12 from autoimmune tongue
deficiency reaction; chronic Decreased gastric
anemia (p. gastritis; or acid leading to
197, Fig. inflammatory discomfort, nausea,
10.14) conditions (e.g., and diarrhea
regional ileitis) Neurologic effects:
paresthesia in the
extremities or loss
of coordination and
ataxia
Type of Specific Signs and Specific
Etiology
Anemia Symptoms Treatment
Aplastic (Temporary or Anemia (pallor, Prompt
anemia (p. permanent) weakness, dyspnea) treatment of
199) Idiopathic Leukopenia the
Myelotoxins (e.g., Thrombocytopenia underlying
radiation, industrial (petechiae; cause and
chemicals, certain excessive bleeding)removal of
drugs) any bone
marrow
suppressants
Blood
transfusion
Bone marrow
transplant
Thalassemia Genetic defect in which Anemia (pallor, Blood
(p. 203) one or more genes for weakness, dyspnea) transfusion
hemoglobin are missing
or variant
Sickle cell Inherited characteristic Usually appears at Drugs that
anemia leading to the formation about 1 year of age reduce
(Figs. 10.16, of an abnormal when fetal sickling (e.g.,
10.17, 10.18) hemoglobin (HbS) hemoglobin is hydroxyurea)
replaced by HbS Avoidance of
Severe anemia strenuous
(pallor, weakness, activity or
tachycardia, and high altitudes
dyspnea) Supportive
Hyperbilirubinemia measures,
(jaundice) including
Splenomegaly relief of pain
Painful crises due
to vascular
occlusion and
infarction
Delayed growth
and development
Congestive heart
failure
Frequent infections
6. See Fig. 10.18 (pp. 200–201) Inheritance pattern is autosomal
recessive; the genotype of an individual with sickle cell anemia is
homozygous.
7. (p. 201) The individual is heterozygous for sickle cell anemia. Less
than half of his or her hemoglobin is abnormal; therefore, the
individual experiences manifestations only in extreme
circumstances.
8. (p. 202)

Mother With Sickle Cell Trait

Father with Sickle Cell Anemia HBs HBa
HBss HBss anemia HBsa trait
HBss HBss anemia HBsa trait

i. 50%
ii. 50%
iii. 0%
iv. 50%
9. (p. 200, Fig. 10.17) An inherited, abnormal form of hemoglobin
(HbS) is circulating in the bloodstream. When these RBCs are
deoxygenated, they crystalize and change shape. The cell
membrane is damaged, leading to hemolysis and shorter cell life
span. The sickled cells cause vascular obstruction, thrombus
formation, tissue infarction, and necrosis. Continued hemolysis
results in severe anemia, hyperbilirubinemia, jaundice,
splenomegaly, and gallstones.
10. (pp. 201–202, Figs. 10.10 and 10.17) deoxygenation of abnormal
hemoglobin when O2 levels are low
11. (pp. 200–201) episodes caused by vascular occlusions and
infarctions leading to permanent damage to organs and tissues;
potential complications such as infection and congestive heart
failure
12. (p. 201, Fig. 10.17)
i. excessive hemolysis, RBC breakdown, and resulting
hyperbilirubinemia
ii. cerebrovascular occlusion by sickled cells
iii. diminished immune capacity (damage to spleen); vascular
occlusions in the lungs; tissue damage and necrosis
iv. congestion of the spleen due to presence of sickled cells in
young individuals
v. chronic stress on the heart due to efforts to improve oxygen
supply and peripheral vascular resistance due to obstructions
13. (p. 202) genetic screening to identify carriers and genetic
counseling to discern the risk for having a child with sickle cell
anemia
14. (p. 208) Polycythemia is increased red blood cell and other cell
production in the bone marrow.
15. (p. 208) Primary polycythemia is a neoplastic disorder of
unknown origin, whereas secondary polycythemia may be a
compensatory mechanism to provide increased oxygen transport
in the presence of lung or heart disease or in individuals living at
high altitudes.
16. (p. 208) signs and symptoms: plethoric and cyanotic appearance;
hepatomegaly; high blood pressure; full and bounding pulse;
dyspnea, headaches, and visual disturbances
complications: thromboses and infarctions in extremities, liver,
kidneys, brain, and heart; congestive heart failure
17. (p. 208) immunosuppressive drugs, radiation, and periodic
phlebotomy

Blood Clotting
18. (p. 193) See Fig. 10.9, p. 190 of the main text.
19. (Warning Signs of Excessive Bleeding box, p. 204)
persistent bleeding from the gums or frequent nosebleeds
 petechiae
frequent purpura and ecchymoses
abnormal persistent bleeding following trauma
bleeding into a joint
hemoptysis
hematemesis—vomiting blood
blood in the feces
anemia
feeling faint and anxious, low blood pressure, rapid pulse
20. (p. 194) CBC; hematocrit; hemoglobin; reticulocyte count; bone
marrow aspiration and biopsy; serum iron, vitamin B12, folic acid,
cholesterol, urea, and bilirubin; bleeding time; prothrombin time;
partial thromboplastin time
21. (p. 204, Fig. 10.9, p. 190)
thrombocytopenia—many causes (e.g., autoimmune reactions):
reduced circulating platelets that initiate the clotting process
defective platelet adhesion caused by ASA and NSAIDs
vitamin K deficiency: decreases prothrombin and fibrinogen levels
liver disease: interferes with the production of clotting factors
inherited defects: cause deficiency in clotting factors
anticoagulant drugs: (e.g., warfarin blocks prothrombin synthesis)
22. (p. 204, Fig. 10.9, p. 190)
i. delays clotting—due to decreased synthesis of clotting factors
ii. delays clotting—decreased aggregation or clumping of platelets
iii. delays clotting—vitamin K, which is necessary for production
of clotting factors, is synthesized by resident flora of large
intestine; prolonged antibiotic therapy may disrupt or destroy
flora
iv. delays clotting—heparin inhibits thrombin formation
 v. delays clotting—vitamin K necessary for synthesis of clotting
factors by liver
vi. promotes clotting—decreased blood velocity, resulting in
pooling of blood
vii. promotes clotting—increased blood viscosity, which decreases
blood velocity and promotes pooling
viii. delays clotting—decreased platelets slow formation of platelet
plug
ix. promotes clotting—increased blood viscosity with resultant
decreased blood velocity
x. delays clotting—anticoagulant that decreases synthesis of
various clotting factors, particularly prothrombin
23. (p. 205, Fig. 10.20) Hemophilia A is transmitted as an X-linked
recessive trait and therefore it manifests in men, but women are
carriers. Males are heterozygous; females are homozygous.
24. (p. 204)

Female Carrier
Father X Xh
X XX normal female (25%) X Xh (25%)
Y XY normal male (25%) Xh Y (25%)

i. 25%—male
ii. 25%—female
iii. 50%
iv. 50%
v. 50%
25. (p. 204, Fig. 10.20B)
i. heterozygous
ii. heterozygous
 Mother
Father XH Xh
XH XHXH XHXh
Y XHY XhY

i. 50%
ii. 25%
iii. female
26. (pp. 206–207, Fig. 10.21) Disseminated intravascular coagulation
(DIC) involves excessive bleeding and clotting. It is a complication
of numerous primary problems that activates the clotting process.
Clotting causes multiple thromboses and infarctions but also
consumes the available clotting factors and platelets. This can lead
to hemorrhage and eventually hypotension or shock.
Manifestations depend on the underlying cause. Hemorrhage is
the most common critical problem combined with low blood
pressure and possibly shock. Multiple bleeding sites are common,
petechiae or ecchymoses may be present, mucosal bleeding is
common, and hematuria may develop. Vascular occlusions may be
present in the blood vessels. Difficulty in breathing and cyanosis
are evident. Neurologic effects include seizures and decreased
responsiveness. Acute renal failure may accompany shock.

Leukocytes
27. (p. 208) Leukemia is a neoplastic disorder involving one or more
types of leukocytes that are present as undifferentiated, immature,
nonfunctional cells that multiply uncontrollably and are found
circulating in large numbers in the blood.
28. (p. 209) Blast cells are primitive undifferentiated nonfunctional
stem cells seen in individuals with severe forms of acute leukemia.
29. (p. 209, Table 10.3) acute or chronic; specific cell type involved
(e.g., acute lymphocytic leukemia [ALL], chronic myelogenous
leukemia [CML])
30. (p. 209) individuals with chromosomal abnormalities, particularly
translocations such as Down syndrome; those exposed to radiation
and certain chemicals
31. (p. 210) bone marrow biopsy
32. (p. 210)

Signs and Symptoms Rationale

Weight loss and fatigue Hypermetabolism associated with neoplastic
growth, anorexia due to infection; pain; side
effects of chemotherapy
Anemia Due to hemorrhage and suppression of
normal RBC production in the bone marrow
Thrombocytopenia Suppression of platelet production in the
bone marrow by proliferating neoplastic
cells
Multiple infections, including Nonfunctional WBCs being produced;
those caused by diminished primary and secondary defense
microorganisms of low against infection
virulence
Increased bleeding and even Thrombocytopenia
severe hemorrhage
Kidney stones Rapid turnover of cells leading to
hyperuricemia
Fever Hypermetabolism and/or infection
Lymphadenopathy Excess production of abnormal leukocytes
causes enlargement and congestion of
lymphoid tissue
Splenomegaly and Excess production of abnormal leukocytes
hepatomegaly causes enlargement and congestion
Bone pain Excessive cell production in the marrow
causes pain due to pressure on nerves

33. (p. 210, Chapter 20) Chemotherapy, singly or in combinations, is

the primary treatment. Adverse effects include bone marrow
depression, nausea and vomiting, hair loss, and skin breakdown;
some drugs cause pulmonary fibrosis. If ineffective, bone marrow
transplantation is another intervention. Biologic agents, such as
interferon to stimulate the immune system, may also be used.
34. (p. 211) The best prognosis is in ALL in children between 1 and 9
years of age (less so in adolescents). The prognosis is poor in
adults, especially those with AML. Patients with chronic leukemia
may live up to 10 years. Prognosis depends on WBC and blast
counts at diagnosis.
35. (p. 209)

Acute Leukemia Chronic Leukemia

Age of onset Childhood and young adults Older individuals
Course of Acute onset; rapid development Insidious onset, milder,
disease of manifestations slower progression
Severity of Acute Milder
symptoms
Number of High Fewer
blast cells
Response to Very good in some types Depends on general health
treatment

Consolidation
36. (pp. 205–211)
i. disseminated intravascular coagulation (DIC)
ii. pernicious anemia
iii. leukemia (especially acute)
iv. hemophilia A
v. polycythemia
vi. aplastic anemia, leukopenia, thrombocytopenia
vii. sickle cell anemia
viii. thalassemia
ix. sickle cell anemia
x. pernicious anemia, vitamin B12 deficiency anemia
xi. polycythemia vera
xii. leukemia
 xiii. leukemia, anemia (especially aplastic and sickle cell), Hodgkin,
multiple myeloma

Chapter 11
Lymphatic System Disorders
Lymphatic System Structures
1. (p. 214, Fig. 11.1) A. Tonsil, B. Left subclavian vein, C. Bone
marrow, D. Spleen, E. Inguinal lymph nodes, F. Thoracic duct, G.
Axillary lymph nodes, H. Thymus, I. Right subclavian vein, J.
Right lymphatic duct, K. Lymph capillaries, L. Blood capillary, M.
Tissue cells, N. Venule, O. Arteriole

Lymphatic System Disorders

2. (p. 217, Fig. 11.8) Giant Reed-Sternberg cell is used for diagnosis. It
is characterized as a giant irregular cell present in the lymph node.
3. (pp. 218–219, Fig. 11.9)
stage I—single lymph node or region
stage II—multiple regions on same side of diaphragm
stage III—lymph node regions on both sides of diaphragm
stage IV—widespread; liver and spleen
4. (pp. 218–219) large, painless, nontender lymph node, usually in the
neck; splenomegaly and enlarged lymph nodes at other locations
later; general signs of cancer such as weight loss, anemia, low-
grade fever, night sweats, and fatigue; recurrent infection
5. (p. 219) radiation, chemotherapy (especially ABVD combo), and
surgery
6. (p. 220) Non-Hodgkin lymphoma is distinguished by multiple
node involvement scattered throughout the body in a
nonorganized pattern of widespread metastasis; intestinal nodes
are frequently involved in the early stages.
7. (p. 220) a neoplastic disease of unknown etiology involving plasma
cells
8. (p. 220) Signs and symptoms include frequent infections due to
impaired antibody production; bone pain due to production of
excess plasma cells in the marrow; pathologic fractures due to the
weakened bones; anemia and bleeding tendencies because blood
cell production is compromised; and proteinuria due to altered
kidney function.

Chapter 12
Cardiovascular System Disorders
Heart
1. See p. 225 Fig. 12.2
A. Left atrium, B. Left AV (mitral) valve, C. Left ventricle, D.
Papillary muscle, E. Interventricular septum, F. Pericardium, G.
Chordae tendineae, H. Inferior vena cava, I. Right ventricle, J.
Right AV (tricuspid) valve, K. Right atrium, L. Aortic semilunar
valve, M. Superior vena cava, N. Aorta.

Atherosclerosis
2. (pp. 237–238) dietary modification; exercise program; cessation of
smoking; drug therapy
3. (p. 235)
• age—cannot be changed
• gender—cannot be changed
• genetic or familial factors—cannot be changed
• obesity—modifiable
• cigarette smoking—modifiable
• sedentary lifestyle—modifiable
• diabetes mellitus—modifiable
• poorly controlled hypertension—modifiable
 • oral contraceptives and smoking in combination—modifiable
• high cholesterol and hypertension—modifiable
4. (Fig. 12.10, pp. 235–236)
• Endothelial injury happens in the artery, often at a young age.
• Inflammation and elevation of C-reactive protein develop.
• White blood cells, especially monocytes and macrophages,
accumulate.
• Lipid accumulates in the intima or inner lining of the artery and
media or muscle layer.
• A plaque forms, and inflammation persists.
• Platelets adhere to damaged surface, forming a thrombus and
partial obstruction.
• Lipid continues to build up at the site of injury, along with
fibrous tissue (atheroma).
• Platelets adhere and prostaglandins release, causing further
inflammation and vasospasm.
• Process continues with larger thrombus formation, potential for
total occlusion, and possibility of embolism.
5. (p. 234 Fig. 12.10, pp. 235–236 and 12.11) Development of
atheromatous plaques narrows the lumen of arteries restricting
flow, causing turbulence, thrombus formation, and potential
embolism. The atheroma also damages the arterial wall,
weakening the structure and decreasing elasticity, and ultimately
may calcify, causing further rigidity. Complications include: 1)
thrombus formation, with partial (angina) or 2) total occlusion,
precipitating a myocardial infarction, 3) embolism and infarction
(stroke and peripheral vascular damage), 4) aneurysm, or 5)
rupture and hemorrhage.
6. (p. 234) primarily large arteries particularly at bifurcations—aorta,
coronary, iliac, carotids
7. (pp. 237–238)
 i. Maintain weight at healthy levels to reduce the risk for metabolic
syndrome, hypertension, and atherosclerosis.
ii. Lower serum cholesterol and LDL in diet by reducing the intake
of saturated fats and using unsaturated or vegetable oils; high
dietary fiber intake also decreases LDL.
iii. Minimize sodium intake to control hypertension.
iv. Control primary disorders such as diabetes and hypertension.
v. Cease smoking.
vi. Exercise appropriate for age and health status to promote
collateral circulation and reduce LDL levels.
vii. Oral anticoagulant therapy can be used in case of thrombus
formation concern.
viii. Surgical intervention may be necessary.
8. (pp. 231–232 Table 12.1, p. 234)
i. lower cholesterol and LDL levels
ii. lower platelet aggregation, leading to a lower chance of
thrombosis and thus leading to a lower chance of heart attacks
and strokes
iii. interfere with clotting factor synthesis (warfarin) or inhibit
thrombin formation (heparin), leading to a lower chance of
thrombosis and a lower chance of heart attacks and strokes
iv. help decrease cardiac workload
9. (p. 238) percutaneous transluminal coronary angioplasty (PTCA);
coronary artery bypass grafting (CABG); laser angioplasty

Angina Pectoris (AP)

10. (p. 238) chest pain
11. (pp. 238–239)
• when there is decreased blood supply (oxygen) to the heart, due
to either arterial obstruction or spasm or
• when there is increased demand for oxygen by the heart or
 • when there is a combination of factors
12. (pp. 238–239)
• atherosclerosis
• arteriosclerosis
• vasospasm
• myocardial hypertrophy
• severe anemias
• respiratory disease
13. (p. 240) myocardial infarction
14. (answers throughout chapter)
i. smoke causes vasoconstriction, leading to increased venous
return and increased heart rate
ii. vasoconstriction, leading to increased venous return and
increased heart rate
iii. sympathetic stimulation increases heart rate
iv. increases heart rate due to increased O2 demands
15. (pp. 239–240, Fig. 12.14) The classic manifestations are recurrent,
intermittent brief episodes of substernal chest pain, described as a
tightness or pressure that may radiate to the neck or left arm. An
anginal attack usually lasts a few seconds or minutes.
16. (pp. 239–240) Coronary vasodilators, such as nitroglycerin, act by
reducing systemic resistance, thus decreasing the demand for
oxygen. Some vasodilators also relieve arterial vasospasm.
Nitroglycerin has an immediate onset of action.
17. (p. 240) sublingually
18. See Emergency Treatment box, p. 240
19. (Emergency Treatment box, p. 240)
• if pain is not relieved with rest and administration of three doses
of nitroglycerin spaced 5 minutes apart (i.e., after 10 minutes)
 • for individual with no history of angina, if pain is unrelieved
within 2 minutes
20. (Table 12.1, p. 234)

Adverse
Drug Group Action and Effects Example
Effects
β-Adrenergic Blocks β-adrenergic Dizziness, Lopressor
blockers receptors, slowing the heart fatigue
rate, reducing work of the
heart
Calcium channel Vasodilator, blocks calcium Dizziness, Adalat
blockers channel, reducing cardiac fainting,
contractility and work headache
Nitrates Reduces cardiac workload; Dizziness; Nitroglycerin
(vasodilators; decreases peripheral headache
transdermal or resistance by vasodilation
oral form)

21. (pp. 237–238 Think About, p. 240)

• antihypertensive to lower blood pressure and cardiac workload
• diuretic to help control blood pressure and prevent edema
• platelet inhibitor to lower platelet aggregation and the chance of
thrombus formation
• antihyperlidemic to lower blood cholesterol and LDL levels and
hopefully slow or arrest progression of atherosclerosis
22. (p. 238 Think About) angioplasty and stent insertion; coronary
bypass graft
23. (pp. 237–238, 240)
• Avoid situations known to precipitates attacks (e.g., stress).
• Stop smoking.
• Consume diet low in saturated and trans-fats.
• Restrict sodium intake.
• Lose weight if overweight.
• Engage in a consistent exercise program.
 • Reduce stress.
24. (p. 235 Think About, pp. 238, 240)
• How long has the individual had angina?
• How frequent are the attacks?
• When was the last one?
• What are the known precipitating factors?
• What is the individual's response to nitroglycerin?
• Does the individual have nitroglycerin with him or her?
• Has the individual suffered a heart attack?
25. (p. 239 Think About, pp. 238, 240)
• stress reduction—explanations and reassurance
• prophylactic use of nitroglycerin

Myocardial Infarction
26. (p. 240) death of cardiac muscle resulting from prolonged
ischemia
27. (pp. 240–241) Infarction may develop in three ways:
i. thrombus buildup to obstruct the artery due to atherosclerosis
(most common)
ii. vasospasm in the presence of a partial occlusion
iii. embolization of a thrombus to a smaller artery that is totally
obstructed
28. (p. 241) pallor, anxiety, fear, diaphoresis, shortness of breath and
tightness in chest, weakness, indigestion, or nausea
29. (p. 240) Transmural infarction involves all three layers of heart.
30. (p. 240) left ventricle
31. (p. 240, Fig. 12.14) Myocardial infarction occurs when a coronary
artery is totally occluded, causing prolonged ischemia and cell
death or infarction of the myocardium. At the point of obstruction,
heart tissue becomes necrotic, and an area of injury, inflammation,
 and ischemia develops around the necrotic zone. Functions of
myocardial contractility and conduction are lost quickly. There is
irreversible damage unless blood supply can be restored with the
first 20 to 30 minutes. Inflammation subsides after 48 hours. The
area of necrosis is gradually replaced by fibrous (nonfunctional)
tissue. The size of the infarct is determined by location of arterial
blockage and presence of collateral circulation.
32. (p. 241) Signs and symptoms include sudden, severe, steady, and
crushing substernal chest pain that radiates to the left arm,
shoulder, jaw, or neck. Other manifestations may occur even if
pain is not present, including pallor, diaphoresis, nausea,
dizziness, weakness, dyspnea, anxiety, fear, hypotension, and low-
grade fever.
33. (p. 241) Diagnosis is confirmed through electrocardiogram (ECG)
changes and serum enzyme and isoenzyme levels. Serum levels of
myosin and cardiac troponin are elevated; serum electrolyte levels
may be abnormal; leukocytosis and an elevated C-reactive protein
(CRP) and erythrocyte sedimentation rate (ESR) are common;
arterial blood gas is altered. Pulmonary artery pressure
measurements should be conducted to determine ventricular
function.
34. (p. 242, Fig. 12.16) Serum enzymes are intracellular enzymes
diffused from necrotic cells into the serum in a typical and
predictable pattern that can be measured. Isoenzymes are
subgroups of a specific enzyme and are found primarily in one
type of tissue. Levels of serum enzymes and isoenzymes can be
used to identify the site of the infarction, confirm a myocardial
infarction, and assess size (severity) of infarction.
35. (pp. 242–243) Electrical activity of myocardium will be altered in
areas of severe ischemia or necrosis.
36. (p. 242) Arrhythmias account for the greatest number of deaths
because they impair the efficiency of the heart, resulting in
decreased perfusion to vital organs as well as the heart itself,
leading to shock.
37. (pp. 241–242) Other complications include cardiogenic shock,
congestive heart failure, and, less frequently, the rupture of
necrotic heart tissue and thromboembolism.
38. (pp. 242–243) Treatment includes rest, which allows the body to
repair damage without stressors; oxygen therapy, which increases
oxygen levels to compensate for decreased cardiac output;
analgesics to relieve pain; anticoagulants to prevent clot formation;
antiarrhythmics to reduce arrhythmias; digoxin, which generally
supports heart function; specific measures to treat shock if present,
which reduce chances of another attack or development of
congestive heart failure; and bypass surgery, which can redirect
blood supply around damaged vessels.
39. (pp. 238–243)
• Angina is usually precipitated by something that increases heart
rate; a myocardial infarction (MI) may occur at rest or even
while asleep.
• Anginal pain is relieved by nitroglycerin and rest; the pain of an
MI is not relieved by nitroglycerin and rest.
• There is no tissue death (permanent damage) with angina; MI
causes cell death.
• Cardiac enzymes and isoenzymes are elevated with MI; there are
no changes with angina. There are permanent ECG changes with
MI; no permanent ECG change occurs with angina.
• There is leukocytosis with MI; white blood cell count is not
elevated with angina.
• CRP is elevated with MI; it is not elevated with angina.
• ESR is elevated with MI but not with angina.
• There are elevated serum levels of myosin and troponin with MI.

