exam 4

Question 1

The type of joint that has the widest range of motion in all planes is the
a. ball-and-socket.
b. condyloid.
c. gliding.
d. saddle

Answer 1

ANS: A

The ball-and-socket joint is the joint that has the widest range of motion (e.g., the hip joint). A condyloid joint may only move in two planes. A gliding joint is only able to glide. A saddle joint has no axial rotation.

Question 2

Spinal vertebrae are separated from each other by
a. bursae.
b. tendons.
c. disks.
d. ligaments.

Answer 2

ANS: C
Except for sacral vertebrae, the spinal vertebrae are separated from one another by disks. Spinal movement is achieved by paraspinous muscles, tendons, and ligaments. Bursae are located in the knee, elbow, shoulder, and hip.

Question 3

The joint where the humerus, radius, and ulna articulate is the
a. wrist.
b. elbow.
c. shoulder.
d. clavicle.

Answer 3

ANS: B
The elbow is the site where the humerus, radius, and ulna meet. The wrist is made up of the radius and the carpal bones of the hand. The shoulder is made up of the humerus and scapula. The clavicle connects to the scapula but not to the humerus.

Question 4

The articulation of the radius and carpal bones is the
a. wrist.
b. elbow.
c. shoulder.
d. clavicle.

Answer 4

ANS: A
The joint comprising the radius and carpal bones is called the wrist.

Question 5

The tibia, fibula, and talus articulate to form the
a. ankle.
b. knee.
c. hip.
d. pelvis.

Answer 5

ANS: A

The tibia, fibula, and talus (or heel) join to form the ankle.

Question 6

Long bones in children have growth plates known as
a. epiphyses.
b. epicondyles.
c. synovium.
d. fossae.

Answer 6

ANS: A
Epiphyses are the growth plates found in long bones in children.

Question 7

The elasticity of pelvic ligaments and softening of cartilage in a pregnant woman are the result of

a. decreased mineral deposition.
b. increased hormone secretion.
c. uterine enlargement.
d. gait changes.

Answer 7

ANS: B
Increased hormone secretion during pregnancy is responsible for the elasticity of pelvic ligaments and softening of the cartilage. These changes help accommodate the growing fetus.

Question 8

Skeletal changes in older adults are the result of
a. increased bone deposition.
b. increased bone resorption.
c. decreased bone deposition.
d. decreased bone resorption.

Answer 8

ANS: B
With age, the skeletal system changes. One of the dramatic changes in skeletal equilibrium is that bone resorption dominates bone deposition.

Question 9

The family history for a patient with joint pain should include information about siblings with
a. trauma to the skeletal system.
b. chronic atopic dermatitis.
c. genetic disorders.
d. obesity.

Answer 9

C

An important history to obtain for a patient with joint pain would be family history of genetic disorders, such as osteogenesis imperfecta, dwarfing syndrome, rickets, hypophosphatemia, and hypercalciuria.

Question 10

Risk factors for sports-related injuries include
a. competing in colder climates.
b. previous fracture.
c. history of recent weight loss.
d. failure to warm up before activity.

Answer 10

ANS: D
Failure to warm up before exercise is one risk factor for sports-related injuries. Climate, previous fractures, and weight loss are not as strong risk factors for sports-related injuries.

Question 11

Light skin and thin body habitus are risk factors for
a. rheumatoid arthritis.
b. osteoarthritis.
c. congenital bony defects.
d. osteoporosis.

Answer 11

ANS: D
People with light skin and a thin body frame are at greater risk for developing osteoporosis. Rheumatoid arthritis, osteoarthritis, and bony defects are not found to have a correlation with light skin and small frame

Question 12

Inquiry about nocturnal muscle spasms would be most significant when taking the musculoskeletal history of
a. adolescents.
b. infants.
c. older adults.
d. middle-age adults.

Answer 12

ANS: C

History taking of older adults should consist of symptoms of nocturnal muscle spasms. Pregnant women and older adults commonly experience nocturnal leg cramps resulting from
imbalances of fluids, hormones, minerals, or electrolytes or dehydration. A particular concern with the older adults is that this may be a sign of intermittent claudication.

Question 13

The musculoskeletal examination should begin when
a. the patient enters the examination room.
b. during the collection of subjective data.
c. when height is measured.
d. when joint mobility is assessed

Answer 13

A

When the patient first walks in the room, the examiner should be observing his or her gait and posture as part of the musculoskeletal examination.

Question 14

Fasciculation occurs after injury to a muscle’s
a. venous return.
b. motor neuron.
c. strength.
d. tendon.

Answer 14

B

Fasciculations can often be visualized as muscle twitching or dimpling under the skin, but they usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases.

Question 15

The physical assessment technique most frequently used to assess joint symmetry is
a. inspection.
b. palpation.
c. percussion.
d. the use of joint calipers.

Answer 15

ANS: A
The assessment technique most commonly used to assess joint symmetry is inspection

Question 16

A goniometer is used to assess
a. bone maturity.
b. joint proportions.
c. range of motion.
d. muscle strength.

Answer 16

C

The angle of a joint can be accurately measured by using a goniometer. A goniometer is used when the joint range of motion is beyond normal limits.

Question 17

When palpating joints, crepitus may occur when
a. irregular bony surfaces rub together.
b. supporting muscles are excessively spastic.
c. joints are excessively lax.
d. there is excess fluid within the synovial membrane.

Answer 17

ANS: A
Crepitus is felt or heard when irregular bony surfaces rub together

Question 18

The temporomandibular joint is palpated
a. under the mandible, anterior to the sternocleidomastoid muscle.
b. above the mandible at midline.
c. anterior to the tragus.
d. at the mastoid process.

Answer 18

C
The temporomandibular joint is palpated just anterior to the tragus of the ear; the fingertips are placed inside the joint space as the patient opens and closes the mouth.

Question 19

The temporalis and masseter muscles are evaluated by
a. having the patient shrug his or her shoulders.
b. having the patient clench his or her teeth.
c. asking the patient to fully extend his or her neck.
d. passively opening the patient’s jaw

Answer 19

ANS: B
Having the patient to bite down and clench their teeth is the method for evaluating the strength of the temporalis and masseter muscles. Cranial nerve V is tested with this same maneuver.

Question 20

The strength of the trapezius muscle is evaluated by having the patient
a. clench his or her teeth during muscle palpation.
b. push his or her head against the examiner’s hand.
c. straighten his or her leg with examiner opposition.
d. uncross his or her legs with examiner resistance.

Answer 20

B

Having the patient apply opposite force with differing head motions, against the examiner’s hand, assesses the sternocleidomastoid and trapezius muscles.

Question 21

Expected normal findings during the inspection of spinal alignment include
a. asymmetric skin folds at the neck.
b. slight right-sided scapular elevation.
c. concave lumbar curve.
d. the head positioned superiorly to the gluteal cleft.

Answer 21

ANS: D
Spinal alignment is considered within normal limits when the patient’s head is positioned directly over the gluteal cleft. The skin folds should be symmetric, the scapulae are at even heights, and both the cervical and lumbar curves are convex.

Question 22

A common finding in markedly obese patients and pregnant women is
a. kyphosis.
b. lordosis.
c. paraphimosis.
d. scoliosis.

Answer 22

ANS: B
Bowing of the back, or lordosis, is more commonly found in pregnant women or obese patients because of an altered center of gravity. Kyphosis is more commonly seen in older adults. Paraphimosis is a penile condition. Scoliosis is more commonly seen in teenagers.

Question 23

A wheelchair-dependent older woman would most likely develop skin breakdown at
a. C7.
b. the iliac crests.
c. L4.
d. the gibbus.

Answer 23

ANS: D
This older woman, most likely kyphotic from osteoporosis, would have the greatest friction point at the gibbus. The gibbus results from collapsed vertebrae, resulting in a sharp, pointy deformity of the back. C7 and L4 remain as concave curves, with less friction. The iliac crests would not protrude as far as the gibbus.

Question 24

When the patient flexes forward at the waist, which spinal observation would lead you to suspect scoliosis?
a. Prominent lumbar hump
b. Prominent cervical concave curve
c. Lateral curvature of the spine
d. Restricted ability to flex at the hips

Answer 24

C

Scoliosis is suspected when there is a noticeable lateral curvature of the spine, or rib hump, as
the patient bends forward at the waist.

Question 25

When a patient abducts an arm and the ipsilateral scapula becomes more prominent (winged), this usually means that
a. there has been an injury to the nerve of the anterior serratus muscle.
b. one of the clavicles has been fractured.
c. there is a unilateral trapezius muscle separation.
d. one shoulder is dislocated.

Answer 25

ANS: A
If the long thoracic nerve is damaged or bruised, it can cause paralysis of the serratus anterior muscle and winging of the scapula, or shoulder blade. This is not a symptom of a fractured clavicle or trapezius muscle separation. A dislocated shoulder would result in a hollowing effect.

Question 26

When the shoulder contour is asymmetric and one shoulder has hollows in the rounding contour, you would suspect
a. kyphosis.
b. fractured scapula.
c. a dislocated shoulder.
d. muscle wasting.

Answer 26

ANS: C
Asymmetric contours to the shoulder with a hollowing in the socket are symptoms of a shoulder dislocation. Kyphosis is a condition of the back; muscle wasting and a scapular fracture do not present with these symptoms.

Question 27

Ulnar deviation and swan neck deformities are characteristics of
a. rheumatoid arthritis.
b. osteoarthritis.
c. osteoporosis.
d. congenital defects.

Answer 27

ANS: A

Deviation of the fingers toward the ulnar side and swan neck deformities are classic symptoms of rheumatoid arthritis. Osteoarthritis, congenital defects, and osteoporosis do not
present with these symptoms.

Question 28

A finding that is indicative of osteoarthritis is (are)
a. swan neck deformities.
b. Bouchard nodes.
c. ganglions.
d. Heberden nodes

Answer 28

D

Heberden nodes are bony overgrowths of the distal end of the fingers and are associated with osteoarthritis. When the overgrowths are concentrated in the proximal interphalangeal joint, they are known as Bouchard nodes and are associated with rheumatoid arthritis, as are swan neck deformities; ganglions are present in nerve conditions.

Question 29

Carpal tunnel syndrome would result in
a. a negative Tinel sign.
b. a negative Phalen test.
c. reduced abduction of the thumb.
d. palm tingling.

Answer 29

ANS: C
Median nerve compression, as in carpal tunnel syndrome, results in a positive Tinel sign, positive Phalen test, reduced abduction of the thumb, and sparing of palm tingling.

Question 30

Cardinal signs for rheumatoid disorders include which of the following? (Select all that apply.)
a. Gradual onset
b. Weakness that is usually localized and not severe
c. Coarse crepitus on motion
d. Joint tenderness
e. Sleep disturbance

Answer 30

ANS: A, D, E
Hallmark signs of rheumatoid arthritis are gradual onset of stiffness for 1 hour after rising, sleep disturbance, joint tenderness, and medium to fine crepitus.

Question 31

The wrist moves in (Select all that apply.)
a. eversion and inversion.
b. proximal radius and ulna articulation.
c. flexion and extension.
d. adduction and abduction.

Answer 31

C,D

The wrist movement is in two planes, flexion and extension or radial and ulnar rotation. Adduction and abduction are for shoulder and hip joints, and eversion and inversion are for ankle movement.

Question 32

The goals of preparticipation sports evaluation include
a. screening for steroid use or abuse.
b. determining the best fit for positions in each sport.
c. determining the risk of injury or death during sports participation.
d. securing a legal contract before recommending limiting participation.

Answer 32

ANS: C
The ultimate goal of preparticipation physical evaluation is to ensure safe participation in an appropriate sports activity.

Question 33

The checkout station for preparticipation physical evaluation is critical because at this point
a. all completed forms are distributed.
b. parental signatures are obtained.
c. the relevant history is obtained.
d. the coordination of follow-ups is reviewed.

Answer 33

ANS: D
At the checkout station, data collected during the evaluation are reviewed and necessary follow-up actions are shared with the athlete and/or parents. In addition, the written report is
distributed.

Question 34

You are conducting a preparticipation physical examination for a 10-year-old girl with Down syndrome who will be playing basketball. She has slight torticollis and mild ankle clonus. Which additional diagnostic test would be required for her?
a. Cervical spine radiography
b. Visual acuity
c. Mini-Mental State Examination
d. Nerve conduction studies

Answer 34

ANS: A
This girl is experiencing symptoms of atlantoaxial joint instability and should therefore have cervical spine radiography with neurologic consultation before beginning sports activities.

Question 35

Part of the screening orthopedic component of the examination includes evaluating the person while he or she is
a. performing push-ups.
b. duck walking.
c. twisting at the waist.
d. crossing the arms over the chest.

Answer 35

ANS: B
Duck walking for four steps assesses hip, knee, and ankle range of motion, strength, and balance.

Question 36

Your 15-year-old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You should question this patient about her
a. sleep patterns.
b. salt intake.
c. aerobic workouts.
d. menstrual cycles

Answer 36

D

The lean body encourages a hypoestrogenic state that can lead to menstrual dysfunction and osteopenia or osteoporosis. This state increases the risk of stress fractures. The patient should be questioned about amenorrhea.

Question 37

One of the most important aspects to consider in the orthopedic screening examination is
a. muscle contraction.
b. flexibility.
c. symmetry.
d. balance.

Answer 37

C

The most important aspects to consider when conducting an orthopedic examination are symmetry of muscle, stature, and joint movement.

Question 38

Which medical condition would exclude a person from sports participation?
a. Asthma
b. Fever
c. Controlled seizures
d. HIV-positive status

Answer 38

ANS: B
Fever can increase cardiopulmonary effort and impair exercise capacity; fever can indicate myocarditis or other infections that make exercise dangerous.

Question 39

A parent is advised to restrict contact sports participation for their child. An example of a sport in which this child could participate is
a. hockey.
b. roller skating.
c. riflery.
d. skateboarding.

Answer 39

ANS: C
Riflery is a noncontact sport. Hockey is considered a collision sport. Roller skating and skateboarding are considered to be limited contact sports.

Question 40

A child has a poorly controlled seizure disorder. He has restricted sports participation but would be able to engage in
a. archery.
b. swimming.
c. weight lifting.
d. badminton.

Answer 40

D

Badminton does not pose an added risk to self or others if the child experiences a seizure during participation.

Question 41

You are auscultating heart tones as part of a sports physical examination. You hear a murmur at the right second intercostal space (aortic area). The murmur increases in intensity when this
teenager goes from a sitting to standing position. The subsequent recommendation should be to
a. consult a cardiologist as soon as possible.
b. have a stress test before completion of the form.
c. participate in low-static, high-dynamic sports.
d. limit contact sports and have an echocardiogram.

Answer 41

ANS: A
The murmur of aortic stenosis is indicative of hypertrophic cardiomyopathy, which may be the cause of sudden death in children and adolescents at rest or during exercise. Therefore, a
cardiology consult should be requested as soon as possible.

Question 42

Why should the preparticipation sports examination take place well in advance of the planned sports activity? (Select all that apply.)

a. To allow completion of therapy for identified problems
b. Because routine health maintenance needs to be addressed
c. Because it should be 6 weeks prior to the planned sports event
d. To allow completion of follow-up testing

Answer 42

ANS: A, D
The preparticipation sports examination should be completed well enough in advance of the planned sports activity so that rehabilitation or therapy for any problems can be completed, as
well as any follow-up testing or referrals.

Question 43

To assess muscle tone, the clinician should:
A. Palpate the patient’s muscle as the muscle is passively stretched
B. Examine how the patient performs active range of motion
C. Palpate the muscles comparing side to side
D. A and C

Answer 43

ANS: D
To assess muscle tone, passively stretch the muscle, ask the patient to relax, and then palpate the muscle, comparing side to side. Alternatively, assessment of muscle tone can be combined with a
determination of the patient’s resistance to passive movement. Tense patients, those with increased muscle tone, will have increased resistance to passive movements. Flaccid or hypotonic muscles
do not have any palpable tension. A spastic muscle has increased resistance, which may vary as the limb is moved, as in “cogwheeling,” such as that found in patients with parkinsonism. Resistance with both flexion and extension is called lead-pipe rigidity, as is sometimes seen in parkinsonism.

