NBPTE Exam Review Flashcards

Question

A young adult who is comatose (Glasgow Coma Scale score of 3) is transferred to a long-term care facility for custodial care. On initial examination, the therapist determines the patient is demonstrating decerebrate posturing. Which limb or body position is indicative of this? A- The UEs in flexion and LEs in extension B- Extreme hyperext of neck and spine w/ BLEs flexed and heels touching buttocks C- All 4 limbs in extension D- All 4 limbs in flexion

Answer 1

C- All 4 limbs in extension With decerebrate posturing (decerebrate rigidity), the upper and lower extremities are held rigidly in extension. Incorrect Choices: In decorticate posture, the upper extremities are held rigidly in flexion while the lower extremities are extended. With opisthotonos, extreme hyperextension of the neck and spine is evident, with both lower extremities flexed and the heels touching the buttocks. All limbs flexed is not typically found in the comatose patient.

Answer 2

D- Use pumice stone to gently remove calluses Foot care precaution for patients with diabetic polyneuropathy should include the use of a pumice stone to gently file calluses. Other advice includes examining footwear for proper fit to prevent callus and corn development. Additionally, patients should never use anything sharp or chemicals to debride corns or calluses. Incorrect Choices: It is important to moisturize but not between the toes as it contributes to skin maceration. It is best to buy shoes at the end of the day when the feet are larger. Buying shoes at the beginning of the day could result in an improper fit. Finally, heating pads and hot water bottles are contraindicated in someone with polyneuropathy. If the patient’s feet are cold, it is recommended they wear socks.

Answer 3

C- Turning head while walking The Berg Balance Test (BBT) is a test of static and dynamic balance in sitting and standing. It includes transitional items of sit-to-stand and stand-to-sit. It does not include items on gait. Turning while walking is an item on both the Tinetti Performance-Oriented Mobility Assessment and the Dynamic Gait Index. Incorrect Choices: All other choices are items on the BBT.

Answer 4

D- Emphysema Pursed lip breathing gives increased resistance to the airways on exhalation. The resistance causes increased pressure, which helps to prevent airway collapse (likely sequelae given the pathophysiology of emphysema). This occurs via collateral ventilation through pores of Kohn and canals of Lambert. Incorrect Choices: Circumferential thoracic burn is a restrictive disorder, and pursed lip breathing will not have any effect on this. Asbestosis is an interstitial lung disease where there are fibrotic changes within the lung tissue. Pursed lip breathing will have no effect on this patient’s breathing pattern. Rib fractures are also a restrictive disorder. In order to improve the breathing pattern, it would be most beneficial to control pain. Pursed lip breathing will have little effect.

Answer 5

D- Discontinuation of NSAID prior to PRP injection Patients are typically advised to suspend the use of NSAIDS prior to a PRP injection because of the potential for NSAIDs to diminish the effects of the injection. Aspirin, acetaminophen and some NSAIDs tend to decrease platelet count. Patients can continue to take COX-2-selective NSAIDs prior to a PRP injection as studies show that COX-2 NSAIDs do not significantly decrease platelet counts or aggregation. Incorrect Choices: The mechanism of action which makes NSAIDs effective pain relievers also inhibits platelet aggregation via the cyclooxygenase-arachidonic acid pathway. Therefore, any dose (decrease, same, or increase) of NSAIDs would likely interfere with the therapeutic potential of the PRP injection.

Answer 6

B- Anterior glide of radial head on humerus An anterior glide of the radius on the humerus would be used to increase elbow flexion. In this case, and according to the concave-convex rule, a concave surface is moving on a convex surface, so the anterior glide will occur in the same direction as the osteokinematic motion of flexion. See Table 2-1 for a review of the concave-convex rule application to peripheral joints. Incorrect Choices: Medial and lateral glides may be used to augment overall mobility but are not the best choice to improve elbow joint flexion. Posterior glide of the radial head would be used to increase elbow extension.

Answer 7

B- Forearms supinated with wrists extended and fingers flexed The patient with tetraplegia at the C6 level does not have triceps to assist in transfers. Independent transfers can be achieved using muscle substitution and positioning to lock the elbow. The hands are positioned anterior to the hips; the shoulders are externally rotated with the elbows and wrists extended, forearms supinated, and fingers flexed. Strong contraction of the anterior deltoid, shoulder external rotators, and clavicular portion of the pectoralis major flexes and adducts the humerus, causing the elbow to extend. Incorrect Choices: Fingers are always flexed (not extended) to preserve tenodesis grasp. Forearms are supinated (not pronated) and the wrist is extended (not flexed).