Cardiac Dysrhythmias (Arrhythmias)

40. (Fig. 12.2, p. 242)
41. (Fig. 12.16, p. 242) SA node to AV node to AV bundle (bundle of
His) to right and left bundle branches to Purkinje fibers
 g j
42. (p. 225, Fig. 12.2)
43. (pp. 224–225, Fig. 12.2, p. 242)
i. P wave: atrial depolarization
ii. QRS complex: ventricular depolarization
iii. T wave: ventricular repolarization
44. (pp. 242–243) alteration of cardiac rate or rhythm
45. (p. 242) Cardiac arrhythmias may be due to damage to the heart's
conduction system or to systemic causes such as electrolyte
abnormalities, fever, hypoxia, stress, infection, or drug toxicity.
46. (p. 244, Table 12.2)
a. heart rate greater than 350 beats per minute; v. fibrillation
b. extra heartbeat arising in the ventricles; viii. premature
ventricular contraction (PVC)
c. heart rate less than 60 beats per minute; ii. bradycardia
d. slowing or no transmission of impulses between atria and
ventricles; vi. heart block
e. additional heartbeat originating in atria; vii. premature atrial
contraction (PAC)
f. restoration of normal cardiac rhythm by electrical shock; i.
cardioversion
g. heart rate between 160 and 350 beats per minute; iv. flutter
h. extra beat originating outside the SA node; iii. ectopic beat
i. heart rate between 100 and 160 beats per minute; ix. tachycardia
47. (pp. 243–245) It interferes with normal ventricular filling and
decreases both period of ventricular diastole and perfusion.
48. (pp. 243–245) It results in decreased cardiac output, which results
in decreased perfusion of vital organs.
49. (p. 233, Table 12.1)
 Drug Adverse
Action and Effects Example
Group Effects
β- Blocks β-adrenergic receptors, slowing Dizziness, Lopressor
Adrenergic the heart rate, prevents sympathetic fatigue
blockers nervous system (SNS) stimulation and
increased demand on heart
Calcium Vasodilator, blocks calcium channel Dizziness, Adalat
channel fainting,
blockers headache
Digitalis Slows conduction through the Nausea, Lanoxin
(cardiac atrioventricular (AV) node, increases fatigue,
glycosides) force of contraction (cardiotonic) to headache,
increase efficiency weakness

50. (p. 245, Table 12.1 and throughout chapter)

• antihypertensive to decrease blood pressure and cardiac
workload
• diuretic to help control blood pressure and prevent edema
• platelet inhibitor to decrease platelet aggregation and decrease
the chance of thrombus formation
• anticoagulant to decrease the chance of thrombus formation
• antihyperlidemic to decrease blood cholesterol and LDL levels
and hopefully slow or arrest progression of atherosclerosis
• nitroglycerin
51. (p. 245, Fig. 12.18) device that provides electrical stimulation
directly to the heart muscle to stimulate heart contraction as
needed or to gain overall control of heart rate
52. (p. 245) Use of electronic equipment (microwaves, dental
Cavitrons) may interfere with normal functioning of a pacemaker.
53. (p. 245) cessation of all activity in the heart—no impulse
conduction, thus a flat ECG

Heart Failure
54. (p. 245) Causes include a problem in the heart itself (e.g., valve
defect or MI) or a condition that increases the workload of the
 heart (e.g., hypertension).
55. (pp. 246–249, Fig. 12.19) Reduced blood flow into systemic
circulation to include kidneys: increased rennin and aldosterone
secretion—resulting in vasoconstriction and increased blood
volume. SNS response increases heart rate and peripheral
resistance. Chambers of the heart tend to dilate, and cardiac
muscle becomes hypertrophied.
56. (p. 247, Fig. 12.21) Backup effects: the chamber and blood vessels
behind or “upstream” from the failing ventricle will not empty
properly, resulting in the accumulation or congestion of blood and
therefore an increased pressure in these areas. Forward effects:
there will be decreased output of blood from the failing ventricle
into the vessels “in front” of it or “downstream.”
57. (pp. 247–249, Table 12.3)

Right-Sided Heart Failure Left-Sided Heart Failure

Cause Infarction of right ventricle, Infarction of left ventricle,
pulmonary valve stenosis, aortic valve stenosis,
pulmonary disease (cor hypertension,
pulmonale) hyperthyroidism
Backup effects Dependent edema in feet, Orthopnea, cough,
hepatomegaly and splenomegaly, shortness of breath,
ascites, distended neck veins, paroxysmal nocturnal
headache, flushed face dyspnea, hemoptysis,
rales
Forward Fatigue, weakness, dyspnea, Fatigue, weakness,
effects exercise intolerance, cold dyspnea, exercise
intolerance intolerance, cold
intolerance
Manifestations See above forward and backup See above forward and
effects. backup effects.
Compensations: tachycardia and Compensations:
pallor, secondary polycythemia, tachycardia and pallor,
daytime oliguria secondary polycythemia,
daytime oliguria

58. (p. 249)

 i. venous congestion in inferior vena cava and other veins draining
abdominal organs
ii. venous congestion in inferior vena cava and other veins draining
abdominal organs
iii. due to pulmonary edema—fluid shifts into upper lobes when
head lowered, causing dyspnea and anxiety, and more fluid
shifts from tissues into blood when recumbent, thus increasing
vascular volume and pressure in pulmonary capillaries
iv. due to fluid congestion in lungs and pulmonary edema
v. as congestion increased in pulmonary circulation, red blood cells
are pushed out of capillaries into alveoli, causing rusty-colored
sputum or blood-specked sputum
vi. due to increased congestion and pressure in superior vena cava
vii. occurs during day—vas fluid accumulates in dependent
regions, and there is decreased renal perfusion; late in disease,
oliguria reflects decreased cardiac output and renal failure
viii. when individual is in supine position, edema in dependent
areas is mobilized, resulting in increased cardiac output, renal
perfusion, and therefore glomerular filtration rate
ix. impaired gas exchange due to pulmonary congestion causes
chronic hypoxia that in turn stimulates release of erythropoietin
—increased RBC production
59. (p. 250)
i. helps prevent fluid retention
ii. could help arrest progression of atherosclerosis
iii. prevent venous stasis and thrombophlebitis
iv. decreases dyspnea and improves arterial blood gases
v. mobilize edema (including pulmonary edema) and promote
excretion of excess fluid, leading to decreased plasma volume
and therefore decreased cardiac workload
vi. prevents hypokalemia, which is a common side effect of
diuretic therapy
 vii. decrease renin secretion and therefore prevent both
vasoconstriction and aldosterone secretion (which causes salt
and water retention)
viii. increases strength of myocardial contractions that increase
cardiac output
ix. decreases thrombosis, particularly in legs
x. decreases anxiety, which can contribute to increased heart and
respiratory rates

Congenital Heart Defects

60. (p. 250–251) Most defects are multifactorial and reflect both
genetic and environmental influences (e.g., chromosomal
abnormalities in Down syndrome). Environmental factors include
viral infections such as rubella and maternal alcoholism (fetal
alcohol syndrome [FAS]) and maternal diabetes.
61. (pp. 251–255, Fig. 12.23, p. 251, Fig. 12.24, p. 252)
i. a hole or defect in the atrial or ventricular septa
ii. failure of a valve to close completely
iii. backward flow or leaking of blood due to valvular
incompetence
iv. abnormally enlarged and floppy valve leaflets that balloon
backward with pressure or posterior displacement of the valve
cusp
v. narrowing of a valve
vi. abnormal heart sounds due to leaky valves (p. 251)
62. (p. 250) by presence of a heart murmur
63. (p. 250) Left-to-right shunt means that blood from the left side of
the heart is recycled to the right side and to the lungs, resulting in
increased volume in the pulmonary circulation, decreased cardiac
output, and an inefficient system—an acyanotic condition. Right-
to-left shunt means that unoxygenated blood from the right side of
the heart bypasses the lung directly and enters the left side of the
 heart and hence the systemic circulation, producing varying
degrees of cyanosis; death may occur in infancy in severe cases.
64. (p. 252) Signs and symptoms include:
• pallor and cyanosis
• tachycardia, with very rapid sleeping pulse, frequently a pulse
deficit
• dyspnea on exertion and tachypnea
• in toddlers and older children, frequently assuming a squatting
position to modify blood flow
• clubbed fingers developed in time
• marked intolerance for exercise and exposure to cold
• delayed growth and development
65. (pp. 251–253, Fig. 12.23) Ventricular septal defect is the most
common congenital heart defect—“hole in the heart.” Large
openings: left-to-right shunt, reducing the flow of blood from the
left ventricle, reducing stroke volume and cardiac output in the
systemic circulation. More blood enters the pulmonary circulation,
compromising its efficiency, and in time, overloads and
irreversibly damages the pulmonary vessels, causing pulmonary
hypertension. This complication, if untreated, would lead to
abnormally high pressure in the right ventricle and reversal of the
shunt to a right-to-left shunt, leading to cyanosis.
Defect Backup Effects Forward Effects Manifestations
Mitral Left atrial Decreased cardiac output Dyspnea,
stenosis hypertrophy orthopnea
Atrial Cyanosis,
arrhythmias fatigue
Mural thrombi Arrhythmias
Pulmonary Heart murmur
congestion Increased risk
Pulmonary for stroke due
hypertension to emboli
originating in
left atrium
Mitral Left atrial Decreased cardiac output Dyspnea,
regurgitation hypertrophy orthopnea
Atrial Cyanosis,
arrhythmias fatigue,
Mural thrombi dizziness
Pulmonary Arrhythmias
congestion Heart murmur
Pulmonary
hypertension
Aortic Left ventricular Decreased cardiac output Dizziness,
stenosis hypertrophy fainting
If severe, Fatigue
increased Heart murmur
congestion in If severe,
left atrium and dyspnea,
pulmonary orthopnea,
congestion cyanosis,
angina
Aortic Left ventricular Increased stroke volume Very strong,
regurgitation hypertrophy and cardiac output bounding
If severe, heart pulse
failure Heart murmur
May develop
symptoms of
heart failure
 Defect Backup Effects Forward Effects Manifestations
Pulmonary Right Decreased blood flow Weakness,
stenosis ventricular through pulmonary fatigue,
hypertrophy circulation, leading to cyanosis
Congestion in decreased gas exchange and Swelling of
right atrium blood to left side of heart feet and
and systemic ankles
veins Symptoms of
Leads to right- right-sided
sided heart heart failure
failure Heart murmur
Pulmonary Right Decreased blood flow Weakness,
regurgitation ventricular through pulmonary fatigue,
hypertrophy circulation, leading to cyanosis
Congestion in decreased gas exchange and Swelling of
right atrium blood to left side of heart feet and
and systemic ankles
veins Symptoms of
Leads to right- right-sided
sided heart heart failure
failure Heart murmur

66. (pp. 250–253, Figs. 12.22 to 12.25)

67. (p. 252) valvular defect; septal defect
68. (p. 253, Fig. 12.24c)
i. pulmonary valve stenosis: restricts outflow from the right
ventricle, leading to right ventricular hypertrophy and high
pressure in the right ventricle leading to the right-to-left shunt
ii. ventricular septal defect (VSD): an opening in the ventricular
septum allows blood to flow between the ventricles
iii. dextroposition of the aorta: promotes blood flow directly from
the right ventricle into the general circulation
iv. right ventricular hypertrophy: thickening of the ventricular wall
because of increased work
The most common cyanotic congenital heart disorder, tetralogy of
Fallot, is a right-to-left shunt of blood through the VSD with
 marked systemic effects. This means that unoxygenated blood
from the right side of the heart bypasses the lungs and enters the
left side of the heart and into the general circulation. The high
proportion of unoxygenated blood produces a bluish color in the
skin and mucous membranes (cyanosis) and marked systemic
effects resulting from hypoxemia.
69. (p. 252) Treatments include surgical repair of defect, valve
replacement, or drug therapy (those used for heart failure).
70. (pp. 252–253)
i. He will be taking a platelet inhibitor such as ASA or an
anticoagulant because despite replacement of damaged valve,
platelets will still aggregate on the replacement. These could
become emboli, therefore increasing risk for stroke.
ii. He will require an antibacterial agent, preferably penicillin
(unless he is allergic) for prophylaxis, because invasive
procedures provide a portal of entry for bacteria that may then
colonize the prosthetic valve, causing infective endocarditis.

Rheumatic Fever, Rheumatic Heart Disease, and Infective

Endocarditis
71. (pp. 255–256) group A β-hemolytic streptococci
72. (pp. 255–256) those between 5 and 15 years of age
73. (pp. 255–256) An acute systemic inflammatory condition resulting
from abnormal immune reaction of an untreated infection, usually
β streptococci. Results in acute cardiac inflammation involving one
or more layers of the heart: pericarditis, myocarditis, and/or
endocarditis. Other sites of inflammation include large joints,
particularly in the legs; migratory polyarthritis; nonpruritic skin
rash; nontender subcutaneous nodules on the extensor surfaces of
wrists, elbows, knees, or ankles; and inflammation of the basal
nuclei in the brain, causing involuntary jerky movements.
Rheumatic heart disease can develop years later.
74. (p. 256)
 i. low-grade fever, leukocytosis, malaise, anorexia, and fatigue
ii. inflammation of the outer layer of the heart; may include
effusion
iii. inflammation develops as localized lesions in the heart muscle,
called Aschoff bodies
iv. inflammation of the inner lining of the heart, especially the
valves, which become edematous; verrucae (small wartlike
lesions) form
v. migratory inflammation of many joints, especially in the legs
vi. erythema marginatum (red macules or papules)
vii. nontender lesions on the extensor surfaces of wrists, elbows,
and knees
viii. inflammation of the basal nuclei in the brain causing
involuntary jerky movements of the face, arms, and legs
75. (pp. 256–257) Endocarditis may lead to permanent scarring of
heart valves, which leads to rheumatic heart disease. If rheumatic
heart disease develops, the individual is now at high risk for
infective endocarditis.
76. (p. 256, Think About box 12.14) CBC (Chapter 11) and serology
for identifying leukocytosis and anemia; monitoring
antistreptolysin O antibody titer; ECG to identify characteristic
changes
77. (p. 256)
 Medication Effects Example
Antibiotics Eradicate bacteria and prevent Penicillin (first
further infection choice unless patient
is allergic)
NSAIDs Decrease acute inflammation to ASA
prevent heart complications Ibuprofen
Relieve joint symptoms
Lower fever
Corticosteroids Decrease immune response and Prednisone
acute inflammation to prevent heart
complications
Antipyretics Decrease fever ASA
Ibuprofen
Acetaminophen
Antiarrhythmics Improve efficiency of heart function Metoprolol
and prevent complications Nifedipine
Digoxin
Muscle Decrease muscle spasms Diazepam
relaxants

78. (p. 255, Figs. 12.27 and 18.28) Rheumatic fever is an acute,
inflammatory disorder caused by abnormal immune response,
following an infection by group A β-hemolytic streptococci.
Rheumatic heart disease is a long-term result of rheumatic fever
that involves permanent scarring of one or more heart valves and a
high risk for infective endocarditis. Scar tissue in the myocardium
may cause arrhythmias.
79. (p. 255) mitral valve
80. (p. 257, Think About) Damaged heart valve stimulates platelet
aggregation, leading to increased risk for emboli and stroke.
81. (pp. 256–257) Damaged endocardial surface provides
environment for bacterial colonization.
82. (p. 257) Some individuals should be premedicated with
antimicrobial drugs before invasive procedures to avoid
bacteremia. There are two predisposing factors for subacute
infective endocarditis: damaged endocardium and portal of entry
 for bacteria or other organisms. Someone with rheumatic heart
disease has damaged heart valves, and the invasive procedure
provides the portal of entry.
83. (p. 254) Despite replacement of damaged valve, there is an
increased susceptibility to thrombus formation, requiring patients
to take daily ASA (Fig. 12.26B).
84. (p. 257) subacute: defective heart valves infected by organisms
with low virulence (e.g., Streptococcus viridans); acute: normal
valves attacked by highly virulent pathogens, (e.g., Staphylococcus
aureus)
85. (p. 257) Those with:
• congenital defects
• rheumatic fever
• mitral prolapse
• prosthetic heart valve(s)
• septal defects
• recent stent insertion (artificial)
• indwelling catheters
• immunosuppression or immunodeficiency such as AIDS
86. (pp. 256–257)
• infection of normal or defective heart valves
• inflammation of the valves and formation of vegetations on the
cusps
• defective opening and closing of valves
• potential for septic emboli causing infarction or infection
• additional scarring and destruction of valve leaflets and chordae
tendinea
87. (pp. 256–257) Subacute infective endocarditis has an insidious
onset. Various new heart murmurs are common. An initial low-
grade fever and fatigue may be signs. Anorexia, splenomegaly,
and Osler nodes on the fingers are often present. There are signs of
 vascular occlusion or infection (abscesses) in remote locations. An
intermittent high fever (septicemia) may develop, and in severe
cases, congestive heart failure develops. Acute endocarditis has a
sudden onset with sudden spiked fever, chills, and drowsiness.
Heart valves are badly damaged and may be torn, causing severe
impairment of heart function. As in the subacute form, septic
emboli may cause infarctions and abscesses in remote sites with
corresponding signs and symptoms of infection.
88. (p. 256) blood culture
89. (p. 256) antimicrobial drugs, usually for a minimum of 4 weeks;
other medication to support heart function is usually required
90. (pp. 255–257)
 Rheumatic Fever Infective Endocarditis
Causative Group A β-hemolytic Acute Staphylococcus aureus
agent(s) streptococci (most common)
Subacute Streptococcus viridans
(most common)
Gram-negative bacilli
Enterococci
Fungi
Predisposing Age: 5–15 Damaged endocardium:
factors Economically rheumatic heart disease,
disadvantaged previous endocarditis,
Living in crowded congenital heart defects,
conditions prosthetic heart valves
Portal of entry for microbes: IV
drug users, indwelling
catheters, recent joint
replacement
Manifestations General: fever, General: fever, leukocytosis,
and leukocytosis, malaise, fatigue, anorexia, elevated ESR
complications fatigue, anorexia Positive blood culture
Heart: pericarditis, Change in heart murmur
myocarditis, endocarditis, Septic emboli
tachycardia, heart Cough, dyspnea
murmur, arrhythmias, Arthralgia, arthritis
heart failure Petechial hemorrhages in skin,
Polyarthritis mucosa, nail bed
Skin manifestations: rash Chest pain
Chorea Confusion, paralysis, stroke
Subcutaneous nodules Blindness
Epistaxis Hematuria
Abdominal pain Abdominal pain
Antibiotic of Penicillin Penicillin or other drug specific
choice for causative agent
Prophylactic Not unless permanent Yes—amoxicillin unless allergic
antibiotic heart valve problems (e.g.,
coverage? rheumatic heart disease);
then amoxicillin

91. (pp. 257–258) Acute pericarditis may involve a simple

inflammation of the pericardium or may be secondary to open
 heart surgery, myocardial infarction, rheumatic fever, systemic
lupus erythematosus, cancer, renal failure, trauma, or viral
infection.

Hypertension
92. (p. 258) High blood pressure, when the systolic pressure is above
120 and the diastolic pressure is above 70 when an individual is at
rest. Essential hypertension develops when blood pressure is
consistently above 140/90 mm Hg. Men are more likely to have
hypertension before 55 years of age, after which age women have a
greater incidence. Differences in systolic and diastolic pressure
increase with age, as the elasticity of arteries is lost.
93. (pp. 258–259) Essential hypertension is idiopathic. Secondary
hypertension results from renal (e.g., nephrosclerosis) or endocrine
(e.g., hyperaldosteronism) disease, or pheochromocytoma.
94. (p. 258) hypertension that is uncontrollable, severe, and rapidly
progressive with many complications and characterized by high
diastolic pressure
95. (pp. 259–260)
• genetic factors—nonmodifiable
• excessive alcohol intake—modifiable
• high sodium intake—modifiable
• obesity—modifiable
• prolonged or recurrent stress—modifiable
96. (pp. 258–259, Figs. 12.29 and 12.30) There is an increase in
arteriolar vasoconstriction, possibly due to increased susceptibility
to various stimuli. There is a major increase in peripheral
resistance, reducing the capacity of the system and increasing
diastolic pressure. Decreased renal blood flow causes an increase
in renin, angiotensin, and aldosterone secretion. Resulting
increases in vasoconstriction and blood volume further increase
blood pressure. Chronic hypertension causes arterial wall damage,
sclerosis, and stenosis. Aneurysms or atheromas may form,
 reducing blood flow to involved area. There is ischemia and
necrosis of involved tissues. The areas most frequently damaged
are the kidneys, brain, and retina. The end result of poorly
controlled hypertension can be chronic renal failure, stroke, vision
loss, or congestive heart failure.
97. (p. 258) It is often asymptomatic in the early stage, and initial
symptoms are usually vague until complications arise.
98. (p. 259) Reduce salt intake, which reduces blood pressure; body
weight, which puts less stress on the heart as it labors to pump
blood through the circulatory system and fat tissue around the
heart itself restrict the movement of the heart muscle; and stress,
which lowers blood pressure and increases cardiovascular fitness,
which strenghthens the heart muscle.
99. (p. 260) patient compliance—i.e., willingness to consistently
follow treatment plan

Antihypertensive Medications
100. (pp. 260–261; Table 12.1)
 Type of Mechanism of Adverse
Examples
Antihypertensive Action and Effects Effects
Diuretics Increased excretion Nausea, Furosemide
of sodium and vomiting Hydrochlorothiazide
water, leading to Orthostatic
decreased blood hypotension,
volume dizziness
Xerostomia
Hypokalemia
ACE inhibitors Block formation of Headache Enalapril
angiotensin II Orthostatic Ramipril
Decrease hypotension, Captopril
aldosterone dizziness Fosinopril
secretion
Prevent
vasoconstriction
Calcium channel Vasodilation Dizziness, Nifedipine
blockers Decrease fainting, Amlodipine
myocardial headache Diltiazem
conduction and Orthostatic
contractility hypotension
Constipation
Gingival
hypertension
β-Adrenergic Prevent increased Bradycardia Metoprolol
blockers heart rate in Dizziness, Atenolol
response to fatigue Propranolol
sympathetic Orthostatic Nadolol
nervous system hypotension
and cholamines Sexual
dysfunction

101. (p. 260) nausea, erectile dysfunction, orthostatic hypotension,

dizziness
102. (p. 261)
• platelet inhibitor: to prevent heart attacks and strokes
• antihyperlidemic: to arrest or slow progression of atherosclerosis

Peripheral Vascular Disease (PVD)

103. (p. 261)
• increasing fatigue and weakness in the legs
• intermittent claudication
• sensory impairment
• weak peripheral pulse distal to the occlusion
• marked pallor or cyanosis when legs elevated; redness when
they are dangling
• skin that is dry and hairless
• toenails that are thick and hard
• poorly perfused extremities that are cold
104. (pp. 261–262)
• reduction in serum cholesterol levels
• platelet inhibitors or anticoagulants to reduce thrombosis
• smoking cessation
• exercise program
• maintaining dependent position for the legs
• peripheral vasodilators
• surgical procedures to increase blood flow
• preventive measures to avoid skin trauma
• antibiotics for gangrenous ulcers
• amputations when necessary to prevent infection spread; relieve
pain
105. (pp. 261–262) localized dilation of an arterial wall
106. (p. 262) Causes include atherosclerosis, trauma (particularly
automobile accidents), syphilis, and congenital defects.
107. (p. 262) rupture, leading to moderate bleeding or severe
hemorrhage and death; or thrombus may develop in the
aneurysm, causing obstruction
108. (p. 262, Fig. 12.33) inherent weakness or defect in vein walls or
valves (familial tendency); long periods of standing
109. (p. 263)
• superficial varicosities on the legs appear as irregular, purplish,
bulging veins in the legs
• edema in the feet
• fatigue and aching in the legs are common
• shiny, pigmented, and hairless skin
• ulcers may develop
110. (p. 264) thrombophlebitis: development of a thrombus in a vein
in which inflammation is present; phlebothrombosis: spontaneous
thrombus development in the absence of inflammation
111. (p. 263)
• blood stasis or sluggish blood flow
• endothelial injury
• increased blood coagulability
112. (p. 264)
• exercise
• elevation of legs
• compression or elastic stockings
113. (p. 264; Chapter 13) Pulmonary embolus is a blood clot (or
sometimes other material) that blocks a pulmonary artery or one of
its branches. It typically originates in leg veins as a result of
thrombophlebitis.

Shock
114. (p. 264) hypotension resulting from a decreased circulating
blood volume, resulting in decreased tissue perfusion and general
hypoxia
115. (pp. 264–266, Fig. 12.34)
• SNS and adrenal medulla stimulated to increase the heart rate,
force of contractions, and systemic vasoconstriction
 • renin secreted to activate angiotensin (a vasoconstrictor);
aldosterone to increase blood volume (sodium and water
retention)
• increased antidiuretic hormone (ADH) to promote water
reabsorption in the kidneys and thereby increase blood volume
• glucocorticoids secreted to help stabilize the vascular system
• acidosis stimulates respirations, increasing oxygen supply
116. (p. 268, Table 12.5)
• Thirst, anxiety, and restlessness occur, because the SNS is quickly
stimulated by hypotension.
• Compensation follows, as vasoconstriction shunts blood from the
viscera and skin to the vital areas.
• Progressive signs include lethargy, weakness, and faintness, and
metabolic acidosis due to decrease in blood flow and blood
pressure. Metabolic acidosis may result, as anaerobic
metabolism increases lactic acid secretion.
117. (pp. 265–267, Figs. 12.34 and 12.35) If shock is prolonged, the
body's responsiveness diminishes as oxygen supply decreases and
wastes accumulate. Compensated metabolic acidosis progresses to
decompensated acidosis (Chapter 6). There is depression of the
central nervous system, loss of cell metabolism, and reduction in
effectiveness of medications. The progression to irreversible shock
results in acute renal failure due to tubular ischemia and necrosis
and acute respiratory distress syndrome (ARDS).
118. (p. 268, Emergency Treatment box)
• Place patient in supine position.
• Cover and keep warm.
• Call 911 or other assistance.
• Administer oxygen if possible.
• Determine underlying cause, and treat if possible (e.g., pressure
for bleeding).
119. (pp. 265–269; Table 12.4, Fig. 12.33)
Type of Specific Specific
Etiology
Shock Manifestations Treatment
Hypovolemic Blood or plasma loss Bleeding Blood or
or Dehydration: vomiting, Burns plasma
hemorrhagic diarrhea Dysphagia, transfusions
“Third spacing” nausea, Fluid and
vomiting, electrolyte
diarrhea replacement
Ascites Treat specific
Signs of cause (e.g.,
peritonitis measures to
stop bleeding)
Cardiogenic Myocardial infarction Warning signs of Antiarrhythmic
Arrhythmias infarction agents
ECG changes ECG
monitoring
See treatment
of myocardial
infarction
Anaphylactic Severe allergic or Severe dyspnea, Epinephrine
hypersensitivity reaction wheezing, chest IM or IV
leads to generalized tightness (EpiPen)
vasodilation Pruritus, Corticosteroids
urticaria (hives), Antihistamines
tingling
Flushing, feeling
of warmth
Septic Severe, overwhelming High fever, Antibacterial
infection possibly with Corticosteroids
chills Antipyretics
Warm, flushed,
dry skin
Rapid, strong
pulse
Hyperventilation
 Type of Specific Specific
Etiology
Shock Manifestations Treatment
Neurogenic Pain or fear Sudden vertigo Spirits of
(syncope) Emotional upset and loss of ammonia
(unpleasant sight or consciousness “smelling
smell) Flushed, warm salts”
skin Lower head
Remove
stimulus

