muscles

Question 1

A 4-year-old patient presents to the primary care clinic with complaints of pain and limited mobility in the upper extremity. The parent reports that the child first experienced pain after the parent pulled quickly on the child’s hand to remove them from the path of an oncoming cyclist. The patient’s arm appears shortened and rotated compared with the unaffected side. Which of the following injuries is most likely?

A.Greenstick fracture of the ulna
B.Pulled elbow
C.Wrist sprain
D.Growth plate injury

Answer 1

Answer: B. Pulled elbow

The presentation of a shortened and rotated arm with pain and limited mobility is indicative of a pulled elbow, also known as radial head subluxation or “nursemaid’s elbow.” This injury occurs when the radial head slips out of the annular ligament, generally from a sudden upward external force applied to the extended arm. Greenstick fracture would likely present with obvious angulation of the forearm. A wrist sprain would involve pain and swelling in the wrist joint. Growth plate injury may present with localized pain, but it does not typically result in the characteristic appearance of a shortened and rotated arm.

Question 2

A 6-year-old is brought to the clinic by their caregiver with complaints of severe pain and swelling in the left knee, which started suddenly 2 days ago. The child refuses to bear weight on the affected leg and has a fever of 102°F (38.9°C). On physical examination, the left knee is warm and erythematous and has a limited range of motion due to pain. Which of the following is the most definitive test to confirm the suspected diagnosis?

A.Serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
B.Ultrasound of the left knee
C.Joint aspiration and synovial fluid analysis

Answer 2

Answer: C. Joint aspiration and synovial fluid analysis

For a suspected case of septic arthritis, the most definitive diagnostic test is joint aspiration and synovial fluid analysis, which requires hospitalization. This test can identify the causative organism and provide direct evidence of infection within the joint space. Serum CRP and ESR will also be ordered, but these markers can be elevated in many inflammatory conditions, including septic arthritis. Ultrasound of the affected joint can suggest the presence of joint effusion, and it may help guide joint aspiration, but it cannot differentiate between infectious and noninfectious causes. X-ray of the joint is generally not helpful in the early stages of septic arthritis as it can appear normal or show only soft tissue swelling.

Question 2

A 13-year-old patient presents with a 4-week history of right hip pain and a noticeable limp. The patient is above the 90th percentile for body mass index (BMI) for their age. On examination, the right hip has limited internal rotation, and the pain intensifies when trying to rotate the hip. Slipped capital femoral epiphysis (SCFE) is suspected. What is the most appropriate initial treatment recommendation for this patient’s condition?

A.Start a regimen of non-steroidal anti-inflammatory drugs (NSAIDs) for pain control
B.Advise weight loss and initiate physical therapy
C.Refer for immediate orthopedic consultation
D.Recommend a trial of bed rest and immobilization of the affected leg

Answer 2

Answer: C. Refer for immediate orthopedic consultation

In a patient with suspected SCFE, especially given the risk factors and clinical presentation, the gold standard treatment approach involves surgical stabilization. Thus, immediate referral to orthopedics is paramount to prevent further slippage and potential complications. While NSAIDs can provide pain relief, they do not address the underlying issue and are not a definitive treatment. Physical therapy might be beneficial in the long term for overall health, but it is not the immediate treatment for SCFE, and delaying appropriate intervention can lead to complications. Bed rest and immobilization can temporarily alleviate symptoms, but they also do not provide definitive treatment, and without surgical intervention the risk of further slippage remains.

Question 2

When performing an assessment, the family nurse practitioner understands that the metacarpophalangeal (MCP) joints are frequently involved with:

Answer 2

RA
Rationale:
The wrist, MCP, and proximal interphalangeal joints, and other small joints of the hands and feet are involved with RA. The great toe is most often involved with gout. The large joints of the hip, knee, and shoulder, along with the distal interphalangeal joint and base of the thumb, are involved with degenerative joint disease (osteoarthritis).

Question 3

An older adult patient complains of fatigue, weakness, lightheadedness, and anorexia. He also complains of hot, swollen proximal interphalangeal(PIP) and metacarpophalangeal (MCP) joints. These symptoms occurred 5 months ago and recurred a few days ago. Which laboratory findings would be most conclusive of these assessments?