Question 44

Muscle strength is assessed by:
A. Having the patient move their muscle against the clinician’s resistance
B. Examining how the patient performs active range of motion
C. Passively stretching the patient’s muscle
D. Performing passive range of motion on the patient’s muscle

Answer 44

ANS: A
Muscle strength is determined by asking the patient either to resist the examiner’s attempt to flex or extend a muscle group or to flex or extend the muscles against the examiner’s resistance. Muscle strength is graded 0 (no evidence of strength) to 5 (complete or full resistance). Pain, contracture, and disease can all affect muscle strength.

Question 45

Which of the following serological diagnostic tests is most specific for rheumatoid arthritis?
A. C-reactive protein (CRP)
B. Rheumatoid factor (RF)
C. Anti-nuclear antibodies (ANA)
D. Anti-citrullinated protein autoantibodies (ACPA)

Answer 45

ANS: D
A variety of laboratory tests are used to diagnose RA, including the rheumatoid factor, which is positive in up to 80% of persons with RA but not specific to this disorder. It is often falsely positive in patients with other diseases, including lupus, sarcoidosis, and syphilis. RA is often associated with normocytic, hypochromic anemia, as well as elevations in sedimentation rate and C-reactive protein. Other laboratory tests that may be positive at diagnosis include antinuclear
antibody (ANA) and anticitrullinated protein (anti-CP) autoantibodies. The anti-CP autoantibodies are more specific to RA than the rheumatoid factor. Radiological images show loss of joint space
and erosion.

Question 46

A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body. There is no history of systemic disease and no history of trauma. On physical examination, the patient has no swelling or decreased range of motion in any of the joints. She indicates specific points on the neck and shoulders that are particularly affected. She complains of tenderness upon
palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Fibromyalgia
D. Polymyalgia rheumatica

Answer 46

ANS: C
In fibromyalgia, the most common symptoms are generalized pain, stiffness, and decreased ROM, with multiple-point tenderness. The diagnostic criteria currently rest on a patient reporting point
tenderness in at least 11 of 18 specified sites (Fig. 14.1) in addition to the presence of widespread pain for at least 3 months. The most common tender sites are in the neck, shoulders, spine, and hips. Other common symptoms include morning stiffness, anxiety, depression, sleep disturbances, “brain fog,” and irritable bowel syndrome.

Question 47

A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical examination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Scleroderma
D. Sarcoidosis

Answer 47

b

RA typically affects the joints symmetrically. Symptoms may wax and wane, but the effects are cumulative and progressive. Although RA can affect any joint, it commonly affects the small joints of the hands and feet, and this is often helpful in diagnosis. There is often history of prolonged morning stiffness and fatigue. Affected joints are often tender, swollen with effusions, warm, and inflamed. The disease most commonly affects metacarpophalangeal and proximal interphalangeal joints.

Question 48

Your patient is a 55-year-old male who presents with sudden, severely tender, swollen, erythematous elbow. The patient reports that he experienced similar symptoms in the past. You note the right elbow has a swollen, tender, soft 3 cm round nodule. The clinician should recognize these are signs and symptoms of:
A. Gouty arthritis
B. Rheumatoid arthritis
C. Epicondylitis
D. Reiter’s syndrome

Answer 48

ANS: A
Gout is a classic cause of monoarthritis, and most cases involve a joint in the lower extremities. Acute pain usually develops in one joint, with swelling, redness, and warmth, and the severity of
the pain increases rapidly. ROM of the affected joint(s) is limited by pain, and there is significant tenderness to the site. Patients who have had gout for an extended time often have gouty tophi, which are soft tissue nodules containing urate crystals. The olecranon bursa is a common site for tophi development, and the tophi are often painful.

Question 49

Sarcoidosis is an autoimmune disease that presents with non-specific symptoms of fatigue, fever, and arthralgias. Which of the following signs should raise suspicion of this disorder?
A. Facial rash across nose and cheeks
B. Bilateral hilar lymphadenopathy on chest x-ray
C. Specific tender points on the body
D. Swelling of metacarpophalangeal joints

Answer 49

ANS: B
Sarcoidosis is an inflammatory disorder in which patients develop granulomas and a wide range of symptoms, including arthritis. It is most commonly diagnosed in persons between ages 20 and 40.
Arthralgias occur in approximately 3% of patients with sarcoidosis, and the most commonly affected joints include the ankles, feet, and hands. The patient may complain of constitutional symptoms, including fatigue, fever, and altered appetite. Respiratory symptoms, including cough, wheezing, and shortness of breath, are primary symptoms. On chest x-ray, hilar lymphadenopathy and pulmonary granulomas are key diagnostic signs.

Question 50

Which of the following infectious diseases is often the cause of a reactive arthritis?
A. Gonococcus infection
B. Beta-hemolytic streptococcus infection
C. Chlamydia infection
D. Norovirus infection

Answer 50

ANS: A
Gonorrhea is a sexually transmitted infection that often involves reactive arthritis. The polyarthritis is often migratory and affects lower extremities as well as the hands. In addition to the arthritis, the
syndrome usually includes a nonpruritic dermatitis and tenosynovitis. Generalized muscle aches and fever are also common.

Question 51

A 34-year-old female presents with fever, general malaise, fatigue, arthralgias and rash for the last 2 weeks. On physical examination, you note facial erythema across the nose and cheeks. Serum
diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems:
A. Fibromyalgia
B. Sarcoidosis
C. Systemic lupus erythematosus
D. Rheumatoid arthritis

Answer 51

ANS: C
SLE has many potential symptoms. The classic findings include a malar rash. Patients often have arthralgias, myalgias, fever, fatigue, Raynaud’s syndrome, and neuropathy. SLE effects depend on
the organs involved and diagnosis can be difficult. A positive ANA occurs at some point in the condition in the majority of patients but is neither consistent nor specific for SLE. Positive anti- DNA and lupus erythematosus prep are also common to SLE.

Question 52

Which of the following microorganisms causes Lyme disease?
A. Clostridia
B. Shigella
C. Borrelia
D. Epstein-Barr virus

Answer 52

C

Lyme disease is caused by the bacterium Borrelia burgdorferi and is transmitted by a bite from a deer tick. Whereas the incubation period ranges from 3 to 30 days, the onset of symptoms typically
appears in 7 to 14 days. Although the disorder can be asymptomatic, the patient generally develops migratory polyarthralgia, myalgia, and neurological findings, including meningitis and/or neuropathy. An early finding is a solitary target lesion that may be followed by multiple lesions.

Question 53

A 60-year-old female patient complains of pain in the hands that is worse in the morning. On physical examination, the thumb metacarpophalangeal joint is swollen on both hands. There is
swelling of the proximal and distal interphalangeal joints bilaterally. These are typical signs of:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Normal aging
D. Gouty arthritis

Answer 53

ANS: A
Compared with RA, OA has a higher likelihood of affecting larger joints, such as the hips and knees. Like RA, OA also frequently involves the small joints of the hands, although it tends to
occur at the distal interphalangeal joints (Heberden’s nodes) and proximal interphalangeal joints (Bouchard’s nodes). Most frequently, the second and/or third digits and the base of the thumb are
involved. The distribution is asymmetrical. The pain and stiffness associated with OA often improve with moderate use and are worse after extended periods of rest. If three or more metacarpophalangeal joints are swollen, the differential should include RA.

Question 54

A 56-year-old male presents with complaints of right-sided neck pain with radiation down the right arm into the right index finger and thumb. He reports a recent fall from a scaffold while painting
on the job. On physical examination, you note a 0/4 biceps reflex on the right compared to 2/4 on the left and 1/5 grip strength of the right hand compared to 5/5 of the left hand. Which of the
following is a test that can be performed to assist in the diagnosis of cervical disk herniation?
A. Spurling’s sign
B. Apley’s sign
C. Lhermitte’s sign
D. A and C

Answer 54

. ANS: D
In cervical spine trauma, cervical disk herniation can occur. A positive Spurling’s sign is noted if this maneuver reproduces neck and radicular pain, suggesting a herniated disk. Spurling’s sign is
tested for by lightly pressing downward on the top of the patient’s head while tilting back and toward the side of pain. Lhermitte’s sign may support suspicion of a herniated disk. This test is conducted by having the patient flex the neck in a chin-to-chest motion and is positive if an electric shock-like sensation down the spine results.

Question 55

Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking the following medications: an ACE inhibitor and beta blocker for treatment of
hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2 diabetes. The patient complains of myalgias of the legs bilaterally and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect?
A. Beta blocker
B. ACE inhibitor
C. Statin medication
D. Metformin

Answer 55

ANS: C
Myalgias are a side effect of lipid-lowering medications called “statins.” If the myalgia is related to rhabdomyolysis, the urine is often reddish-brown. When drug-induced myalgia is present, there is
often eosinophilia. For rhabdomyolysis myalgia, the serum creatine kinase is significantly elevated.

Question 56

A 75-year-old female patient complains of fatigue as well as pain and stiffness of the shoulders and neck. There is no history of trauma or exercised-induced pain. Medications include a beta blocker and ACE inhibitor. Medical history includes giant cell arteritis and Raynaud’s syndrome. Physical examination is unremarkable. There is no swelling or erythema over the temporal arteries. There is
no swelling, erythema, limitation in range of motion or point tenderness over the shoulder joints. The neck has normal range of motion and no tenderness or swelling. Which of the following
disorders should be included in the list of possible diagnoses?
A. Rheumatoid arthritis
B. Polymyalgia rheumatic
C. Drug-induced myalgia
D. Fibromyalgia

Answer 56

ANS: B
Polymyalgia rheumatica is usually identified in adults aged 60 or older. The actual etiology of this condition is unknown. Giant cell arteritis occurs in about 15% of those with polymyalgia rheumatica, and the two conditions may be different expressions of the same etiology. The patient typically complains of sudden onset of widespread pain. Commonly affected sites include the neck, shoulders, and pelvis. Pain is accompanied by fatigue and stiffness. The stiffness is most profound in the morning. There is no actual muscle weakness. Unlike RA, there is no small joint inflammation and effusion.

Question 57

A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered
in the differential diagnosis?
A. Joint infection
B. Chondromalacia patella
C. Prepatellar bursitis
D. All of the above

Answer 57

D

Prepatellar bursitis is also called housemaid’s knee, which is common to persons whose occupation requires extended periods of kneeling, such as plumbers and carpet layers. This bursitis can also be
caused by an infection. The patient complains of pain in the area inferior to and over the patella, and there is swelling and inflammation of the bursa. Chondromalacia patella is seen in young
active persons of either gender. The condition is also commonly called patella-femoral syndrome and runner’s knee. The pain involves the anterior knee, often develops gradually, and is moderate
in intensity. Pain can be reproduced by pressing the patella against the femoral condyles, and there is tenderness around the patella. Other maneuvers that reproduce the pain include applying
pressure against the patella as the patient extends the lower leg, flexing the quadriceps, and moving the patella from side to side. Crepitus and effusion are often present.

Question 58

A 17-year-old male complains of severe right knee pain. He was playing football when he heard a “pop” at the moment of being tackled and his knee “gave away” from under him. On physical
examination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate:
A. Knee ligament injury
B. Osgood-Schlatter disease
C. Prepatellar bursitis
D. Chondromalacia patella

Answer 58

ANS: A
The anterior, medial, and lateral knee ligaments are vulnerable to injury in athletic activities. The mechanism through which the anterior cruciate ligament (ACL) is typically injured involves
deceleration combined with sudden turning or pivoting. The medial collateral ligament (MCL) is most prone to injury through motions that place valgus stress on the knee. Compared with ACL and MCL injury, damage to the lateral collateral ligament (LCL) is much rarer but typically occurs when sudden varus stress is placed on the knee. The patient often relates history of an acute trauma followed by the onset of pain, swelling, and limited mobility. Often patients recall hearing or feeling a “pop” at the moment of injury and/or “give-away” sense. ACL injury is identified through a positive drawer (Fig. 14.9) and/or Lachman’s test (Fig. 14.10). Laxity of the LCL is assessed by
placing varus stress on the knee with the leg both extended and flexed.

Question 59

A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot. On physical examination, the
patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon?
A. Straight leg raising sign
B. Lumbar herniated disc on x-ray
C. Loss of left sided patellar reflex
D. Urinary incontinence

Answer 59

ANS: D
With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient’s posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, ROM, and any obvious signs of discomfort are noted. Observe the patient walking on heels and on toes, noting any signs of weakness. Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended,
the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated.

Question 60

Your patient is 40-year-old baseball player who needs his yearly physical exam. He reports a 5- year history of chronic lower back pain due to spinal stenosis. Which of the following findings
indicate spinal stenosis?
A. Lumbar x-ray demonstrates vertebral osteophytes
B. Positive straight leg raising sign upon physical exam
C. Lumbar MRI shows decreased intervertebral space
D. A and C

Answer 60

. ANS: D
Caused by progressive degenerative spine changes, spinal stenosis is most common at middle age or later. Spinal stenosis pain is usually worse during the day. It is aggravated by standing and relieved by rest. The pain varies from severe to mild. OA signs may be present. RAdiological findings may indicate extensive vertebral osteophytes and degenerative disk disease. An MRI or CT scan can be helpful if initial x-rays are inconclusive.

Question 61

Which of the following disorders has a strong genetic component and causes loss of spinal mobility and progressive erosion of the sacroiliac joint?
A. Syringomyelia
B. Spinal stenosis
C. Ankylosing spondylitis
D. None of the above

Answer 61

ANS: C
Ankylosing spondylitis is one of the spondyloarthropathies, which have genetic predispositions and are inflammatory disorders. Early symptoms include LBP and stiffness, which gradually become persistent and increase in severity. There is loss of spine mobility, and posture gradually changes with flexion of the neck, increased kyphosis of the thoracic region, and loss of the lumbar curve. The gene HLA-B27 is present in most patients. Radiographs show abnormality of the sacroiliac joint with progressive erosion. A CT scan is useful to identify sacroiliitis.

Question 62

Whenever a patient presents with acute non-traumatic shoulder pain, the clinician should make sure to exclude a:
A. Cardiac origin of symptoms
B. Gastrointestinal condition
C. Cervical spine disorder
D. All of the above

Answer 62

ANS: D
Acute shoulder syndromes frequently arise from inflammation. Most frequently, the capsule of the glenohumeral joint, supraspinatus tendon, and the subacromial bursa are involved. When patients
present with shoulder pain, always consider the possibility of cardiac, cervical neck, or gastrointestinal cause. Cardiac pain commonly radiates to the left shoulder. Cervical spine degeneration and osteoarthritis frequently causes right- or left-sided shoulder pain. Gastrointestinal disorders, such as cholecystitis, frequently cause pain radiation to the right shoulder.

Question 63

A 34-year-old baseball pitcher complains of pain in the left shoulder, particularly with raising the left arm when attempting to pitch. Which of the following is a test used to diagnose rotator cuff injury?
A. Apley’s test
B. Trousseau test
C. Hawkin’s test
D. A and C

Answer 63

ANS: D
The rotator cuff consists of the supraspinatus, infraspinatus, subscapularis, and teres minor. Injury to the rotator cuff is typically due to chronic impingement with degenerative changes over time.
The patient typically complains of anterior and lateral shoulder pain that increases with arm elevation and reaching overhead. The pain is usually progressive and may be associated with repetitive activities. Pain at night may cause sleep disturbance. ROM is typically preserved. Apley’s (see Fig. 14.2) and Hawkins’ (see Fig. 14.3) tests may reproduce the pain, depending on the component of the rotator cuff involved. There may be point or diffuse tenderness to the
shoulder area. Crepitus and/or arm weakness suggest an acute tear.