Answer 8

B- Reduction of wound surface area in first month A significant decrease in wound area during the first month is the most significant prognostic indicator of full wound closure for diabetic foot ulcerations. Significant reduction of wound area in the first few weeks is also a predictor of complete wound healing in venous and pressure ulcerations. Incorrect Choices: Although the other options are important for wound healing and contribute to a reduction in wound surface area, individually they represent an earlier stage of wound healing and are not as predictive of complete wound healing.

Answer 9

B- Inflammatory bowel disease Inflammatory bowel disease (IBD) refers to two inflammatory conditions: Crohn's disease and ulcerative colitis. The etiology of these two disorders is unknown but thought to be due to genetic or immunologic influences on the gastrointestinal (GI) tract. Both diseases cause inflammation inside the intestine as well as significant problems in other parts of the body including polyarthritis and migratory arthralgias. Diarrhea, constipation, abdominal pain, fever, rectal bleeding, night sweats, skin rashes and uveitis are other clinical signs and symptoms of IBD. IBD is a different clinical entity than IBS–irritable bowel syndrome. Incorrect Choices: Common signs and symptoms of colorectal cancer include rectal bleeding; hemorrhoids; abdominal, pelvic, back, and sacral pain; diarrhea, nausea and vomiting; constipation; and unexplained weight loss. Diverticulitis involves inflamed pouches of intestine that can also lead to abdominal pain and nausea. Left lower quadrant pain is another common symptom of diverticulitis, along with flatulence, bloody stools, and constipation. Patients with pancreatitis typically complain of epigastric pain that radiates to the mid back; nausea, vomiting and diarrhea; abdominal distention; and malaise. They may also exhibit jaundice and in severe cases may exhibit a bluish discoloration of the abdomen (Cullen's sign) or discoloration of the flanks (Grey Turner's sign) due to hemorrhage.

Answer 10

D- Ineffective cough for secretion clearance Both the MIP and MEP findings indicate significant ventilator muscle weakness. The patient will have difficulty drawing air in and forcefully expelling it, which are two phases of an effective cough. Therefore, the patient will have difficulty clearing their secretions. See Tables 5-1 and 5-2 for normal values of MIP and MEP. Incorrect Choices: A patient with Guillain-Barré syndrome will present as if they have a restrictive lung disease. The patient will have decreased costal expansion, but it will be symmetrical. Both increased I:E ratio and subcostal angle are findings consistent with someone with obstructive lung disease and lung hyperinflation, not restrictive lung disease.

Answer 11

A- Platelet count of 20,000 A patient with a platelet count of 20,000 is at increased risk for bleeding. Percussion may cause microtraumas and increased bleeding risk. Incorrect Choices: While dyspnea in Trendelenburg is uncomfortable, the position could be modified so that percussion and vibration can be completed. While an SaO2 range of 88% to 94% on room air is a consideration, it would not preclude this intervention. This should be monitored closely while considered positions maximize ventilation and perfusion. While this patient will require assistance for positioning, it doesn’t eliminate this treatment intervention. Pneumonia is an indication for manual airway clearance techniques. The therapist will need to complete the techniques in multiple postural drainage positions to optimize efficiency.

Answer 12

D- Continue with outlined exercise program for that session The physical therapist provided an exercise program, and it is appropriate for the PTA to continue to follow it. Incorrect Choices: There is no need to terminate exercise since the patients have an established exercise program. It is within a PTA’s scope of practice to progress a program, so there is no need to maintain the same intensity of exercise. There is no need to reduce the intensity of the program, as the PTA can monitor and progress a program.

Answer 13

B- Myopathy Myopathy typically impacts proximal muscles to a greater extent than distal muscles. Cholesterol lowering drugs (statins) are a risk factor for the development of myopathy. Incorrect Choices: Guillain-Barré syndrome (GBS) typically follows a respiratory illness or vaccination and causes rapid demyelination of multiple peripheral nerves resulting in rapid and acute proximal to distal weakness. Although myasthenia gravis causes fatigue and ultimately weakness in multiple muscles in the bilateral upper and lower extremities, it also presents with mild ptosis and involvement of ocular and/or oropharyngeal muscles. Amyotrophic lateral sclerosis may also cause fatigue/weakness, but it typically presents with asymmetric weakness and is defined by both lower and upper motor neuron involvement.

Answer 14

A- Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) The mCTSIB is ideally suited to assess the influence of the patient’s diverse sensory impairments(vestibular, somatosensory, vision) on postural stability. Incorrect Choices: Options #2-4 do not directly assess the patient’s sensory impairments and are specifically intended to measure static stability, functional stability limits, and mobility, respectively.