Answer 3

normal MCV and high. serum ferritin

Question 4

How is the talar tilt test conducted?

Answer 4

The talus is tilted into adduction and abduction and the laxity of the ligament is graded.
Rationale:
The talar tilt test is a ligamentous stress test that detects excessive ankle inversion by examining the integrity of the lateral ankle ligaments, particularly the calcaneofibular ligament. Anterior ankle stability is tested in the anterior drawer test, in which the tibia is grasped by the examiner’s one hand while the heel is firmly grasped, and backward pressure is applied to the tibia with the examiner’s other hand. In passive range of motion, the examiner inverts, everts, dorsiflexes, and plantar flexes the foot and ankle. The patient puts the foot and ankle through the complete range in active range of motion.

Question 5

A 66-year-old male patient presents with lower back pain, fatigue, and weight loss for the last 4 months. Five months ago, he had a right humeral fracture. Laboratory analysis reveals serum calcium 12.2 mg/dL, hemoglobin 9.2 g/dL, and hematocrit 27.1%. A lumbar x-ray is ordered and displays areas of hypodensity in the vertebral column and generalized osteopenia. Dipstick urinalysis reveals increased albumin. Which of the following tests would provide the most definitive diagnosis?

Answer 5

bone marrow aspiration,biopsy

Question 6

A 45-year-old female complains of knee pain when kneeling and a “clicking” noise when walking up steps. The family nurse practitioner notes slight knee effusion and tenderness when palpating the patella against the condyles. What is the diagnosis for this patient?

Answer 6

Chondromalacia patella.
Rationale:
These are common symptoms of chondromalacia patella. With anterior cruciate tears, the patient generally cannot bear weight on the extremity without it buckling or giving way. With a dislocated patella, the patient would have severe pain associated with considerable effusion (loss of normal knee hollow on sides of patella) and possible patellofemoral compartment. Patellar tendonitis, or jumper’s knee, causes pain, weakness, and swelling of the knee joint, but no “clicking” noises.

Question 7

A 6-year-old child with osteogenesis imperfecta (OI) experiences frequent long bone fractures. The nurse practitioner discusses treatment options with the child’s parents. Which of the following interventions should be included in the child’s treatment plan?

A.Encouraging weight-bearing exercises to strengthen the bones
B.Prescribing bisphosphonate medications to improve bone density
C.Recommending regular consumption of dairy products for calcium intake
D.Implementing physical therapy for range-of-motion exercises

Answer 7

Answer: B. Prescribing bisphosphonate medications to improve bone density

Bisphosphonate medications can help improve bone density in individuals with OI and reduce the risk of fractures. Encouraging weight-bearing exercises to strengthen the bones, recommending regular consumption of dairy products for calcium intake, and implementing physical therapy for range-of-motion exercises may be appropriate in certain situations but are not specific treatment modalities for OI. The primary focus in OI treatment is often on medication interventions, such as bisphosphonates, to improve bone density and reduce the risk of fractures.

Question 8

A patient with an intolerance to glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) presents with a gout flare. The patient reports intense joint pain, redness, and swelling, which are preventing them from participating in activities of daily living (ADLs). Which of the following is the recommended standard dosing of colchicine for this patient?

A.Initial dose of 0.2, followed 1 hour later by another 1.6 mg
B.Initial dose of 1.2, followed 24 hours later by another 0.6 mg
C.Initial dose of 2.0, followed 4 hours later by another 0.8 mg
D.Initial dose of 1.2 mg, followed 1 hour later by another 0.6 mg

Answer 8

nswer: D. Initial dose of 1.2 mg, followed 1 hour later by another 0.6 mg

For patients who are intolerant to glucocorticoids and NSAIDs, colchicine can be used to treat a gout flare. Colchicine is most effective when taken within 24 hours of onset of a gout flare and should be administered in a total dose on day 1 not to exceed 1.8 mg. The standard initial dose is 1.2 mg, followed 1 hour later by another 0.6 mg