Question 64

Which of the following is a sign of glenohumeral instability?
A. Positive Lachman test
B. Negative Spurling’s sign
C. Positive apprehension test
D. Negative Lhermitte sign

Answer 64

C

Unlike the other conditions affecting the shoulder, glenohumeral instability is most common in young patients who are physically active. The instability can result in displacement of the humeral
head in various directions. The patient will experience sudden onset of pain and be unwilling to move the arm. The displacement may follow an acute injury/trauma or may be associated with specific movements or overuse. A positive apprehension test suggests glenohumeral instability. This can be somewhat validated by performing the relocation test, in which the apprehension test
is immediately followed by placing mild anterior pressure on the arm paired with external rotation

Question 65

Your patient is a 43-year-old female golfer who complains of arm pain. On physical examination, there is point tenderness on the elbow and pain when the patient is asked to flex the wrist against
the clinician’s resistance. These are typical signs of:
A. Carpal tunnel syndrome
B. Osteoarthritis of the wrist
C. Epicondylitis
D. Cervical osteoarthritis

Answer 65

ANS: C
Epicondylitis involves inflammation of the tendon/tendon insertion of the forearms. This tendinitis results in either lateral elbow pain associated with overuse of the wrist extensors (tennis elbow) or
in medial elbow pain associated with overuse of involving wrist flexion and rotation (golfer’s elbow). Point tenderness is noted at the medial or lateral epicondyle. The onset and severity of pain
is usually gradual and progressive but may have relatively acute onset following an activity involving significant repetitive use. The pain may be referred to the forearm and is increased by
the offending motion (wrist flexion, extension, or rotation). Pain is usually greater when the motion is made against resistance.

Question 66

A 3-year-old male toddler complains of sudden arm pain. The mother indicated that pain occurred suddenly while his 9-year-old sister was helping him get dressed. The child presents with the arm
flexed while protecting his elbow. On physical examination, there is tenderness along the radius with no swelling or evidence of trauma. This is a typical history of:
A. Nursemaid’s elbow
B. Epicondylitis
C. Smith fracture
D. Nursery pseudo-fracture

Answer 66

ANS: A
Also known as pulled elbow or toddler’s elbow, nursemaid’s elbow involves the head of the radius slipping under the annular ligament in children, usually between 1 and 4 years of age. The condition occurs when traction is applied to the young child’s hand or wrist. There is a history of sudden onset of pain associated with sudden immobility of the affected arm as the child protects the elbow. The parent may be able to identify a situation in which the child’s hand was held and traction applied. The child may have moved in an opposite direction or injury could occur while pulling the arm through clothing. There is no associated swelling or inflammation. Examination is otherwise normal with the exception of resistance to attempts to move the arm, elbow, and, possibly, wrist. There may be tenderness along the upper margin of the radius.

Question 67

A 46-year-old administrative assistant complains of pain in the wrist that radiates into the palm and into the fingers. The clinician can test the patient for carpal tunnel syndrome by eliciting which of the following signs?
A. Tinel’s sign
B. Apley’s sign
C. Finkelstein sign
D. Lhermitte’s sign

Answer 67

ANS: A
Carpal tunnel syndrome causes a range of neurological symptoms, including pain, paresthesia, and weakness. Frequently, nighttime pain is an early symptom. There may be a swelling at the wrist related to inactivity or flexion at night. The pain and/or paresthesias typically involve the anterior aspects of wrist, medial palm, and first three digits on the affected hand. However, pain may radiate up the forearm to the shoulder with numbness and tingling along the median nerve. Over time, hand weakness often develops. Pain and paresthesia are often relieved by the patient “shaking” the affected hand in a downward fashion; this is called the flicking sign. A positive
Tinel’s sign is elicited by tapping on the median nerve at the carpal tunnel, causing pain and tingling along the median nerve. Phalen’s maneuver reproduces the pain after 1 minute of wrist flexion against resistance.

Question 68

Which of the following describes the pathology of De Quervain’s tenosynovitis?
A. Irritation of a tendon located on the radial side of the wrist, near the thumb.
B. Impingement of the median nerve, causing pain in the palm and fingers
C. Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist
D. Ulnar nerve compression at the olecranon process

Answer 68

A

De Quervain’s tenosynovitis involves irritation of a tendon located on the radial side of the wrist, near the thumb. With overuse, the tissues surrounding the tendon sheath hypertrophy, causing pressure on the tendon and making it difficult to move. The pain is usually limited to the radial aspect of the wrist and area immediately around the base of the thumb. Pain increases with use of the hand, such as with gripping maneuvers. Other symptoms include swelling, decreased sensation, and limited ROM with a locking sensation with thumb motion. The Finkelstein maneuver (Fig. 14.7) is used to diagnose De Quervain’s disease. A positive test results in pain, which is often
severe. Patients who can repeatedly open and close the fist with smooth thumb motion are unlikely to have De Quervain’s.

Question 69

What is the most common cause of hip pain in older adults?
A. Osteoporosis
B. Osteoarthritis
C. Trauma due to fall
D. Trochanteric bursitis

Answer 69

ANS: B
There are many potential causes of hip pain. Among adults, the most common cause is OA with degenerative changes. In younger patients, the cause is often strain of the muscles or tendons. In
comparison to other joints, the hip is often difficult to assess, in part because much of the joint and its periarticular structures lie deeper than those of other joints.

Question 70

A 33-year-old male marathon runner presents with knee pain. Which of the following tests is positive if the meniscus of the knee is torn?
A. McMurray’s test
B. Straight leg raising sign
C. Anterior drawer sign
D. Lachman test

Answer 70

ANS: A
Tears or disruptions of the meniscus sheath of cartilage are associated with OA in older persons and with athletic activities in younger persons. There is typically a sudden onset of pain and
swelling over the lateral or medial joint line as well as locking and painful popping. Onset often follows a twisting injury. Point tenderness is present over the joint line, with mild effusion. A positive McMurray’s test is often present.

Question 71

A 23-year-old female presents with ankle pain due to a fall while walking on ice 1 hour ago. You watch her limp as she walks into the emergency room. On physical examination, the ankle is erythematous, swollen, and tender to touch. The patient cannot stand on the affected ankle. Range of motion is severely limited on inversion of the ankle. On palpation, there is no pain with pressure
on the medial or lateral malleolus. Should this patient be sent for ankle x-rays according to the Ottawa ankle rules?
A. No, the ankle shows no tenderness over the medial or lateral malleolus
B. Yes, the patient is unable to bear weight on the ankle
C. Yes, ankle range of motion is limited
D. No, range of motion of the ankle is not limited in all planes

Answer 71

ANS: B
The following Ottawa rules recommend x-ray of the ankle if either one of the following conditions exist:

Inability to bear weight for four steps
(both immediately and in emergency department)

Bone tenderness at posterior edge or tip
of either malleolus

Question 72

A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical examination, there is no point tenderness
over the medial or lateral ankle malleolus. There is no foot tenderness except at the base of the fifth metatarsal bone. According to the Ottawa foot rules, should an x-ray of the feet be ordered?
A. Yes, there is tenderness over the fifth metatarsal
B. No, there is not tenderness over the navicular bone
C. Yes, the patient cannot bear weight on the foot
D. A and C

Answer 72

ANS: D
Foot Rule: Order film if one of the following is met:

Inability to bear weight for four steps (both immediately and in emergency department)

Bone tenderness at navicular or base of fifth metatarsal

Sensitivity = 100%

Specificity = 79%

Question 73

A 36-year-old female patient complains of foot pain when she wears high heels. There is no history of trauma or arthritis. On physical examination, there is tenderness at the space between the third
and fourth metatarsal bones. Foot x-ray shows no evidence of stress fracture. This history is typical of:
A. Plantar fasciitis
B. Morton’s neuroma
C. Achilles tendonitis
D. None of the above

Answer 73

ANS: B
Morton’s neuroma, also called interdigital neuroma, is actually not neuroma but rather fibrous tissue thickening along digital nerves, typically in the space between the third and fourth intermetatarsals. They occur most frequently in women and may be associated with footwear, such as heels. Most common is localized pain that is increased with walking and decreased with rest and/or removal of shoes. Palpation often reproduces the sharp pain.

Question 74

2 first degree relatives with breast cancer, one was diagnosed before the age of 50.

Three or more first or second degree relatives with breast cancer, regardless of age at diagnosis

First degree relative with bilateral breast cancer

A combination of breast and ovarian cancer among first and second degree relatives

Answer 74

genetic risk factors

Question 75

Children > 30 or nulliparity
Early menarche & late menopause
> age
Significant # of women with no risk factors

Answer 75

personal risk factos of breast cancer

Question 76

Bilateral “lumpy” texture to breast (esp. upper outer quadrant) which is tender, well defined, mobile & responds to menstrual cycle; most common between ages 30-50

Answer 76

Fibrocystic Breast Disease

Question 77

Fibroadenoma: painless, solid, well defined, mobile masses in area of nipple or upper-outer quadrant; most common between 15-25; no link with breast CA;

Answer 77

Benign Breast Disease

Question 78

Multiple sex partners
HPV infection
History of STD’s
sex @ young age
multiple birth
Smoking
HIV

Answer 78

Risk Factors for Cervical Cancer

Question 79

Normal saline viewed under microscope shows clue cells, trichomonads, WBC

Answer 79

Wet mount (wet prep)

Question 80

dissolves epithelial cells and debris, facilitating visualization of fungus, hypae and yeast often seen in candidiasis

Answer 80

KOH

Question 81

after mixing sample with KOH, volatile amines released-positive if odor is present

Answer 81

Whiff test

Question 82

Vaginal pH >4.5,

The presence of clue cells (bacterial clumping upon the borders of epithelial cells) Clue cells should constitute at least 20% of all epithelial cells (an occasional clue cell does not fulfill this criteria).

Positive amine, “whiff” or “fishy odor” test

Homogeneous, non-viscous, milky-white discharge adherent to the vaginal walls.

Answer 82

Bacterial Vaginosis

Question 83

Strawberry cervix
Itching and discharge
frothy white discharge
no odor

Answer 83

trich

Question 85

Silent epidemic in women
75% have no symptoms
If symptoms present
Discharge
Dyspareunia
Painful urination

Answer 85

Chlamydia

Question 86

Thick white discharge
Vulvar itching
exoriations

Answer 86

Candidiasis

Question 87

The autonomic nervous system coordinates which of the following?
a. High-level cognitive function
b. Balance and affect
c. Internal organs of the body
d. Balance and equilibrium

Answer 87

C

The autonomic nervous system coordinates the internal environment of the body by the sympathetic and parasympathetic nervous systems. The other options are associated with the
cerebral cortex; its function consists of determining intelligence, personality, and motor function.

Question 88

The major function of the sympathetic nervous system is to
a. orchestrate the stress response.
b. coordinate fine motor movement.
c. determine proprioception.
d. perceive stereognosis.

Answer 88

ANS: A
Stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies for fight or flight (stress response). The cerebellum plays a key role in the coordination of fine motor movements. Recognition of body parts and awareness of body position (proprioception) are dependent on the parietal lobe. Stereognosis is the ability to perceive the weight and form of solid objects by touch and is not under sympathetic control

Question 89

The parasympathetic nervous system maintains the day-to-day function of
a. digestion.
b. response to stress.
c. lymphatic supply to the brain.
d. lymphatic drainage of the brain.

Answer 89

ANS: A

The parasympathetic division functions in a complementary and counterbalancing manner to conserve body resources and maintain day-to-day body functions, such as digestion and elimination.

Question 90

Cerebrospinal fluid serves as a
a. nerve impulse transmitter.
b. red blood cell conveyer.
c. shock absorber.
d. mediator of voluntary skeletal movement.

Answer 90

ANS: C
Cerebrospinal fluid circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber.

Question 91

Diabetic peripheral neuropathy will likely produce
a. hyperactive ankle reflexes.
b. diminished pain sensation.
c. exaggerated vibratory sense.
d. hypersensitive temperature perception.

Answer 91

ANS: B
Peripheral neuropathy is a disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves, usually in the hands and feet. Patients may have sensations of numbness, tingling, burning, and cramping. In moderate to severe diabetic neuropathy, there is wasting of the foot muscles, absent ankle and knee reflexes, decreased or no vibratory sensation below the knees, and/or loss of pain or sharp touch
sensation to the midcalf level.

Question 92

The thalamus is the major integration center for the perception of
a. speech.
b. olfaction.
c. pain.
d. thoughts

Answer 92

ANS: C

The thalamus is the major integrating center for the perception of various sensations such as pain and temperature, serving as the relay center between the basal ganglia and cerebellum. The reception of speech and interpretation of speech are located in the Wernicke area. The olfactory sense is processed in the parietal lobe. The cerebrum holds memories, allows you to plan, and enables you to imagine and think.

Question 93

The awareness of body position is known as
a. proprioception.
b. graphesthesia.
c. stereognosis.
d. two-point discrimination.

Answer 93

ANS: A
Recognition of body parts and awareness of body position are known as proprioception. This is dependent on the parietal lobe. The other options are assessment techniques that test for sensory impairment.

Question 94

Which area of the brain maintains temperature control?
a. Epithalamus
b. Thalamus
c. Abducens
d. Hypothalamus

Answer 94

ANS: D
The hypothalamus is the major processing center of internal stimuli for the autonomic nervous system. It maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity. The epithalamus houses the pineal body and is responsible for sexual development and behavior. The thalamus conveys all sensory impulses, except olfaction, to and from the cerebrum before their distribution to appropriate associative
sensory areas. The abducens is the sixth cranial nerve with motor function responsible for lateral eye movement.

Question 95

If a patient cannot shrug his or her shoulders against resistance, which cranial nerve (CN) requires further evaluation?
a. CN I, olfactory
b. CN V, trigeminal
c. CN IX, glossopharyngeal
d. CN XI, spinal accessory

Answer 95

ANS: D

CN XI is responsible for the motor ability to shrug the shoulders. CN I is associated with smell reception and interpretation. CN V is associated with opening of the jaw, chewing, and sensation of the cornea, iris, conjunctiva, eyelids, forehead, nose, teeth, tongue, ear, and facial skin. CN IX is associated with swallowing function, sensation of the nasopharynx, gag reflex, taste, secretion of salivary glands, carotid reflex, and swallowing.

Question 96

Motor maturation proceeds in an orderly progression from
a. peripheral to central.
b. head to toe.
c. lateral to medial.
d. pedal to cephalic.

Answer 96

B

Motor maturation proceeds in a cephalocaudal direction. Motor control of the head and neck develops first, followed by the trunk and extremities. The other choices are incorrect because they relate the maturation sequence inappropriately, from outward to central

Question 97

Normal changes of the aging brain include
a. increased velocity of nerve conduction.
b. diminished perception of touch.
c. increased total number of neurons.
d. diminished intelligence quotient.

Answer 97

B

Sensory perceptions of touch and pain are diminished by aging. The velocity of nerve impulse conduction declines, so responses to stimuli take longer. The number of cerebral neurons is thought to decrease by 1% a year, beginning at 50 years of age; however, the vast number of reserve cells inhibits the appearance of clinical signs.

Question 98

The area of body surface innervated by a particular spinal nerve is called a
a. dermatome.
b. nerve pathway.
c. spinal accessory area.
d. cutaneous zone.

Answer 98

ANS: A
The sensory and motor fibers of each spinal nerve supply and receive information to a segment of skin known as a dermatome. Nerve pathway and spinal accessory area refer to nerve routes. Cutaneous zone refers to a skin area that transmits fine mechanical information and normal exogenous thermal information at the same time.

Question 99

A neurologic past medical history should include data about
a. allergies.
b. circulatory problems.
c. educational level.
d. immunizations.

Answer 99

B

The neurologic past medical history should include data concerning neurovascular problems such as stroke, aneurysm, and brain surgery. The other answers are not pertinent medical information for the neurologic past medical history.

Question 100

Which is the technique most often used for evaluating the neurologic system?
a. Auscultation
b. Inspection
c. Palpation
d. Percussion

Answer 100

ANS: B
The evaluation tool of inspection is used most often. Inspection of gait and response to questions can provide data concerning neurologic system function.

Question 102

When assessing superficial pain, touch, vibration, and position perceptions, you are testing
a. cerebellar function.
b. emotional status.
c. sensory function.
d. tendon reflexes.

Answer 102

ANS: C
Superficial pain, touch, vibration, and position perceptions are sensory functions

Question 103

You are initially evaluating the equilibrium of Ms. Q. You ask her to stand, with her feet together and arms at her sides. She loses her balance. Ms. Q has a positive
a. Kernig sign.
b. Homan sign.
c. McMurray test.
d. Romberg sign.