Answer 15

D- Jersey finger Jersey finger is the eponym for a rupture or avulsion fracture of the flexor digitorum profundus (FDP) tendon at its insertion on the distal phalanx. The ring finger is involved in 75% of cases of jersey finger because it is more prominent than the other digits during grip. The mechanism of injury is forceful extension of the DIP joint during maximal contraction of the FDP. The key physical examination finding is an inability to actively flex the DIP joint in isolation. Incorrect Choices: A boutonniere deformity results from rupture of the central tendinous slip of the extensor tendon mechanism. With boutonniere deformities, the PIP is in a position of flexion and between the two lateral bands of the extensor mechanism. A swan neck deformity results from injury to the volar plate or transverse retinacular ligament, producing a deformity of flexion of the MCP and DIP joints with relative hyperextension of the PIP. Boutonniere and swan neck deformities may result from trauma but are often seen in patients with rheumatoid arthritis. A mallet finger results from rupture or avulsion of the terminal tendon of the extensor mechanism at the insertion on the distal phalanx. The mechanism of injury is usually traumatic forced flexion of the DIP joint and results in a deformity of flexion of the DIP with an inability to produce active extension.

Answer 16

D- most recent PFT results Recent pulmonary function test results will give the therapist information regarding the severity of the lung disease. This information will assist in determining how much the patient will progress. Incorrect Choices: While the current medication list will help determine how the patient is currently being managed, it doesn’t give any information about his or her function. The previous history of the disease will not translate well into what the patient’s function has been. It is possible that he or she has been quite functional despite terrible disease such that an acute exacerbation with little reserve will leave him or her quite limited. An acute asthma exacerbation will likely not appear on a chest x-ray, nor would chronic disease.

Answer 17

D- Increased knee flexion resistance Prosthetic causes of circumduction include a long prosthesis, locked knee unit, inadequate knee flexion, inadequate suspension, small or loose socket, and plantar flexed foot. Incorrect Choices: An unstable knee unit will cause forward flexion during stance. Inadequate socket flexion will result in lordosis during stance. A high medial wall or abducted hip joint will result in an abducted gait.

Answer 18

D- Community Balance and Mobility Scale (CBMT) The patient's performance on the dizziness handicap inventory and Mini-BEST reinforce their symptoms (both at rest and exertion) have improved and fall risk is very low. The CBMT is the correct answer as it includes higher level balance and mobility items, to include running short distances. It is also a reliable and valid tool for patients who have experienced a TBI (see Table 3-16). Incorrect Choices: The FGA and FIM do not assess higher level balance and mobility items. The FSST requires dynamic mobility and balance in multiple planes but does not specifically address running or other higher level community tasks.

Answer 19

C- Decreased bone density In addition to production of a thick and sticky mucus that blocks the airways, patients with CF also produce a thick mucus that can block the common bile duct leading to malabsorption of nutrients and resulting in decreased bone density. A resisted exercise program can assist with reversing the effects of the disease process. Incorrect Choices: CF primarily affects the respiratory and digestive systems. There is no evidence that carpal tunnel syndrome or other peripheral neuropathies are a common complication of cystic fibrosis. Patients with cystic fibrosis may present with polyarthralgias (joint swelling and stiffness) and joint contractures, but a strength training program would not be the best intervention to address these impairments.

Answer 20

C- Lateral malleolus The typical location of an arterial ulcer is the distal lower leg (toes, foot), the lateral malleolus, or the anterior tibial area. Incorrect Choices: The typical location of a venous ulcer is the distal lower leg and the medial malleolus.

Answer 21

B- Starting at proximal portion of limb and working distally to move lymph toward right lymphatic duct Manual lymphatic drainage is a component of a CDT plan for patients with lymphedema. Because of the very low forces present in the lymph system, lymph load in proximal areas must be relieved prior to progressing to areas where lymphedema is present. This proximal to distal approach maximizes any benefits that may occur from this treatment technique. Additionally, the anatomy of the lymph system requires movement of lower extremity lymph toward the thoracic duct. Only right upper quarter lymph would be directed toward the right lymphatic duct. Incorrect Choices: Intermittent pneumatic compression may be a treatment alternative when care is utilized to avoid damaging the lymph system by using low pressure, sequential compression. Additionally, the practice is limited to use in the upper extremity due to the unacceptable risk of causing genital lymphedema if performed in the lower extremity. Deep tissue friction massage is not indicated in patients with lymphedema. Aggressive manipulation of the integument may cause damage to lymphatic structures.

Answer 22

D- Displace the rear axle forward for more efficient arm push This patient is obese. A bariatric wheelchair with heavy-duty, extra-wide wheels is necessary. The rear axle is displaced forward compared to the standard wheelchair to allow for more efficient arm push. Incorrect Choices: Moving the front casters closer to the drive wheels would decrease stability (not increase). Friction rims and antitipping devices are adjustments that may be necessary for the patient with a spinal cord injury.