Question 9

A child presents with pain and swelling in the wrist. The parent reports that the child fell forward chasing a pet. The appearance of the arm and wrist resemble a “dinner fork.” The nurse practitioner diagnoses this as:

A.Navicular fracture
B.Colles fracture
C.Greenstick fracture
D.Lachman’s fracture

Answer 9

Answer: B. Colles fracture

A Colles fracture is a fracture of the distal radius of the forearm along with dorsal displacement of the wrist. Also known as a “dinner fork” fracture due to the appearance of the arm and wrist. A Colles fracture is commonly associated with falling forward with an outstretched hand. A navicular fracture is a scaphoid bone fracture that presents with wrist pain on palpation of the anatomic snuffbox. A greenstick fracture results in the tension side of the cortex of the radius or ulna being fracture but this does not have a “dinner fork” appearance. Lachman sign is a test suggestive of anterior cruciate ligament (ACL) damage of the knee.

Question 10

Which of the following describes a step in reduction of radial head subluxation?

A.Hold the child in the nurse practitioner’s lap throughout the procedure.
B.Allow the affected extremity to remain unconstrained throughout the procedure.
C.Slowly press down on the radial head while pronating the forearm and flexing the elbow.
D.Listen and feel for a click to indicate success.

Answer 10

Answer: D. Listen and feel for a click to indicate success.

For reduction of radial head subluxation (pulled elbow or “nursemaid’s elbow”), the child should be placed in a family member’s lap to hold them still and to provide comfort and reassurance. To proceed, the nurse practitioner places their thumb on the affected radial head while supporting the elbow. In a single, quick motion, the nurse practitioner presses on the radial head while supinating the forearm and extending the elbow. Then, while maintaining the thumb on the radial head and keeping the forearm supinated, the nurse practitioner flexes the elbow. The nurse practitioner should hear or feel a click upon successful reduction.

Question 11

In a patient with osteoarthritis without known cardiovascular disease who is at increased risk of gastrointestinal (GI) bleeding, which of the following analgesics is preferred?

A.Naproxen
B.Celecoxib
C.Ibuprofen
D.Acetaminophen

Answer 11

Answer: B. Celecoxib

Celecoxib is preferred in patients without known cardiovascular disease who are at increased risk of GI bleeding due to its greater long-term GI safety profile compared with naproxen and ibuprofen. Acetaminophen is no longer recommended for the treatment of osteoarthritis given safety concerns and nonclinically significant effects on pain.

Question 12

A 32-year-old female patient has been diagnosed with ankylosing spondylitis. While she has been managing her pain with non-steroidal anti-inflammatory drugs (NSAIDs), she continues to experience persistent symptoms and limited spinal mobility. Physical therapy has also provided limited benefit. Which of the following treatments would be the next appropriate step in the management of her condition?

A.High-dose corticosteroids
B.Allopurinol
C.Tumor necrosis factor (TNF) inhibitors
D.Calcium channel blockers (CCBs)

Answer 12

Answer: C. Tumor necrosis factor (TNF) inhibitors

TNF inhibitors, such as infliximab, etanercept, and adalimumab, are biologic medications that can be very effective in treating ankylosing spondylitis, especially when first-line treatments (like NSAIDs) are not effective enough. They work by targeting and inhibiting the TNF protein, which plays a role in inflammatory processes. While corticosteroids can be used for short-term relief from acute flare-ups of ankylosing spondylitis, they are not a first-line or long-term treatment option due to the potential side effects of chronic use. Allopurinol is primarily used for the treatment and prevention of gout and is not effective in treating ankylosing spondylitis. CCBs are mainly used to treat hypertension and certain cardiac conditions. They have no role in the management of ankylosing spondylitis.

Question 13

Metatarsus adductus is

Answer 13

medial deviation of hte foregoots

Question 14

A male patient presents with buttock pain that increases while sitting. The patient is a runner and reports running downhill recently. The patient reports noticing the pain when he could no longer sit on his wallet in his back pocket without having symptoms. Which of the following is most likely with this presentation?