Answer 103

ANS: D
The Romberg test has the patient stand with the eyes closed, feet together, and arms at the sides. A slight swaying movement of the body is expected, but not to the extent of falling. Loss of balance results in a positive Romberg test. The Kernig sign indicates meningeal irritation, the Homan sign indicates venous thrombosis, and the McMurray test is a rotation test for demonstrating a torn meniscus.

Question 104

The finger to nose test allows assessment of
a. coordination and fine motor function.
b. point location.
c. sensory function.
d. stereognosis.

Answer 104

A

To perform the finger to nose test, the patient closes both eyes and touches his or her nose with the index finger, alternating hands while gradually increasing the speed. This tests coordination and fine motor skills. All the other choices test sensory function without motor function.

Question 105

You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the
a. back.
b. palms
c. fingertips.
d. upper arms.

Answer 105

ANS: C
The fingertips can discern two points with a minimal distance of 2 to 8 mm, the back, 40 to 70 mm, the palms, 8 to 12 mm, and the upper arms, 75 mm.

Question 106

As Mr. B enters the room, you observe that his gait is wide-based and he staggers from side to side while swaying his trunk. You would document Mr. B’s pattern as
a. dystonic ataxia.
b. cerebellar ataxia.
c. steppage gait.
d. tabetic stamping.

Answer 106

ANS: B
A cerebellar gait (cerebellar ataxia) occurs when the patient’s feet are wide-based, with a staggering gait, lurching from side to side, often accompanied by swaying of the trunk. Dystonic ataxia is jerky dancing movements that appear nondirectional. Steppage gait is noted when the hip and knee are elevated excessively high to lift the plantar-flexed foot off the ground. The foot is brought down with a slap and the patient is unable to walk on the heels. Tabetic stamping occurs when the legs are positioned far apart, lifted high, and forcibly
brought down with each step; in this case, the heel stamps on the ground.

Question 107

Deep pressure tests are used mostly for patients who are experiencing
a. absent superficial pain sensation.
b. gait and stepping disturbances.
c. lordosis, osteoporosis, or arthritis.
d. tonic neck or torso spasms.

Answer 107

A

Deep pressure sensation is tested by squeezing the trapezius, calf, or biceps muscle, thus causing discomfort. When superficial pain sensation is not intact, further assessments of temperature and deep pressure sensation are performed.

Question 108

Vibratory sensory testing should be routinely done for the patient with
a. Parkinson disease.
b. diabetes.
c. cerebral palsy.
d. Guillain-Barré syndrome.

Answer 108

ANS: B
Diabetic neuropathy must be routinely assessed in all diabetic patients. In moderate to severe cases, decreased or absent vibratory sensation occurs below the knees, which should be assessed with a tuning fork. The other choices do not result in sensation deficits.

Question 109

To assess a cremasteric reflex, the nurse strokes the
a. sole of the foot and observes whether the toes fan down and out.
b. abdomen and observes whether the umbilicus moves away from the stimulus.
c. inner thigh and observes whether the testicle and scrotum rise on the stroked side.
d. palm and observes whether the fingers attempt to grasp.

Answer 109

ANS: C
Stroking the inner thigh of a male patient (proximal to distal) will elicit the cremasteric reflex. The testicle and scrotum rise on the stroked side. Stroking the sole of the foot elicits a Babinski sign. Stroking the abdomen elicits an abdominal reflex. Stroking the palm elicits a
palmar grasp.

Question 110

When you ask a patient to close his or her eyes and identify an object placed in the hand, you are evaluating
a. stereognosis.
b. graphesthesia.
c. vibratory sensation.
d. extinction phenomenon.

Answer 110

A

Stereognosis is the ability to recognize an object through touch and manipulation. Tactile agnosia, an inability to recognize objects by touch, suggests a parietal lobe lesion. Graphesthesia tests the patient’s ability to identify the figure being drawn on the palm. The
vibratory sense uses a tuning fork placed on a bony prominence, and the extinction phenomenon tests sensation by simultaneously touching bilateral sides of the body with a sterile needle

Question 111

The ability to recognize a number traced on the skin is called
a. stereognosis.
b. graphesthesia.
c. an extinction phenomenon.
d. two-point discrimination.

Answer 111

B

The ability to recognize a number traced on the skin is called graphesthesia. Stereognosis is the ability to recognize an object through touch and manipulation. The extinction phenomenon
test and two-point discrimination assess a person’s ability to discern the number of pinpoints and their location.

Question 112

Which condition is consistent with Brown-Séquard syndrome?
a. Central sensory loss that is generalized
b. Motor paralysis on the lesion side of the body
c. Multiple peripheral neuropathy of the joints
d. Spinal root paralysis below the umbilicus

Answer 112

B

Parietal spinal sensory syndrome (Brown-Séquard syndrome) is noted when pain and temperature sensation occur one to two dermatomes below the lesion on the opposite side of the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of the body.

Question 113

To assess spinal levels L2, L3, and L4, which deep tendon reflex should be tested?
a. Triceps
b. Patellar
c. Biceps
d. Achilles

Answer 113

ANS: B
To assess spinal levels L2 to L4, the patellar reflex should be tested. The patellar tendon is the only deep tendon that assesses the lumbar spinal level. The triceps and biceps tendon are tested to assess the cervical spine, whereas the Achilles tendon is tested to assess the sacral spine.

Question 114

When using a monofilament to assess sensory function, the nurse

a. uses two simultaneous monofilaments on similar bilateral points and then compares results.
b. applies both a monofilament and a pin on similar bilateral points and then compares results.
c. applies pressure to the monofilament until the filament bends.
d. strokes the monofilament along the skin from proximal to distal areas

Answer 114

C

The monofilament is placed on several smooth spots of the patient’s plantar foot for seconds. Adequate pressure applied by the monofilament is measured by the bend of the monofilament.

Question 115

Visible or palpable extension of the elbow is caused by reflex contraction of which muscle?
a. Achilles
b. Biceps
c. Patellar
d. Triceps

Answer 115

D

The triceps tendon, when directly hit with the reflex hammer just above the elbow, will cause contraction of the triceps muscle and extension of the elbow

Question 116

It is especially important to test for ankle clonus if
a. deep tendon reflexes are hyperactive.
b. deep tendon reflexes are hypoactive.
c. the Romberg sign is positive.
d. the patient has peripheral neuropathy.

Answer 116

A

Test the ankle clonus when reflexes are hyperactive. Support the patient’s knee in a flexed position and briskly dorsiflex the foot with your other hand. If clonus is present, there is recurrent ankle plantar flexion movement as long as the examiner retains the foot in
dorsiflexion. Sustained clonus signifies the hypertonia of an upper motor neuron lesion.

Question 117

On a scale of 1+ to 4+, which deep tendon reflex score is appropriate for a finding of clonus in a patient?
a. 1+
b. 2+
c. 3+
d. 4+

Answer 117

D

1+ indicates a sluggish or diminished reflex. 2+ indicates an active or expected response. 3+ indicates more brisk than expected, slightly hyperactive. 4+ indicates brisk, hyperactive, with intermittent or transient clonus.

Question 118

Which sign is associated with meningitis and intracranial hemorrhage?
a. Babinski sign
b. Asymmetric tonic neck reflex
c. Doll’s eye movement
d. Nuchal rigidity

Answer 118

D

A stiff neck or nuchal rigidity is a sign associated with meningitis and intracranial hemorrhage. Test this by lifting the head of the patient to touch the chin while the patient lies in a supine position. Pain and resistance to neck motion are associated with nuchal rigidity.

Question 119

Cranial nerve XII may be assessed in an infant by
a. watching the infant’s facial expressions when crying.
b. observing the infant suck and swallow.
c. clapping hands and watching the infant blink.
d. observing the infant’s rooting reflex.

Answer 119

B

Cranial nerve (CN) XII may be assessed in an infant by observing the infant suck and swallow, by pinching the nose, and then observing for the mouth to open and the tip of the tongue to rise in a midline position. Watching the infant’s facial expressions when crying
assesses CN VII. Clapping hands and watching the infant blink tests CN VIII. Observing the rooting reflex assesses CN V.

Question 120

You are most concerned for the infant who has a
a. weak palmar grasp at 3 months.
b. strong stepping reflex at 2 months.
c. weak plantar reflex at 9 months.
d. strong tonic neck at 6 months.

Answer 120

ANS: D
The tonic neck reflex must disappear before the infant can roll over or bring his or her hands to their face; it should disappear by 6 months. The other choices are within expected ranges

Question 121

At what age should the infant begin to transfer objects from hand to hand?
a. 2 months
b. 4 months
c. 7 months
d. 10 months

Answer 121

C

Transferring objects hand to hand begins at 7 months. Purposeful release of objects is noted as a normal finding by 10 months. Purposeful movements, such as reaching and grasping for
objects, begin at about 2 months of age. The progress of taking objects with one hand begins at 6 months. There should be no tremors or constant overshooting of movements.

Question 122

An acute polyneuropathy that commonly follows a nonspecific infection occurring 10 to 14 days earlier and that primarily affects the motor and autonomic peripheral nerves in an ascending pattern is
a. cerebral palsy.
b. HIV encephalopathy.
c. Guillain-Barré syndrome.
d. Rett syndrome.

Answer 122

C

Guillain-Barré syndrome—acute idiopathic polyneuritis—is an acute polyradiculoneuropathy that commonly follows a nonspecific infection that occurred 10 to 14 days earlier. It is characterized by ascending symmetric weakness with sensation preserved. An increase in severity occurs over days or weeks. A decrease in or absent strength and sensory loss may result, along with motor paralysis and respiratory muscle failure.

Question 123

Which is a concern, rather than an expected finding, in older adults?
a. Reduced ability to differentiate colors
b. Bilateral pillrolling of the fingers
c. Absent plantar reflex
d. Reduction in upward gaze

Answer 123

ANS: B
Bilateral pillrolling is indicative of Parkinson disease; the other choices are expected findings with aging.

Question 124

Which condition is potentially life-threatening if not treated expeditiously with antibiotics?
a. HIV encephalopathy
b. Dementia
c. Parkinson disease
d. Bacterial meningitis

Answer 124

D

Meningitis is an inflammatory process in the meninges. Bacterial meningitis is a life-threatening illness if not rapidly treated with appropriate antibiotics. All the other diseases are neurologic disorders not treatable by antibiotics.

Question 125

Ipsilateral Horner syndrome indicates a cerebrovascular accident (CVA) occurring in the
a. anterior portion of the pons.
b. internal or middle cerebral artery.
c. posterior inferior cerebellar artery.
d. vertebral or basilar arteries.

Answer 125

C

The posterior inferior cerebellar artery supplies the lateral and posterior portion of the medulla. A CVA involving this artery can produce a neurologic sign of ipsilateral Horner syndrome in the eye.

Question 126

The immune system attacks the synaptic junction between the nerve and muscle fibers, blocking acetylcholine receptor sites in
a. myasthenia gravis.
b. encephalitis.
c. multiple sclerosis.
d. cerebral palsy.

Answer 126

A

Myasthenia gravis is a chronic autoimmune neuromuscular disease involving the lower motor neurons and muscle fibers. The immune system of infected individuals produces antibodies that destroy acetylcholine receptor sites at the neuromuscular junction. This blocks the nerve impulse from reaching the muscle and produces muscle fatigue. Encephalitis is acute inflammation of the brain and spinal cord involving the meninges. It is often caused by a virus, such as the herpes simplex virus. Multiple sclerosis is a progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin in the brain’s white matter, leading to obstructed transmission of nerve impulses and decreased brain mass. Cerebral palsy is a permanent disorder of movement and posture development associated with nonprogressive (static) disturbances that occurred in the developing fetal or infant brain.

Question 127

Persons with Parkinson disease have an altered gait characterized by
a. short shuffling steps.
b. the trunk in a backward position.
c. exaggerated swinging of the arms.
d. lifting the legs in a high-stepping fashion.

Answer 127

A

The altered gait of Parkinson disease has short shuffling steps, the posture is stooped forward, and the arms have limited swing.

Question 128

The tests for cortical sensory function include which of the following? (Select all that apply.)
a. Two-point discrimination
b. Extinction phenomenon
c. Superficial pain
d. Stereognosis
e. Touch

Answer 128

ANS: A, B, D
The following tests are tests for cortical sensory function—stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, and point location.

Question 129

When is the mental status portion of the neurologic system examination performed?
a. During the history-taking process
b. During assessment of cranial nerves and deep tendon reflexes
c. During the time when questions related to memory are asked
d. Continually, throughout the entire interaction with a patient

Answer 129

D

A mental status evaluation should be continually performed throughout the patient encounter. Assessing and validating clues to determine the individual’s ability to interact within the environment is a priority of the mental status evaluation.

Question 130

A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken language. This indicates a lesion in the
a. temporal lobe.
b. Broca area.
c. frontal cortex.
d. cerebellum.

Answer 130

A

The temporal lobe, specifically in the Wernicke speech area, is responsible for the comprehension of spoken and written language.

Question 131

The ability for abstract thinking normally develops during
a. infancy.
b. early childhood.
c. adolescence.
d. adulthood.

Answer 131

ANS: C
Abstract thinking is an intellectual maturation that develops during adolescence.

Question 132

The Mini-Mental State Examination (MMSE) may be used to
a. estimate cognitive changes quantitatively.
b. estimate personality disorders qualitatively.
c. diagnose neurologic disorders.
d. determine the cause of memory loss.

Answer 132

ANS: A
The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to document cognitive changes serially.

Question 133

Assessing orientation to person, place, and time helps determine
a. ability to understand analogies.
b. abstract reasoning.
c. attention span.
d. state of consciousness.

Answer 133

ANS: D
Orientation to person, place, and time are measures of states of consciousness and awareness.

Question 134

When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing which of the following?
a. Level of consciousness
b. Abstract reasoning
c. Emotional stability
d. Memory

Answer 134

ANS: B
Asking the patient to tell you the meaning of a proverb, metaphor, or fable assesses the patient’s ability to reason abstractly. Asking the patient to tell you the meaning of a proverb or metaphor does not assess level of consciousness, emotional stability, or memory. The
Mini-Mental State Examination tests memory.

Question 135

Impairment of arithmetic skills is often the result of
a. impaired execution of motor skills.
b. impaired judgment.
c. perceptual distortions.
d. depression.

Answer 135

ANS: D
The patient with depression can display difficulty with simple arithmetic calculations.

Question 136

Peripheral neuropathy is most likely to be manifested by
a. impaired memory.
b. impaired abstract reasoning.
c. impaired writing ability.
d. hallucinations.

Answer 136

ANS: C
Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe damage, or a cerebellar lesion.

Question 137

Recent memory may be tested by
a. asking the patient to name the past four presidents.
b. asking the patient to listen to and repeat a series of numbers.
c. showing the patient four items and asking him or her to list the items about 10 minutes later.
d. asking the patient about verifiable information, such as his or her mother’s maiden name.

Answer 137

ANS: C
Showing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory.

Question 138

Loss of immediate and recent memory with retention of remote memory suggests
a. attention-deficit/hyperactivity disorder (ADHD).
b. impaired judgment.
c. stupor.
d. dementia.

Answer 138

ANS: D
Dementia is the loss of both immediate and recent memory while retaining remote memories. ADHD is associated with recent and remote memory impairment. Impaired judgment is a thought process dysfunction. Stupor is impaired consciousness.

Question 139

You ask the patient to follow a series of short commands to assess
a. judgment.
b. attention span.
c. arithmetic calculations.
d. abstract reasoning

Answer 139

ANS: B
Asking the patient to follow a series of short commands will test attention span.

Question 140

Which observation would be most significant when assessing the condition of a patient who has judgment impairment?
a. Repeated failure to fulfill family obligations
b. Forgetting family members’ birth dates
c. Going to church three times a week
d. Planning for retirement in 20 years

Answer 140

ANS: A
Inadequately dealing with family and social affairs indicates impaired judgment, whereas the other choices do not.

Question 141

Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the assessment of
a. mood and feelings.
b. attention span.
c. thought process and content.
d. abstract reasoning.

Answer 141

ANS: C
Thought process and content are examined while observing the patient’s patterns of thinking, especially appropriateness of sequence, logic, coherence, and relevance to the topics discussed.

Question 142

Which type of hallucination is most commonly associated with alcohol withdrawal?
a. Olfactory
b. Visual
c. Auditory
d. Tactile

Answer 142

ANS: D
Tactile hallucinations are most commonly associated with alcohol withdrawal.