Consolidation
120. (pp. 263–264)
i. right-sided heart failure
ii. thrombophlebitis
iii. myocardial infarction; arrhythmias
iv. rheumatic fever, endocarditis
v. thrombophlebitis
vi. heart failure
vii. congenital defects, rheumatic fever, rheumatic heart disease,
tetralogy of Fallot, septal defects, valvular defects—stenosis and
regurgitation
viii. myocardial infarction
ix. rheumatic fever
x. left-sided heart failure, mitral stenosis, mitral regurgitation
121. (Table 12.1)
i. antihypertensive, antiarrhythmic, prophylactic antianginal
ii. antianginal—prophylactic or acute
iii. scarlet fever, rheumatic fever, rheumatic heart disease
iv. antihypertensive antiarrhythmic, prophylactic antianginal
v. heart failure, antiarrhythmic
vi. heart failure, hypertension
vii. arrhythmias, post–myocardial infarction, rheumatic fever
viii. antihypertensive
Chapter 13
Respiratory System Disorders
1. (p. 274, Fig. 13.1) See Fig. 13.1 of the text.
A. Upper respiratory system, B. Nasal cavity, C. Oral cavity, D. Tongue,
E. Pharynx, F. Larynx (voice box), G. Lower respiratory system, H.
Left lung, I. Left main bronchus, J. Pleura, K. Bronchiole, L.
Diaphragm, M. Alveoli, N. Heart, O. Right lung, P. Right main
bronchus, Q. Trachea, R. Epiglottis
2. (p. 281) See Fig. 13.7 of the text.
A. Eupnea, B. Tachypnea, C. Bradypnea, D. Apnea, E. Hyperpnea, F.
Cheyne-Stokes respiration, G. Ataxic breathing, H. Kussmaul
respiration, I. Apneusis, J. Obstructed breathing
3. (p. 284, Fig. 13.8) otitis media, sinusitis, pneumonia
4. (pp. 284–286, Table 13.3, p. 284)
 Croup
Epiglottitis Bronchiolitis
(Laryngotracheobronchitis)
Usual age 3 months to 3 years 3–7 years 2–12 months
Cause Virus Haemophilus influenzae Virus: respiratory
syncytial virus
(RSV)
Onset Gradual Rapid Gradual
Pathology Inflammation of mucosa of Supraglottic Inflammation of
larynx and trachea inflammation and mucosa of
obstructs airway swelling of epiglottis bronchioles
obstruct airway obstructs small
passages
Significant Hoarse, barking cough Drooling, dysphagia, Increasing
signs and Inspiratory stridor high fever, appears ill, dyspnea,
symptoms Restlessness rapid respirations and paroxysmal cough,
pulse, tripod position wheezing, chest
at play retractions, flared
nostrils
Treatment Cool, moisturized air from Oxygen and Supportive or
a humidifier, shower, or antimicrobial therapy symptomatic with
croup tent with intubation or monitoring of
tracheotomy if blood gases in
necessary severe cases

5. (p. 286, Fig. 13.10, p. 284, Table 13.4)

 Interstitial
Lobar Pneumonia Bronchial Pneumonia
Pneumonia
Causative agent Streptococcus Multiple bacteria Influenza virus
pneumoniae Mycoplasma
Onset Sudden and acute Insidious Variable
Distribution All of one or two lobes Scattered small patches Diffuse
within lungs throughout
lung
Pathophysiology Inflammation of Inflammation and Interstitial
alveolar wall and purulent exudate in inflammation
leakage of cells, fibrin, alveoli often arising around alveoli
and fluid into alveoli from prior pooled Necrosis of
causing consolidation secretions or irritation bronchial
epithelium
Signs and High fever and chills Mild fever Variable fever,
symptoms Productive cough with Productive cough headache
rusty sputum with yellow-green Aching
Rales progressing to sputum muscles
absence of breath Dyspnea Nonproductive
sounds in affected hacking cough
lobes
Treatment Antibacterial Antibacterial Erythromycin
medication in medications or tetracycline
combination with
fluids; drugs to reduce
fever; and oxygen
Pneumococcal vaccine
is recommended for
the elderly and those
at risk for other
disease

6. (p. 289) Pneumocystis carinii pneumonia (PCP) is an atypical pneumonia

that occurs as an opportunistic and often fatal infection in patients with
AIDS. The etiologic agent is a fungus that is inhaled and attaches to
alveolar cells, causing necrosis and diffuse interstitial inflammation.
Onset is marked by dyspnea and a nonproductive cough.
7. (pp. 289–290) SARS-CoV (severe acute respiratory syndrome [SARS]-
associated coronavirus) is the microbial agent responsible for SARS. It is
transmitted by respiratory droplets during close contact.
8. (p. 290) Flulike symptoms are present for 3 to 7 days, followed several
days later by a dry cough and marked dyspnea. By day 7, chest
radiographs indicate spreading patchy areas of interstitial congestion
and severe hypoxia; there may be thrombocytopenia, lymphopenia, and
elevated liver enzymes (due to viral damage). The final stage is severe,
sometimes fatal respiratory distress.
9. (p. 290)
stage 1: fever, headache, myalgia, diarrhea
stage 2: nonproductive cough, severe dyspnea, hypoxia
stage 3: severe hypoxia, respiratory and metabolic acidosis
10. (p. 290) medications: ribavirin (antiviral) and GC-methylprednisolone;
oxygen with mechanical ventilation
11. It is difficult to control the spread of an unidentified causative agent
because the type of microbe has not been identified as bacterial, viral, or
fungal. The routes of transmission may not be known. The agent's
sensitivity to antimicrobial medications is not known. The usual course
of the infection (i.e., complications and prognosis) may not be known.

Tuberculosis
12. (p. 290) acid-fast, aerobic, slow-growing bacillus that is resistant to
drying and many disinfectants
13. (p. 290) The cell wall prevents digestion and destruction by defensive
cells.
14. (p. 292) Individuals who are at high risk for contracting tuberculosis are
those whose resistance is lowered because of immunodeficiency,
malnutrition, alcoholism, conditions of war, or chronic disease. There
may be a genetic susceptibility. Children are vulnerable, as are the
homeless. Patients with AIDS are also at high risk.
15. (pp. 288–291, Fig. 13.12) In the primary infection, the pathogen is
engulfed by macrophages and causes a local inflammatory reaction,
usually on the periphery of the upper lobe. Some bacilli migrate to the
lymph nodes, activating a type IV hypersensitivity response.
Lymphocytes and macrophages cluster to form a granuloma at the site
of inflammation. The granuloma contains the bacilli, some of which
remain alive, forming a tubercle. Caseation necrosis develops in the
 center of the tubercle. The secondary infection is the active infection. It
often arises years after primary infection as a result of decreased host
resistance. Tissue necrosis and cavitation occur, forming a large open
area in the lung and erosion into the bronchi and blood vessels.
Hemoptysis is common. Infection may spread to other body systems,
and bacilli may infect sputum.
16. (p. 291) Ghon tubercle is the core of caseation necrosis, surrounded by
lymphocytes and macrophages. It is eventually walled off by fibrous
tissue and usually becomes calcified.
17. (p. 291) Primary tuberculosis is asymptomatic. Secondary infection has
an insidious onset with vague symptoms of anorexia, malaise, fatigue,
and weight loss; afternoon low-grade fever and night sweats; prolonged
and increasingly severe cough; and productive, purulent sputum, often
containing blood.
18. (p. 291) rapidly progressive form in which multiple granulomas affect
large areas of the lungs with rapid dissemination via the bloodstream;
resistant to treatment
19. (p. 291) with chest radiograph, acid staining of sputum specimen, and
sputum culture
20. (pp. 291–292; Chapter 3, Type IV Delayed Hypersensitivity) The
Mantoux test is the tuberculin test. A positive skin test does NOT mean
the person has active TB. It means that there has been adequate
exposure to cause a hypersensitivity reaction.
21. (p. 292) isoniazid (INH); rifampin; ethambutol; pyrazinamide;
streptomycin; multiple drugs required to prevent the development of
resistant strains; 3 months to 1 year or possibly longer, depending upon
the health of the individual—e.g., someone who also has full-blown
AIDS will probably take TB medications for the rest of his or her life.
22. (p. 292) An individual will become noncontagious when sputum is
negative for microbes, usually about 1 to 2 months. Drugs are prescribed
for a longer period to ensure eradication of the infection.
23.
• individuals whose skin test has converted from negative to positive
within the past 2 years
 • individuals who have radiographic changes consistent with
tuberculosis, even if their sputum is negative
• anyone who is living with, or has frequent close contact with, an
individual with active tuberculosis
• individuals who have immunosuppression due to disease or
medications
• individuals who are HIV positive or have full-blown AIDS
• individuals with hematologic cancer
24. (p. 293) Isoniazid, rifampin, ethambutol, pyrazinamide, and
streptomycin; usually prescribed for 6 months to 1 year
25. (Think About, p. 301) Have regular skin tests and, if the test is positive,
regular chest radiographs; maintain host resistance (get adequate rest
and nutrition).
26. (Think About, p. 302)
• What was the date of the skin test?
• Was the individual vaccinated against TB as a child?
• Has the individual had any known contact with a person who has TB
or a history of TB?
• Did the individual have a follow-up chest radiograph or sputum
specimen for an acid-fast bacilli (AFB) test?
• Did the doctor prescribe medication?
• Is the individual taking the medication? How long has he been taking
the medication?
27. (p. 302)
• Was TB actually diagnosed, or was it a positive skin test?
• Was the individual prescribed medications?
• How long were the medications prescribed for?
• Did the individual actually take the medication at the intervals and for
the time period prescribed?
• When was the individual's last chest radiograph?

Cystic Fibrosis
28. (p. 294; Chapter 7, Table 7.1) an autosomal recessive inherited disorder
29. (p. 123, Chapter 7, Fig. 7.4) Both parents are heterozygous, i.e., carriers
of cystic fibrosis CF). There is a 25% probability that the baby's siblings
will have CF.
30. (p. 293, Chapter 7, Fig. 7.4) There is a 50% probability that the child will
have CF and a 50% probability that he or she will be a carrier.
31. (p. 294, Fig. 13.14) Cystic fibrosis is a common genetic disorder
involving a protein in chloride ion transport in cell membranes. This
defect in the exocrine glands causes thick secretions, such as tenacious
mucus. Primary effects are seen in lungs and pancreas where mucus
blocks passages. In the lungs, there is progressive destruction of lung
tissue and atelectasis, and infections are common. Bronchiectasis and
emphysematous changes develop. Eventually, respiratory failure or cor
pulmonale develops. In the digestive tract, the first indication of
abnormality may be meconium ileus in newborns. Pancreatic blockage
leads to digestive enzyme deficit in the intestines. Malabsorption and
malnutrition develop. Potential pancreatic glandular tissue damage
results in diabetes mellitus in some individuals. Biliary obstruction leads
to fat and fat-soluble vitamin malabsorption and deficiencies.
Ultimately, the general state of malabsorption, malnutrition, and
dehydration develops. The salivary glands are mildly affected, causing
patchy fibrosis. Sweat glands are affected, producing high chloride
sweat and potential electrolyte disturbance in hot weather or during
strenuous exercise. Obstructions in male (vas deferens) and female
(cervix) reproductive systems lead to sterility or infertility.
32. (p. 295) meconium ileus at birth; salty skin; signs of malabsorption:
steatorrhea, abdominal distention, and failure to gain weight; chronic
cough and frequent respiratory infections; progressive hypoxia, fatigue,
and exercise intolerance; growth failure
33. (p. 295) electrolyte analysis of sweat; stool analysis for fat content and
trypsin; pulmonary function tests, radiographs, and blood gases; genetic
analysis
34. (p. 306) interdisciplinary team approach; replacement therapy for
pancreatic enzymes and bile salts; specialized diet; measures to avoid
dehydration; chest physiotherapy; bronchodilators and humidifiers;
aggressive treatment of infections; oxygen therapy for advanced disease
35. (p. 309) With treatment, individuals with CF, on average, live into early
adulthood. Death is usually brought on through respiratory infections
and respiratory or heart failure.

Lung Cancer
36. (pp. 296–297) Venous return and lymphatics bring tumor cells from
many distant sites to the heart and then into the pulmonary circulation.
37. (p. 296) cigarette smoking, especially heavy smokers; secondhand
smoke; chronic obstructive pulmonary disease (COPD); genetic factors;
occupational or industrial exposure to carcinogens
38. (pp. 297–298) obstruction of air flow by tumor growth into the
bronchus; inflammation surrounding the tumor stimulates cough and
predisposes secondary infection; pleural effusion, hemothorax,
pneumothorax due to inflammation or erosion of pleura; paraneoplastic
syndrome; general systemic effects of cancer
39. (pp. 297–298) Early signs related to respiratory involvement include
persistent productive cough, dyspnea, and wheezing; radiographic
changes signifying pneumonia; hemoptysis; pleural involvement—
effusion; pneumothorax or hemothorax; chest pain; hoarseness; facial or
arm edema and headache due to compression of superior vena cava;
dysphagia; and atelectasis. Systemic signs include weight loss, anemia,
and fatigue. Paraneoplastic syndrome is indicated by signs of specific
endocrine disorder. Signs of metastasis depend on site (e.g., bone).
40. (p. 298)
• surgical resection or lobectomy
• chemotherapy
• radiation
• photodynamic therapy

Aspiration
41. (p. 298) passage of food or fluid, vomitus, drugs, or other foreign
material into the trachea and lungs
42. (p. 299) young children; children with congenital anomalies such as
cleft palate; any individual with depressed swallowing or gag reflex
 (e.g., following anesthesia or stroke or comatose patients); individuals
who eat or drink while lying down or talk while eating
43. (p. 299)
Solid objects lodge in the airway and totally block airflow at that place.
Large objects may occlude the trachea and block all airflow.
Solid objects lodging in a bronchus lead to nonaeration and collapse of
the area distal to the obstruction (p. 299, Fig. 13.17).
Ball-valve effect of solid object: air flows in on inspiration, airway closes
on expiration.
Swelling of some foods (beans) causes them to become more firmly
lodged.
Sharp, pointed objects, like bone fragments, may traumatize mucosa and
cause inflammation that further adds to the airway barrier.
Fatty or irritating solids such as peanuts cause inflammation, creating
edema and further impeding airflow.
Irritating liquids (e.g., vomitus, alcohol) cause severe inflammation,
narrowing airways, and can increase secretions; if alveoli are
involved, gaseous exchange may be impaired: this is called chemical
or aspiration pneumonia.
Complications include respiratory distress syndrome, pulmonary
abscess, and systemic effects of aspirated solvents.
44. (p. 299) coughing and choking with marked dyspnea; stridor and
hoarseness (upper airway obstruction); wheezing (liquids); tachycardia
and tachypnea; nasal flaring, chest retractions; inability to speak or
make a sound (total obstruction of larynx or trachea)
45. (Emergency Treatment for Aspiration, p. 299) Stand behind the victim
with encircling arms; position a fist, thumb side against the abdomen,
just below the sternum; place the other hand over the fist; and thrust
forcefully inward and upward.

Asthma
46. (p. 300) a disease that involves periodic episodes of severe but
reversible bronchial obstruction
47. (p. 300) Extrinsic asthma involves acute episodes triggered by a type I
hypersensitivity reaction to an inhaled antigen. A familial history of
 other allergies is common. Onset usually occurs in children. Intrinsic
asthma usually occurs in adulthood. Other types of stimuli target
hyperresponsive tissues in the airway, initiating the acute attack. These
stimuli include respiratory infections, exposure to cold, exercise, certain
drugs such as aspirin, stress, and inhalation of irritants such as cigarette
smoke.
48. (p. 301, Fig. 13.18) an acute allergic response to stimuli affecting the
bronchioles, resulting in inflammation of the mucosa with edema,
contraction of smooth muscle (bronchoconstriction), and increased thick
mucus secretion in the air passages, with resulting airway obstruction
and interference with airflow and oxygen supply
49. (p. 301)
• hyperinflation of the lung, with increased residual volume
• atelectasis
• respiratory and metabolic acidosis
• status asthmaticus
• chronic asthma and obstructive lung disease
50. (p. 299)
• cough, dyspnea, tightness in the chest, and agitation as airway
obstruction increases; cannot talk
• wheezing
• rapid and labored breathing
• coughing up thick and tenacious mucus
• tachycardia and perhaps pulsus paradoxus
• hypoxia
• respiratory alkalosis, initially due to hyperventilation
• respiratory acidosis, in time, due to air trapping
• marked fatigue causes reduced respiratory effort and weaker cough
• metabolic acidosis
• severe respiratory distress; hypoventilation leading to hypoxemia and
respiratory acidosis
• respiratory failure: decreasing responsiveness, cyanosis
51. (p. 302)
 • avoidance of triggering stimuli
• a program of desensitization or “allergy shots” for allergens that
cannot be avoided (e.g., house dust)
• good ventilation: at home, school, work
• conditioning exercises to strengthen muscles of respiration and
improve cardiovascular fitness (swimming is particularly good as
long as the water is not too cold)
• relaxation techniques to help cope with stressful situations and
hopefully to avoid precipitating an attack
• prophylactic medications, such as flu vaccinations or inoculations
• avoidance of individuals with respiratory infections
52. (p. 302)

Example and
Drug Group Action and Effects Adverse Effects
Route
Bronchodilators Relax bronchial smooth Tachycardia, Inhalants:
muscle, leading to palpitations, CNS albuterol or
bronchodilation stimulation: salbutamol
tremors, insomnia (Ventolin)
Stinging sensation metaproterenol
in mouth (Alupent)
Corticosteroids Decrease inflammation Oral fungal Inhalation:
Decrease the immune (candidal) beclomethasone
response (hypersensitivity) infections with (Beclovent)
inhalants Oral:
Cushing with oral prednisone
administration
Histamine Inhibit release of histamine Rare Inhalation:
release from sensitized mast cells cromolyn
inhibitors Decrease the number of (Intal)
eosinophils
Leukotriene Block inflammatory GI distress occurs Inhalation:
receptor response in order to rarely montelukast
antagonists prevent (Singulair)
bronchoconstriction and zafirlukast
mucus production (Accolade)

53. (p. 302) Bronchodilators can be used during an acute asthmatic attack
because their mechanism of action is to relax bronchial smooth muscle
with minimal effects on the heart.
54. (p. 302)
• How frequent are the individual's asthmatic attacks?
• When was the last one?
• What are the triggering stimuli for an acute episode?
• How long do they usually last?
• What is the treatment the individual uses during bronchospasm?
• Has the individual had any emergencies when he had to seek medical
help?

Chronic Obstructive Pulmonary Disease (COPD)

55. (p. 303, Table 13.5) Smoking is the leading causative factor.
Contributing factors include cystic fibrosis and bronchiectasis; many
occupational lung diseases such as silicosis, asbestosis, farmer's lung,
and industrial/urban pollution.
56. (p. 302) Both conditions are characterized by hypoxia—this stimulates
release of erythropoietin by the kidneys, which in turn stimulates
increased production of red blood cells.
57. (p. 303) destruction of pulmonary alveolar walls and septa, leading to
large permanently inflated alveolar air spaces
58. (p. 303)
• loss of surface area for gas exchange
• loss of pulmonary capillaries, affecting perfusion and diffusion of
gases
• loss of elasticity, affecting ability of lung to recoil on expiration
• altered ventilation-perfusion ratio
• decreased support for other pulmonary structures such as the small
bronchi, leading to further collapse and obstruction of airflow during
expiration
59. (p. 307) Hyperventilation is a compensatory mechanism that alone
helps maintain adequate oxygen levels until late in the disease;
therefore, the patient's color is normal (i.e., pink), unlike in many
respiratory disorders that are characterized by hypoxia and cyanosis.
60. (p. 306)
• barrel chest
 • pneumothorax
• frequent infections
• pulmonary hypertension and cor pulmonale
• clubbed fingers
• secondary polycythemia
61. (p. 307) Hypercapnia develops, resulting in respiratory acidosis.
Hypoxia leads to metabolic acidosis. Blood pH decreases.
62. (p. 307) Hypoxia becomes the driving force for respiration as
respiratory control adapts to chronic hypercapnia.
63. (p. 306) Barrel chest refers to the hyperinflation of lungs that leads to
increased anterior-posterior diameter of chest. The chest appears like a
barrel. The condition develops because accessory muscles of expiration
hypertrophy.
64. (p. 306)
• avoidance of respiratory irritants and sources of infections
• smoking cessation
• immunization against influenza and pneumonia
• pulmonary rehabilitation
• nutrition counseling: maintenance of adequate nutrition and hydration
• bronchodilators, antimicrobials, and oxygen therapy when needed
• lung reduction surgery
65. (p. 307) Following chronic irritation of the bronchi, the mucosa is
inflamed and swollen; there is hypertrophy and hyperplasia of the
mucous glands and increased secretions and fibrosis and thickening of
the bronchial wall and further obstruction. Secretions pool distal to the
obstruction and are difficult to remove; oxygen levels are low; and
cyanosis may occur during coughing episodes.
66. (p. 307) constant productive cough
67. (p. 307) Hypoxia is characteristic feature, particularly during coughing
episodes. This results in poor color or cyanosis. Pulmonary congestion
and cor pulmonale also commonly occur with chronic bronchitis,
resulting in peripheral edema. Thus, there is a designation as a “blue
bloater” as opposed to someone with emphysema, a “pink puffer.”
68. (p. 307) Treatments include reducing exposure to irritants, prompt
treatment of infections, influenza and pneumonia vaccination, and use
of expectorants, bronchodilators, chest therapy, low-flow oxygen, and
nutritional supplementation.
69. (p. 303, Table 13.5)
 Chronic
Asthma Emphysema
Bronchitis
Etiology and Family history of Smoking Smoking
predisposing allergies Air pollution Air pollution
factors Air pollution Genetic factors
Sedentary lifestyle
Obesity
Location Small bronchi, Alveoli Bronchi
bronchioles
Pathophysiology Inflammation, Destruction of Increased mucous
bronchoconstriction, alveolar walls; loss glands and
increased mucus of elasticity, secretions;
production; impaired expiration, inflammation and
obstruction; repeat barrel chest, infection;
attacks lead to damage hyperinflation obstruction
Signs and Cough, dyspnea, Some coughing, Early constant
symptoms wheezing, thick, marked dyspnea unproductive
tenacious mucus cough, some
dyspnea
Complications Cyanosis if status Some infections Cyanosis;
asthmaticus Cor pulmonale: frequent
sometimes, late infections
Cor pulmonale
 Chronic
Asthma Emphysema
Bronchitis
Treatments Avoidance of Avoidance of Reducing
triggering stimuli respiratory irritants exposure to
A program of and sources of irritants
desensitization or infections Prompt
“allergy shots” for Smoking cessation treatment of
allergens that cannot Immunization infections
be avoided (e.g., house against influenza Influenza and
dust) and pneumonia pneumonia
Good ventilation: at Pulmonary vaccination
home, school, work rehabilitation Use of
Conditioning exercises Nutrition expectorants,
to strengthen muscles counseling: bronchodilators
of respiration and maintenance of Chest
improve adequate nutrition physiotherapy
cardiovascular fitness and hydration Low-flow
Fitness (swimming is Bronchodilators, oxygen and
particularly good as antimicrobials, and nutritional
long as the water is not oxygen therapy supplementation
too cold) when needed
Relaxation techniques Lung reduction
to help cope with surgery
stressful situations and
hopefully to avoid
precipitating an attack
Flu vaccinations or
inoculations
Avoidance of
individuals with
respiratory infections

70. (p. 307) Bronchiectasis is an irreversible abnormal dilation of the

bronchi. Dilations can be saccular or elongated. This condition can be
caused by cystic fibrosis or COPD.
71. (p. 308) Pneumoconioses is a chronic restrictive disease resulting from
long-term exposure to irritating particles such as asbestos. Treatment
involves identifying and ending exposure to the damaging agent.

Pulmonary Edema
72. (p. 309) Causes include inflammation in the lungs, increasing capillary
permeability; low plasma protein levels, decreasing plasma osmotic
 pressure; pulmonary hypertension, increasing hydrostatic pressure.
73. (p. 309, Fig. 13.22) Pulmonary edema occurs when excess fluid
develops in the alveolar tissue. This fluid interferes with gaseous
exchange, leading to severe hypoxemia. This accumulation of fluid
interferes with the action of surfactant, leading to difficulty in expansion
of lungs, which ultimately collapse.
74. (p. 309) Signs and symptoms include cough, orthopnea, and rales;
hemoptysis as congestion increases; frothy sputum; dyspnea; cyanosis
due to increasing hypoxemia.
75. (p. 309) Sputum becomes frothy when air mixes with secretions and
becomes blood-tinged as a result of ruptured capillaries in the lungs.
76. (p. 309) When the individual is placed in a supine position, the fluid
that has accumulated in the bases of the lungs starts to shift into the
upper lobes. Venous return to the heart and lungs is increased when in a
supine position. The individual feels a sense of suffocation. This is called
orthopnea.
77. (p. 309) Causative factors must be treated and supportive care such as
oxygen therapy is provided; positive pressure mechanical ventilation
may be necessary in severe cases. Upper body is elevated. Diuretics may
be given to reduce fluid.