A.Piriformis syndrome
B.Ankylosing spondylitis
C.Hamstring injury
D.Morton’s neuroma

Answer 14

Answer: A. Piriformis syndrome

The patient is presenting with signs and symptoms suggestive of piriformis syndrome, or entrapment neuropathy of the sciatic nerve. Some runners develop this condition with downhill running because the piriformis muscle undergoes eccentric contraction. The most common presenting symptom is buttock pain of gradual onset that increases while sitting (“wallet sign”). Morton’s neuroma is inflammation of the digital nerve of the foot between the third and fourth metatarsals. A hamstring injury often presents with posterior thigh pain with focal warmth and tenderness. Classic features of ankylosing spondylitis are low back and neck pain, impaired spinal mobility, and postural abnormalities.

Question 15

Which of the following laboratory findings is present in most patients with systemic lupus erythematosus (SLE) and can be used for diagnosis?

A.Rheumatoid factor (RF)
B.Uric acid level
C.Anti-cyclic citrullinated peptide (CCP) antibodies
D.Antinuclear antibodies (ANA)

Answer 15

Answer: D. Antinuclear antibodies (ANA)

In nearly all patients with SLE, the ANA test is positive at some point during their disease course. An elevated uric acid level is seen in a patient with gout. RF and CCP antibodies may help exclude a diagnosis of rheumatoid arthritis (RA) in patients with SLE and predominant arthralgias. Anti-CCP antibodies have a higher specificity for RA and are more useful to distinguish arthritis associated with RA. About 20% to 30% of patients with SLE have a positive RF, so it has less diagnostic yield.

Question 16

While performing a physical examination on a 13-year-old child, the nurse practitioner suspects that the patient has scoliosis based on which assessment?

A.Lateral deviation of the thoracic spine
B.Concave curvature of the cervical spine
C.Convex curvature of the thoracic spine
D.Elongation of the lumbar spine

Answer 16

Answer: A. Lateral deviation of the thoracic spine

Scoliosis is lateral deviation of the spine, primarily the thoracic spine. Concave curvature of the cervical spine and convex curvature of the thoracic spine are characteristics of a normal spinal alignment. Scoliosis does not cause elongation of the lumbar spine.

Question 17

A 28-year-old female patient presents with fatigue, joint pain, and a rash over her cheeks and the bridge of her nose that worsens with sun exposure. She mentions intermittent hair loss and recalls having mouth ulcers a couple of times over the past year. She denies any history of kidney problems, seizures, or blood disorders. The nurse practitioner decides to order laboratory tests to further assess the patient. Which laboratory finding combined with the patient’s presentation would confirm a suspected diagnosis?

A.Elevated rheumatoid factor (RF)
B.Low erythrocyte sedimentation rate (ESR)
C.Elevated serum uric acid
D.Positive anti-Smith (anti-Sm) antibodies

Answer 17

Answer: D. Positive anti-Smith (anti-Sm) antibodies

The diagnosis of systemic lupus erythematosus (SLE) often involves a combination of clinical findings and laboratory results. While many different antibodies can be present in SLE, anti-Smith (anti-Sm) antibodies are among the most specific for the disease. Although they may not be present in all patients with SLE, a positive result alongside the patient’s other symptoms strongly supports this diagnosis. RF can be elevated in some patients with SLE, but it is more characteristically elevated in rheumatoid arthritis; elevated serum uric acid is typically associated with gout and certain kidney conditions. The patient’s presentation is suggestive of SLE, not RF or gout. In SLE, the ESR is often elevated, indicating inflammation. A low ESR would not typically support a diagnosis of SLE in the presence of the patient’s other symptoms.

Question 18

A 37-year-old male patient complains of an acute onset of pain and redness of his left wrist. He denies trauma or injury to the wrist. He reports that the condition has occurred on the same wrist before. The symptoms started at night after drinking a few glasses of wine. During the physical exam, the left wrist is red, swollen, and tender to palpation. The skin is intact but feels warm to the touch. Which of the following is recommended for the initial treatment of this flare?