Question 143

Flight of ideas or loosening of associations is associated with
a. aphasia.
b. dysphonia.
c. multiple sclerosis.
d. psychiatric disorders.

Answer 143

ANS: D
Flight of ideas, loosening of associations, word salads, neologisms, clang associations, echolalia, and utterances of unusual sounds are all associated with psychiatric disorders.

Question 144

The Glasgow Coma Scale is used to
a. determine the cause of decreased consciousness.
b. diagnose disorders that alter level of consciousness.
c. quantify consciousness.
d. predict response to stimulant medications.

Answer 144

ANS: C
The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is used to quantify consciousness.

Question 145

Which condition is considered progressive rather than reversible?
a. Delirium
b. Dementia
c. Depression
d. Anxiety

Answer 145

ANS: B
Dementia is considered progressive and irreversible. Delirium has the potential for reversal. Depression and anxiety are reversible.

Question 146

A clinical syndrome of failing memory and impairment of other intellectual functions, usually related to obvious structural diseases of the brain, describes
a. delirium.
b. dementia.
c. depression.
d. anxiety.

Answer 146

ANS: B
Dementia results from a chronic progressive deterioration of the brain that results in failing memory and impairment of other intellectual functioning.

Question 147

Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD?
a. It occurs before 7 years of age.
b. It is usually related to mental retardation.
c. It is usually related to dementia.
d. It is manifested by prolonged periods of catatonic behavior.

Answer 147

ANS: A
ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or prolonged periods of catatonic behavior.

Question 148

An aversion to touch or being held, along with delayed or absent language development, is characteristic of
a. attention-deficit/hyperactivity disorder.
b. autism.
c. dementia.
d. mental retardation.

Answer 148

ANS: B
Autistic disorder involves a combination of behavioral traits (lack of awareness of others, aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of objects) and communication deficits (usually echolalia [parrot speech]).

Question 149

You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is apathetic and has disturbed thoughts and language patterns. The nurse recognizes this
behavior pattern as consistent with a diagnosis of
a. depression.
b. autistic disorder.
c. mania.
d. schizophrenia.

Answer 149

ANS: D
Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in language and speech, emotions and social withdrawal, and apathy. Depression and mania do not have the language or speech component. Autistic disorders are not psychotic disorders, and they usually begin before 3 years of age.

Question 150

While interviewing a patient, you ask him to explain the ―Lion and the Mouse‖ to assess
a. reading comprehension.
b. attention span.
c. mood and feeling.
d. reasoning skills.

Answer 150

ANS: D
Having the patient explain fables or metaphors determines abstract reasoning skills.

Question 151

The Mini-Mental State Examination (MMSE) should be administered for the patient who
a. gets lost in her neighborhood.
b. sleeps an excessive amount of time.
c. has repetitive ritualistic behaviors.
d. uses illegal hallucinogenic drugs.

Answer 151

A

The MMSE is a tool used to quantitatively estimate cognitive function or to serially document cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive impairment.

Question 152

Which clinical assessments test attention span? (Select all that apply.)
a. Spell WORLD backward.
b. Draw a clock.
c. Say the days of the week.
d. Do arithmetic calculations.
e. Explain ―a stitch in time saves nine.‖

Answer 152

ANS: A, C, D
Clinical assessments to test attention span include spell WORLD backward, say the days of the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining a ―stitch in time saves nine‖ tests abstract reasoning.

Question 153

Which are signs and symptoms of dementia? (Select all that apply.)
a. Aphasia
b. Apathy
c. Odd behaviors
d. Disintegration of personality
e. Lack of awareness of others

Answer 153

ANS: A, B, D
Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd behaviors and lack of awareness of others are characteristics of autism.

Question 154

Montgomery tubercles are most prominent in the breasts of
a. adult males.
b. patients with lung disease.
c. pregnant women.
d. pubertal females.

Answer 154

ANS: C
Montgomery tubercles undergo hypertrophy and become more prominent in the breasts of pregnant and lactating women.

Question 155

Most women with breast cancer
a. lack the BRCA1 or BRCA2 gene.
b. risk increases with aging.
c. have a aunt who had breast cancer.
d. continue to menstruate after age 52.

Answer 155

ANS: B
Risk of breast cancer increases with aging. Female patient’s with inherited BRCA1 or BRCA2 mutation have a 45% to 80% chance of developing breast cancer during their lifetime. Having a first-degree relative with breast cancer doubles the risk. Menopause after the age of 55 slightly increases the risk.

Question 156

A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?
a. Drinking three glasses of wine per week
b. Early menopause
c. Nulliparity
d. Late menarche

Answer 156

ANS: C
Nulliparity, or late age at the birth of the first child (after 30 years old), is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily

Question 157

If your patient has nipple discharge, you will most likely need a
a. Vacutainer tube.
b. glass slide and fixative.
c. specimen jar with formaldehyde.
d. tape strip to test pH.

Answer 157

B

A glass slide and fixative are used for microscopic examination of the discharge to identify its cellular makeup.

Question 158

While examining a 30-year-old woman, you note that one breast is slightly larger than the other. In response to this finding, you should
a. note the finding in the patient’s record.
b. ask the patient if she has ever had breast cancer.
c. tell the patient to get a mammogram as soon as possible.
d. tell the patient to get a mammary sonogram as soon as possible.

Answer 158

A

Often one breast is slightly larger than the other. This is a normal variation and no further intervention is required.

Question 159

A 23-year-old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your response to this finding is to
a. instruct her that this is a side effect of birth control injection therapy.
b. suggest pregnancy testing.
c. question her use of tanning beds.
d. schedule an appointment with a surgeon.

Answer 159

B

In light-skinned women, pregnancy produces enlarged breasts with a darker areola. Neither hormonal injections nor the use of tanning beds will change the color of the areola as does pregnancy. Surgical consultation is not necessary.

Question 160

In patients with breast cancer, peau d’orange skin is often first evident
a. in the axilla.
b. in the upper inner quadrant.
c. on or around the nipple.
d. at the inframammary ridge.

Answer 160

ANS: C
The areola is the most common initial site for visualization of peau d’orange skin.

Question 161

A firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40-year-old patient’s breast. You should
a. ask the patient if she has a history of breast cancer.
b. refer the patient to a surgeon.
c. ask the patient to have a mammogram as soon as possible.
d. record the finding in the patient’s record.

Answer 161

D
The inframammary ridge thickens and can be felt more easily with age. It is an expected, normal finding, without indications for further action.

Question 162

When examining axillary lymph nodes, the patient’s arm is
a. raised fully above the head.
b. extended at the side.
c. flexed at the elbow.
d. crossed over the chest.

Answer 162

ANS: C
To examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.

Question 163

Male gynecomastia associated with illicit or prescription drug use can be expected to
a. lessen when the body becomes accustomed to the drug.
b. resolve after the drug is discontinued.
c. leave permanent breast enlargement when the drug is discontinued.
d. cause purulent drainage if left untreated.

Answer 163

ANS: B
Gynecomastia associated with illicit or prescription drug use (e.g., antihypertensive drugs, estrogens, steroids) usually resolves after the offending drug is discontinued and does not require further intervention.

Question 164

A nursing mother complains that her breasts are tender. You assess hard, shiny, and erythemic breasts bilaterally. You should advise the patient to
a. massage gently and continue nursing.
b. apply warm compresses and stop nursing.
c. monitor her temperature and restrict fluids.
d. sleep wearing a bra and wash her breasts with antibacterial soap.

Answer 164

ANS: A
This patient has mastitis. The aim of treatment is to promote breast drainage. You should not advise the patient to apply warm compresses and stop nursing. Applying warm compresses
will not encourage breast milk flow, and stopping nursing will increase the risk of a breast infection turning into a breast abscess. Monitoring her temperature and restricting fluids do not encourage breast milk flow. Sleeping with a bra and washing the breasts with antibacterial soap do not encourage breast milk flow. Only mild soaps are advised; harsh soaps can dry and crack the nipple and compound infection.

Question 165

You are conducting a clinical breast examination for your 30-year-old patient. Her breasts are symmetric, with bilateral, multiple tender masses that are freely movable and with well-defined borders. You recognize that these symptoms and assessment findings are consistent with
a. fibroadenoma.
b. Paget disease.
c. cancer.
d. fibrocystic changes.

Answer 165

D

Fibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. A fibroadenoma is usually nontender. Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Cancer is usually nontender.

Question 166

Your patient is a nursing mother who asks you to look at a mole she has under her left breast at the inframammary fold. The mole is nontender and soft and has grown in size since she started nursing. There are no other changes to the mole. This mole probably represents an undiagnosed
a. Montgomery tubercle.
b. case of Paget disease.
c. supernumerary nipple.
d. fat necrosis.

Answer 166

ANS: C
Supernumerary nipples usually resemble moles and occur, as in this example, along the milk line. Those that have glandular tissue may enlarge under hormonal influences. They may not be recognized as extra nipples in infants because they are usually small and not well formed.

Question 167

When conducting a clinical breast examination, the examiner should
a. forgo the examination if the patient has had a recent mammogram.
b. keep the patient’s breasts completely covered to respect modesty.
c. dim the lights to minimize anxiety.
d. inspect both breasts simultaneously.

Answer 167

ANS: D
Simultaneous observation of both breasts is essential to detect differences between breast size, symmetry, contour, and skin color.

Question 168

Mrs. Weber is a 65-year-old patient who has presented at the clinic with a complaint of a tender breast mass that she discovered during breast self-examination. You have completed a physical examination on Mrs. Weber and have palpated a mass of the right breast in the lower outer quadrant. When providing patient education to Mrs. Weber regarding the breast mass, you will explain that the characteristics of a cancerous mass would be which of the following?
(Select all that apply.)
a. Immobile and firm
b. Pain on palpation
c. Irregular border edges
d. Mobile and rubbery
e. Nontender

Answer 168

ANS: A, C, E
Characteristics of cancerous breast masses are irregular or stellate, hard, fixed, nontender, and poorly delineated.

Question 169

Ms. Lawson is a 41-year-old patient who presents for a routine annual examination. During her breast examination, you are also completing a lymphatic examination. Which of the following lymph nodes are examined during a breast examination? (Select all that apply.)
a. Supraclavicular
b. Lateral axillary nodes
c. Anterior cervical nodes
d. Anterior axillary nodes
e. Posterior cervical nodes

Answer 169

ANS: A, B, D
During a routine breast examination it is common practice to examine lymph nodes. When enlarged and fixed, lymph nodes can indicate the presence of cancer. Common lymph nodes included in this examination are the supraclavicular, lateral axillary, and posterior cervical lymph nodes.

Question 170

1. Posteriorly, the labia minora meet as two ridges that fuse to form the
   a. fourchette.
   b. vulva.
   c. clitoris.
   d. perineum.

Answer 170

ANS: A
The labia minora join posteriorly to form the fourchette.

Question 171

A cervical polyp usually appears as a
a. grainy area at the ectocervical junction.
b. bright red, soft protrusion from the endocervical canal.
c. transverse or stellate scar.
d. hard granular surface at or near the os.

Answer 171

ANS: B
Cervical polyps are bright red, soft, and fragile. They usually protrude from the endocervical canal.

Question 172

Which structure is located posteriorly on each side of the vaginal orifice?
a. Skene glands
b. Clitoris
c. Perineum
d. Bartholin glands

Answer 172

D
Bartholin glands are found posteriorly on each side of the vaginal orifice.

Question 173

During sexual excitement, how is the vaginal introitus lubricated?
a. The Bartholin glands secrete mucus.
b. The clitoris produces moisture.
c. The Skene glands drain fluid.
d. The urethral surfaces secrete water.

Answer 173

ANS: A
The Bartholin glands secrete mucus into the introitus for lubrication during sexual stimulation.

Question 174

The vaginal mucosa of a woman of childbearing years should appear
a. smooth and pink.
b. moist and excoriated.
c. dry and papular.
d. transversely rugated.

Answer 174

D

Between puberty and menopause, the vagina is transversely rugated; after menopause, it loses its rugation.

Question 175

The adnexa of the uterus are composed of the
a. corpus and cervix.
b. fallopian tubes and ovaries.
c. uterosacral and broad ligaments.
d. vagina and fundus.

Answer 175

ANS: B
The fallopian tubes and ovaries are collectively referred to as the adnexa of the uterus.

Question 176

A bluish color to the cervix during pregnancy is called (the)
a. McDonald sign.
b. Spinnbarkeit.
c. Goodell sign.
d. Chadwick sign.

Answer 176

D

The Chadwick sign is a bluish color to the cervix during pregnancy. The Goodell sign is an increase in vascularity and softening of the cervix. Spinnbarkeit refers to the quality of elastic mucus during mittelschmerz, and the McDonald sign is fundal flexing on the cervix.

Question 177

The pelvic joint that separates most appreciably during late pregnancy is the
a. sacroiliac.
b. symphysis.
c. sacrococcygeal.
d. iliofemoral.

Answer 177

B
Of the four pelvic joints, the one that moves appreciably later in pregnancy is the symphysis pubis.

Question 178

Pregnancy-related cervical changes include
a. flattening and lengthening.
b. thinning and reddening.
c. hardening and pallor.
d. softening and bluish coloring.

Answer 178

D

During pregnancy, the cervix softens (Goodell sign) and then appears bluish (Chadwick sign).

Question 179

Mrs. Robinson, a 49-year-old patient, presents to the office complaining of missing her menstrual period. She asks about menopause. You explain to her that the conventional definition of menopause is
a. the first day of the last menstrual period.
b. 1 year with no menses.
c. the last day of the last menstrual period.
d. the cessation of ovulation.

Answer 179

ANS: B
Menopause is defined as 1 year without menses.

Question 180

Which systemic feature is related to the effects of menopause?
a. Increased abdominal fat distribution
b. Decreased LDL levels
c. Cold intolerance
d. Decreased cholesterol levels

Answer 180

A

Systemic effects of menopause include increased intraabdominal body fat, increased LDL and cholesterol levels, and hot flashes.

Question 181

Ms. A, age 32, states that she has a recent history of itchy vaginal discharge. Ms. A has never been pregnant. Her partner uses condoms and she uses spermicide for birth control. Which of
the following data are most relevant to Ms. A’s problem?
a. Bowel habits
b. Douching routines
c. Menstrual flow
d. Nutritional factors

Answer 181

ANS: B
When obtaining history of present illness information for the woman with a vaginal discharge, you should inquire about her douching habits. Douching is not only medically unnecessary but it can also mask, or even worsen, conditions such as bacterial vaginosis or a yeast infection.

Question 182

Which risk factor is associated with cervical cancer?
a. Endometriosis
b. Low parity
c. Multiple sex partners
d. Obesity

Answer 182

ANS: C
Cervical cancer is associated with certain HPV strains. Multiple sex partners increase the risk of HPV infection.

Question 183

The risk of ovarian cancer is increased by
a. the use of oral contraceptives.
b. cigarette smoking.
c. age between 35 and 50 years.
d. early age at first intercourse.

Answer 183

ANS: A
There is a relationship between the number of menstrual cycles and risk of ovarian cancer. Early menarche and menopause after 50 years of age increase the risk.

Question 184

The form of gynecologic cancer that is increased in obese women is
a. vaginal.
b. cervical.
c. ovarian.
d. endometrial.

Answer 184

D

Obesity increases a woman’s chance of developing endometrial cancer by twofold to fivefold.

Question 185

The mother of an 8-year-old child reports that she has recently noticed a discharge stain on her daughter’s underwear. Both the mother and daughter appear nervous and concerned. You would need to ask questions to assess the child’s
a. drug ingestion.
b. fluid intake.
c. risk for sexual abuse.
d. hormone responsiveness.

Answer 185

ANS: C
Vaginal discharge in a child could be related to a chemical irritation from soaps, lotions, or powders or to urinary tract infections. Concerned parents and children should be assessed for the risk of sexual abuse.

Question 186

The female patient should ideally be in which position for the pelvic examination?
a. Fowler
b. Prone
c. Lateral supine
d. Lithotomy

Answer 186

ANS: D
Ideally, the woman should be in a lithotomy position for a pelvic examination.