Pulmonary Embolus
78. (p. 309) a blood clot or mass of material that obstructs the pulmonary
artery or a branch of it
79. (p. 309) Most pulmonary emboli originate in the deep veins, primarily
in the legs. Other potential sources include fat emboli from the bone
marrow (fractures), vegetations resulting from endocarditis, amniotic
fluid emboli, and tumor cell emboli.
80. (p. 310)
• bedridden patients who have been immobile for long periods (e.g.,
hospitalized patients)
• anyone with leg trauma
• mothers during childbirth
• patients with congestive heart failure (CHF)
 • patients with dehydration or increased coagulability of the blood
• patients who have cancer
• airplane or automobile passengers who remain seated for prolonged
periods of time
81. (p. 310, Fig. 13.22) The effects depend on the size and location of the
embolism. Small pulmonary emboli are frequently “silent” or
asymptomatic. Multiple small emboli, however, equal the effect of a
large embolus. Moderate-sized emboli usually cause respiratory
impairment. Large emboli affect the cardiovascular system, causing
right-sided heart failure and shock. Sudden death often occurs.
82. (p. 310) With a small embolus, symptoms include transient chest pain,
cough, or dyspnea. With a larger embolus, symptoms include chest pain
that increases with coughing or deep breathing, and tachypnea and
dyspnea develop suddenly; later, hemoptysis and fever, anxiety and
restlessness, pallor, and tachycardia occur. A massive emboli is
characterized by severe crushing chest pain; low blood pressure; rapid,
weak pulse; and loss of consciousness. Fat emboli are distinguished by
development of acute respiratory distress, petechial rash on the trunk,
and neurologic signs such as confusion and disorientation.
83. (p. 312) heparin or fibrinolytic agent

Expansion Disorders
84. (pp. 312–314, 311, Fig. 13.24)
 Atelectasis Bronchiectasis
Definition Nonaeration or Irreversible dilation or widening of bronchi
collapse of a lung or with damage to smooth muscle and pooling
part of a lung of secretions
Etiology Total obstruction of Complication of:
an airway Cystic fibrosis
Compression of COPD
airway Childhood infections
Increased alveolar Aspiration of foreign bodies
surface tension
Fibrotic tissue in
lungs or pleura
Following anesthesia
or prolonged bed
rest
Complications Permanent lung Recurrent lung infections
damage
Signs and Dyspnea; increased Chronic productive cough
symptoms respirations Purulent sputum
Tachycardia Rales and rhonchi
Chest pain Dyspnea, hemoptysis
Abnormal chest Foul breath
expansion Weight loss, anemia, fatigue
Tracheal shift

85. (pp. 313–315, Table 13.7, p. 314, Fig. 13.24, p. 313)

Pleural Effusion Pneumothorax

Definition Excessive fluid in pleural cavity Air in pleural cavity
Etiology Inflammation or secondary to Spontaneous
tumor in lung or chest wall Rupture of a bleb (emphysema)
Erosion by tumor
Cavitation due to TB
Puncture wound (broken rib,
gunshot/knife wound)
Signs and Dyspnea Increased, labored respirations
symptoms Chest pain with dyspnea
Increased heart and respiratory Pain
rates Asymmetrical chest movements
Absence of breath sounds in Tachycardia
affected area
86. (p. 315, Fig. 13.26) Flail chest results from fractures of the thorax
(usually from falls and automobile accidents)—usually includes
fractures of three to six ribs in two places or fracture of the sternum and
a number of consecutive ribs resulting in paradoxical movement during
inspiration and mediastinal flutter if injury is extensive.
87. (p. 320) Causes of acute respiratory failure include chronic conditions
such as emphysema, combination of a chronic with an acute disorder
such as emphysema complicated by pneumonia or pneumothorax, acute
respiratory disorders such as chest trauma, pulmonary embolus, or
acute asthma, and many neuromuscular diseases such as myasthenia
gravis, amyotrophic lateral sclerosis (ALS), and muscular dystrophy.
88. (pp. 317–319)
 Infant Respiratory Distress Adult Respiratory Distress
Syndrome Syndrome
Etiology Premature birth resulting in Systemic sepsis
decreased surfactant Prolonged shock
Burns and smoke inhalation
Aspiration
Near-drowning
Pathophysiology Lungs collapse with each Damage to surfactant-
expiration, resulting in diffuse producing cells and increased
atelectasis, poor lung perfusion, capillary permeability, leading
and increased alveolar capillary to diffuse atelectasis and
permeability, causing fluid and decreased tidal volume and
fibrin to leak into alveoli that vital capacity and fluid
decreases lung expansion and accumulation in lungs, all of
gas exchange which predispose to
pneumonia
Signs and Respirations greater than Marked dyspnea
symptoms 60/minute Tachycardia
Nasal flaring; chest retractions Decreased partial pressure of
Decreased blood pressure, oxygen (PO2)
cyanosis, depressed Rales
responsiveness Frothy sputum
Apnea Cyanosis
Lethargy
Treatment Corticosteroids to mother Treat underlying cause
during labor Mechanical ventilation and O2
Synthetic surfactant
Mechanical ventilation and O2

89. (p. 320)

a. air in the pleural cavity; iii. pneumothorax
b. abnormal widening of the bronchi; iv. bronchiectasis
c. excessive fluid in pleural cavity; i. pleural effusion
d. chronic disorder resulting from continued exposure to irritating
particles; vi. pneumoconiosis
e. fungal infection of the lungs; v. histoplasmosis
f. collapse of a portion of the lung; ii. atelectasis

Consolidation
90. (pp. 321–322)
 i. asthma
ii. pulmonary edema
iii. pulmonary edema
iv. emphysema
v. tuberculosis
vi. asthma
vii. Pneumocystis carinii pneumonia
viii. cystic fibrosis
ix. atelectasis
x. chronic bronchitis
xi. pulmonary embolus
xii. adult respiratory distress syndrome
xiii. pneumothorax
xiv. cystic fibrosis
xv. cystic fibrosis
xvi. tuberculosis
xvii. bronchiectasis
xviii. pleurisy
xix. tuberculosis
xx. asthma

Chapter 14
Nervous System Disorders

Acute Disorders
1. (p. 329, Fig. 14.3) See Fig. 14.1 of the text.
Anatomic Features: A. Motor cortex, B. Central sulcus, C. Sensory cortex,
D. Parietal lobe, E. Occipital lobe, F. Visual association, G. Cerebellum,
H. Medulla, I. Pons, J. Temporal lobe, K. Lateral sulcus, L. Frontal lobe,
M. Premotor cortex.
Functional Features: N. Intellect Personality, O. Broca's speech area, P.
Auditory area, Q. Memory, R. RAS, S. Vital centers, T. Balance
equilibrium coordination, U. Visual area, V. Wernicke's area.
2. (pp. 326–327) dura mater: outer layer; subdural space: beneath the dura;
arachnoid; subarachnoid space: below the arachnoid—contains
cerebrospinal fluid (CSF); pia mater: closest to the brain
3. (p. 327) The CSF provides a cushion for the brain and spinal cord and is
produced by the choroid plexuses located in the ventricles.
4. (p. 335)
i. Acetylcholine (ACh)
ii. Ach
iii. PNS is ACh, SNS is norepinephrine
5. (p. 337, Table 14.4)
i. increased heart rate
ii. secretion of epinephrine and norepinephrine
iii. bronchodilation
iv. pupil dilation
v. decreased
6. (p. 338) cerebral cortex and the reticular activating system (RAS) in the
brainstem
7. (p. 339) cessation of brain function (e.g., flat or inactive EEG), absence of
brainstem reflexes or responses, absence of spontaneous respirations
without ventilator assistance, certainty of irreversible brain damage by
confirmation of the cause of the dysfunction
8. (pp. 340–341; Table 14.6) Aphasia refers to an inability to comprehend or
express language. Types:
i. Expressive, or motor aphasia: impaired ability to speak or write
fluently or appropriately. Areas of the brain affected: Broca's area of
frontal lobe, inferior motor cortex.
ii. Receptive, or sensory aphasia: inability to read or understand the
spoken word. Area of brain affected: Wernicke's area in the left
temporal lobe.
iii. Global aphasia: generally describes a combination of expressive and
receptive aphasia. Areas of the brain affected: any major damage to
the brain including Broca's and Wernicke's areas and communicating
fibers.
9. (p. 341, Fig. 14.6; Table 14.7, p. 342) brain hemorrhage, trauma, cerebral
edema, infection, tumors, or accumulation of excessive amounts of CSF
10. (p. 341, Table 14.7)
• increase in pressure in the brain
• decrease in arterial blood flow into the “high pressure” area
• pressure increases at the site of the problem initially but gradually is
dispersed throughout the CNS
• brain compression
• decrease in functionality of neurons, both locally and generally
• brain death
11. (pp. 341–342, Fig. 14.7, p. 341; Table 14.7, p. 342)
Early manifestations:
• decreasing level of consciousness or responsiveness (lethargy);
pressure on RAS (brainstem) or cerebral cortex
• severe headache; stretching or distortion of meninges or walls of large
blood vessels
• vomiting; pressure on emetic center in medulla
• increasing blood pressure with increasing pulse pressure; Cushing
reflex, response to cerebral ischemia causes systemic vasoconstriction
• slow heart rate; response to increasing blood pressure
• papilledema; increased pressure of CSF causes swelling around the
optic disc
• pupil becomes fixed and dilated on ipsilateral side of lesion initially;
eventually, both pupils become fixed and dilated; pressure on cranial
nerve III (oculomotor)

Tumors
12. (p. 344) signs of increased intracranial pressure, often beginning with
morning headaches that increase in severity and frequency; vomiting;
and lethargy and irritability; focal or generalized seizures may be the
first sign

TIAs and CVAs

13. (p. 346) temporary localized reduction of blood flow in the brain
14. (p. 346) The manifestations of a transient ischemic attack (TIA) are
directly related to the location of the ischemia. The patient remains
conscious. Intermittent short episodes of impaired function, such as
muscle weakness in an arm or leg, visual disturbances, or numbness and
paresthesia in the face, may occur. Transient aphasia or confusion may
develop. The attack may last a few minutes or longer but rarely lasts
more than 1 to 2 hours, and then the signs disappear.
15. (p. 346) They warn of the potential development of an obstruction
related to atherosclerosis that may lead to a cerebrovascular event
(stroke).
16. (p. 346) TIAs do not cause permanent brain damage; a stroke
(cerebrovascular accident [CVA]) does. TIAs are caused by partial
arterial obstruction or spasm; strokes (CVAs) are caused by total
obstruction or hemorrhage.
17. (p. 348) Individuals with:
• diabetes
• hypertension (especially if chronic, severe in the elderly)
• systemic lupus erythematosus
• elevated cholesterol levels (hypercholesterolemia)
• hyperlipidemia
• atherosclerosis
• history of TIAs
• increasing age
• obstructive sleep apnea
• heart disease
• combination of oral contraceptives and cigarette smoking
18. (Warning Signs box 14.1, p. 348)
• sudden transient weakness, numbness, or tingling in the face, an arm
or leg, or on one side of the body
• temporary loss of speech, failure to comprehend, or confusion
• sudden loss of vision
• sudden severe headache
• unusual dizziness or unsteadiness
19. (p. 348)
i. occlusion of an artery by an atheroma (most common)
ii. embolism lodging in the cerebral artery
iii. intracerebral hemorrhage
20. (p. 344, Fig. 14.13) Infarction of brain tissue results from lack of blood;
tissue necrosis results from total occlusion of a cerebral blood vessel or
the consequence of a ruptured cerebral vessel. Within 5 minutes of
ischemia, irreversible cell damage occurs. A central area of necrosis
develops, surrounded by an area of inflammation. As time passes, the
tissue liquefies, leaving a cavity. The cerebral edema increases the
neurologic deficits. As the edema decreases, functions performed by the
inflamed area start to return.
21. (p. 348, Table 14.8)
 Thrombus CVA Embolus CVA Hemorrhage CVA
Predisposing Atherosclerosis Atherosclerosis Hypertension
factors Left ventricular MI
Rheumatic heart
disease
Valvular disease
Prosthetic heart
valves
Endocarditis
Arrhythmias
Heart failure
Onset Gradual Sudden Sudden
May be preceded by
TIAs
Often at rest
Effects Localized Localized Widespread
Increased ICP
Often fatal
Immediate Fibrinolytic agents Fibrinolytic agents Ligation of ruptured
treatment —“clot buster” Thrombectomy vessel if accessible
Prognosis Depends on size and Depends on size and Depends on size and
location of injury, location of injury, location of injury,
plus speed of plus speed of plus speed of
initiation of treatment initiation of treatment initiation of treatment
Poorest prognosis—
most often fatal
CVA, cerebrovascular accident; ICP, intracranial pressure; MI, myocardial infarction; TIA, transient
ischemic attack.

22. (p. 348)

• MI in left side of heart: rheumatic heart disease, endocarditis, valvular
disease, prosthetic heart valves, left-sided heart failure, arrhythmias
• carotid arteries
23. (p. 347)
• because damage much more widespread—often increased ICP
• both hemispheres involved
• sudden onset—no time for development of collateral circulation
• secondary effects of bleeding: vasospasm, electrolyte imbalances,
acidosis, cellular edema
24. (p. 327, Fig. 14.1) Manifestations depend on location of the obstruction,
size of artery involved, and the functional area affected. However, the
four general types of deficits include:
i. motor deficits: contralateral muscle weakness or paralysis (hemiplegia)
ii. sensory deficits: contralateral paresthesia or numbness; possibly loss
of vision
iii. speech deficits: aphasia when the dominant side of the brain is
involved
iv. cognitive and emotional manifestations: confusion, loss of problem-
solving skills, personality changes, impairment of spatial relationships
25. (p. 348)
• medications: depend on underlying problem
• antihypertensives
• platelet inhibitors or anticoagulants
• glucocorticoids
• physiotherapy
• occupational therapy
• speech therapy
26. (p. 327, Fig. 14.1) loss of movement and sensation on the right side of
the body (contralateral); expressive or motor aphasia

Cerebral Aneurysms
27. (p. 349, Fig. 14.14) localized dilation in an artery; cerebral aneurysms
are often multiple and usually occur at the points of bifurcation on the
circle of Willis.
28. (p. 349) increased blood pressure (e.g., during exertion)
29. (p. 349) Enlarging aneurysm may cause pressure on the surrounding
structures, such as the optic chiasm or cranial nerves, resulting in visual
disturbances and headaches as tension increases on the vessel wall and
meninges. Small leaks cause headaches, photophobia, and periods of
confusion, slurred speech, or weakness. Nuchal rigidity may develop.
Massive ruptures result in immediate severe headaches, vomiting,
photophobia, and perhaps seizures or loss of consciousness. Death may
occur shortly after rupture.
Infections
30. (pp. 350–353)

Meningitis Encephalitis
Causative agents Meningococci Western equine virus
Escherichia coli West Nile virus
Influenza Herpes simplex
Pneumococci
Predisposing Other infections (sinusitis, Insect bites
factors otitis, mumps, measles)
Abscessed tooth
Head trauma or surgery
Pathophysiology Increased ICP Infection involves tissue of brain
Edema of arachnoid and pia and cord, especially basal ganglia
maters May include meninges
Purulent exudates that cover Necrosis and inflammation may
brain surface and is in CSF lead to permanent damage
Manifestations Sudden onset Severe headache
Severe headache, back pain, Stiff neck
photophobia Vomiting
Nuchal rigidity Lethargy
Vomiting Seizures
Irritability, lethargy, stupor, Fever
or seizures Change in neurologic function
Fever and chills Decreasing level of consciousness
Leukocytosis
Treatment Appropriate antimicrobial Antiviral agent if available
agent Supportive measures
CSF, cerebrospinal fluid; ICP, intracranial pressure.

31. (p. 353) Varicella-zoster virus—occurs years after the primary infection,
the chickenpox (usually occurs in childhood)
32. (p. 354) The cause of Reye syndrome has not yet been fully determined,
but it is linked to a viral infection, such as influenza, in young children
who have been treated with aspirin (ASA). The major pathologic
changes occur in the brain and the liver. A noninflammatory cerebral
edema develops, leading to increased ICP. Brain function is severely
impaired by cerebral edema and the effects of high ammonia levels in
serum related to liver dysfunction. The liver enlarges, develops fatty
changes in the tissue, and progresses to acute failure. The resultant
metabolic abnormalities include hypoglycemia and increased lactic acid
 in the blood and body fluids, which also contribute to acute
encephalopathy. In some cases, the kidneys are also affected.

Injuries
33. (pp. 354–355)
i. resulting from a mild blow to the head—causes reversible interference
with brain function
ii. bruising of brain tissue with rupture of small blood vessels and
edema—usually results from a blunt blow to the head
iii. simple cracks in the bone
iv. involves trauma where brain tissue is exposed to the environment
v. occurs at the base of the skull—often causes leaking of CSF through
ears or nose
vi. occurs when an area of the brain contralateral to the site of direct
damage is injured as the brain bounces off the skull
34. (pp. 356–357, Fig. 14.18)
i. results from bleeding between the dura and the skull
ii. between the dura and the arachnoid
iii. space between the arachnoid and pia mater
iv. bleeding within the brain
35. (p. 358, Figs. 14.17 and 14.18)
• skull fracture: tissue damage and bleeding resulting in increased ICP,
ischemia, and necrosis; compression of brainstem with potential loss
of vital functions
• contusion: edema and minor bleeding
• brain motion: tissue damage and bleeding resulting in increased ICP,
ischemia, and necrosis; compression of brainstem with potential loss
of vital functions
• secondary damage due to bleeding, inflammation, and edema;
hematoma and possible infection; tissue damage and bleeding
resulting in increased ICP, ischemia, and necrosis; compression of
brainstem with potential loss of vital functions
• if unconscious for a prolonged period, other problems may develop;
immobility may result in pneumonia or decubitus ulcers (pp. 357–358)
36. (pp. 357–358)
• seizures
• cranial nerve impairment
• otorrhea or rhinorrhea—leaking of CSF from the ear or nose,
respectively
• otorrhagia—blood leaking from the ear
• fever due to hypothalamic impairment or cranial or systemic infection
• stress ulcers—from increased gastric secretions
37. (p. 358) glucocorticoids, antimicrobials, surgery, oxygen therapy
38. (p. 358, Figs. 14.21)
• hyperextension or hyperflexion of the neck
• dislocation of vertebra
• compression fractures
• penetrating injuries such as knife or bullet wounds
• decreased responses
39. (p. 357, Figs. 14.21, and 14.22)
• Damage may be temporary or permanent; laceration of nerve tissue
usually results in permanent loss of conduction in affected nerve
tracts.
• Complete transection or crushing causes irreversible loss of all
function at and below the level of injury.
• Partial transection may allow recovery of some function.
• Bruising is reversible damage when edema and bleeding are mild.
• Prolonged ischemia and necrosis lead to permanent damage.
• Edema and hemorrhage occur above and below the injury.
• Impaired respiration may occur when injury occurs in cervical region.
• Spinal shock can occur.
• Complications include autonomic dysreflexia, immobility,
contractures and decubitus ulcers, respiratory and urinary infections,
loss of function (e.g., sexual function), and reproductive capacity.
40. (p. 358, Fig. 14.21) Signs and symptoms depend on the level of the cord
at which the injury occurred as well as the time that has elapsed since
 the injury (i.e., early stage of spinal shock or postspinal shock).
Spinal shock (immediately following injury):
• all function normal above the level of inflammation
• no sensory or motor impulses below the injury
• no reflexes: flaccid paralysis
• no sensation, urinary retention, paralytic ileus
• low, labile blood pressure

Permanent effects—post–spinal shock:

• cervical injury—total block:
• no sensation
• no voluntary movement (spastic paralysis)
• no central control of SNS
• no voluntary control of bladder and bowel
• lumbar injury:
• normal function upper body
• no function at level of injury
• no sensory of voluntary movement below injury
• reflexes present below injury
• spastic paralysis
• bowel and bladder incontinence
41. (p. 358)
• traction or surgery to relieve pressure and repair tissues
• glucocorticoids
• supportive care and rehabilitation to prevent complications related to
immobility
42. answer to crossword puzzle
Congenital Neurologic Disorders

Hydrocephalus
43. (p. 363) a condition in which excess cerebrospinal fluid accumulates in
the skull, compressing the brain tissue and blood vessels
44. (p. 363) developmental abnormalities such as stenosis or atresia;
tumors, infection, or scar tissue at any age
45. (pp. 364–365) Excess CSF leads to compression of brain tissue and
blood vessels, which results in brain damage. The amount of brain
damage depends on the rate at which pressure increases and the time
before treatment.
46. (p. 363, Fig. 14.25) Noncommunicating, or obstructive, hydrocephalus
occurs in babies when the flow of CSF through the ventricular system is
blocked. In communicating hydrocephalus, absorption of CSF through
subarachnoid villi is impaired, resulting in increased CSF pressure.
47. (pp. 364–365) It depends on the age of the patient. In neonates or young
infants (prior to suture closure), manifestations include enlarged head,
bulging fontanels, dilated scalp veins, eyes showing “sunset” sign,
sluggish pupil response, lethargy and restlessness, and shrill cries when
infants are picked up. In older children and adults, manifestations
include classic signs of increased intracranial pressure.
48. (p. 365) Treatment is surgery to remove the obstruction or provide a
shunt for CSF.

Spina Bifida
49. (pp. 364–365) neural tube defect due to failure of the vertebral posterior
spinous process to fuse
50. (pp. 364–365, Fig. 14.26)
i. A: spina bifida occulta: develops when the spinous processes do not
fuse, but herniation of the spinal cord and meninges does not occur;
may not be visible; often a dimple or tuft of hair is present
ii. B: meningocele: same bony defect as spina bifida except herniation of
the meninges occurs through the defect, and the meninges and CSF
form a sac on the surface
iii. C: myelomeningocele: most serious form; herniation of the spinal
cord and nerves along with the meninges and CSF occurs, resulting in
considerable neurologic impairment; often seen in conjunction with
hydrocephalus
51. (p. 366) elevated alpha-fetoprotein (AFP) in maternal blood; AFP in
amniotic fluid by amniocentesis
52. (pp. 365–366)
• multifactorial basis with both genetic and environmental factors
contributing
• high familial incidence and associated defects such as anencephaly
• environmental factors include exposure to radiation, gestational
diabetes, and deficits of vitamin A or folic acid
53. (p. 366)
• meningocele and myelomeningocele are visible as protrusions over the
spine
• extent of neurologic defect depending on level of the defect
(myelomeningocele)
• impaired sensory and motor function at and below the level of
herniation
• muscle weakness or paralysis
• fecal and urinary incontinence, depending on the level of damage
54. (p. 366) surgery and occupational and physical therapy to manage the
neurologic deficits

Cerebral Palsy
55. (p. 366) Major causes of cerebral palsy: hypoxia or ischemia, which can
occur prenatally (caused by placental complications), perinatally (a
difficult delivery), or postnatally (vascular occlusion, hemorrhage,
aspiration, or respiratory impairment in the premature infant). An
infection or metabolic abnormalities such as hypoglycemia in mother or
infant may also cause cerebral palsy.
56. (p. 366) necrosis of brain tissue in the perinatal period as a result of
malformation, mechanical trauma, hypoxia, hemorrhage, hypoglycemia,
hyperbilirubinemia; necrosis and atrophy may be generalized or
localized; all children have some altered mobility and an assortment of
other individual problems based on the extent of brain damage.
57. (p. 367, Table 14.9)
• spastic paralysis due to damage to the pyramidal tracts (diplegia), the
motor cortex (hemiparesis), or general cortical damage
(quadriparesis); characterized by paralysis, hyperreflexia, and
increased muscle tone
• dyskinetic disease due to damage to the extrapyramidal tract, basal
nuclei, or cranial nerves; manifested by athetoid or choreiform
involuntary movements and loss of coordination with fine
movements
• ataxic cerebral palsy resulting from damage to the cerebellum and
manifesting as loss of balance and coordination
58. (p. 367) impairment of intellectual function; communication and speech
difficulties; seizures; visual problems
59. (pp. 367–368)
• early stimulation programs for motor skills, coordination, and
intellectual development
• speech and language pathology assessment to assist in feeding and
swallowing problems
• regular physical therapy and use of devices such as braces to improve
mobility and decrease deformities
 • development and maximization of motor skills, eye-hand
coordination, and reflex responses
• monitoring hearing and vision and appropriate communication
therapy
• medications to control seizures

Seizure Disorders
60. (p. 367) A seizure is an uncontrolled excessive discharge (firing) of
neurons in the brain.
61. (pp. 367–368) A seizure results from a sudden spontaneous and
uncontrolled depolarization of neurons; it causes abnormal motor and
sensory activity and possible loss of consciousness.
62. (p. 368) Primary seizures are idiopathic. Secondary (acquired) seizures
have an identifiable cause such as posttraumatic syndrome.
63. (p. 369) initiated by tumor, infection, or hemorrhage in the brain; high
fever; some systemic disorders (renal failure or hypoglycemia); or
sudden withdrawal from sedatives or alcohol or narcotics
64. (p. 368, Box 14.1)
• generalized seizure: has multiple foci in deep structures of both
cerebral hemispheres and the brainstem—causes loss of consciousness
• partial seizure: single origin, often in cerebral cortex—may or may not
cause altered consciousness
65. (p. 368) An absence or petit mal seizure is a generalized seizure that is
more common in children, lasts for 5 to 10 seconds, and may occur
many times during the day. There is a brief loss of awareness (child may
simply stare into space) and sometimes transient facial movements,
which may occur several times a day, with no memory of the episode.
66. (p. 368) In some individuals, signs such as nausea, irritability,
depression, or muscle twitching may occur some hours before the onset
of a seizure.
67. (p. 368) peculiar visual or auditory or olfactory sensation that
immediately precedes the loss of consciousness; examples of auras are
the smell of burnt toast, bright flashing lights, buzzing sounds; the
significance of an aura is that a seizure is imminent.
68. (p. 368) physical stimuli such as loud noises or bright lights;
biochemical stimuli such as stress, excessive premenstrual fluid
retention, hypoglycemia, or hyperventilation (alkalosis)
69. (p. 368) A tonic-clonic seizure may occur spontaneously or after simple
seizures. The pattern for this type of seizure is:
tonic stage:
• nausea, irritability, depression, or muscle twitching
• aura (which may precede a loss of consciousness in some individuals)
• loss of consciousness
• strong tonic muscle contraction
• jaws clench, air is forced out of the lungs, a cry escapes, respiration
ceases
clonic stage:
• muscles contract and relax in a series of jerky movements involving
the entire body
• increased salivation (foaming at the mouth), bowel/bladder
incontinence may occur
• contractions subside, the body turns limp, and consciousness
eventually returns
• individual is confused and tired, muscles ache, individual falls into
deep sleep

Typical duration is several minutes; should not last longer than 5

minutes.
70. (pp. 369–370) hypoxia, airway obstruction, acidosis, status epilepticus
71. See Emergency Treatment For Seizures box, (p. 369)
72. (pp. 368–370)
• if individual stops breathing during seizure
• when a seizure lasts more than 5 minutes
• when one seizure immediately follows another
• if individual hurts himself or herself (e.g., due to a fall at onset of
seizure)
• if individual has not recovered consciousness after 30 minutes
73. (p. 369, Box 14.1)
simple partial seizure: arises from a single damaged area, often in cortex
• characterized by repeated motor activity
• memory and consciousness remain

complex partial seizure: usually arises from temporal lobe with possible
limbic system or frontal lobe involvement
• characterized by bizarre behavior that may be mistaken for psychiatric
condition, such as inappropriate repetitive movements
• frequently experiences auditory or visual hallucinations
• individual is unresponsive
74. (p. 370) anticonvulsants and sedatives such as barbiturates
75. (p. 370) Adverse effects of anticonvulsants include leukopenia with
increased susceptibility to infection and reduced blood clotting ability
and gingival hyperplasia (particularly phenytoin). Adverse effects of
barbiturates include increased liver enzyme activity affecting the dosage
of other medications, drowsiness, and osteomalacia.
76. (p. 370) Status epilepticus are recurrent tonic-clonic seizures without
return to full consciousness. They can be life threatening. IV diazepam,
oxygen, and fluids are used to treat this condition.
77. (pp. 368–370)
• How well is the individual's disorder controlled—when was the last
seizure and how frequently do they occur?
• Were any known precipitating factors present: stress, bright lights,
certain noises or odors, hyperventilation, exercise, hot environmental
temperatures, recent alcohol consumption, nitrous oxide?
• Was there the presence of an “aura”? How much time is there between
the aura and the onset of a seizure?
• How long do seizures usually last?
• How long does it take to recover from a seizure?
• What does the individual want you to do if he or she has a seizure
(e.g., who to notify)?
78. (p. 369) awareness and avoidance of potential precipitating factors;
stress reduction, which may require sedation (e.g., before a dental
 treatment)
79. (p. 370) i. EEG; ii MRI

Chronic Degenerative Disorders

Multiple Sclerosis (MS)

80. (p. 370, Fig. 14.28) progressive demyelinations of neurons in the brain,
spinal cord, and cranial nerves
81. (p. 370) unknown etiology; possibly autoimmune disorder with genetic,
immunologic, and environmental components
82. (p. 370) women between 20 and 40 years of age; individuals of
European descent; those living in temperate climates; close relatives of
individuals with MS
83. (p. 370, Fig. 14.29) Plaques are the characteristic lesions of MS and refer
to the areas of inflammation and demyelination. These can cause loss of
myelin in the white matter of the brain and/or spinal cord. This loss of
myelin will greatly decrease the conductivity of the nerve fibers.
84. (p. 370) motor, sensory, and autonomic
85. (p. 371) There is no definitive test for MS. Multiplicity of effects and
recurrences based on patient history and physical examination point to
the correct diagnosis. MRIs are best to detect multiple CNS lesions.
Often patients have elevated protein, gamma globulin, and lymphocytes
in the CSF. Visual evoked potential tests measure the activity of the
brain in response to the stimulation of specific sensory pathways and
can detect a slowing of conduction due to demyelination. Optical
coherenece tomography (OCT) is a relatively new imaging tool that can
clearly show the retinal structures including the optic and retinal nerves.
Since these nerves are often an early target of MS, their condition can
give an indication of damage caused by MS.
86. (pp. 370–371) Early manifestations include blurred vision, weakness in
the legs, scotoma, diplopia, dysarthria if the cranial nerves are involved,
and paresthesias if sensory nerves are affected. Progressive signs are
weakness and paralysis extending to upper limbs, loss of coordination,
and bladder, bowel, and sexual dysfunction. Chronic fatigue and
sensory deficits such as paresthesias and loss of position sense in the
 upper body are also progressive signs. Depression or euphoria may
occur later.
87. (p. 372) There is no specific treatment available. The following may be
used to control exacerbations:
• glucocorticoids
• interferons
• muscle relaxants
• avoidance of excessive fatigue, stress, injury, or infection
• physical therapy and exercise
• specific therapies for vision, speech, etc.
88. (p. 372) Glucocorticoids will decrease inflammation, and it is possible
neural function will return. Interferon will suppress the immune
response and may slow progression of the disease.