A.Interleukin-1 inhibitor
B.Oral glucocorticoids
C.Aspirin
D.Intraarticular glucocorticoids

Answer 18

Answer: B. Oral glucocorticoids

Oral glucocorticoids (e.g., prednisone), nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., naproxen, indomethacin), or colchicine can be used to treat a gout flare. Aspirin is not used because of the paradoxical effects of salicylates on serum urate. Intraarticular glucocorticoids are indicated if the patient is unable to tolerate oral medications. Interleukin-1 inhibitors (e.g., anakinra, canakinumab) are indicated for patients who are unresponsive or have contraindications to initial therapy.

Question 19

A caregiver brings a 6-year-old patient to the primary care clinic expressing concern about the child’s persistent habit of walking on their tiptoes. The patient has an otherwise normal developmental history and denies any pain or discomfort. There is no family history of neuromuscular disorders. The patient demonstrates full passive dorsiflexion of the ankles and has a normal neurological examination. Which of the following is the most likely diagnosis?

A.Cerebral palsy
B.Muscular dystrophy
C.Tight Achilles tendon
D.Idiopathic toe walking

Answer 19

Answer: D. Idiopathic toe walking

Idiopathic toe walking refers to the habit some children develop of walking on their toes in the absence of any medical condition. The patient demonstrates no other neurological or musculoskeletal abnormalities, which makes idiopathic toe walking the most likely diagnosis. Cerebral palsy is a neurological disorder that can manifest with toe walking, but it also presents with other motor abnormalities and developmental delays. Muscular dystrophy is a genetic condition that leads to progressive muscle weakness and loss, and toe walking could be a sign; however, without other indicative symptoms or a family history, this diagnosis is less likely. A tight Achilles tendon could cause toe walking, but the patient’s normal passive dorsiflexion indicates that this is not the underlying cause.

Question 20

Which of the following terms refers to the bones of the hands?

A.Carpals
B.Phalanges
C.Metatarsals
D.Metacarpals

Answer 20

Answer: D. Metacarpals

Metacarpals refers to the bones of the hands. Carpals refers to the bones of the wrist. Phalanges refers to the bones that make up the fingers and toes. Metatarsals refers to bones of the feet.

Question 21

A 4-month-old patient is brought to the primary care clinic with the noted deformity of both feet turning inward and downward. On examination, the nurse practitioner observes the “club-like” appearance of the infant’s feet, with the soles facing each other. The caregiver reports no family history of such deformities. Which of the following is the most appropriate initial treatment recommendation for this infant’s condition?

A.Referral for the Ponseti method
B.Over-the-counter foot supports and braces
C.Intra-articular steroid injections
D.Watchful waiting approach until the child begins to walk

Answer 21

Answer: A. Referral for the Ponseti method

The Ponseti method is the initial step in treatment of congenital talipes equinovarus (CTEV), or “clubfoot.” This approach, which is managed by an orthopedic specialist, incorporates manipulative stretching followed by serial casting and aims to gradually correct the foot’s position over time.

Question 22

A soccer player presents at an urgent care clinic complaining of swelling and pain on the medial aspect of the right knee. The patient reports twisting the knee when quickly changing directions while running. On physical examination, the knee is swollen with joint tenderness on the medial side of the knee. The patient is unable to squat, kneel, or fully extend the knee. Based on this presentation, the orthopedic maneuver that the nurse practitioner should use to assess for possible injury is known as which test?

A.Flexion pinch
B.Anterior drawer
C.Lachman
D.Empty can

Answer 22

Answer: A. Flexion pinch

Acute meniscal tears often occur when a person changes direction in a way that involves rotating or twisting the knee, usually while playing sports. Patients with meniscal injury often present with joint line tenderness, abnormal knee motion, inability to squat or kneel, joint effusion, and inability to fully extend the knee or loss of smooth passive motion. The flexion pinch test involves flexing the knee and palpating the lateral and medial posterior joint lines for tenderness. A positive finding suggests injury to the meniscus of the knee. The anterior drawer and Lachman tests are used to evaluate an injury to the anterior cruciate ligament. The empty can test can be used to assess supraspinatus function when performing a physical examination of the shoulder.