Question 187

When you plan to obtain cytologic studies, speculum introduction may be facilitated by
a. lubrication with gel.
b. lubrication with warm water.
c. use of a plastic speculum.
d. opening the blades completely.

Answer 187

ANS: B
It is generally thought that gel lubrication may interfere with cytologic studies; therefore, most clinicians lubricate the speculum with warm water. Although gel lubrication would facilitate speculum introduction, the gel could interfere with cytologic studies. Use of a plastic speculum or opening the blades completely would not facilitate speculum introduction.

Question 188

Which one of the following is a proper technique for the use of a speculum during a vaginal examination?
a. Allow the labia to spread, and insert the speculum slightly open.
b. Insert one finger, and insert the opened speculum.
c. Press the introitus downward, and insert the closed speculum obliquely.
d. Spread the labia, and insert the closed speculum horizontally.

Answer 188

C
Use two fingers of one hand to push the introitus down to relax the pubococcygeal muscle. Then hold the closed speculum with the other hand, and insert the speculum past your fingers obliquely.

Question 189

When collecting specimens, which sample should be obtained first?
a. Chlamydial swab
b. Gonococcal culture
c. Pap smear
d. Wet mount

Answer 189

ANS: C
A Pap smear is obtained first and then other samples to test for gonorrhea, chlamydia, Trichomonas, bacterial vaginosis, or candidiasis are obtained. Pap smear results are affected by the presence of blood, and vaginal infections result in more friable tissues; therefore, the Pap smear should be obtained first.

Question 190

The presence of a fishy odor after adding potassium hydroxide to a wet mount slide containing vaginal mucus suggests
a. bacterial vaginosis.
b. yeast infection.
c. chlamydial infection.
d. pregnancy.

Answer 190

ANS: A
A positive whiff test suggests bacterial vaginosis.

Question 191

The assessment of which structure is not part of the bimanual examination?
a. Cervix
b. Bladder
c. Uterus
d. Ovaries

Answer 191

ANS: B
The bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries

Question 192

Mrs. Reilly brings her 6-year-old daughter in with complaints of a foul vaginal discharge noted in her underpants. The most common cause of a foul vaginal discharge in children is a(n)
a. accident.
b. foreign body.
c. infection.
d. ruptured hymen.

Answer 192

B

A foul vaginal discharge in the preschool-age girl is most likely indicative of the presence of a foreign body.

Question 193

A 3-year-old girl is being seen because of a foul vaginal odor. To inspect the vaginal vault, you should first
a. insert a pediatric vaginal speculum.
b. place the child prone and in the fetal position.
c. insert a cotton-tipped applicator and press down.
d. pull the labia forward and slightly to the side.

Answer 193

D

Applying anterior labial traction allows the hymenal opening and the interior of the vagina to become visible, almost to the cervix. The presence of a foreign body will be visible with this maneuver.

Question 194

A mother brings her 8-year-old daughter to the clinic because the child says it hurts to urinate after she fell while riding her bicycle. On inspection, you find posterior vulvar and gross perineum bruising. These findings are consistent with
a. chronic masturbation.
b. congenital defects.
c. acute urinary tract infection.
d. sexual abuse.

Answer 194

ANS: D
A straddle injury from a bicycle seat is usually evident over the symphysis pubis; injuries resulting from sexual molestation are generally more posterior and may involve the perineum grossly.

Question 195

What accommodations should be used for the position of a hearing-impaired woman for a pelvic examination?
a. The patient should assume the M or V position.
b. Her legs should be farther apart.
c. The head of the table should be elevated.
d. The lithotomy position with obstetric stirrups should be used.

Answer 195

C

The woman with a hearing impairment will need to see the clinician and/or an interpreter during the examination; therefore, her head should be elevated.

Question 196

Asking the woman to close the introitus during a pelvic examination is a test for
a. endometriosis.
b. rectocele.
c. cervical polyps.
d. sphincter tone.

Answer 196

ANS: D
The test for sphincter tone is to have the woman squeeze the vaginal opening around your finger. A rectocele can be seen as a bulge on the posterior wall. Endometriosis is suggested with tender nodules along the uterosacral ligaments. Cervical polyps can be inspected without squeezing.

Question 197

Itchy, painful, small red vesicles are typical of
a. condyloma acuminatum.
b. condyloma latum.
c. herpes simplex lesions.
d. syphilitic chancre

Answer 197

ANS: C
Herpetic lesions are painful, itchy red vesicles; condyloma acuminatum are warty lesions on the genitalia; condyloma latum are secondary syphilis lesions that appear as flat, round, or oval papules covered by a gray exudate; and a chancre is a painless ulcer.

Question 198

A young, sexually active woman comes to the urgent care clinic complaining of suprapubic abdominal pain. She is afebrile with rebound tenderness to the right side. There is no dysuria
and no vaginal discharge or odor. A pelvic examination is done. She has pain with cervical motion, and you palpate a painful mass over the left adnexal area. Your prioritized action is to
a. swab for gonococcal infection and then dip her urine.
b. obtain a surgical consult immediately.
c. remove the foreign body.
d. dip her urine and then swab for Chlamydia.

Answer 198

B

The presenting symptoms of a tubal pregnancy are a surgical emergency. The only diagnostic test should be a pregnancy test.

Question 199

When carrying out a mental status exam on a non-English speaking patient, it is important to have a(n):
A. Patient’s family member, who is bilingual, interpret for the patient
B. Objective interpreter ask the questions for the patient
C. Friend of the patient interpret the questions for the patient
D. Any of the above is acceptable

Answer 199

ANS: B
Ask the family or significant other whether the patient’s behavior patterns have changed. If the patient does not speak or write English, have an interpreter available during the examination. It is important to have an objective interpreter ask the patient translated questions. The patient may not be truthful or forthcoming if he/she knows the interpreter. A friend or relative may slant the mental status exam questions or influence the patient regarding the answers. A good screening tool for use in the outpatient setting is the Mini-Mental Status Exam, described in detail in Chapter 20.

Question 200

**

When examining the carotid arteries, the clinician should:
A. Ask the patient to hold his/her breath while auscultating the carotid arteries
B. Use the bell of the stethoscope to listen over the carotid arteries
C. Palpate one carotid artery at a time
D. All of the above

Answer 200

ANS: D
Auscultation of the carotid arteries is an important portion of the neurological examination, particularly for elderly patients. The patient should be asked to hold his or her breath during auscultation. The bell of the stethoscope is used to auscultate for bruits. One carotid artery at a time is palpated. A bruit in the carotid artery may be an indicator of potential stroke or carotid artery stenosis and should be followed by further tests, such as carotid duplex and carotid ultrasound.

Question 201

**

A 44-year-old male presents to the emergency room with the “worst headache of his life.” He is holding his head and appears severely distressed. This is a patient symptom that should prompt a
clinician to look for signs of a:
A. Migraine headache
B. Subdural hematoma
C. Subarachnoid haemorrhage
D. Brain tumor

Answer 201

ANS: C
The pain associated with subarachnoid hemorrhage is generally described as severe and acute in onset. The onset is often described as a thunderbolt or lightning. The severity is described as “the
worst headache of my life.” It is generally made worse by lying down. There is often associated nausea and/or vomiting and possible rapid deterioration in neurological function. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The pain will gradually worsen over days to weeks. Headache due to a brain tumor is difficult to diagnose. A headache that awakens a patient from sleep is often a brain tumor.
Headache with neurological deficits should also raise suspicion of brain tumor.

Question 202

An 8-year-old child presents to the emergency room with a severe unilateral, throbbing headache. She is lying on the gurney with her eyes closed while holding her head. She denies ever having this
kind of headache in the past. She complains of sensitivity to light and noise. An appropriate history question to ask the parent would be:
A. What do you think triggered the headache?
B. Have you had a fever?
C. Does anyone in your family suffer from migraine headache?
D. B and C

Answer 202

D

A migraine is one of the most common types of vascular headache and accounts for a significant percentage of clinic and emergency department visits each year. They occur more frequently in women and the majority of patients report a family history of migraine. Onset of migraine is uncommon after the age of 40 years. They generally do not occur daily and are often associated with the menstrual cycle. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is
often aggravated by movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia.

Question 203

A 41-year-old male patient presents to the emergency department complaining of severe headache pain. He describes it as a piercing, right sided head pain that occurred earlier in day for about 1
hour and now is recurring. You note lacrimation and rhinorrhea on the right side of the face. Which of the following types of headache is the patient describing?
A. Sinusitis
B. Cluster headache
C. Migraine
D. Subdural hematoma

Answer 203

ANS: B
Cluster headaches have rapid crescendo patterns, peaking in approximately 10 to 15 minutes and often lasting 30 to 60 minutes per episode (rarely lasting over 2 hours each). Attacks occur as
frequently as two to three times per day. The pain is generally in the area of the trigeminal nerve and is described as unilateral, penetrating, sharp, excruciating, and unrelenting in nature. There
may be associated unilateral lacrimation, nasal congestion or rhinorrhea, pallor, flushing, conjunctival redness, ptosis—all on the same side as the pain.

Question 204

An 85-year-old female patient arrives by ambulance to the emergency department accompanied by her husband. He reports that his wife had been ill with pneumonia and, 2 days ago, went to the family physician who prescribed azithromycin twice a day. The husband reports that he is making sure she gets the medicine. His wife has been staying in bed and resting. She awoke from sleep last
night and was extremely agitated, left the house, and was walking outside. She did not recognize her husband and wanted to call the police. Which of the following is an appropriate question for the history?
A. Does your wife have dementia or frequent episodes of confusion?
B. Has your wife been running a fever?
C. Is your wife allergic to any medication?
D. Has your wife ever had a mental status exam?

Answer 204

ANS: A
Delirium can be observed in both elderly and younger patients and is generally defined as an acute confusional state, affecting all aspects of cognition and mentation. The signs and symptoms of delirium generally have a more acute or rapidly progressive onset as opposed to the slow, gradual decline noted in the organic dementias. The acute mental status change is often associated with other signs or symptoms—such as hallucinations, illusions, incoherent speech, and constant aimless activity—that help to narrow the differential diagnosis. Electrolyte disturbances, infection, and polypharmacy are frequent causes of delirium in the elderly.

Question 205

A 60-year-old female complains of several episodes of dizziness and nausea that started this morning. She denies trauma, falling, or loss of consciousness. She has a 5-year history of hypertension and takes a beta blocker daily. On physical examination, there are no neurologic deficits or any abnormal findings and ECG is normal. Which of the following tests should be performed?
A. Test the patient for Kernig’s sign
B. Test the patient for Brudzinski sign
C. Perform the Hallpike maneuver
D. Assess for Babinski’s sign

Answer 205

ANS: C
Characterized by sudden-onset dizziness lasting less than 30 seconds and following a head position change, benign positional vertigo (cupulolithiasis) may be accompanied by nystagmus. It usually
subsides but may recur at any time. In addition to the history, a provocative test for positional nystagmus can be performed (Hallpike maneuver), although it is not always positive. The provocative test involves moving the patient quickly from a sitting position to a lying position with the head turned to the side and the head dependent over the side of the examination table. After a few seconds, vertigo and nystagmus occur. This response fatigues with immediate repetition of the test.

Question 206

ménière’s ’disease presents with the following triad of symptoms:
A. Vertigo, nystagmus, hearing loss
B. Vertigo, tinnitus, hearing loss
C. Vertigo, syncope, hearing loss
D. None of the above

Answer 206

B

The exact cause of Ménière’s disease is unknown. However, the symptoms are associated with increased fluid and pressure in the labyrinth. Ménière’s disease commonly involves a triad of symptoms: severe vertigo, tinnitus, and hearing loss. The vertigo is transient but recurrent. The tinnitus and hearing loss may also be intermittent and/or recurrent but often become worse over time. A sensation of ear fullness may precede an episode. During the episode, vertigo is often debilitating and is associated with nausea and vomiting. The tinnitus and hearing loss are usually unilateral.

Question 207

A 77-year-old male is brought into the emergency department accompanied by his daughter. She reports that her father has been complaining of right-handed weakness for 2 to 3 hours and that she
has noticed him slurring his speech. On physical examination, the right hand grip strength is 1/ 5 compared to the left hand grip of 5/5. A facial droop is noted on the right side of the face. Cranial nerve dysfunction is noted in the right-sided CNVII, CN V, CNIX, CNX, CNXI, and CNXII. The clinician should request the following diagnostic test immediately:
A. MRI of head
B. CT of the head
C. Lumbar puncture
D. ECG

Answer 207

ANS: B
Strokes are divided into two main categories: thrombotic and hemorrhagic; however, the two can be difficult to differentiate using clinical signs and symptoms. The onset is usually an abrupt
altered level of consciousness accompanied by hemiparesis or hemiplegia. Patients may experience confusion, memory impairment, and aphasia. Signs and symptoms vary with the location and
severity of the stroke. Mentation and cognitive changes may be temporary or permanent depending on the extent of injury. Communication alterations stemming from fluent or receptive aphasia may be mistaken as dementia. A CT scan, without contrast, is the preferred imaging study in early stroke because hemorrhage may be difficult to determine on an MRI in the first 48 hours. In
studies of ischemic stroke patients, researchers have shown the reversibility of abnormalities on CT or MRI through the use of thrombolytic therapy within a 3-hour window.

Question 208

A female patient presents to the clinic with complaints of a severe, throbbing, unilateral headache. She complains of seeing flashes of light prior to the headache. She complains of sound and light
sensitivity as well as nausea. The clinician should recognize these as symptoms of:
A. Epilepsy with aura
B. Cluster headache
C. Migraine headache
D. Normal pressure hydrocephalus

Answer 208

ANS: C
Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or
pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia. There may be tenderness to palpation of the temporal arteries. Auras, if experienced, may include blurred vision and scotoma and/or other
prodromal symptoms, such as anorexia, irritability, restlessness, or paresthesias lasting from 30 minutes to 3 hours before the onset of migraine pain.

Question 209

On a history and physical examination of a 34-year-old patient, during the review of systems, he reports occasional episodes of headache. He describes the headache pain as a “band is around his
head” and tightness in the neck and shoulders. The clinician should recognize these symptoms as:
A. Tension headache
B. Cluster headache
C. Sinusitis
D. Migraine headache

Answer 209

ANS: A
Typical symptoms of tension headache include mild to moderate nonthrobbing pressure, or squeezing pain, that can occur anywhere in the head or neck. The pain often starts slowly as a dull
and aching discomfort that progresses to holocranial pain and pressure. The pain can recur intermittently, lasting from minutes to hours, usually remitting with rest or removal of the stressful
trigger. There is usually no associated nausea and vomiting. Although patients may report photophobia and phonophobia, it is less severe than those associated with migraines. Tension headaches are not aggravated by movement or activity. The neck muscles are often tight to palpation.

Question 210

An 81-year-old patient with heart failure comes into the emergency room accompanied by his daughter. The daughter reports that her father “banged his head” as he was getting out of the car 4
days ago. He did not complain of headache pain, so she did not obtain medical advice. She reports that she noticed a mild facial droop, slurring of speech, and gait disturbance in her father today.
She reports that her father takes Coumadin, digoxin, and an ACE inhibitor. On physical examination, there is decreased right hand grip 2/5 strength and decreased right quadriceps strength 2/ 5 compared to the left side 5/5. CT scan shows an intracranial bleed. Which of the following is the most probable diagnosis?
A. Subarachnoid hemorrhage
B. Epidural hematoma
C. Subdural hematoma
D. Intracerebral hemorrhage

Answer 210

C

Subdural hematomas can be either acute or chronic. Acute subdural hematomas are usually associated with an acute head injury and can cause a range of symptoms, including headache and loss of consciousness. A chronic subdural hematoma in the elderly population may enlarge significantly before the patient begins to notice head pain. The headache associated with subdural
hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The physical findings vary depending on the severity of the trauma but may include progressive neurological deterioration, which may advance to include coma. The elderly patient with head trauma and anticoagulants should raise suspicion of subdural hematoma.