Parkinson Disease
89. (p. 372) a progressive degenerative disorder affecting motor function
90. (pp. 372–373) There are progressive degenerative changes in the basal
nuclei, principally in the substantia nigra. Decreased secretion of
dopamine results in an imbalance between excitation and inhibition in
the basal nuclei, which causes resting tremors, muscular rigidity,
difficulty in initiating movement, and postural instability.
91. (p. 373, Fig. 14.30) Early manifestations include fatigue, muscle
weakness, muscle aching, decreased flexibility, less spontaneous change
in facial expression, tremors in the hands at rest, and “pill-rolling”
motion. Progressive signs include tremors affecting hands, feet, face,
tongue, and lips; increased muscle rigidity; difficulty in initiating
movement; bradykinesia and lack of associative involuntary
movements; and characteristic stooped posture. Late signs include
festination or a propulsive gait; difficulty engaging in complex activities;
voice changes; difficulty chewing and swallowing; drooling; masklike
facies; and autonomic dysfunction, such as urinary retention,
constipation, and orthostatic hypotension.
92. (p. 373) phenothiazines
93. (p. 373) dopamine; levodopa; selegiline; anticholinergic drugs
ALS, Myasthenia Gravis, and Huntington Disease
94. (pp. 374–376)
 Amyotrophic Lateral Huntington
Myasthenia Gravis
Sclerosis (ALS) Disease
Etiology Idiopathic, Idiopathic Autosomal
degenerative disorder Autoimmune dominant
10% genetic Thymus disorders disorder
Pathophysiology Progressive loss of Development of IgG Progressive
neurons in cerebral autoantibodies to brain atrophy,
cortex, brainstem, and acetylcholine especially basal
spinal cord in diffuse receptors, preventing ganglia and
asymmetrical pattern muscle stimulation frontal cortex
Facial and ocular Depletion of
muscles first, then GABA
arm and trunk Decreased
brain levels of
acetylcholine
Manifestations Loss of fine motor Diplopia; ptosis Rapid, jerky
coordination, usually in Loss of facial (choreiform)
hands first expression movements in
Stumbling and falls Difficulty chewing arms and legs
Muscle cramping or and swallowing Intellectual
twitching Marked muscle impairment
Dysarthria fatigue and Progressive
Finally, impaired weakness in head, rigidity and
swallowing and neck, and arms akinesia,
respiration Upper respiratory making
infections voluntary
movement
difficult
Progressive
dementia
Treatment No specific treatment Anticholinesterase No specific
Supportive measures agents treatment
Ultimately ventilator Glucocorticoids Supportive
Plasmapheresis to measures
remove antibodies Muscle
from blood relaxants to
Thymectomy if control
hyperplastic or if abnormal
tumor is present movements
 Amyotrophic Lateral Huntington
Myasthenia Gravis
Sclerosis (ALS) Disease
Prognosis Fatal HCO3– respiratory Fatal HCO3– Incurable—
failure or infection respiratory failure or progressive
infection Detection of
carriers and
genetic
counseling

Dementia
95. (pp. 376–378) Alzheimer disease; cerebrovascular disease—multiple
microinfarcts; Creutzfeldt-Jakob disease; AIDS
96. (p. 376)
• progressive cortical atrophy—leads to dilated ventricles and widening
of sulci
• neurofibrillary tangles in the neurons and senile plaques containing
beta-amyloid precursor protein
• deficit in neurotransmitter acetylcholine
97. (p. 376) A specific cause is unknown; at least four defective genes on
different chromosomes have been associated with the disease.
98. (p. 377) In the early stage, manifestations include gradual loss of
memory and lack of concentration and an impaired ability to learn new
information and to reason. There are behavioral changes such as
irritability and hostility. Cognitive function, memory, and language
skills decline; apathy, indifference, and confusion become marked;
managing activities of daily living becomes increasingly difficult. In the
later stages, there is an inability to recognize family members; lack of
awareness or interest in environment; incontinence; and loss of
functionality.

Mental Illness
99. (pp. 378–379) The following types of behavior may be exhibited:
• positive symptoms such as delusions and bizarre behavior
• negative symptoms such as flat emotions and decreased speech
• disorganized thought processes
 • delusions of false beliefs and ideas such as grandeur or power over
others
• poor problem-solving ability
• short attention span
• impaired communication
• hallucinations or abnormal sensory perception
• social withdrawal
• neglected personal self-care
100. (p. 379) frequently cause side effects related to excessive
extrapyramidal activity (or parkinsonian signs) such as dystonia and
tardive dyskinesia: involuntary muscle spasms in the face, neck, arms,
or legs
101. (p. 379)
• selective serotonin reuptake inhibitors (SSRIs) such as Prozac
• serotonin-norepinephrine reuptake inhibitors (SNRIs) such as Effexor
• tricyclic antidepressants (TCAs) such as Elavil
• monamine oxidase (MAO) inhibitors such as Parnate

Panic Disorder
102. (p. 379) repeated episodes of intense fear without provocation,
palpitations or tachycardia, hyperventilation, sweating, sensation of
choking or smothering, nausea

Spinal Cord Disorder

Herniated Disk
103. (p. 380, Fig. 14.33) protrusion of the nucleus pulposus (the inner
gelatinous component of the intervertebral disc) through a tear in the
annulus fibrosus, the outer covering of the intervertebral disc
104. (p. 380) If pressure on the nerve tissue or blood supply is prolonged or
severe, permanent nerve damage might occur.
105. (p. 380) The most common site of a herniated disc is at the
lumbosacral discs, at L4 to L5 or L5 to S1. This results in lower back
pain, radiating down one or both legs, that is exacerbated by coughing
 or straight leg raising. Paresthesia or numbness and tingling, as well as
muscle weakness, if compression is severe (motor nerves), may result.
106. (pp. 380–381) conservative treatment, including bed rest; application
of heat, ice, or traction, or drugs such as analgesics, antiinflammatory
agents, and skeletal muscle relaxants; surgery if compression persists:
laminectomy or discectomy; chemonucleolysis; fusion

Consolidation
107. (pp. 382–383)
• nature of the disorder—etiology, is it progressive?
• duration and degree of impairment
• Who is the primary care provider?
108. (pp. 382–383)
• Try to arrange for individual who is responsible for care to be present
at appointments.
• Always provide written instructions regarding follow-up treatment,
and so on; this is particularly important for individuals who are living
in group homes or nursing homes where there are multiple care
providers.
• Provide clear explanations.
• Provide demonstrations whenever possible (e.g., how to floss teeth).
109. (pp. 382–383)
i. multiple sclerosis
ii. myasthenia gravis
iii. Parkinson and Huntington
iv. Alzheimer
v. Parkinson
vi. Huntington
vii. amyotrophic lateral sclerosis (ALS)
viii. Huntington
ix. multiple sclerosis, myasthenia gravis
x. Parkinson
xi. multiple sclerosis, Alzheimer
 xii. Huntington and Alzheimer
xiii. Parkinson
xiv. Alzheimer
xv. Creutzfeldt-Jakob

Chapter 15
Disorders of the Eye, Ear, and Other Sensory Organs

Eye
1. (p. 387, Fig. 15.1)
A. Medial rectus muscle, B. Retinal artery, C. Retinal vein, D. Optic
nerve, E. Central retinal artery and vein, F. Meninges, G. Optic disc,
H. Fovea centralis, I. Sclera, J. Choroid, K. Retina, L. Lateral rectus
muscle, M. Conjunctiva, N. Posterior chamber, O. Anterior chamber,
P. Lens, Q. Cornea, R. Pupil, S. Iris, T. Canal of Schlemm, U. Ciliary
muscle, V. Suspensory ligament, W. Posterior cavity
2. (p. 388)
i. measures visual acuity
ii. checks central and peripheral vision
iii. assesses interocular pressure
iv. examines interior eye structures
v. measures the angle of the anterior chamber
3. (pp. 388–389)
i. nearsightedness
ii. farsightedness
iii. farsightedness associated with aging
iv. irregular curvature in the cornea or lens
v. double vision or paralysis of upper eyelid
4. (p. 389)
i. infection involving a hair follicle on the eyelid—usually caused by
staphylococci
ii. inflammation or infection involving the conjunctiva: inflammation can
be caused by allergies or irritating chemicals; infection can be caused
 by Staphylococcus aureus (pinkeye); Chlamydia trachomatis and
gonorrhea cause infections of the respiratory tract and may infect eyes
of newborns; Neisseria gonorrhoeae can cause infection by self-
inoculation
iii. eye infection caused by Chlamydia trachomatis—causes follicles to
develop on the inner surface of eyelids
iv. infected cornea, very painful, can be caused by the Herpes simplex
virus
5. (pp. 390–391, Fig. 15.4) increased intraocular pressure caused by an
excessive accumulation of aqueous humor
6. (p. 391, Fig. 15.4) Narrow-angle glaucoma occurs when the angle
between the cornea and the iris in the anterior chamber is decreased by
factors such as abnormal anterior insertion of the iris. Wide-angle, or
chronic, glaucoma is a degenerative disorder in older individuals. The
trabecular network and canal of Schlemm become obstructed,
diminishing the outflow of aqueous humor.
7. (p. 391) the elderly, older than 50 years of age
8. (p. 392)
• increased intraocular pressure
• loss of peripheral vision
• corneal edema and altered light refraction, leading to blurred vision
and appearance of “halos” around lights
• mild eye discomfort
• acute episodes may be triggered by pupil dilation (narrow-angle)
• eye pain, nausea, and headache; blurred vision; bulging and cloudy
cornea
• pupil dilated and unresponsive to light
9. (pp. 392–393) Therapeutic interventions include regular administration
of β-adrenergic blockers (reduce secretions) or cholinergic agents
(contract the pupil) and/or surgery, such as laser iridotomy, for acute
narrow-angle glaucoma if severe.
10. (pp. 392–393)
 Macular
Cataract Detached Retina
Degeneration
Etiology Aging, trauma, Aging Marked myopia
or congenital Genetics Aging
factors Environmental
Metabolic factors
abnormalities
Maternal
infections
Pathology Progressive Growth of Retina lifted from choroid as
clouding of lens membrane over vitreous seeps behind tear,
retina, starting at retinal cells stop functioning and
fovea centralis may die
Effect on Progressive Loss of central “Floaters”—light or dark
vision blurring and vision floating spots
darkening of Altered depth Growing area of blackness in
vision perception visual field
Treatment Lens removal Limited by type Scleral buckling
and replacement Photoactivated Laser therapy
with intraocular drugs
lens Laser treatment

11. (p. 393) For the dry type of AMD, nutrition is assessed to ensure that
vitamin, mineral, and antioxidant intake are sufficient. A high-dose
formulation of antioxidants and zinc has been shown to reduce the risk.
In the wet type of AMD, photodynamic therapy (photosensitive drug
plus laser) may help seal off neovasculature. The older method, laser
photocoagulation, may also be used to seal vessels without the photo-
activated drug, Visudyne, which is used in photodynamic therapy. The
new drug, pegaptanib (Macugen) may slow vascular growth, and
therapy using the drug anti-vascular endothelial growth factor (anti
VEGF) has shown promise. An intraocular shot of an anti-VEGF drug
inhibits the formation of new blood vessels behind the retina and may
keep the retina free of leakage.
12. (pp. 391–394)
i. cataracts
ii. macular degeneration
iii. glaucoma
iv. macular degeneration
v. glaucoma
 vi. glaucoma

Ear
13. (p. 394, Fig. 15.8)
A. Temporal bone, B. Auditory ossicles, C. Malleus, D. Incus, E. Stapes,
F. Semicircular canals, G. Oval window, H. Vestibular nerve, I.
Cochlear nerve, J. Auditory nerve (VIII), K. Cochlea containing organ
of Corti, L. Vestibule, M. Auditory (eustachian) tube, N. Inner ear, O.
Middle ear, P. External ear, Q. Tympanic membrane, R. External
auditory canal, S. Pinna
14. (p. 396) Conduction deafness occurs when sound is blocked in the
external or middle ear. For example, wax accumulation, a foreign object,
scar tissue, or adhesions may cause conduction deafness. Sensorineural
deafness is due to damage to the organ of Corti or auditory nerve. For
example, infection, particularly viral, such as rubella, influenza, or
herpes; head trauma; or ototoxic drugs may cause sensorineural
deafness.
15. (p. 396) Otitis media is an inflammation or infection of the middle ear
cavity. Common causative bacteria include Haemophilus influenzae,
pneumococci, β-hemolytic streptococci, and staphylococci. Viruses can
also cause otitis media—viral infections are often followed by a
secondary bacterial infection.
16. (p. 397) Antibacterials if caused by bacteria; ibuprofen or
acetaminophen if it is a viral infection—to reduce discomfort; viral
infection can be followed by antibacterials if infection does not clear up.
17. (p. 398) Otitis externa is an infection of the external auditory canal and
the pinna. It is usually bacterial but may be fungal as well.
18. (p. 398) a disorder of the inner ear or labyrinth due to intermittent
development of excessive endolymph that stretches the membranes and
interferes with function of the hair cells in the cochlea and vestibule (p.
398); manifestations include episodes lasting minutes or hours causing
vertigo, tinnitus, and unilateral hearing loss
19. (p. 399)
i. infants and young children
ii. swimmers; frequent users of ear plugs or earphones
 iii. beginning in adults between 30 and 50 years of age

Chapter 16
Endocrine System Disorders
1. (p. 401, Fig. 16.1)
A. Pituitary gland, B. Pineal gland, C. Parathyroid glands on posterior
thyroid, D. Thyroid gland, E. Thymus, F. Adrenal gland, G. Pancreas,
H. Kidney, I. Ovary in female, J. Testis in male
2. (p. 401) Hormones are chemical messengers and can be classified by:
• Action: control or hormone levels (e.g., blood calcium levels)
• Source: endocrine organ (e.g., adrenal gland)
• Chemical structure: amino acid derivatives or steroids
3. (p. 401) negative feedback
4. (p. 403) an excessive amount of hormone or a hormonal deficit
5. (p. 401) Radioimmunoassay and immunochemical assays

Diabetes Mellitus
6. (p. 404, Table 16.2) familial history (type 1); obesity, advancing age (type
2)
7. (p. 404, Table 16.2)
• Type 1: genetic factor (family history); autoimmune destruction of
pancreatic beta cells
• Type 2: familial, lifestyle, and environmental factors, especially obesity
8. (p. 405) An insulin deficit leads to the following sequence of events and
can be categorized into the initial stage and progressive effects:
Initial stage:
• decreased transportation and use of glucose
• hyperglycemia
• glucosuria
• polyuria with loss of fluid and electrolytes
• fluid loss through the urine and high blood glucose levels—
dehydration
 • polydipsia due to dehydration
• lack of nutrients entering the cells, stimulating appetite and leading to
polyphagia

Progressive effects:
• catabolism of fats and proteins due to lack of glucose in cells; resulting
in ketosis as metabolites accumulate—ketoacidosis
• ketonuria
• glomerular filtration drops, resulting in decompensated metabolic
acidosis
9. (p. 405, Fig. 16.4) The lack of glucose in cells results in catabolism of fats,
leading to excessive buildup of fatty acids and their metabolites, ketone
(ketoacids).
10. (p. 408, Table 16.3) Warning signs include:
• polyuria: hyperglycemia results in excess glucose in the urine as renal
tubular reabsorption capacity is exceeded; the glucose in the filtrate
exerts osmotic pressure, increasing the volume of urine produced
• polydipsia: fluid and electrolyte loss due to glucosuria results in
dehydration and stimulation of the thirst response (hypothalamus)
• polyphagia: lack of nutrients in cells stimulates appetite
• weight loss: particularly with type 1, due to fat catabolism
11. (p. 406) Diagnosis is established from the following: fasting blood
glucose level, glucose tolerance test, and glycosylated hemoglobin test.
12. (p. 406) Dietary modifications include dieting to reduce weight or
maintain optimum weight; adding more complex carbohydrates, getting
adequate protein, and taking in low saturated fats and fiber to reduce
cholesterol levels; having minimal intake of simple and refined sugars;
and balancing and reducing food intake to match insulin availability,
metabolic needs, and activity level.
13. (pp. 406–407) Oral hypoglycemics act in a number of different ways to
lower blood sugar; some stimulate beta cells to release more insulin,
others reduce insulin resistance of cells and hepatic glucose production,
and another type increases cell sensitivity to insulin.
14. (p. 407)
 • hypoglycemia
• gastrointestinal disturbances; anorexia, nausea, vomiting
• anemia
• pruritus (itching)
• liver and kidney damage
• metallic taste (with metformin)
15. (p. 407) The various forms of insulin differ in onset of action, peak
insulin levels, and duration of action.
16. (p. 407) Insulin can be administered by subcutaneous injections,
continuous subcutaneous infusion (“insulin pump”), or inhalation,
which was just approved by the U.S. Food and Drug Administration
(FDA).
17. (pp. 409–410, Fig. 16.3) Factors that could precipitate a hypoglycemic or
insulin reaction include increased physical exercise, skipping a meal or
fasting, delayed or inadequate food intake, insulin overdose (too much
insulin), and nutritional and/or fluid and electrolyte imbalances due to
nausea and vomiting.
18. (pp. 407–408) Verify that patients have eaten and taken appropriate
medications.
Schedule appointments that do not unduly delay meals.
19. See p. 410, Table 16.4.
20. (pp. 411–412) Diabetic neuropathy is a disorder of peripheral nerves
that produces impaired sensation, numbness, tingling, weakness, and
muscle wasting. It results from ischemia and altered metabolic process.
Degenerative changes occur in both unmyelinated and myelinated
fibers. There is a risk for tissue trauma and infection. Autonomic nerve
degeneration leads to bladder incontinence, impotence, diarrhea, and
impaired vasomotor reflexes. Vascular impairment decreases tissue
resistance and slows healing; sensory impairment means that an
individual may not realize that he or she has injured himself and
therefore does not implement appropriate measures.
21. (p. 412) Risk for infection is greatly increased when vascular and
sensory impairment coexist.
22. (p. 412)
 • tuberculosis
• infections in the feet and hands
• fungal infections
• urinary tract infections
• periodontal disease
23. (pp. 408–412) There may be delayed healing because of decreased
circulation to the injured site due to both macroangiopathy and
microangiopathy. Individuals are more prone to infections, which will
further delay healing.
24. (p. 415, Chapter 22) diabetes that develops during pregnancy and
usually ends with delivery of the infant
25. (pp. 410–411, Figs. 16.3 and 16.4)
 Hypoglycemic Shock Ketoacidosis
Other names Insulin shock Diabetic coma
Insulin reaction
Cause Hypoglycemia Hyperglycemia
Precipitating Increased physical exercise Excessive food and/or
factors Skipping a meal or fasting alcohol intake
Delayed or inadequate food intake Inadequate insulin—
Insulin overdose—too much insulin skipped or delayed
Nutritional and/or fluid and Increased requirement for
electrolyte imbalances due to nausea insulin: infection, stress,
and vomiting glucocorticoids
Speed of onset Rapid Slow
Manifestations Apprehensive, headache Increased hunger and
Pale, cold, diaphoretic, “clammy” thirst
Hungry, thirsty Polyuria
Appears intoxicated: unexpected Fatigue, confusion
behavior, slurred speech, incoherent, Nausea and vomiting
disoriented, staggering gait Signs of dehydration:
Difficulty problem solving flushed, warm, dry skin
Muscle twitching, tremors and mucous membranes
Seizures Acetone breath
Permanent brain damage Tachycardia and lowered
Death blood pressure
Rapid, deep breathing
Loss of consciousness
Emergency Glucose in rapidly absorbed form Insulin
treatment Fluid and electrolyte
replacement
Sodium bicarbonate
Speed of Rapid Slow
response to
emergency
treatment
Prevention Never interfere with normal Never tell a diabetic not to
mealtimes of diabetic take medication without
Never tell diabetic to fast without medical consult
seeking medical consult Careful observation for
Have available a ready source of warning signs
glucose
Careful observation for warning
signs

26. (pp. 404–407)

 Type 1
Type 2 (NIDDM)
(IDDM)
Percentage of individuals with DM 20% 80%
Age at onset Preadolescent Older than 30 years of
age
Speed of onset of symptoms Acute Insidious
Family history Yes Very strong
Body build (BMI) Thin Obese
Presence of autoantibodies Yes No
Insulin receptor defects No Yes
Severity of manifestations Acute Mild
Stability (i.e., maintenance of normal blood More difficult More stable
glucose)
Frequency of complications Frequent Less common
Occurrence of ketoacidosis Frequent Less common
Frequency of hypoglycemia Frequent Less common
Treatment with insulin Always Less common
Treatment with oral hypoglycemics No Frequent
DM, Diabetes mellitus; IDDM, insulin-dependent diabetes mellitus; NIDDM, non–insulin-dependent
diabetes mellitus.

Parathyroid Disorders
27. (pp. 413–414)
• Hypoparathyroidism: congenital lack of parathyroid glands, following
surgery or radiation in the neck region, or as a result of autoimmune
disease
• Hyperparathyroidism: adenoma, hyperplasia, secondary to renal
failure
28. (p. 413, Fig. 16.10) Hypoparathyroidism leads to hypocalcemia, which
affects nerve and muscle function. It can lead to weak cardiac muscle
contractions but increased excitability of nerves, leading to spontaneous
contractions of skeletal muscle: twitching and spasms.
29. (p. 414, Fig. 16.10, p. 417) Hyperparathyroidism causes hypercalcemia,
which leads to forceful cardiac contractions; osteoporosis due to excess
bone demineralization; and increased predisposition to kidney stones.

Acromegaly
30. (p. 415) excess growth hormone secretions from a pituitary adenoma in
the adult
31. (p. 415, Fig. 16.12)
Manifestations include:
• bones that become broader and heavier
• soft tissues that grow, resulting in enlarged hands and feet
• a thicker skull
• changes in facial features

Complications include:
• nerve and blood vessel compression in the skull
• carpal tunnel syndrome
• arthritis
• diabetes
• hypertension and cardiovascular disease

Antidiuretic Hormone
32. (pp. 418–422) Diabetes insipidus is due to insufficient antidiuretic
hormone (ADH; also known as vasopressin) release—no sugar in urine;
diabetes mellitus is caused by a lack or insufficient release of insulin or
insulin resistance—sugar in urine.

Thyroid Disorders
33. (p. 417, Figs. 16.13 and 16.14) A goiter is an enlargement of the thyroid
gland that is often visible on the neck; it is caused by hypothyroidism
(endemic goiter) and hyperthyroidism (toxic goiter).
34. (p. 420, Table 16.5)
 Hyperthyroidism Hypothyroidism
Forms Graves disease Infant: cretinism
Adult: myxedema
Etiology Autoimmune: thyroid- Congenital:
stimulating antibodies • Thyroid agenesis or dysgenesis
Adenoma: thyroid or • Lower TSH or T3 and T4
pituitary Adult:
Toxic goiter • Autoimmune (Hashimoto disease)
• Surgical removal
• Drugs
Serum T3 and High Low
T4 levels
Metabolic rate High Low
Nervous Restlessness, anxiety, Child: severe mental retardation
system effects irritability Decreased reflexes
Insomnia Fatigue, sluggishness
Tremors Headache
Impaired concentration Slow intellectual functions
Coma
Cardiovascular Tachycardia Bradycardia
effects Palpitations, Decreased CO
arrhythmias Decreased blood pressure
Increased blood
pressure
Cardiomegaly
Severe: angina pectoris,
myocardial infarction
Respiratory Hyperventilation Hypoventilation
effects Dyspnea
Skeletal effects Increased resorption Retarded bone age
Advanced bone age “Stubby hands”
Osteoporosis
Muscular Increased tone leading Decreased tone and reflexes
effects to tremors and Muscle weakness
twitching Decreased peristalsis leading to
Diarrhea constipation, flatulence, and abdominal
distention
Skin and hair Increased sweating Pale; yellowish hue
Flushed warm skin Cool
Soft nails Dry and rough
Thin, silky hair Hair brittle and coarse
Alopecia
Loss of lateral third of eyebrows
 Hyperthyroidism Hypothyroidism
Temperature Increased body Decreased body temperature
tolerance temperature Cold intolerance
Heat intolerance
Eyes Exophthalmos Puffy
Decreased blinking
and eye movements
“Lid lag”
Body weight Decreased with Increased with decreased appetite
(BMI) increased appetite
Presence of With Graves disease With endemic goiter
goiter
Treatment Antithyroid agents Replacement therapy
Radioactive iodine
Thyroidectomy

Adrenal Disorders
35. (pp. 421–422, Figs. 16.16 to 16.18, Table 16.6)
 Cushing Syndrome Addison Disease
Etiology Adrenal tumor Autoimmune destruction
Glucocorticoid therapy Prolonged treatment with
Pituitary tumor corticosteroids
Paraneoplastic syndrome Infections: tuberculosis, fungi,
cancer
Physical Round “moon face” Hyperpigmentation of skin,
appearance Thinning of skin particularly in creases—also
Purple striae buccal mucosa and tongue
Ecchymoses —“bronzing”
Cervical or supraclavicular fat
pads—“buffalo hump”
Hirsutism
Alopecia
Protruding abdomen
Fluid and Increased Na+ and CI– Decreased Na+ and CI–
electrolytes Decreased K+ Increased K+
Increased HCO3– and Increased H+ and decreased
decreased H+ HCO3–
Water retention resulting in Dehydration
edema
Blood pressure Increased Decreased
Blood sugar Increased Normal or decreased
Musculoskeletal Atrophy Weakness
effects Osteoporosis
Inflammatory Decreased Decreased
response
Immune Decreased Decreased
response
Response to Decreased Decreased
stress
Treatment Surgery Replacement therapy
Palliative treatment (e.g.,
diuretics, antihypertensives,
hypoglycemics, or insulin
antibiotics)

36. (p. 421) Excessive glucocorticoids depress both inflammation and

immunity, thereby impairing normal defenses. Antibacterial drugs are
prescribed in an effort to prevent infection.

Consolidation
37. (p. 425)
i. thyroid (T3 and T4) hypersecretion
ii. growth hormone hypersecretion as a child
iii. hyposecretion of thyroid hormones T3 and T4 as an adult
iv. hyposecretion of ADH
v. growth hormone hypersecretion as an adult
vi. hypersecretion of glucocorticoids
vii. hyposecretion of growth hormone
viii. hyposecretion of insulin
ix. hyposecretion of mineralocorticoids, glucocorticoids, and androgens
x. hyposecretion of thyroid hormones as a child
38. (p. 425)
i. diabetes mellitus, Cushing, acromegaly
ii. hyperthyroidism
iii. diabetes mellitus, Addison, Cushing
iv. hypothyroidism
v. Cushing, hyperthyroidism, hyperparathyroidism
vi. cretinism (hypothyroidism as child)
vii. hyperparathyroidism
viii. Addison, hypothyroidism
ix. hypothyroidism—cretinism, hyposecretion of growth hormone
x. Addison
xi. diabetes mellitus type 1, hyperthyroidism—Graves, hypothyroidism
—Hashimoto
xii. inappropriate ADH syndrome, hypothyroidism—myxedema,
Cushing
xiii. hyperthyroidism—Graves
xiv. hypothyroidism
xv. Cushing
xvi. Cushing, hypothyroidism
xvii. Addison, Cushing, hyperthyroidism
 xviii. diabetes mellitus, inappropriate ADH syndrome, hyperthyroidism,
Cushing
xix. diabetes mellitus, hyperthyroidism
xx. hyperthyroidism (Graves), hypothyroidism (endemic)
xxi. acromegaly
xxii. hyperthyroidism
xxiii. inappropriate ADH syndrome, Addison
xxiv. hypoparathyroidism

Chapter 17
Digestive System Disorders
1. (p. 429, Fig. 17.1)
A. Parotid salivary gland, B. Oropharynx, C. Submandibular salivary
gland, D. Diaphragm, E. Cardiac sphincter, F. Stomach, G. Pyloric
sphincter, H. Pancreas, I. Transverse colon, J. Descending colon, K.
Jejunum, L. Sigmoid colon, M. Rectum, N. Anus, O. Appendix, P.
Cecum, Q. Ileum, R. Ileocecal valve, S. Ascending colon, T. Large
intestine, U. Duodenal papilla, V. Duodenum, W. Common bile duct,
X. Gallbladder, Y. Liver, Z. Esophagus, AA. Trachea, BB. Sublingual
salivary gland, CC. Tooth, DD. Tongue, EE. Mouth, FF. Hard palate
2. (pp. 442–488)
a. drug used to decrease nausea and vomiting; iv. antiemetic
b. formation of gallstones; x. cholelithiasis
c. greasy, loose stools; i. steatorrhea
d. loss of appetite; v. anorexia
e. opportunistic oral fungal infection; viii. candidiasis
f. outpouching of the mucosa in colon; xi. diverticulum
g. tarry stools caused by bleeding; ii. melena
h. difficulty swallowing; iii. dysphagia
i. inflammation of tissue surrounding the teeth; ix. gingivitis
j. retention of feces; vii. impaction
k. vomit containing blood; vi. hematemesis
3. (p. 435)
 • distention or irritation in digestive tract: distention due to gas
following abdominal surgery; constipation
• unpleasant sights or smells: sight of blood; odor of emesis or feces
• pain or stress: performance anxiety; after surgery; going to dentist
• stimulation of vestibular apparatus in inner ear: motion sickness;
amusement rides
• increased intracranial pressure: brain tumors, hydrocephalus; cerebral
hemorrhage
• stimulation of chemoreceptor trigger zone: drugs, alcohol
4. (p. 440, Table 17.3)
• treat cause (e.g., analgesics for pain; laxatives or enema to relieve
constipation)
• antiemetic drugs
• sedatives
• antacids
• good ventilation to remove noxious odors
5. (p. 437)
• increased age and weakness of smooth muscles in the intestines
• inadequate dietary fiber
• inadequate fluid intake
• failure to respond to the defecation reflex
• muscle weakness and inactivity
• neurologic disorders such as multiple sclerosis and spinal cord trauma
• drugs, such as opiates, CNS depressants, or anticholinergic drugs
• some antacids, iron medications, and bulk laxatives (with insufficient
fluid intake)
• obstruction caused by tumors or strictures
6. (p. 437) increased fiber and fluid intake
7. (p. 446, Fig. 17.11) Causes include:
• A: esophageal fibrosis
• B: esophageal compression
• C: esophageal diverticulum
 • D: congenital atresia of the esophagus
• E: congenital tracheoesophageal fistula
• F: neurologic damage to cranial nerves V, VII, IX, X, and XII
• G: achalasia
8. (p. 448, Fig. 17.13, p. 448) Part of the stomach is elevated and protrudes
through an opening (hiatus) in the diaphragm into the thoracic cavity.
9. (p. 448) Signs and symptoms include postprandial heartburn or pyrosis,
a brief substernal burning sensation, often accompanied by sour taste;
belching from regurgitation of gastric contents, especially when in a
reclining position; and dysphagia.
10. (p. 449) eliminating factors that reduce lower esophageal sphincter
(LES) pressure, such as caffeine, fatty foods, alcohol, cigarette smoking,
and certain drugs.
11. (p. 449) GERD is gastroesophageal reflux disease, the periodic flow of
gastric contents into the esophagus. GERD is caused by hiatal hernia as
well as other conditions that lower LES pressure or increase
intraabdominal pressure.
12. (p. 449, Table 17.3) antacids; histamine2 (H2 receptor) antagonists;
proton pump inhibitors
13. (p. 449) Acute gastritis is an inflammation of the gastric mucosa due to
a variety of causes, including infection, food or drug allergy, ingestion of
spicy or irritating food, excessive alcohol intake, ingestion of aspirin or
other ulcerogenic drugs, ingestion of toxic substances, radiation, or
chemotherapy. Acute gastroenteritis is inflammation of both the
stomach and intestine, usually caused by infection but may result from
food or drug allergies.
14. (pp. 449–450)
 Acute Gastritis Chronic Gastritis
Etiology Infections Peptic ulcers
Food allergies Alcohol abuse
Spicy or irritating foods Aging
Drugs: aspirin; chemotherapy Pernicious anemia
Ingestion of corrosive or toxic
substances
Radiation
Signs and Epigastric discomfort Anorexia, nausea,
symptoms vomiting
Epigastric pain; cramps
Intolerance of spicy foods
Hematemesis

15. (p. 450, Table 17.4).

16. (p. 450)
• Enterotoxigenic E. coli (ETEC) causes diarrhea in infants and travelers
in countries in which proper sanitation is lacking. The organism
colonizes the small intestine and produces enterotoxins that may
cause minor discomfort to severe cholera-like symptoms.
• Enteroinvasive E. coli (EIEC) penetrates and reproduces in and
destroys the epithelial cells of the colon. The organism does not
produce enterotoxins but causes severe diarrhea and fever.
• Enteropathogenic E. coli (EPEC) is very similar to EIEC; however, it is
reported to produce and enterotoxin similar to Shigella.
• Enteroaggregative E. coli (EAggEC) produces persistent diarrhea in
young children. In addition to producing an enteroaggregative heat
stable toxin, it also produces a hemolysin produced by strains that
commonly cause urinary tract infections.
• Enterohemorrhagic E. coli (EHEC) is caused by a specific strain,
O157:H7. These strains of E. coli release verocytotoxins (Shigella-like
toxins) in the intestine, which cause damage to the mucosa and to the
blood vessel walls, and subsequently may affect blood vessels in the
kidneys and elsewhere.

Ulcers
17. (p. 451, Fig. 17.1) Ulcers occur in the proximal duodenum (most
common), antrum of the stomach, and lower esophagus.
18. (p. 451) Factors include decreased mucosal resistance (gastric ulcers),
excessive HCl or pepsin secretion (duodenal ulcers), and presence of
bacterium H. pylori.
19. (pp. 451–452) Acid or pepsin penetrates the mucosal barrier. Tissues are
exposed to continued damage because of acid diffusion into the gastric
wall. Ulcers may erode more deeply into muscle layers and eventually
perforate the wall. Inflammation surrounds the crater. Bleeding occurs
when erosion invades a blood vessel. Bleeding may involve persistent
loss of small amounts of blood or massive hemorrhage, depending on
the size of the blood vessel involved.
20. (p. 453) Complications include:
• hemorrhage
• perforation, resulting in chemical peritonitis and, ultimately, bacterial
peritonitis
• obstruction of the digestive tract due to scarring and stricture
formation
21. (pp. 453–454) Signs and symptoms include:
• epigastric burning or aching pain, usually 2 to 3 hours after meals and
at night
• heartburn, nausea, vomiting, and weight loss, especially after alcohol
or irritating food
• iron deficiency anemia or occult blood in the stool
22. (p. 454) Treatment includes:
• drug therapy: usually combination of antimicrobials and acid
reducers; coating agents or antacids for symptomatic relief
• reducing exacerbating factors
• vagotomy
• partial gastrectomy or pyloroplasty in patients with perforated or
bleeding ulcers

Cancer
23. (pp. 454–455)
 Symptoms and
Etiology Pathophysiology Treatment
Complications
Esophagus Chronic Circumferential Dysphagia Surgery and
esophagitis or mass causing radiation
Hiatal obstruction
hernia
Alcohol
abuse
Smoking
Stomach Diet: Ulcerative-type Asymptomatic Combination
nitrates and lesion in until late therapy: surgery
smoked mucosa or Indigestion (gastric resection),
foods protruding Feelings of chemotherapy, and
Genetics mass or polyp fullness radiation
Chronic Infiltrates into Weight loss
atrophic muscularis and and fatigue
gastritis serosa Occult blood
Polyps Spreads to liver in stool
and ovaries Iron
deficiency
anemia
Liver Cirrhosis Mass that Anorexia, Chemotherapy
Hepatitis B obstructs bile vomiting, Resection if tumor is
and C ducts and weight loss single and not large
Prolonged hepatic Jaundice
exposure to sinusoids Portal
carcinogenic Frequent site of hypertension
chemicals metastases from Splenomegaly
Metastases other sites
from
abdominal
organs
Pancreas Cigarette Mass that Abdominal Surgery, radiation,
smoking obstructs ducts pain and chemotherapy
Genetics Congestion and Weight loss
inflammation Jaundice
Pancreatitis
Early metastases
 Symptoms and
Etiology Pathophysiology Treatment
Complications
Colorectal Age: older May be Cramping Surgery, both
than 55 polypoid Feeling of curative and
Familial May be incomplete palliative; may be
multiple ulcerative emptying accompanied by
polyposis If Change in radiation and
Ulcerative circumferential, bowel pattern chemotherapy
colitis may cause and fecal
obstruction consistency
Metastasize to Occult blood
liver in stool or
melena

Gallbladder Disease
24. (p. 457) women with high cholesterol levels in the bile; obesity, high
cholesterol intake, and multiparity; use of oral contraceptives or
estrogen supplements; individuals with hemolytic anemia, alcoholic
cirrhosis, or biliary tract infections
25. (p. 457) Signs and symptoms include sudden severe waves of pain in
the upper right quadrant of the abdomen or epigastric area, often
radiating to the back or right shoulder; nausea and vomiting; increasing
and then decreasing pain (if the stone moves on); and increasing pain
followed by jaundice.

Liver Disease
26. (pp. 457–460, Fig. 17.18, p. 459)
• prehepatic; results from excessive destruction of red blood cells
(RBCs), e.g., physiologic jaundice of some newborns, hemolytic
anemias, transfusion reactions
• intrahepatic: due to liver disease resulting in impaired uptake of
bilirubin from the blood and decreased bilirubin conjugation (e.g.,
individuals with liver disease such as hepatitis or cirrhosis)
• posthepatic: obstruction of biliary flow due to congenital atresia of the
bile ducts, cholelithiasis; inflammation or tumors of the liver
27. (p. 458) infectious mononucleosis or amebiasis; chemical or drug
toxicity
28. (pp. 462–464, Table 17.5)
 Hepatitis A Hepatitis B Hepatitis C
Causative agent HAV: RNA virus HBV: double-stranded HCV: RNA virus
DNA virus
Transmission Oral-fecal: “enteric” Blood and body fluids Blood and body
fluids
High-risk Individuals living in IV drug users Same as for
groups large institutions Individuals engaging HBV, especially
(e.g., prisons, nursing in unprotected sex IV drug users
homes) Those requiring Recipients of
Children with poor hemodialysis blood and blood
toileting behavior Infants born to HBV+ products before
Individuals living mothers 1990
with inadequate Those with multiple Recipients of
sanitation and water tattoos and body organ
for hygiene piercings transplants
Travelers to Health care workers Recipients of
developing countries Recipients of blood artificial
Individuals who and blood products insemination
engage in oral-anal before 1984
sex
Age All ages More prevalent after More prevalent
puberty after puberty
Incubation 2–6 weeks 1–6 months (average 2 weeks to 6
period 60–90 days) months (average
6–9 weeks)
Duration of 2 months 4–12 weeks 2–12 weeks
signs and
symptoms
Carrier state None Yes Yes
present/absent
Complications Rare Chronicity Chronicity:
Hepatocellular more than 50%
carcinoma Hepatocellular
Cirrhosis and liver cancer
failure Cirrhosis and
Fulminant hepatitis liver failure
 Hepatitis A Hepatitis B Hepatitis C
Serologic Anti-HAV IgM: HBsAg (surface Anti-HCV:
markers indicative of acute antigen): indicator of indicator of
infection infection infection; NOT
Anti-HAV IgG: Anti-HBs: recovery protective
indicative of past and noninfectivity; HCV RNA:
exposure effective protection indicator of
HBeAg (core antigen): infection
marker of active
infection
Anti-HBe: signals
onset of resolution
Anti-HBc (core
antigen): marker of
recent infection: NOT
protective
HBV DNA: indicator
of infection
Medications None Chronic cases with With elevated
abnormal liver ALT: Interferon
function tests: alpha-2b
Interferon alpha-2b Ribavirin
Lamivudine
Immunoglobulin Yes Yes No
vaccine

29. (p. 458) from virus or bacterially contaminated stool or food or fomites
(inanimate objects) to hands to mouth and fomites by poor hygiene and
unsanitary toilet practices (e.g., not washing hands after bowel
movement); examples include:
• virus that has been excreted in stool of infected individual is ingested
(as contaminated food or water) by another individual
• children with poor toileting behavior, particularly in large day care
centers
• poor handwashing in nursing homes
• eating shellfish from contaminated water
30. (p. 462) It is an incomplete RNA virus that requires the presence of
HBV so as to replicate.
31. (p. 462, Table 17.5) by serologic markers
32. (p. 462, Table 17.5, p. 462) by fecal-oral route
 p p y
33. (p. 464) General signs and symptoms include:
• preicteric stage: fatigue and malaise, anorexia and nausea, and general
muscle aching; elevated serum levels of liver enzymes (AST, ALT)
• icteric stage: jaundice; light-colored stool; dark urine and pruritic skin;
tender, enlarged liver, causing mild aching pain; blood clotting times
elevated in severe cases
• posticteric stage: reduction in signs, may last for several weeks;
depending on specific viral etiology
34. (p. 462) Hepatitis B has a relatively long incubation period, averaging
about 2 months. Long incubation periods make it more difficult to track
sources and contacts for infections. A carrier state is also common for
HBV, in which the individual is asymptomatic but is contagious for the
disease.
35. (p. 463) progressive destruction of liver tissue, leading eventually to
liver failure
36. (p. 463) Causes include:
• alcoholic liver disease
• biliary cirrhosis: associated with immune disorders and disorders
causing biliary obstruction such as stones or cystic fibrosis
• postnecrotic cirrhosis: linked with chronic hepatitis or long-term
exposure to toxic chemicals
• metabolic: usually caused by storage disorders, such as
hemochromatosis
37. (p. 463) Liver demonstrates extensive diffuse fibrosis and loss of lobular
organization. Nodules of regenerated hepatocytes may be present but
are nonfunctional because the vascular network and biliary ducts are
distorted. Fibrosis interferes with the blood supply. Bile may back up,
causing ongoing inflammation and damage. Initial hepatomegaly is
replaced by small, shrunken, and scarred liver.
38. (pp. 463–464) Lost or impaired liver functions include:
• decreased removal and conjugation of bilirubin
• decreased bile production
• impaired digestion and absorption of nutrients, especially fats and fat-
soluble vitamins
 • decreased production of blood-clotting factors and plasma proteins
• impaired glucose/glycogen metabolism
• inadequate storage of iron and vitamin B12
• decreased inactivation of hormones, such as aldosterone and estrogen
• decreased removal of toxic substances from the blood
39. (p. 464, Table 17.6) Signs and symptoms include fatigue; anorexia;
ascites; general edema; esophageal varices, hemorrhoids; splenomegaly;
anemia; leukopenia, thrombocytopenia; increased bleeding, purpura;
hepatic encephalopathy, tremors, confusion, coma; gynecomastia,
impotence, irregular menses; jaundice; and pruritus.
40. (pp. 464–465) blockage of blood flow through the liver leading to high
pressure in the portal veins
41. (pp. 463–465)
• ascites, splenomegaly, esophageal varices
• impaired respiration
• increased risk for peritonitis
• impaired digestion and absorption
42. (p. 466) Interventions include supportive or symptomatic treatments,
such as avoiding fatigue and exposure to infection; dietary restrictions
on protein and sodium; high carbohydrate intake and vitamin
supplementation; use of diuretics to balance serum electrolytes;
paracentesis to remove excess fluid; albumin transfusions;
antimicrobials such as neomycin to remove intestinal flora; surgery for
esophageal varices; and liver transplantation.

Pancreatitis
43. (pp. 468–469) gallstones and alcohol abuse
44. (p. 468, Fig. 17.31) Pancreatitis results in premature activation of
pancreatic enzymes inside the pancreatic duct, followed by
autodigestion of pancreatic tissue. There is tissue necrosis and severe
inflammation of pancreas. Leakage of enzymes into general circulation
may cause shock, disseminated intravascular coagulation, and acute
respiratory distress syndrome. Leakage of enzymes into the peritoneal
cavity continues to destroy tissue and causes massive inflammation,
 leading to severe pain, hemorrhage and shock, peritonitis, and
hypovolemic shock.
45. (p. 468) Signs and symptoms include severe epigastric or abdominal
pain radiating to the back, which increases when supine; signs of shock,
including low blood pressure, pallor, and sweating; rapid but weak
pulse; low-grade fever; and abdominal distention and decreased bowel
sounds.
46. (p. 469) Treatment includes stopping all oral intake; relieving bowel
distention; treating shock and electrolyte imbalances; and prescribing
analgesics (but NOT morphine).

Intestinal Disorders
47. (p. 469) malabsorption syndrome, primarily in childhood; genetic
factors resulting in defect in intestinal enzymes needed to complete
digestion of gliadin, a breakdown product of gluten.
48. (p. 469, Fig. 17.32B) The combination of a digestive block with an
immunologic response results in a toxic effect on the intestinal villi; villi
atrophy, resulting in decreased enzyme production and reduced surface
area for absorption of nutrients, resulting in malabsorption and
malnutrition.
49. (p. 469) steatorrhea, muscle wasting, and failure to gain weight;
irritability and malaise are common
50. (p. 472) Treatment is adopting a gluten-free diet, avoiding grains such
as wheat, barley, and oats.
51. (p. 472) Crohn disease and ulcerative colitis are chronic inflammatory
bowel diseases of unknown etiology that involve the inflammation and
subsequent destruction of intestinal tissue.
52. (pp. 470–472, Table 17.7, Fig. 17.30).
 Crohn Disease Ulcerative Colitis
Individuals at European ancestry, European ancestry, Ashkenazi Jews,
high risk Ashkenazi Jews young adults (20s and 30s)
Etiology Genetic basis; high Genetic basis; high familial tendency
familial tendency
Location of Terminal ileum; Colon, rectum
lesions sometimes colon
Characteristics Transmural: all layers Mucosa only: continuous
of lesions “Skip” lesions Ulcerations
Granuloma
Complications Malabsorption; Malabsorption (rarely)
malnutrition Toxic megacolon leading to obstruction
Steatorrhea Iron deficiency anemia
Adhesions; strictures
Intestinal obstruction
Fistulas and fissures
Signs and Loose or semiformed Frequent watery stools with blood and
symptoms stool mucus
Melena Cramping pain
Cramping, abdominal Fever
pain Weight loss
Anorexia, weight loss,
fatigue
Delayed growth in
children

53. (p. 472) Treatment includes identification and removal of stressors,

antiinflammatory medications, antimotility agents, nutritional
supplements, antimicrobials, immunotherapeutic agents, and surgical
resection (ileostomy or colostomy).
54. (pp. 473–474, Fig. 17.35).
• The appendiceal lumen becomes obstructed by a fecalith, gallstone, or
foreign material or from twisting or spasm.
• Fluid builds up inside the appendix and pathogens proliferate.
• Inflammation with purulent exudate occurs, and appendix swells,
compressing blood vessels.
• Increasing pressure and congestion lead to ischemia and necrosis,
resulting in increased permeability of the wall.
• Bacteria and toxins escape through the wall into the area, resulting in
abscess formation or localized bacterial peritonitis.
 • Abscess develops when adjacent omentum adheres to appendiceal
surface in an attempt to wall off the inflammation.
• Localized infection or peritonitis develops and may spread along
peritoneal membranes.
• Necrosis and gangrene develop in the appendiceal wall.
• The appendix ruptures or perforates, releasing contents into the
peritoneal cavity.
55. (pp. 474–475)
• general periumbilical pain
• nausea and vomiting
• increasing severity of pain, which becomes localized in lower right
quadrant (LRQ)
• LRQ tenderness
• pain may subside temporarily following rupture
• pain recurs with steady, severe abdominal pain
• low-grade fever and leukocytosis
• onset of peritonitis includes rigid abdomen, tachycardia, and
hypotension
56. (pp. 475–476) A diverticulum is a herniation or outpouching of the
mucosa through the muscular layer of the colon. Diverticulitis refers to
inflammation of the diverticula.
57. (p. 478, Fig. 17.39) Warning signs vary depending on location of the
tumor within the bowel.
• ascending colon: liquid stool; occult blood or melena; anemia, fatigue;
late palpable mass
• transverse colon: semisolid stool; anemia, occult blood, change in
bowel habits
• descending colon: solid stool; constipation, discomfort; abdominal
fullness and distention; red or dark blood in stool
• rectum: solid stool; abdominal discomfort and cramps; ribbon or pellet
stool; incomplete emptying; red blood on surface of stool
58. (p. 480, Fig. 17.41)
A. Inguinal hernia, B. Volvulus, C. Intussusception, D. Tumor, E.
Diverticulitis
59. (p. 480, Fig. 17.41) Intestinal obstruction is a mechanical obstruction of
the flow of the intestinal contents. Gases and fluids accumulate in the
proximal area, distending the intestine. Increasingly strong contractions
occur. Increasing intraluminal pressure leads to more secretions and
compression of the veins, preventing absorption. Intestinal distention
leads to persistent vomiting and loss of fluid and electrolytes, resulting
in hypovolemia. If the obstruction is not removed, ischemia and necrosis
of the intestinal wall may result, leading to potential gangrene,
depending on the cause. There is decreased innervation and cessation of
peristalsis (decrease in bowel sounds). There is rapid overgrowth of
intestinal bacteria and production of endotoxins, which leak into
peritoneal cavity (peritonitis) and the bloodstream (septicemia and
bacteremia). In time, there is perforation and generalized peritonitis. If
the obstruction is functional rather than mechanical, then peristalsis
ceases, and there is distention of intestine. There are no reflex spasms.
The rest of sequence is the same as above.
60. (p. 482) Signs and symptoms include:
• mechanical obstruction of small intestine
• severe, colicky abdominal pain
• borborygmi (audible rumbling sounds) and intestinal rushes
• vomiting and abdominal distention occur quickly
• restlessness and sweating with tachycardia
• signs of dehydration, weakness, confusion, and shock
• in paralytic ileus, bowel sounds decrease or are absent and pain is
steady
• large intestine obstruction: develops slowly and signs are mild
• constipation and mild lower abdominal pain
• abdominal distention, anorexia
• vomiting and more severe pain
61. (p. 482) inflammation of the peritoneal membranes
62. (p. 482) chemical irritation; bacterial invasion
63. (p. 483, Fig. 17.44)
• local inflammation of the peritoneum and omentum producing a thick,
sticky exudate; abscess formation; reduction in peristalsis (attempts to
 keep inflammation, infection localized)
• rapid dissemination of irritants or bacteria throughout abdomen with
distention and reflex abdominal spasm (involvement of parietal
peritoneum)
• vasodilation and increased capillary permeability of peritoneal
membrane; edema; leakage of fluid into peritoneal cavity (“third
spacing”); hypovolemic shock
• fluid becomes sequestered in peritoneal cavity; leaked fluid becomes
purulent as infection spreads; nausea and vomiting from intestinal
irritation and pain, adding to fluid/electrolyte loss
• complications if intervention delayed; nerve conduction is impaired,
peristalsis decreases leading to obstruction; movement of bacteria and
toxins into bloodstream resulting in bacteremia and septicemia
64. (pp. 483–484) Signs and symptoms include sudden and severe
generalized abdominal pain, localized tenderness, pain increasing with
movement (individual often restricts breathing), vomiting, signs of
dehydration and hypovolemia, fever and leukocytosis, abdominal
distention, rigid abdomen (involvement of parietal peritoneum), and
decreased bowel sounds (paralytic ileus and secondary obstruction).
65. (p. 484) Treatment includes surgery and drainage of infection site,
antimicrobial drugs, replacement therapy, and nasogastric suction to
relieve distention.