Question 211

Which of the following microorganisms is a common cause of meningitis?
A. Enterococcus
B. Haemophilus influenza
C. Influenza virus
D. Chlamydia

Answer 211

ANS: B
Meningitis involves inflammatory central nervous system (CNS) disease generally caused by either viral or bacterial infection. The etiology of meningitis includes community-acquired, post-
traumatic, aseptic, carcinomatous, or transferred from another bodily source. The most common organisms belong to such genera as Streptococcus, Neisseria (meningitides), Haemophilus
(influenzae), Listeria, Staphylococcus (aureus) as well as gram-negative bacilli and gram-positive cocci. Meningitis can affect persons of all ages, including children.

Question 212

A 43-year-old male presents to the emergency department in a stupor accompanied by his wife. She called the ambulance because her husband was difficult to awaken this morning. She reports
that for the last 3 days, he has had fever and upper respiratory infection. Yesterday he had a headache. He has had no medical treatment. On physical examination, the patient demonstrates
103 fever, sluggish pupil response, and nuchal rigidity. Which of the following should the clinician attempt to elicit next?
A. Hallpike maneuver
B. Kernig’s sign
C. Epley maneuver
D. Babinski’s sign

Answer 212

ANS: B
In meningitis fever, photophobia, phonophobia, nausea, vomiting, and nuchal rigidity occur. Patients can rapidly decline to delirium, seizures, and, if untreated, coma. On neurological examination, the patient may be lethargic and febrile and have altered mentation along with nuchal rigidity and/or guarding, contracted and sluggish pupils, and a generally “toxic” appearance. Brudzinski’s and Kernig’s signs are helpful in assessing potential meningeal conditions (see Box 15.6). Delirium or acute confusion necessitates immediate transfer to an emergency department for treatment, as the patient can rapidly deteriorate to coma.

Question 213

Spina bifida is a disorder that is associated with a headache syndrome caused by:
A. Chiari malformation
B. Normal pressure hydrocephalus
C. Meningioma
D. Temporal arteritis

Answer 213

ANS: A
Chiari malformations are brainstem malformations. There are three types of Chiari malfunction. Chiari type I is most often associated with occipital headaches and generally seen in the adult population but can be diagnosed at any age. Type I symptoms may be very vague and transient, and it is often misdiagnosed as another neurological disease. Type II is generally diagnosed in infants or children and is associated with myelomeningocele or other open neural tube defects or in adults with undiagnosed spina bifida occulta or tethered cord. Type III malformation is rare, diagnosed in infants, associated with cervical myelomeningocele or pseudomeningocele, and carries a very poor prognosis.

Question 214

Which of the following is a common trigger of migraine headache?
A. Missed meals
B. Menses
C. Alcohol
D. All of the above

Answer 214

ANS: D
Common Migraine Triggers:
* Stress
* Caffeine
* Altered sleep
* Specific foods, missed meals
* Menses
* Alcohol
* Hormone supplements

Question 215

Your patient with a cervical herniated disc presents with a weakened biceps reflex. The biceps reflex is a test of the following spinal nerves:
A. C3 to C4
B. C4 to C5
C. C5 to C6
D. C7 to T1

Answer 215

ANS: C
Biceps: C5, C6
Brachioradialis: C5, C6
Triceps: C6, C7
Patellar: L3, L4
Achilles: S1

Question 216

In order to test abstract thought on the mental status exam, the clinician can ask:
A. Count by serial 7’s backward
B. Spell the word “world” backward
C. Draw a clock that shows 2:30
D. How is your brother-in-law related to you?

Answer 216

ANS: D

Orientation—The patient should normally be aware of person, date, and place. Ask the patient
his or her full name, current date, and place in which the examination is being done.
Memory—Recent and remote memory should normally be intact. Ask what the patient had for
lunch yesterday (recent) and where he or she graduated from elementary school (remote).
Fund of knowledge (take into consideration the patient’s level of education)—Ask about any
recent news events or significant upcoming or past holiday.
Attention span—Ability to focus on the interviewer without being easily distracted. Ask the
patient to repeat a short list of numbers (e.g., 7-8-9-3-0-2). Inability to repeat six or more
numbers indicates attention deficit.
Concentration—Ability to concentrate on a question or task. Ask the patient to remember three
unrelated words (red, happy, and five) and then to repeat them in 5 minutes, or ask the patient
to count backward from 100 by 7.
Language—Use and understanding of language. Ask the patient to write a full sentence or to
spell world backward. Distinguish between dysphonias and dysarthrias, as these indicate
mechanical disturbances often due to CN dysfunction. Assess fluency of speech by asking the
patient to repeat “no ifs, ands, or buts about it.” Dysfluent speech is Broca’s aphasia. Speech
that is devoid of content indicates Wernicke’s aphasia.
Abstract thoughts—Ask the patient to interpret a common proverb (e.g., a stitch in time saves
nine), or ask the patient to answer an abstract question (e.g., “Is my sister’s brother a man or a
woman?”).

Question 217

A 56-year-old woman brings her 78-year-old father to the emergency room. The patient complains that sometimes he can’t think straight. His daughter reports that her father has been “tripping over his own feet” and has become incontinent of urine in the last few days. The patient’s medications include an ACE inhibitor and beta blocker. On physical examination, vital signs are within normal limits, heart and lungs show no abnormalities, cranial nerves are intact, and sensation and muscle strength are normal. A mental status exam is normal. Imbalanced gait and a positive Romberg test
are apparent. Which of the following are possible disorders?
A. Cerebellar dysfunction
B. Normal pressure hydrocephalus
C. Early dementia
D. A & B

Answer 217

D

Normal pressure hydrocephalus is not fully understood. It is seen primarily in persons over 60 years of age and involves enlargement of the ventricles, often without increased CSF pressure; intraventricular pressures may be high or normal. One of the theorized causes includes intermittent pressure increases. It is slightly more common in men than in women. The patient often first
notices some degree of gait disorder, followed by the onset of a “clouding” of thought processes, which gradually progress. The typical picture is a patient who has a triad of gait disturbance,
altered thought processes, and urinary incontinence. Strength and sensation are usually within normal limits. However, focal neurological findings are present and include increased deep tendon
reflexes, the inability to tandem walk, positive Babinski, and/or positive Romberg.

Question 218

A 65-year-old woman is accompanied by her daughter for a physical examination. She has mild heart failure and takes digitalis and an ACE inhibitor. As you examine the patient, you note flat affect, hand tremor, and slowed movements. The tremor is worsened at rest. There are no neurologic deficits. Hand grip, sensation of face and extremities, and lower extremity muscle strength are within normal limits and bilaterally equal. DTRs are equal bilaterally. CN II to XII are
intact. The mental status exam is normal. These are key signs of:
A. Chiari malformation
B. Normal pressure hydrocephalus
C. Parkinson’s disease
D. Drug toxicity

Answer 218

ANS: C
Parkinson’s disease occurs with approximately equal sex distribution, and usually begins between 45 and 65 years of age. Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. There is a flattened affect and blank stare. There is bradykinesia of gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal. Although
Alzheimer’s disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer’s.

Question 219

A 65-year-old male complains of a headache that feels “like a knife is cutting into his head.” He also reports feeling right-sided scalp and facial pain and “seeing double” at times. He has a history of hypertension and hyperlipidemia. His medications include beta blocker, statin drug, and an ACE inhibitor. On physical examination, you note palpable tenderness over the right side of the forehead. There are no neurological deficits. Vision is 20/20 with lenses. No weakness of extremities. CN II to XII are intact. The history corresponds to which of the following disorders?
A. Drug toxicity
B. Giant cell arteritis
C. Cluster headache
D. Migraine headache

Answer 219

ANS: B
Temporal arteritis is also referred to as giant cell arteritis or cranial arteritis. It is characterized by chronic inflammation and the presence of giant cells in large arteries, usually the temporal artery,
but can occur in the cranial arteries, the aorta, and coronary and peripheral arteries. It affects the arteries containing elastic tissue, resulting in narrowing and eventual occlusion of the lumen. It
occurs more among persons over 50 years of age and is slightly more common in females than in males. The cause is unknown, but there seems to be a genetic predisposition. If left untreated,
arteritis can rapidly lead to blindness that is often irreversible. The most common chief complaint is head pain that is lancinating, sharp, or “ice pick” in nature. Patients often complain of visual
changes, including amaurosis, diplopia, blurred vision, visual field cuts, eye pain, periorbital edema, and intermittent unilateral blindness. Other common presenting symptoms include scalp
and/or jaw tenderness, facial pain, and tenderness to palpation over the affected artery. The pain is generally hemicranial but can be bilateral or diffuse. There may be eye pain, which is usually
bilateral; periorbital edema may be present. Other potential associated symptoms include an intermittent fever (generally low grade), nausea, and/or weight loss.

Question 220

In dementia, which of the following cognitive functions is most commonly lost first?
A. Recognizing persons
B. Knowing the place
C. Estimating the time
D. Long-term memory

Answer 220

ANS: C
When evaluating a patient’s mental status, assess orientation by asking the patient to recite his or her full name, current location/place (clinic, hospital, home, etc.), and the date (day of the week, month, or year). Knowledge of time is generally impaired first, followed by place. The inability to recite or recognize one’s name implies a significant deficit in mental status.

Question 221

A 78-year-old female comes to the clinic for a physical examination. She is accompanied by her daughter and looks to her daughter to answer questions during the interview. She was diagnosed with early Alzheimer’s disease 2 years ago, and her daughter would like her current mental status evaluated. You ask the patient her daughter’s name, and she answers correctly. You ask her the date and time,
and she answers incorrectly. You hand the patient a pencil and ask her if she knows what it is. She replies with, “Is it a stick?” You ask the patient to put on a patient gown, and she does not know how to perform the task. These are examples of disorientation to time and:
A. Agnosia and apraxia
B. Anomia and aphasia
C. Agnosia and ataxia
D. Apathy and ataxia

Answer 221

ANS: A
Most organic dementias develop over months to years. There are typically no physical motor or sensory alterations until the condition is advanced. Memory impairment is the predominant symptom. There may be impairment in another area of cognitive functioning, such as with aphasia (producing language as well as understanding it), agnosia (perceptual impairment of environment), apraxia (inability to perform complex motor acts), and impairment in executive functioning (inability to plan, organize, sequence, and think abstractly). Ataxia is not a symptom of dementia— it is a problem with gait usually due to cerebellar dysfunction.

Question 222

You are an emergency room clinician that assisted with CPR on a 20-year-old trauma patient. The CPR was unsuccessful, the patient expired, and you need to explain this to the family in the waiting room. Upon telling the mother about the death of her son, she becomes dizzy and faints. What is the most likely cause for the woman fainting?
A. Cardiogenic shock
B. Vasovagal response
C. Syncope due to hypoxia
D. Dizziness and vertigo

Answer 222

ANS: B
Neurocardiogenic syncope, also called vasovagal syncope, is a common cause of dizziness and fainting. It is due to a sudden decrease in blood pressure and heart rate after prolonged standing,
with stress, or from dehydration. It is a result of sympathetic sensitivity, causing a reflexive response that suddenly causes bradycardia and venous dilation. Hypotension and dizziness result.

Question 223

An 88-year-old female is accompanied by her daughter to the emergency department. The daughter explains that her mother was having her hair washed at the beauty salon, then complained of
dizziness and fainted. The 88-year-old patient has a history of hypertension for which she takes a beta blocker. Otherwise she was in her usual state of health until this incident. On examination, she
has no neurological deficits. Which of the following conditions should be considered?
A. Benign positional vertigo
B. Wertebrobasilar insufficiency
C. Labyrinthitis
D. Dehydration

Answer 223

ANS: B
Vertebrobasilar insufficiency is seen mostly in the elderly and is exacerbated by extension of the neck or changes in head position. There is temporary interruption of circulation in the posterior
brain due to vertebral artery occlusion. Benign paroxysmal positional vertigo, or cupulolithiasis, is the most common vestibular disorder, resulting from otolithic crystals/particles detaching from the
utricle membrane and migrating to the semicircular canal. It can occur spontaneously with motion or position change or as a result of vascular or labyrinth trauma. Characterized by sudden-onset
dizziness lasting less than 30 seconds and following a head position change, cupulolithiasis may be accompanied by nystagmus. It usually subsides but may recur at any time. Labyrinthitis is caused
by the invasion of the ear by bacteria or a virus. The bacterial version is more serious because it may lead to meningitis. Prompt treatment with antibiotics is necessary. Labyrinthitis is characterized by severe vertigo, nystagmus, and hearing loss. Suppurative labyrinthitis may be secondary to bacterial otitis media or other bacterial infection. Serous labyrinthitis can be secondary to a variety of viral illnesses, including measles, mumps, chickenpox, influenza, mononucleosis, and adenovirus

Question 224

Which of the following statements is true regarding generalized anxiety disorder?
A. Recent studies suggest that chronic anxiety disorders may increase the rate of cardiovascular-related mortality
B. Women are 60% more likely than men to experience an anxiety disorder over their lifetime
C. More than 90% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings
D. All of the above

Answer 224

ANS: D
Women are 60% more likely than men to experience an anxiety disorder over their lifetime. Both functional impairment and morbidity has been linked to anxiety disorders, and recent studies
suggest that chronic anxiety disorders may increase the rate of cardiovascular-related mortality. Anxiety disorders often go unrecognized and untreated in primary care (Fernández et al. 2012;
Kroenke et al. 2007). Anxiety is an unpleasant feeling of apprehension, often accompanied by perspiration, palpitation, stomach discomfort, restlessness, difficulty sitting still, and even tightness in the chest. More than 90% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings (Stern & Herman 2003).

Question 225

Patients with anxiety frequently complain of:
A. Chest pain
B. Dizziness
C. Shortness of breath
D. A and B

Answer 225

ANS: D
More than 90% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings (Stern & Herman, 2003). Patients may initially complain of
only somatic symptoms before they are ultimately diagnosed with a primary anxiety disorder (DeVane et al., 2005). Patients with anxiety often present with the following symptoms: chest pain (with negative angiogram), irritable bowel, unexplained dizziness, migraine headache, and chronic fatigue.

Question 226

Which of the following statements is true regarding phobia?
A. The anxiety associated with phobia is out of proportion to the actual danger or threat in the situation
B. Diagnosis is based on the presence of symptoms for at least a 6-month duration
C. Persons with phobias have apprehension of a future attack, which is referred to as anticipatory anxiety
D. A and B

Answer 226

ANS: D
The anxiety involved in phobia must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account. Diagnosis is based on the presence
of symptoms for at least a 6-month duration, regardless of age, to minimize overdiagnosis of transient fears. Panic attacks are discrete episodes of intense anxiety that peak within 10 minutes and are associated with autonomic arousal. After an initial panic attack, apprehension of a future attack often occurs and is referred to as anticipatory anxiety.

Question 227

Which of the following is true about separation anxiety?
A. It is a fear mainly expressed by children and adolescents under age 18
B. It is a fear limited to children under age 8.
C. A duration of 6 months is required to minimize overdiagnosis of transient fears
D. A and C

Answer 227

ANS: D
While separation anxiety has historically (through DSM-IV) been classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an anxiety disorder, recognizing the expression of anxiety symptoms in adulthood. Previously, the diagnostic criteria included onset before age 18; however, a substantial number of adults report onset of separation anxiety after age 18. For example, attachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. A duration of 6 months is required to minimize overdiagnosis of transient fears (e.g., when a new parent returns to work and places an infant in the care of another).