Consolidation
66. (p. 440, Table 17.3)
i. antiinflammatory (e.g., inflammatory bowel disease (Crohn, ulcerative
colitis)
ii. antiemetic (e.g., acute gastritis, gastroenteritis)
iii. antibiotic (e.g., peptic ulcers, inflammatory bowel disease [Crohn,
ulcerative colitis], diverticular disease, peritonitis)
iv. acid reduction—proton pump inhibitor (e.g., hiatus hernia,
gastroesophageal reflux disease, chronic gastritis)
v. antidiarrheal (e.g., gastroenteritis, dumping syndrome, inflammatory
bowel disease [Crohn, ulcerative colitis])
vi. laxative (e.g., diverticular disease)
 vii. coating agent (e.g., chronic gastritis, gastroesophageal reflux disease,
peptic ulcer)

Chapter 18
Urinary System Disorders
1. (p. 490, Fig. 18.1)
A. Ribs, B. Adrenal gland, C. Renal artery, D. Kidney (left), E. Aorta, F.
Ureter, G. Rectum, H. Ureteral opening, I. Trigone, J. Urethra, K.
Penis, L. Prostate gland, M. Urinary bladder, N. Pelvis, O. Inferior
vena cava, P. Hilum, Q. Renal vein
2. (p. 492, Fig. 18.3)
A. Afferent arteriole, B. Glomerular capillaries, C. Efferent arteriole, D.
Distal convoluted tubules, E. Collecting duct, F. Arcuate vein, G.
Urine flow, H. Peritubular capillaries, I. Loop of Henle, J. Arcuate
artery, K. Proximal convoluted tubule
3. (p. 495) cloudy: may indicate the presence of large amounts of protein,
blood cells, or bacteria and pus; dark color: may indicate hematuria,
excessive bilirubin, or concentrated urine; unpleasant or unusual odor:
may indicate infection or may result from certain dietary components or
medications
4. (p. 495, Fig. 18.6) blood (hematuria); protein (proteinuria, albuminuria);
bacteria (bacteriuria); pus (pyuria); urinary casts; glucose and ketones
5. (p. 496, Table 18.2) Diuretics are used to remove excess sodium ions and
water from the body. They increase the excretion of water, which
reduces fluid volume in tissues and blood. Examples:
hydrochlorothiazide, furosemide.
6. (pp. 497–498, Fig. 18.7) Hemodialysis is provided in a hospital or dialysis
center. A patient's blood moves via an implanted shunt through a
dialysis machine, where exchange of wastes, fluid, and electrolytes takes
place across a semipermeable membrane via ultrafiltration, diffusion,
and osmosis and then is returned to the patient's bloodstream.
Peritoneal dialysis is administered at home or in a dialysis unit and can
be administered while the patient is asleep or ambulatory. Dialyzing
fluid is instilled via catheter into the peritoneal cavity and allowed to
remain there, facilitating exchanges of wastes and electrolytes by
 diffusion and osmosis across a semipermeable membrane; then the
dialysate is drained from the cavity via gravity into a container.
7. (p. 498) Complications include an infected shunt or formation of blood
clots, sclerosis and damage to blood vessels involved in the shunt, and
increased risk for infection by hepatitis virus or HIV.
8. (p. 498) Although rare, there is always the possibility that the equipment
was not sterilized properly and the dialysis patient will be exposed to
these viruses.
9. (p. 498) Any invasive procedure such as dental scaling or extractions
may introduce bacteria into the blood, resulting in a temporary
bacteremia.
10. (pp. 498–499, Fig. 18.8) Predisposing factors include prostatic
hypertrophy and urinary retention in older men, congenital
abnormalities in children, incomplete bladder emptying, reduced fluid
intake, impaired blood supply to the bladder, and immobility. Women
are anatomically more vulnerable to infection because of the shortness
and width of the urethra, the proximity of the urethra to the anus, and
the frequent irritation to the tissues caused by sexual activity, tampons,
bubble bath, and deodorants.
11. (pp. 499–500) Manifestations of cystitis include lower abdominal pain;
dysuria, urgency, frequency, and nocturia; systemic signs of infection
(fever, malaise, nausea, and leukocytosis); cloudy urine with an unusual
odor; and urinalysis indicating bacteruria. Manifestations of
pyelonephritis include signs and symptoms of cystitis, pain associated
with renal disease (dull aching pain in lower back), more marked
systemic signs, and urinalysis similar to that of cystitis plus the addition
of urinary casts.
12. (p. 500, Figs. 18.9 and 18.10) Antistreptococcal antibodies, resulting
from earlier infection, create an antigen-antibody complex that lodges in
the glomerular capillaries, activating the complement to cause an
inflammatory response in both kidneys. This leads to increased capillary
permeability and cell proliferation, resulting in leakage of protein and
RBCs into the glomerular filtrate. When inflammation is severe, it
interferes with filtration, causing decreased glomerular filtration rate
(GFR) and fluid retention. Acute renal failure is possible if blood flow is
sufficiently impaired. Renin secretion is likely to be triggered, leading to
 elevated blood pressure and edema. If the process becomes chronic, the
kidneys will be scarred.
13. (p. 501) Signs and symptoms include:
• dark and cloudy urine
• facial and periorbital edema, followed by generalized edema
• elevated blood pressure
• flank pain
• general signs of inflammation, including malaise, fatigue, headache,
anorexia, and nausea
• oliguria
14. (p. 501)
• blood tests showing elevated serum urea and creatinine, elevated
antistreptococcal antibodies (ASO and ASK), and decreased
complement level
• metabolic acidosis with low serum pH and bicarbonate
• proteinuria, gross hematuria, and erythrocyte casts
15. (p. 501) sodium restriction, decreased protein and fluid intake; drug
treatment includes glucocorticoids to reduce inflammation and
antihypertensives to reduce blood pressure
16. (p. 502)
• abnormality in the glomerular capillaries and increased permeability
resulting in proteinuria (albuminuria)
• hypoalbuminemia leading to generalized edema due to decreased
plasma osmotic pressure
• low or normal blood pressure with hypovolemia or elevated
depending on angiotensin levels
• hypovolemia leading to aldosterone secretion and more severe edema
• high levels of blood cholesterol and lipoprotein in the urine due to
unknown factors, possibly liver response to protein loss in the urine
17. (p. 502) most significant sign: massive edema or anasarca; potential
consequences include:
• weight gain
• pallor
 • anorexia
• dyspnea
• decreased exercise tolerance
• skin breakdown and subsequent infection
18. (p. 502) glucocorticoids, ACE inhibitors, and antihypertensives
19. (p. 503) Causative factors include excessive amounts of insoluble salts
in the filtrate (e.g., hypercalcemia due to hyperparathyroidism;
hyperuricemia due to gout or cancer chemotherapy).
20. (p. 504) Small stones that are “passed” will be visible and can be
analyzed for content.
21. (p. 504) Signs and symptoms include flank pain due to distention of the
renal capsule; renal colic (intense spasms of pain in the flank area
radiating into the groin), perhaps accompanied by nausea and vomiting;
cool moist skin; and rapid pulse. Diagnosis is confirmed by radiologic
examination.
22. (p. 504) buildup of urine due to obstruction of outflow, causing a
dilated area proximal to the obstruction in either ureter or kidney and
resulting in tissue atrophy and necrosis
23. (p. 504, Fig. 18.12, p. 505) secondary complication of calculi, tumors,
scar tissue in the kidney or ureter, stenosis or kinking of the ureter, and
untreated prostatic enlargement; developmental defects
24. (p. 505) smoking
25. (p. 508) “arteriosclerosis” of renal vasculature
26. (pp. 504–506) primary vascular changes in the kidney or secondary to
essential hypertension, diabetes mellitus (see diabetic nephropathy and
Fig. 25.6), or another condition
27. (pp. 506–507)
• Vesicoureteral reflux: due to a defective valve in the bladder
• Agenesis: failure of one kidney to develop
• Hypoplasia: failure of a kidney to develop to normal size
• Ectopic kidney: kidney and ureters are displaced out of normal
position
• “Horseshoe” kidney: fusion of two kidneys during development
Renal Failure
28. (p. 507, Fig. 18.16, Table 18.3) Causes include bilateral kidney disease,
such as glomerulonephritis; severe and prolonged circulatory shock or
heart failure; sepsis; nephrotoxins; ischemia; pyelonephritis; and
occasionally mechanical obstructions such as calculi, blood clots, or
tumors, only when affecting both kidneys (bilateral).
29. (pp. 509–511) Reverse the primary problem quickly, and provide
dialysis.
30. (p. 509, Table 18.3) Causes include nephrosclerosis, diabetes mellitus,
nephrotoxins, chronic exposure, chronic bilateral kidney inflammation
or infection, and polycystic disease.
31. (p. 509, Fig. 18.16) Renal insufficiency is the second stage of chronic
renal failure when about 75% of the nephrons are lost. End-stage renal
failure or uremia occurs when more than 90% of nephrons are lost and
GFR is negligible.
32. (pp. 509–510, Table 18.3, Fig. 18.16)
i. fluid, wastes retained; all body systems affected; oliguria or anuria;
hypocalcemia, hyperphosphatemia, hyponatremia, hyperkalemia;
acidosis
ii. congestive heart failure (CHF), arrhythmias, hypertension
iii. encephalopathy (lethargy, memory lapses, seizures, tremors)
iv. osteodystrophy (Fig. 18.17, p. 512), osteoporosis, and tetany
v. impotence and decreased libido in men; menstrual irregularities in
women
vi. dry, pruritic, and hyperpigmented skin; easy bruising; uremic frost in
terminal stage
33. (p. 510)
i. GFR declines and tubule function is lost
ii. potassium retained as GFR decreases
iii. decreased renal activation of vitamin D leading to decreased GI
calcium absorption; high phosphate levels
iv. decreased GFR
v. decreased production of erythropoietin leading to decreased RBC
production; bone marrow depression
 vi. red bone marrow function depressed by altered blood chemistry that
leads to decreased platelet production
vii. increased blood volume due to decreased GFR
viii. increased blood volume; increased renin secretion
ix. electrolyte imbalances, particularly hypocalcemia and hyperkalemia
x. increased blood volume and increased blood pressure
xi. due to development of heart failure
xii. due to accumulation of nitrogenous wastes in blood, particularly
urea: acidosis
xiii. due to hypocalcemia and encephalopathy
xiv. due to bone demineralization (hypocalcemia stimulates secretion of
parathyroid hormone [PTH], which causes bone resorption)
xv. abnormal metabolism of hormones; increased wastes in serum
xvi. due to presence of uremic frost
xvii. urea catabolism; ammonia being excreted in respirations
xviii. due to hypocalcemia, resulting in increased secretion of PTH
34. (p. 511) Most drugs are excreted primarily via the kidney. With renal
failure, the rate of drug excretion decreases, resulting in accumulation of
the medication. This can result in increased adverse, potentially toxic
drug effects.
35. answer to crossword puzzle
Chapter 19
Reproductive System Disorders
1. (pp. 537–538)
• males: changes in sperm or semen, hormonal abnormalities, physical
obstruction of the sperm passage
• females: hormonal imbalances resulting from altered function of
hypothalamus, anterior pituitary gland, or ovaries; structural
abnormalities; obstruction of fallopian tubes; abnormal vaginal pH;
cigarette smoking

Male
2. (p. 515, Fig. 19.1)
A. Parietal peritoneal membrane, B. Ureter, C. Surface of urinary
bladder, D. Seminal vesicle, E. Urinary bladder opened, F. Ampulla,
G. Ejaculatory duct, H. Prostatic urethra, I. Prostate gland, J. Rectum,
K. Membranous urethra, L. Bulbourethral gland, M. Spongy urethra,
N. Penis, O. Ductus deferens, P. Urethra, Q. Epididymis, R. Testis, S.
 Seminiferous tubules, T. Scrotum, U. Prepuce (foreskin), V. Glans
penis
3. (pp. 516–517)
i. urethral opening on the ventral surface of the penis
ii. urethral opening on the dorsal surface of the penis
iii. undescended testes (Fig. 19.2)
iv. excessive fluid collects between the layers of the tunica vaginalis (Fig.
19.3)
v. cyst containing fluid and sperm that develops between the testes and
the epididymis
vi. dilated vein in the spermatic cord (Fig. 19.3)
4. (p. 518) young men in association with urinary tract infections, older
men with benign prostatic hypertrophy, and in all men: sexually
transmitted diseases, instrumentation such as catheterization, and
repeated E. coli infections
5. (p. 518) Escherichia coli
6. (p. 520)
• dysuria
• urinary frequency
• urgency
• lower back pain or lower abdominal discomfort
• severe inflammation that may cause:
• decreased urinary stream
• hesitancy in initiating urination
• incomplete bladder emptying
• nocturia
7. (pp. 518–519) hyperplasia of the prostatic tissue with formation of
nodules surrounding the urethra, compression of the urethra, and
variable degrees of urinary obstruction
8. (p. 519, Fig. 19.5) Incomplete bladder emptying due to obstruction leads
to frequent infections, and continued obstruction leads to distended
bladder, dilated ureters, hydronephrosis, and possible renal damage.
9. (p. 519) hesitancy, dribbling, decreased force of the urinary stream,
frequency, nocturia, recurrent infections
10. (pp. 519–520) A single cause has not been determined. Genetic
mutations, high androgen and insulin-like growth factors, and recurrent
prostatic infections appear to be causative factors. It is common in men
of North American and northern European descent. There is a higher
incidence in the black population.
11. (p. 519) Warning signs include hard nodule in the periphery of the
gland on rectal examination, elevated prostate specific antigen (not
diagnostic, also occurs with benign prostatic hypertrophy), and signs of
urinary obstruction.
12. (p. 519) metastasis to bone
13. (p. 520) Serum tests for prostate specific antigen (PSA) and prostatic
acid phosphatase
14. (p. 520) Use of antitestosterone drugs that act as testosterone-blocking
agents may be suggested to reduce hormonal effects on androgen-
sensitive tumors.
15. (p. 521) Risk factors include familial incidence, cryptorchidism,
infection, and trauma.
16. (p. 521) Manifestations include hard, painless, usually unilateral mass;
enlarged or “heavy” testes; dull aching pain in the lower abdomen;
hydrocele or epididymitis; and gynecomastia.
17. (p. 521) Treatment includes a combination of surgery, radiation, and
chemotherapy.

Female
18. (p. 522, Fig. 19.8A)
A. Ovary, B. Fallopian tube, C. Fimbriae, D. Coccyx, E. Posterior fornix,
F. Cervix, G. Vagina, H. Rectum, I. Anus, J. Vaginal orifice, K. Labium
minus, L. Labium majus, M. Clitoris, N. Urethra, O. Symphysis pubis,
P. Urinary bladder, Q. Peritoneal membrane, R. Uterus
19. (p. 526)
i. painful menses
ii. no menses
 iii. painful intercourse
20. (p. 526, Fig. 19.11)
A. Retroversion, B. Retroflexion-flexion posteriorly, C. Retrocession, D.
Anteflexion, E. Uterine prolapse, F. Rectocele, G. Cystocele
21. (pp. 523–524) the menstrual cycle:
• menstruation: sloughing of endometrial tissue if no fertilization has
taken place
• endometrial proliferation stage: maturation of ovarian follicle
• maturing follicle secretes estrogen: endometrial layers thicken
• luteinizing hormone (LH) levels increase: ovulation occurs
• ovarian follicle is converted into the corpus luteum: increase in
production of progesterone
• progesterone increases development of endometrial blood vessels in
preparation of fertilized ovum

If fertilization of the egg does not occur, hormone levels drop, and the
corpus luteum and endometrium begin to degenerate, eventually
sloughing off and beginning the cycle again.

Endometriosis
22. (p. 527, Fig. 19.10) the presence of endometrial tissue outside of the
uterus on structures such as the ovaries, ligaments, or colon
23. (p. 527, Fig. 19.10) The ectopic endometrium responds to cyclic
hormonal changes just as the normal uterus does; there is no exit point
for shed tissue and blood, which causes local inflammation and pain,
recurring with each menstrual cycle. Fibrous tissue may cause adhesions
and obstruction of involved structures, such as urinary bladder, colon,
and ovary (infertility).
24. (p. 528) dysmenorrhea
25. (p. 530) Treatment involves hormonal suppression of endometrial
tissue and surgical removal of ectopic tissue.

Vaginal Candidiasis
26. (pp. 527–528) Predisposing factors include antimicrobial therapy for an
unrelated bacterial infection, immunodeficiency states, and increased
glycogen or glucose in secretions (e.g., from use of oral contraceptives
and diabetes mellitus).
27. (p. 528)
• red and swollen pruritic mucous membranes
• thick, white, curdlike discharge
• white patches adhering to the vaginal wall
• dysuria
• dyspareunia

Pelvic Inflammatory Disease (PID)

28. (p. 528) an infection of the reproductive tract, particularly the fallopian
tubes and ovaries; includes cervicitis, endometritis, salpingitis, and
oophoritis
29. (p. 528) Predisposing factors for PID include sexually transmitted
disease, prior episode of vaginitis or cervicitis, insertion of an IUD or
other instrument, septicemia, or peritoneal infections.
30. (pp. 528–531, Fig. 19.11)
• vaginitis or cervicitis of polymicrobial etiology
• ascending inflammation and infection from uterus into fallopian tubes,
causing edema and obstruction
• exudate contaminates ovary and surrounding tissue
• peritonitis may develop, with pelvic abscess formation
• potential septicemia
• adhesions and strictures common sequelae, leading to infertility or
ectopic pregnancy, as well as affecting surrounding structures such as
the colon
31. (p. 530)
• lower abdominal pain, which may be sudden and severe or gradually
increasing in intensity
• steady pain that increases with walking
• tenderness
 • purulent discharge
• dysuria
• fever and leukocytosis
• abdominal distention and rigidity indicate peritonitis
32. (p. 531) Complications if untreated include pelvic abscess, septicemia,
death, adhesions, and strictures of surrounding tissues: infertility or
ectopic pregnancy.
33. (p. 532) aggressive antimicrobial therapy

Breast Cancer
34. (p. 532) Risk factors include being older than 50 years of age, having a
genetic predisposition, familial occurrence, hormonal influences
(especially exposure to high estrogen levels), long menstrual cycles, and
delay in first pregnancy. Exogenous estrogen in oral contraceptives or
postmenopausal supplements as a cause is controversial. Other factors
include fibrocystic disease, prior carcinoma in the uterus or other breast,
and radiation of the chest.
35. (p. 532)
• majority arise from malignant transformation of ductal epithelial cells
• local infiltration of surrounding tissues and adherence to skin causing
dimpling
• spread to nearby axillary lymph nodes early
• widespread dissemination follows quickly, including metastases to
lung, brain, bone, and liver
36. (p. 533) Manifestations include:
• single small, hard, painless nodule in the breast; freely moveable in
early stages
• dimpling of the skin, fixation of the nodule to the skin, retraction of or
discharge from the nipples, and change in breast contour
37. (p. 533) Therapeutic interventions include surgical removal of the
tumor with minimal tissue loss or a more radical mastectomy combined
with radiation, chemotherapy, and hormone therapy. Surgical removal
of some lymph nodes is usually warranted. The ovaries are removed if
the tumor is responsive to hormones. New classes of targeted drugs are
 also being developed and used in therapies primarily focusing on the
suppression of cancer cell growth factors.
38. (p. 533) Early detection measures include breast self-examination
regularly for all women older than 20 years of age and mammography,
especially if family history warrants and routinely after 40 years of age.

Cervical Cancer
39. (p. 534) Increased use of Pap smear for screening has had two results:
• Early detection allows for effective treatment at an early stage,
improving prognosis and survival.
• Early detection while cancer is still in situ; more cases are detected
earlier in a younger population.
40. (p. 535) Individuals at high risk include Hispanic-American women,
those with multiple sexual partners, those with promiscuous partners,
early sexual intercourse in teen years, a history of STDs, and
environmental factors such as smoking cigarettes.
41. (p. 535, Fig. 19.19)
• cervical dysplasia—mild
• cervical dysplasia—severe
• malignant neoplasm
• carcinoma in situ
• invasive carcinoma
42. (p. 536) asymptomatic early but detectable by Pap smear; slight
bleeding or watery discharge; anemia or weight loss
43. (p. 536) Biopsy confirms the diagnosis. Surgery and radiation constitute
the usual treatment measures with chemotherapy in the later stages.
When chemotherapy is used, a combination of two drugs is sometimes
used such as Gemcitabine and Cisplatin.