Question 228

In obsessive-compulsive disorder, a common obsession:
A. Is that of “contamination” and washing or avoidance of a particular object that is contaminated
B. Involves repetitive behaviors in response to preoccupations with perceived flaws in physical appearance
C. Is a marked fear of being the center of attention or behaving in a way that will result in embarrassment or humiliation
D. None of the above

Answer 228

ANS: A
Obsessive-compulsive disorder is defined by obsessions (recurring thoughts) and compulsions (recurrent actions) over which the patient has little or no control. These defining characteristics
interfere with functioning and may cause embarrassment. The most common obsession is that of “contamination” and washing or avoidance of a particular object that is contaminated. Another
common obsession is self-doubt, associated with repeatedly checking to see that routine safety chores are done. Body dysmorphic disorder involves repetitive behaviors or mental acts in
response to preoccupations with perceived defects or flaws in physical appearance. Social anxiety disorder (formerly called social phobia) is characterized by a marked fear of being the center of
attention or behaving in a way that will result in embarrassment or humiliation

Question 229

Which of the following medications may cause depression in some individuals?
A. Amantadine
B. “Statin” anti-lipidemia drugs
C. Levodopa
D. A and C

Answer 229

ANS: D
Drugs That Can Cause Depression
* Antihypertensives (reserpine, propranolol, methyldopa, guanethidine monosulfate,
and clonidine hydrochloride)
* Corticosteroids and hormones (cortisone acetate, estrogen, and progesterone)
* Antiparkinsonian drugs (levodopa and carbidopa, amantadine hydrochloride)
* Antianxiety drugs (diazepam, chlordiazepoxide)
* Accutane
* Birth control pills

Question 230

With all mental health diagnoses, the clinician should be sure to:
A. Exclude medical conditions that can cause physiological anxiety
B. Review all medications regarding possible mental health side effects
C. Recognize that the presence of anxiety influences treatment and prognosis
D. All of the above

Answer 230

ANS: D
As with all mental health symptoms, the first step in the differential diagnosis is to rule out any general medical condition (Box 17.6) or medication use as the physiological cause of the anxiety. A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision-making.

Question 231

It is important for the clinician to recognize that a recurrence of depression is:
A. 50% likely after one episode
B. 70% likely after two episodes
C. 90% likely after three episodes
D. All of the above

Answer 231

ANS: D
There is a 5% to 11% lifetime prevalence for depression; morbidity is comparable to angina and advanced coronary artery disease. The risk of recurrence of depression is 50% after one episode, 70% after two episodes, and 90% after three episodes.

Question 232

What percentage of patients who commit suicide have depressive illness?
A. 100%
B. 90%
C. 70%
D. 50%

Answer 232

ANS: C
Untreated and undertreated depression significantly increases the risk of suicide: One out of seven people with recurrent depressive illness commit suicide, 70% of suicides have depressive illness,
and 70% of suicides see their primary care provider within 6 weeks of suicide. Suicide is the seventh leading cause of death in the United States (Stahl, 2008).

Question 233

Depression can cause the following physiological changes:
A. Lack of appetite or overeating
B. Avolition or agitation
C. Insomnia or hypersomnia
D. All of the above

Answer 233

D

Depression can present in a variety of ways, and the cluster of symptoms can vary markedly from one individual to the next. For example, depression may cause severe sleep disturbance for one
individual and hypersomnia in another. Some individuals with depression complain of weight gain, whereas others lose weight because they find it hard to eat. Avolition is a common presenting
feature in depression, but some individuals experience restlessness and agitation

Question 234

Abuse of alcohol or street drugs is a frequent cause of:
A. Mania
B. Obsessive-compulsive disorder
C. Depression
D. Hypomania

Answer 234

ANS: C
As with other mental health assessments, psychiatric history and history of alcohol and/or drug use should always be elicited; they are commonly associated with depression. What appears to be major depression may actually be a result of alcohol or street drug use (Shea, 1998).

Question 235

When assessing an individual with depression, it is important for the clinician to:
A. Ask if there are thoughts of suicide
B. Ask if there is a plan for suicide
C. Ask if the individual wants to harm others
D. All of the above

Answer 235

ANS: D
Clinical depression often involves recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicidal attempt or a specific plan for committing suicide.

Question 236

It is widely recognized that bereavement-associated depression can last for up to:
A. 6 months
B. 1 year
C. 2 years
D. 5 years

Answer 236

ANS: C
It is recognized that the duration for bereavement is more commonly 1 to 2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive
episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of
worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality
characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as nonbereavement-related major depressive episodes.

Question 237

In bereavement-associated depression:
A. Antidepressant medications usually do not provide relief
B. The same antidepressants used for non-bereavement depression can provide relief
C. Only SSRI antidepressants can provide relief for grieving individuals
D. Only TCA antidepressants can provide relief for bereaved individuals

Answer 237

ANS: B
Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non-bereavement-related depression. Most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode. However, separation or loss of a loved one is a major stressor that can precipitate a major depressive episode.

Question 238

Clinical depression with mixed features:
A. Indicates at least three manic symptoms coexist with a major depressive episode
B. Is more prevalent in older adults than adolescents and young adults
C. Decreases the likelihood that the illness exists in a bipolar spectrum
D. All of the above

Answer 238

ANS: A
The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained. Mixed episodes are more prevalent in adolescents and young adults than in older adults

Question 239

A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least:
A. 1 week
B. 2 weeks
C. 3 months
D. 6 months

Answer 239

ANS: A
Bipolar disorder is a cluster of disorders that reflect a marked flux in mood. A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least 1 week. This mood must coexist with at least three of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in
pleasurable activities with a high potential for painful consequences.

Question 240

Hypomania is different from mania in that:
A. Hypomania does not cause impaired social or occupational functioning
B. Hypomania does not require hospitalization
C. Mania can endure for a longer period of time than hypomania
D. A and B

Answer 240

ANS: D
Hypomanic episodes differ from manic episodes in the degree of severity. Hypomanic episodes are not usually sufficiently severe to cause marked impairment in social or occupational functioning or
to require hospitalization (APA, 2013). They may, however, evolve into fully manic episodes. The mnemonic “DIG FAST” is helpful for remembering the critical criteria for mania

Question 241

High distractibility or leaving projects unfinished is characteristic of:
A. Hypomania
B. Mania
C. Obsession
D. Cyclothymic disorder

Answer 241

ANS: B
A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least 1 week. This mood must coexist with at least three of the following symptoms: inflated
self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. Hypomanic episodes differ from manic episodes in the degree of severity. Hypomanic episodes are not usually sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization (APA, 2013). They may, however, evolve into fully manic episodes. The mnemonic “DIG FAST” is helpful for remembering the critical criteria for mania

Question 242

In order to diagnose an individual with bipolar I syndrome, the clinician should look for episodes of:
A. Irritability and rage
B. Grandiosity and high self-esteem
C. Rapidly alternating moods
D. None of the above

Answer 242

ANS: C
Bipolar I disorder is characterized by the occurrence of one or more manic episodes or mixed episodes. Mixed episodes are characterized by a period of time (lasting at least 1 week) in which
the criteria are met both for manic episode and for a major depressive episode nearly every day. Social and/or occupational functioning are severely impaired as the individual experiences rapidly alternating moods

Question 243

It is a psychiatric emergency if a patient confides in you that:
A. There are no reasons for him to keep from dying
B. He is having episodes of elation and increased energy
C. He is experiencing free floating anxiety and fear
D. Death and dying is constantly on his mind

Answer 243

ANS: A
Completed suicides occur in 10% to 15% of individuals with bipolar I disorder. Suicide ideation and attempts are more likely in the depressive or mixed state (APA, 2013). Therefore, suicide risk
should always be assessed in a psychiatric evaluation. Box 17.12 lists several questions for assessing suicide risk. If the responses identify a detailed plan for ending life, a lack of hope that things can be better in the future, or an inability to identify reasons for not dying (such as not wanting to leave loved ones), it is considered a psychiatric emergency, requiring immediate intervention.

Question 244

In bipolar II disorder, individuals:
A. Do not experience depression
B. Do not experience manic episodes
C. Have episodes of elation and high energy
D. Do not experience hypomania

Answer 244

ANS: B
Bipolar II disorder is determined when the clinical course includes one or more major depressive episodes and at least one hypomanic episode. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning (APA, 2013). To meet the bipolar II criteria, the individual has not experienced a manic or mixed episode.

Question 245

For premenstrual dysphoric disorder (PMDD) the clinician should:
A. Give patients a trial of an SSRI to see if it relieves symptoms
B. Recognize that oral contraceptives can relieve symptoms
C. Ask the patient to keep a diary of mood and menses for 2 months
D. Diagnose the disorder only if the patient exhibits psychotic symptoms

Answer 245

ANS: C
Premenstrual dysphoric disorder (PMDD) is characterized by recurrent symptoms that occur during the luteal phase of the menstrual cycle and remit during menstruation. Even though many
women express mood changes and other symptoms during the premenstrual phase, 5% to 9% fully meet the criteria for PMDD. Differential diagnosis includes bipolar disorder, thyroid dysfunction,
premenstrual syndrome, exacerbation of unipolar depression, anxiety disorder, and cyclothymic disorder. Careful tracking of symptoms for at least 2 months is advised to determine a diagnosis of PMDD

Question 246

Which of the following mental health disorders commonly affects substance abusers?
A. Obsessive-compulsive disorder
B. Antisocial personality
C. Mania
D. None of the above

Answer 246

ANS: B
Comorbidity with other psychiatric conditions is high in substance abusers. Antisocial personality disorder is present in a high percentage (35% to 60%) of patients presenting for treatment of
substance abuse and dependence. Other psychiatric disorders associated with substance-related disorders include mood disorders and anxiety disorders.

Question 247

Which of the following is a feature of physical dependence in substance abusers?
A. Tolerance
B. Compulsive behavior
C. Withdrawal
D. A and C

Answer 247

ANS: D
Features of physical dependence, such as tolerance and withdrawal, can be normal responses to prescribed medications that affect the central nervous system and needs to be differentiated from
addiction. Moreover, although marijuana abuse can be functionally very impairing, physical dependence is not part of the clinical picture. These mental and behavioral aspects are more specific to substance use disorders than the physical domains of tolerance and withdrawal, which are not unique to addiction (

Question 248

Eating disorders are driven by:
A. Perfectionism
B. Feelings of inadequacy
C. Obsessive-compulsive disorder
D. A and B

Answer 248

ANS: D
As explained in Schwitzer et al. (2001, 158), eating disorders are driven by “(1) perfectionism regarding body image, romantic and other personal relationships, and grades; (2) a fragile sense of
self, feelings of inadequacy, and a need to be bolstered by others; (3) self-doubt expressed as sexual intimacy questions and ambivalence about whether one is thin enough to attract a romantic partner and whether one should want to please a partner at all; and (4) a sense of powerlessness in intimate relationships and the world generally.”

Question 249

Individuals with anorexia are below % of the normal weight for their height, which is not attributed to a medical condition.
A. 25
B. 50
C. 85
D. 100

Answer 249

C

Individuals with anorexia are below 85% of the normal weight for their height, which is not attributable to a medical condition. Normal weight can also be determined by a body mass index equal to or below 17.5 kg/m2 (APA, 2013). Individuals with anorexia do not believe they need to gain weight and have an intense fear of becoming fat even though they are underweight. This fear is not relieved if additional weight is lost.

Question 250

A significant physical finding in females with anorexia is:
A. An irregular menstrual cycle or amenorrhea
B. Hair loss
C. Ascites
D. Esophageal tear

Answer 250

ANS: A
While the restricting pattern is more common in anorexia, binge-purge behaviour may also exist. Although purging may follow a binge episode, purging may also be used even after the consumption of small amounts of food. A significant physical finding in anorexia is an irregular menstrual cycle or amenorrhea. Questions used to screen for anorexia are listed in Box 17.14.

Question 251

Which of the following questions is not used to diagnose an individual with anorexia?
A. “Do you think your current weight is normal or excessive?”
B. “Do you think that any part of your body is still too fat?”
C. “Do you have concern or fear about gaining weight even though you are underweight?”
D. “Do you want to gain weight?”

Answer 251

ANS: D

1. “Do you think your current weight is normal or excessive?”
2. “Do you think that any part of your body is still too fat?”
3. “Do you have concern or fear about gaining weight even though you are
   underweight?”

Question 252

Individuals with bulimia are commonly:
A. Overweight
B. Normal weight
C. Underweight
D. Obese

Answer 252

ANS: B
Individuals with bulimia are usually within the normal range for weight. The essential features of bulimia nervosa are binge eating and the use of inappropriate compensatory methods to prevent
weight gain, such as vomiting or purging.

Question 253

Individuals with bulimia commonly have:
A. Low self-esteem
B. Loss of teeth enamel
C. Enlarged parotid glands
D. All of the above

Answer 253

ANS: D
A feature of bulimia is an inability to control binges. Individuals with bulimia have a high degree of dissatisfaction with appearance and often have low self-esteem. Physical findings may be a noticeable loss of dental enamel on the lingual surfaces of the front teeth as a result of recurrent vomiting. Teeth may become chipped, and there may also be an increase in dental cavities. The parotid glands may also be enlarged. Calluses or scars may be noted on the dorsal surface of the hand from inducing vomiting. If the dominant hand is used, calluses or scars may be evident on only that hand. There may be electrolyte imbalances—frequently hypokalemia, hyponatremia, and hypochloremia.

Question 254

To diagnose a patient with binge eating, a binge is defined as occurring at least:
A. Once a week for 3 months.
B. Twice a week for 6 months
C. Three times a week for 3 months
D. None of the above

Answer 254

ANS: A
Binge eating is often done alone, is not associated with hunger, and is done to the point of feeling uncomfortable. The minimum average frequency of binge eating required for diagnosis is once weekly over the past 3 months (compared to at least twice weekly for 6 months in DSM-IV). Patients present as overweight with marked distress associated with the binge episodes.

Question 255

Thought disorders are evaluated in terms of:
A. The patient’s ability to form an accurate assessment of reality
B. How the patient presents his or her ideas
C. The patient’s perception of stimuli in the environment
D. All of the above

Answer 255

ANS: D
Thought disorders are evaluated as they relate to (1) content of thought, (2) form of thought, and (3) perception. Assessment of the content of thought relates to the client’s ability to form an
accurate assessment of reality. Major difficulties in this area may include delusions, which involve false beliefs held to be true despite proof that they are false or irrational. Examples of delusional
thinking include delusions of persecution or of grandeur, somatic delusions, paranoia, and magical thinking. The second category, form of thought, is assessed by listening to how the client presents his
or her ideas. Does the client present with looseness of associations? In such situations, the client is unaware that the topics are unconnected. When this is extreme, the practitioner may be unable to understand what the client is talking about. Other difficulties with form of thought include circumstantiality and tangentiality. Circumstantiality is the delay in presenting a point because of
numerous unnecessary and tedious details. Tangentiality is the inability to get to the point, owing to the introduction of unrelated topics. The degree of circumstantiality and tangentiality can vary
significantly. For example, an anxious patient might shift from topic to topic with some awareness of doing so. This would not be considered a thought disorder problem. Serious thought disorder
might include neologisms (invented words), word salad (a group of words put together randomly), and clang associations (choice of words based on rhyming). The third category, perception, refers to hallucinations and illusions. Hallucinations are false sensory perceptions that are not associated with external stimuli and may involve any of the five senses. Illusions are misperceptions or misinterpretations of real external stimuli

Question 256

A schizoaffective disorder is characterized by:
A. Mood component coexisting with the schizophrenic symptoms
B. Thought disorder that comes and goes
C. Psychotic disorder with substance abuse
D. Schizophrenia with auditory and visual hallucinations

Answer 256

ANS: A
In schizophrenia, psychotic features are evident with two or more of the following characteristics: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. The last of these characteristics, negative symptoms, refers to affective flattening, poverty of speech, avolition, anhedonia, and social isolation. Schizophrenia subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual. Differential diagnoses include schizophreniform disorder, characterized by schizophrenic symptoms of 1 to 6 months; schizoaffective disorder, characterized by a prominent mood component coexisting with the
schizophrenic symptoms; delusional disorder, characterized by at least 1 month of no bizarre delusions without an active phase of symptoms of schizophrenia; brief psychotic disorder, characterized by symptoms that last more than 1 day but remit by 1 month; and substance-induced psychotic disorder, characterized by symptoms directly related to an abused substance, toxin, or medication.

Question 257

It is important for the clinician to recognize that elderly patients may present with drug-induced psychosis particularly with:
A. Beta blocker drugs
B. Anticholinergic drugs
C. Antibiotics
D. Antiviral agents

Answer 257

ANS: B
In addition to street drugs or commonly abused drugs, anticholinergic agents can precipitate delirium, especially in elderly patients. Anticholinergic medications can cause a patient to present
with hyperthermia, blurred vision, dry skin, facial flushing, and delirium. The mnemonic “hot as a pepper, blind as a bat, dry as a bone, red as a beet, and mad as a hatter” can be used to describe this toxic state (Shea, 1998). It is important to note that anticholinergic syndrome may be incomplete or hidden by other medications, such as opiates, and not present as a classic anticholinergic syndrome.