Endometrial Cancer
44. (p. 536) Individuals at high risk include those with a history of
increased estrogen levels, postmenopausal women who have taken
exogenous estrogen, infertile women, those who took sequential oral
 contraceptives early, obese women, those with diabetes, and those with
hypertension.
45. (p. 537)
• endometrial hyperplasia of the glandular epithelium (due to excessive
estrogen stimulation)
• slow growth and infiltration of uterine wall
• continued growth results in tumor mass filling the interior of the
uterus and infiltrating and extending through the wall into
surrounding structures
• grading and staging determined by degree of cell
differentiation/undifferentiation (grade) and extent of spread (stage)
46. (p. 537) Manifestations include painless vaginal bleeding or spotting
(early sign), palpable mass, discomfort or pressure in the lower
abdomen, and bleeding following intercourse (late sign).
47. (p. 537) surgery and radiation therapy

Sexually Transmitted Diseases (STDS)

48. (pp. 538–542, Table 19.1)

Chapter 20
Neoplasms and Cancer
1. (p. 549)
i. a tumor, a cellular growth that is no longer responding to normal body
controls
ii. tumor of differentiated cells that reproduce at higher than normal rate
but do not spread
iii. tumor of undifferentiated, nonfunctional cells that reproduce rapidly,
infiltrate surrounding areas, and may spread by metastases to other
organs and tissues
iv. malignant tumors of epithelial tissue
v. malignant tumors of connective tissue
vi. growth of undifferentiated cells of varying size and shape
2. (p. 547) normal organization, growth inhibition, cell-to cell
communications—all absent (Alternate answers: cell membranes,
surface antigens are altered)
3. (p. 547, Table 20.1)

Benign Tumor Malignant Tumor

Pancreas Adenoma Adenocarcinoma
Fat Lipoma Liposarcoma
Bone Osteoma Osteosarcoma
Liver Hepatoma Hepatocarcinoma
Cartilage Chondroma Chondrosarcoma
Skin Epithelioma Carcinoma; melanoma

4. (p. 547, Table 20.2)

Benign Tumors Malignant Tumors

Cells Similar in appearance Varied in size and shape with large nuclei
to normal cells Many undifferentiated
Differentiated Mitosis increased and atypical nuclei present
Mitosis normal
Growth Relatively slow Rapid growth
Cells adhere in one Cells lack adhesion, infiltrate adjacent tissue
mass No capsule
No invasion of tissue
Usually encapsulated
Spread Remain localized Invade nearby tissues and may metastasize to
distance sites through blood and lymph vessels
Systemic Rare—except in CNS Often present
effects
General Life-threatening in Destroy local tissue function if untreated
prognosis certain locations (e.g., Many metastasize to vital organs, causing
brain) death if not treated

5. (p. 549, Box 20.1) unusual bleeding or discharge anywhere in the body;
change in bowel or bladder habits (e.g., prolonged diarrhea or
discomfort); a change in a wart or mole (i.e., color, size, or shape); a sore
that does not heal (on the skin or in the mouth, anywhere); unexplained
weight loss; anemia or low hemoglobin, and persistent fatigue;
persistent cough or hoarseness without reason; a solid lump, often
painless, in the breast or testes or anywhere on the body
6. (p. 551)
 p
i. ischemia, necrosis, and areas of inflammation around the tumor;
potential for infection
ii. blockage of secretion or normal flow of air (bronchi), food (GI tract),
blood, or lymph depending on location
iii. pain and loss of function
iv. hemorrhage, inflammation, necrosis
v. loss of normal tissue function
7. (pp. 549–550)
i. anorexia, fatigue, pain, stress, nutrient trapping, altered metabolism,
and cachectic factors produced by macrophages
ii. anorexia, decreased appetite and food intake, chronic bleeding, and
bone marrow depression
iii. host resistance decline; tissue breakdown and diminished immune
system function; immobility
iv. local invasion/erosion of blood vessels by tumor; bone marrow
depression, and hypoproteinemia
8. (p. 550) additional problems associated with certain tumors (e.g.,
bronchogenic carcinoma cells producing ACTH, causing manifestations
of Cushing syndrome)
9. (p. 550)
i. indicator of effects of chemotherapy and radiation; hemoglobin and
erythrocyte counts may be low—often a general sign of cancer
ii. tests of blood and body fluids for tissue enzymes or hormones
associated with particular cancers (e.g., carcinoembryonic antigen
[CEA], human chorionic gonadotropin [hCG], prostate-specific
antigen [PSA] tests)
iii. signs of abnormal growth or changes in organs and tissues
iv. histopathologic confirmation of diagnosis of malignancy
10. (p. 551) Malignant tumor cells lack cohesiveness and easily separate
from the growing tumor mass; if invasive and eroding blood or
lymphatic vessels, tumor cells can enter the circulation and reach distant
sites. This is called metastasis.
11. (p. 552) Grading is a reflection of the degree of differentiation or
undifferentiation (degree of malignancy) of the tumor cells. Staging is
 the classification of tumors that reflects the extent of disease, that is, size
of primary tumor, extent of lymph node spread, and metastasis (as in
breast cancer).
12. (pp. 553–554, Fig. 20.8) Initiating factors cause the first irreversible
cellular changes in the process of carcinogenesis. Promoters cause
additional changes in DNA, resulting in less differentiation and greater
rate of mitosis.
13. (p. 555, Table 20.3)
i. viruses: hepatitis virus (hepatic cancer)
ii. radiation: (skin cancer)
iii. chemical exposure: (lung cancer)
iv. chronic irritation or inflammation: ulcerative colitis (breast cancer)
v. increasing age: (many cancers are more common in older individuals)
vi. diet: high-fat diet (colon cancer)
vii. hormones: estrogen (endometrial cancer)
viii. genetics: chromosomal abnormalities (leukemia)
14. (p. 550; Chapter 7) Malignant tumors often have altered “nonself”
antigens on their surface, which, if detected early, may invoke an
immune response that prevents the growth and spread of the tumor. If
the immune system is compromised or deficient (e.g., in individuals
with AIDS), then transformed cells go undetected until sufficient growth
has occurred to establish the tumor.
15. (pp. 555–556) Radiation, surgery, and chemotherapy are often used in
combination to completely eradicate local tumor and treat and/or
prevent metastases. Biologic modifiers and hormones may be used to
limit the growth of specific tumors.
16. (p. 556) curative: used if tumor is small and localized; palliative: in
advanced cancer, intended to reduce the manifestations and
complications related to the cancer; prophylactic: used to prevent
metastasis
17. (p. 558) Radiation causes mutations in the tumor cell DNA, preventing
mitosis and tumor growth and causing immediate cell death; it also
damages blood vessels, cutting off tumor blood supply.
18. (p. 558) Antimitotics, antimetabolites, alkylating agents, and some
antibiotics interfere with protein synthesis and DNA replication at
different points in the tumor cell cycle, therefore decreasing growth of
the tumor.
19. (p. 559) Radiation and chemotherapy are most effective against
reproducing cells, both normal and malignant because of their effects on
DNA replication. Therefore, normal cells that are dividing regularly are
at the greatest risk (e.g., skin, GI tract mucosa, bone marrow, and
gonads). Adverse effects include bone marrow depression (resulting in
anemia, infections, bleeding, etc.), nausea and vomiting, and hair loss.
20. (pp. 559–560) Biologic response modifiers are agents that augment the
natural immune response to improve immune surveillance and removal
of abnormal cells.
21. (p. 560) Gene therapy treatment is designed to replace mutated genes
with healthy ones, inactivate mutated genes, and introduce new genes.
22. (pp. 559–560) sex hormones when the tumor growth is dependent on,
or accelerated by, such hormones; hormone blocking agents, often
effective in reducing tumors and preventing recurrences; angiogenesis
inhibitor to prevent enhanced blood supply to tumors by preventing
endothelial cell growth; analgesics for pain management; narcotics as
pain intensity increases
23. (p. 561) basal cell carcinoma
24. answer to crossword puzzle
Chapter 21
Congenital and Genetic Disorders
1. (p. 567) Congenital defects/anomalies refer to disorders present at birth;
they include genetic (inherited) as well as developmental disorders.
2. (p. 567) errors in chromosomal duplication or reassembly during
meiosis, resulting in abnormal placement of part of a chromosome
(translocation), altered structure (deletion), or abnormal number of
chromosomes
3. (p. 570) agents that cause damage during embryonic or fetal
development; often difficult to define
4. (p. 566) Inherited disorders are any disorders resulting from
abnormalities or damage to the genetic makeup, whereas chromosomal
 defects usually result from errors during meiosis when the
chromosomes are segregating, when the DNA fragments are displaced
or lost and therefore could involve many genes.
5. (p. 570) Autosomal recessive disorders: both parents must pass on the
defective gene to produce an affected child. Autosomal dominant
disorders: an affected parent has a 50% chance to pass the disorder to a
child. X-linked dominant disorders: dominant allele carried on the X
chromosome—males and females can be affected. X-linked recessive
disorders: alleles carried by the X chromosome—manifested in
heterozygous males—heterozygous females are carriers.
6. (pp. 570–576, Fig. 21.1)
i. monosomy: when one member of a chromosome pair is lost during
meiosis
ii. trisomy: when there is extra duplication of one member of a
chromosome pair, yielding three chromosomes instead of two
7. (pp. 572–573, Box 21.1) Multifactorial disorders occur when a
combination of factors is responsible for the congenital disorder, that is,
polygenic—caused by multiple genes or inherited tendency that is
expressed following exposure to environmental factors. Examples
include anencephaly, cleft lip and palate, clubfoot.
8. (p. 573, Fig. 21.9) The most critical time for development is the first 2
months of gestation, when organogenesis occurs. Exposure to damaging
substances may cause developmental abnormality, premature birth,
high risk for further illness in the infant, and increased risk for sudden
infant death syndrome. The effects of exposure depend on the stage of
development at the precise time of the exposure.
9. (p. 573) Difficulties encountered during or after birth that may
temporarily deprive the newborn of oxygen can cause brain damage
(e.g., cerebral palsy).
10. (p. 569) maternal age older than 35 years
11. (p. 575) A carrier of an infectious disease is contagious and can pass the
infection to others. A carrier of a genetic disorder is heterozygous for
that particular disorder and usually does not have any manifestations of
the disorder; he may pass the faulty gene on to his children.
12. (p. 570) autosomal recessive and X-linked recessive disorders
13. (p. 571) heterozygous; does not usually become symptomatic
14. (p. 569, Fig. 21.4)

i. father
ii. 50%
iii. 0%—there is no carrier state in autosomal dominant disorders; an
individual with the faulty gene has the disorder
15. (p. 574, Fig. 21.4)

i. both
ii. 75%
16. (p. 574, Fig. 21.4)

i. a. neither
b. mother
 c. both
ii. a. 0%
b. 50%
c. 100%
d. 50%
17. (p. 574, Fig. 21.4)

i. a. neither
b. both
c. both
ii. a. 25%
b. 50%
c. 100%
d. 50%
18. (p. 574, Fig. 21.4)

i. a. father
b. mother
c. mother
ii. a. 50%
b. 50%
 c. 50%
d. 50%
19. (p. 574, Fig. 21.4)
i. homozygous
ii. both
iii. 25%
iv. 50%
20. (p. 574, Fig. 21.4)

i. a. both
b. neither
c. neither
ii. a. 100%
b. 0%
c. 0%
d. 100%
21. (p. 574, Fig. 21.4)
Square A

Square B
 Referring to Square A:
i. a. neither
b. mother
ii. 25%
iii. male
iv. 25%—female
v. a. 25%
b. 25%

Referring to Square B:
i. a. father
b. neither
c. mother
ii. a. 100%
b. 0%
c. 0%
d. 0%
22. (p. 574, Fig. 21.4) There is a 25% chance of producing a female with the
disorder.

23. (p. 574, Fig. 21.4)

 i. Xd Y
ii. mother
iii. daughter—0%; son—50%
iv. brother—sex-linked disorder; in order for a female to be affected,
father would have the disorder
v. 50% of sisters will be carriers, 0% of brothers
24. (p. 568, Box 21.1)
25. (p. 570, Fig. 21.1) Down syndrome is a chromosomal disorder that is
diagnosed prenatally through amniocentesis and karyotyping. The
karyotype of an individual with Down syndrome is trisomy 21.
26. (p. 576) Down syndrome is trisomy 21, which results in numerous
defects in physical and mental development, including hypotonic
muscles, loose joints, cervical instability, delayed developmental states,
cognitive impairment, and delayed sexual development. Miscellaneous
other conditions may be present, including visual, hearing, and
digestive problems; celiac disease; congenital heart disease; decreased
resistance to infection; and a high risk for leukemia.
27. (p. 576) Individuals with Down syndrome may have a small head and
flat facial profiles, slanted eyes, Brushfield spots in the irises, a mouth
that tends to hang open, a large protruding tongue and high arched
palate, and small hands with single palmar creases.

Chapter 22
Complications of Pregnancy
1. (p. 580) embryonic stage: 3 to 8–10 weeks after fertilization; fetus: the
term is used after 8–10 weeks; organogenesis: during embryonic stage,
all organs are formed by the end of 8 weeks
2. (p. 580) low birth weight, increased irritability, increased risk for
stillbirth, increased risk for placenta previa and abruptio placentae
3. (p. 580) human chorionic gonadotropin (hCG); accurate only in first 10
weeks, then placenta takes over
4. (p. 585)
a. milk production; iv. lactation (p. 585)
 b. pregnancy; i. gestation (p. 585)
c. inflammation of uterine lining; v. endometritis (p. 590)
d. number of pregnancies; ii. gravidity (p. 585)
e. number of viable pregnancies; iii. parity (p. 585)
5. (pp. 583–585)
i. ectopic pregnancy—tubal pregnancy, when the fertilized ovum
implants outside the uterus (p. 587)
ii. preeclampsia and eclampsia—pregnancy-induced hypertension (p.
587)
iii. gestational diabetes mellitus—increased glucose intolerance and
increased blood glucose levels (p. 588)
iv. placenta previa—when the placenta is implanted in the lower uterus
or over the cervical os (p. 588)
v. abruptio placentae—premature separation of the placenta from the
uterine wall (p. 588)
vi. thromboembolism and thrombophlebitis—clot formation in the veins
of the legs or pelvis and potential for embolization if clot breaks free
(p. 588)
vii. disseminated intravascular coagulation (DIC)—increased activation
of clotting mechanism, usually not a primary problem; however, can
be serious complication resulting in diffuse blood clots and
consumption of clotting factors (p. 588)
viii. Rh incompatibility—can develop when Rh factor antigens on fetal
red blood cells differ from those on maternal red blood cells; immune
response of Rh-negative mother to Rh-positive fetal antigens,
resulting in anti-Rh antibodies in the maternal bloodstream, that is,
maternal anti-Rh sensitization with potential for hemolytic disease
during subsequent pregnancies (p. 588)
ix. infections—puerperal infection (childbed fever); cervical lacerations
or episiotomy repairs are vulnerable to infection; predisposition to
endometritis—may spread to cause pelvic cellulitis or peritonitis (pp.
589–590)
x. adolescent pregnancy (p. 174), intrauterine growth restriction,
maternal anemia, pregnancy-induced hypertension
6. (pp. 584–585; Fig. 22.2) Rh-negative mother exposed to Rh-positive
blood via transfusion or pregnancy with Rh-positive fetus; immune
response, anti-Rh sensitization resulting in potential for hemolytic
disease in subsequent Rh-positive pregnancies
7. (pp. 584–585) RhoGAM is Rh immunoglobulin, containing anti-Rh
antibodies; when given to an Rh-negative woman who has not been
previously sensitized, it confers temporary passive immunity and thus
prevents maternal sensitization to Rh antigen.
8. (p. 586) Teenager has own nutritional needs to be met, especially
calcium, protein, and iron; teenager may not seek adequate prenatal
care; lack of adequate nutrition for both teenager and fetus; woman's
pelvis may be too small, increasing risk during labor and delivery.

Chapter 23
Complications of Adolescence
1. (p. 588) Generally considered to begin with the development of
secondary sex characteristics (10 to 12 years of age) and continues until
physical growth is completed at about 18 years of age.
2. (pp. 589–590 and standard chart within the back cover of text)

Height Weight BMI N, Ov, Ob

4′7″ 130 30.2 Ob
4′7″ 100 23.2 N
4′11″ 100 20.2 N
5′2″ 140 25.6 Ob
5′7″ 180 28.2 Ob
5′7″ 210 32.9 Ob
BMI, Body mass index; N, normal; Ob, obese; Ov, overweight.

3. (pp. 589–590) type 2 diabetes mellitus, elevated blood cholesterol/lipid

levels, increased blood pressure
4. (p. 590) presence of significant abdominal fat mass resulting in an
increased waistline measurement, changes in glucose and lipoprotein
metabolism
5. a. (pp. 591–593) condition characterized by alternating “binge and
purge” behavior; iv. bulimia nervosa (pp. 598–599)
 b. extreme weight loss due to self-starvation; iii. anorexia nervosa (p.
598)
c. demineralization of bone; i. osteoporosis (p. 593)
d. bone infection; ii. osteomyelitis (pp. 595–596)
6. (pp. 590–591) A. Lordosis, B. Kyphosis, C. Scoliosis
7. (p. 591) minor trauma such as a fracture or soft-tissue injury; sickle cell
anemia
8. (p. 591) The pathophysiology of osteomyelitis includes (1) accumulation
of local purulent exudate, which destroys the bone in the damaged area,
causing severe pain due to pressure on the nerves; if the fluid pressure is
severe, may cause separation of the periosteum; (2) stimulation of
surrounding bone development walls off the area; (3) if the periosteum
separates as a result of excess pressure, a sinus may develop, spreading
the infection; and (4) possible spread of infection to involve the joint,
causing infectious arthritis, and possible damage to the joint and
epiphyseal plate.
9. (pp. 591–592) Onset is more marked and large joints, such as knees,
wrist, and elbows, are more frequently involved; more systemic effects
are apparent.
10. (p. 593) Anorexia nervosa is extreme weight loss due to self-starvation;
bulimia nervosa is characterized by binge eating and purging.
11. (pp. 593–594) Propionibacterium acnes, Staphylococcus
12. (p. 599) Epstein-Barr virus (EBV)
13. (p. 594) Manifestations include sore throat, headache, fever, malaise,
and fatigue; lymphadenopathy; rash on the trunk; lymphocytosis and
monocytosis; and positive heterophil antibody. Complications include
hepatitis, ruptured spleen, and meningitis.
14. (p. 594) Turner syndrome: one X chromosome is missing. It affects
sexual development in females and causes other abnormalities as well.
Anomalies include malformations of the heart and genitourinary
system, and retarded growth. At puberty growth spurt, development of
secondary sex characteristics and initiation of menstrual cycle are
absent.
15. (p. 594) the discomfort that occurs in varying degrees during the first or
second day of menstruation

Chapter 24
Complications of Aging
1. (p. 598) genetically programmed (cell death [apoptosis]); “wear-and-
tear” cellular damage; “free radicals” (i.e., peroxides); other options:
latent viruses, increased autoimmune reactions, environmental agents
2. (pp. 598–602)
i. (p. 604) In general, hormone secretions remain relatively constant, but
tissue receptor sensitivity diminishes (see reproductive system for
additional female changes, e.g., menopause).
ii. (p. 604) female: menopause, when ovaries cease production of
estrogen and progesterone, resulting in rise in serum levels of follicle-
stimulating hormone (FSH) and luteinizing hormone (LH); decreased
sex hormone levels result in thinning of the mucosa, loss of elasticity
and glandular secretions in the vagina and cervix, which may cause
inflammation and dyspareunia; pH of vaginal secretions become more
alkaline, predisposing to infections; breasts decrease in size; “hot
flashes” due to hormone level changes; emotional lability
male: gradual decline in testosterone, decrease in testes size and sperm
production but remain potent or fertile; benign prostatic hypertrophy
—common problem in older males
iii. (p. 605) Both become thin and fragile; increased susceptibility to
injury and inflammation; and slower wound healing.
iv. (p. 605) Fatty tissue and collagen fibers accumulate in heart muscle;
size and number of cardiac muscle cells decline, reducing strength of
cardiac contractions. Pathologic changes include vascular
degeneration, which reduces cardiac output and reserve.
Degenerative changes promote arteriosclerosis and atherosclerosis.
v. (p. 606) Loss of calcium and bone mass due to aging may lead to
osteoporosis, osteoarthritis, degeneration of intervertebral discs, and
increased risk for herniation or rupture. Skeletal mass declines with
aging, resulting in atrophy of skeletal muscle.
vi. (p. 607) Ventilation decreases due to reduction of lung tissue
elasticity; calcification of costal cartilage reduces movement; skeletal
 muscle atrophy; vascular degeneration leads to decreased perfusion
and gas exchange.
vii. (p. 607) Natural reduction in brain mass occurs with aging and leads
to various degenerative changes in the brain; decline in various
functions, including reflexes, memory, and so on; diminished
autonomic nervous system (ANS) adaptability, leading to
temperature sensitivities; degenerative changes in the eye, resulting in
various conditions such as presbyopia, cataracts, glaucoma; hearing
loss; diminished sense of taste and smell—appetite loss.
viii. (p. 608) increased risk for oral infections, periodontal disease, loss of
teeth; decreased appetite, potential malnutrition; diminished
salivation causes difficulty chewing and swallowing, xerostomia (dry
mouth); swallowing difficulties due to medications or other
neurologic problems; obesity and associated disease risks (e.g.,
diabetes, gallstones, hypertension); atrophy of GI tract mucosa
causing malabsorption of essential nutrients, including vitamins and
minerals; predisposition to malignancy
ix. (p. 609) reduced kidney function due to loss of glomeruli and
degeneration of tubules; reduced bladder control—muscles become
weaker as a result of aging
3. (p. 603) Infections are common as a result of impaired circulation and
delayed or diminished healing capacity; diminished immune
responsivity; urinary system disorders requiring frequent
catheterization, predisposing to infection. Cancer is more common in
elderly—the immune system is less effective, and higher cumulative
exposure to carcinogens has occurred.
4. (pp. 602–603)
a. inability to control urination; v. incontinence
b. farsightedness; vii. presbyopia
c. predetermined cell death; iii. apoptosis
d. excessive urination at night; vi. nocturia
e. opacity of the ocular lens; ii. cataract
f. deposition of fat in arterial walls; i. atherosclerosis
g. dry mouth; viii. xerostomia
h. increased intraocular pressure; iv. glaucoma
Chapter 25
Immobility and Associated Problems
1. (pp. 607–609)
musculoskeletal effects: muscles lose strength, endurance, and mass
very quickly, atrophy and develop flaccidity; impaired venous return,
development of dependent edema; bone demineralization leading to
osteoporosis, shortening and decreased flexibility of connective tissue
such as ligaments and tendons
cutaneous effects: impaired circulation leads to skin breakdown and
reduced regeneration; decubitus ulcers
cardiovascular effects: reduced venous return and cardiac output;
orthostatic hypotension; blood pooling in dependent areas, resulting
in edema; thrombus formation; potential embolism
respiratory effects: decreased depth of respirations; diminished gaseous
exchange; diminished cough resulting in fluid, secretion
accumulation; predisposition to respiratory complications: infection,
obstruction, and atelectasis; potential for food and water aspiration
gastrointestinal effects: constipation; appetite reduction: malnutrition,
fatigue, and depression
urinary effects: urinary stasis with potential for calculus formation and
urinary tract infection (UTI)
effects on children: normal growth delayed; spinal or bony deformities;
other developmental disorders
2. (pp. 613–614)
a. stationary blood clot; viii. thrombus
b. collapse of lung tissue; i. atelectasis
c. sudden drop in blood pressure when change in position occurs vi.
orthostatic hypotension
d. breakaway thrombus iv. embolus
e. pressure sore or bedsore; iii. decubitus ulcer
f. paralysis below the waist; vii. paraplegia
g. joint deformity caused by excessive scarring; ii. contracture
h. paralysis of one side of the body; v. hemiplegia
i. loss of bone mass; x. osteoporosis
 j. loss of muscle tone; ix. flaccidity
3. (p. 609) sedatives (to promote sleep and reduce anxiety) and analgesics
(to control pain)

Chapter 26
Stress and Associated Problems
1. (p. 611) A stressor is any factor that creates a significant change in the
body's homeostasis. It may be physical, psychological, or both.
2. (p. 611) aging, pathologic disorders
3. (p. 612; Fig. 26.1) Norepinephrine from the sympathetic nervous system
(SNS) and the adrenal medulla causes general vasoconstriction and
increased blood pressure.
Epinephrine from the adrenal medulla causes increased heart rate and
general vasoconstriction, resulting in increased blood pressure,
vasodilation in skeletal muscle, bronchodilation, and increased blood
glucose.
ACTH (adrenocorticotropic hormone) from the anterior pituitary gland
stimulates the adrenal cortex.
Cortisol from the adrenal cortex results in increased stability in the
cardiovascular system and enhances the effects of the catecholamines,
elevates blood glucose, reduces inflammatory and immune responses,
and stimulates the CNS.
Aldosterone from the adrenal cortex increases the reabsorption of
sodium and water, increasing blood pressure.
ADH (antidiuretic hormone) from the posterior pituitary gland increases
retention of water, increasing blood pressure.
4. (p. 612, Fig. 26.1) Significant effects of the sympathetic nervous system
(SNS) during the stress response include elevated blood pressure and
increased heart rate, bronchodilation and increased ventilation,
increased blood glucose levels, and CNS arousal.
5. (pp. 613–614) Prolonged stress can lead to a variety of serious
complications, including disruption of intellectual function and
memory, renal failure, or stress ulcers. Severe stress can also lead to
infection due to depression of the inflammatory response and the
 immune system. Opportunistic infections may develop, and normally
nonpathogenic organisms may cause infection. Continued stress may
impede the healing of tissue following trauma or surgery. This may lead
to increased risk for infection and scar tissue at the site.
6. (p. 615) adequate rest, healthy diet, change in lifestyle, regular moderate
exercise, counseling and support services, relaxation techniques,
antianxiety medications, assessing options/goals

Chapter 27
Substance Abuse and Associated Problems
1. (p. 618) physiologic dependence; the body has adapted to the drug so
that discontinuing use will result in withdrawal signs such as tremors
and/or cramps; psychological dependence: a continuing desire to take
the drug so as to function; addiction: the uncontrollable compulsion to
use the substance often, with serious consequences for the individual,
the family, and society—considered the most serious form of substance
abuse
2. (pp. 619–620) psychological imbalances, personality deficits, biologic
abnormalities, dysfunctional interpersonal relationships, or some
combination of any of these factors
3. (p. 621) first: lipid accumulation in the cells (fatty liver), second:
inflammation and necrosis (alcoholic hepatitis), and third: fibrosis or
scar tissue formation
4. (p. 622) for heroin addiction, methadone; for alcohol addiction,
disulfiram (Antabuse)
5. (p. 619)
a. Speed: iv. amphetamines
b. Ecstasy: v. MDMA
c. Blow: viii. heroin
d. Angel dust: ii. phencyclidine
e. Ice: i. methamphetamine
f. Snow: vii. cocaine
g. Special K: v. MDMA
h. Weed: vi. marijuana
Chapter 28
Environmental Hazards and Associated Problems
1. (p. 625) damaging the cell membrane eventually causing cell lysis,
alteration, or interference in cellular metabolic pathways, leading to
cellular mutations that could cause cancer
2. (p. 626) hemolytic anemia, inflammation and/or ulceration of the
digestive tract, inflammation of the kidney tubules, damage to the
nervous system
3. (p. 626) particulate (e.g., asbestos); gaseous (e.g., sulfur dioxide)
4. (p. 627) Hyperthermia is an excessive elevation of body temperature.
Syndromes associated with it are heat cramps, heat exhaustion, and heat
stroke.
5. (p. 628) Local hypothermia usually involves fingers, toes, ears, or
exposed parts of the face and can result in necrosis/gangrene. Systemic
hypothermia usually involves many body tissues over a wide area and
can result in tissue necrosis as well as hypovolemic shock.
6. (p. 628) cells undergoing rapid mitosis such as epithelial tissue, bone
marrow, and gonads
7. (pp. 629–630) direct injection of toxin into body, transmission of an
infectious agent through the bite/sting, allergic reaction to a substance in
the bite/sting