Answer 23

D- Examine the right foot, leg, and hip for injury or infection The most common cause of unilateral inguinal lymph node swelling is injury or infection involving the distal foot, leg, thigh, or hip. Abrasions in these areas, fairly routine for many athletes, are potential sources. Insect bites are another possible cause. The therapist should perform a thorough examination and treat any injuries or wounds appropriately. Incorrect Choices: Although mononucleosis (Epstein-Barr virus) is prevalent in young males, there were no complaints of sore throat or fatigue. The only swollen lymph nodes detected were in the right inguinal area. It is unlikely that mononucleosis is the source. Asking the patient about STDs at this point in the examination is also premature. STDs can result in swollen lymph nodes (chlamydia, gonorrhea, etc.) and not necessarily present with other symptoms; but, is this the next step in the PT examination? If the swollen lymph nodes were more extensive and had remained so for 2 or 3 weeks, then referral to a physician would be in order.

Answer 24

B- Prone, w/ pillow under hips and bed flat Prone with a pillow under the hips and the bed flat will raise the posterior basal segments up to facilitate drainage. This is an acceptable modified position for drainage of the posterior basal segment of the left lower lobe. Incorrect Choices: The side-lying position with the bed flat will drain the lingula more than the posterior basal segments. With the bed elevated in side-lying, the pillow position is just for comfort but will not facilitate drainage. Raising the bed up will cause drainage to go toward the base of the lungs, which would not be effective. If the head of the bed is elevated up in prone, drainage will also be more difficult.

Answer 25

A- TTP at distal lateral malleolus The Ottawa Ankle Rules (see Box 2-10) were developed to provide clinicians with guidelines for determining when to order an x-ray following an acute ankle injury. Palpation tenderness of either malleoli is one of the criteria. The Ottawa Ankle Rules are highly sensitive and accurately rule out a fracture following an acute ankle injury. Incorrect Choices: The other choices are each common and important examination findings in patients after ankle sprain, but none of them is a component of the Ottawa Ankle Rules.

Answer 26

C- To rule out liver and muscle dysfunction from statin A small percentage of patients (<5%) who take statins (atorvastatin such as Lipitor, or others) can experience myalgia, cramps, stiffness, spasm, or weakness affecting exercise tolerance. The patient needs to see the primary care physician to have the dose or medication changed. Incorrect Choices: Determining the appropriate exercise intensity is within the scope of a physical therapist’s practice. A physical therapist (PT) is the appropriate professional in this case, so no referral is needed. These signs and symptoms are not consistent with cirrhosis or gallbladder disorders. Exercise would not worsen this condition.

Answer 27

B- Slow rocking on therapy ball Relaxation can be achieved using slow rocking (slow vestibular stimulation). Incorrect Choices: Rhythmic stabilization is a proprioceptive neuromuscular facilitation (PNF) technique used to improve postural stability. Spinning and rolling on a scooter board are interventions used to increase mobility based on fast vestibular stimulation.

Answer 28

D- Exercises targeting hip/knee muscles According to the Patellofemoral Pain Clinical Practice Guidelines (CPG; see Box 2-8), there is strong evidence to support the prescription of therapeutic exercises that target both the hip and knee musculature. Hip exercises should focus on the gluteal muscles. Knee exercises may include both weightbearing and non-weightbearing exercises targeting the quadriceps and hamstring muscles. Incorrect Choices: According to the Patellofemoral Pain CPG, there is only moderate evidence for the use of the other three answer choices. Running gait retraining, patellar taping, and patellofemoral knee orthoses are all interventions that physical therapists may consider in patients with patellofemoral pain. Running gait retraining may include multiple sessions of cuing to adopt a non-rearfoot strike pattern, cuing to increase cadence, and cuing to reduce peak hip adduction.

Answer 29

D- Concurrent validity Concurrent validity is a type of criterion validity. It is used when comparing two measures at the same time to determine if the experimental measure (in this case the smartphone video) can be used as a substitute for the reference measure/gold standard (three-dimensional motion capture). Incorrect Choices: Face validity indicates that a measure appears to measure what it is intended to measure. It is the weakest form of validity. Content validity is used to determine if the items that make up an instrument represent all possible content that defines the variable of interest. Predictive validity is a type of criterion validity and is used to determine if an experimental measure can predict a future outcome.

Answer 30

A- 1 MHz and 1.5 watts/cm2. 1 MHz MHz frequency is recommended for target tissue deeper than 2 cm, and 1.5 watts/cm² would increase the rate of heating, allowing it to be treated in a reasonable time frame. Incorrect Choices: The frequency 3 MHz does not penetrate past 2 cm and would not be effective at the hip. A rate of heating of 0.5 watts/cm² intensity is very slow and would result in a prolonged treatment time.

Answer 31

D- Reapply a new hydrocolloid dressing and record the findings in the chart. Hydrocolloidal dressings are typically changed every 3 to 5 days or when drainage leaks out. An odor and yellowish color is to be expected as the dressing material melts. Incorrect Choices: The decision about what type of dressing to apply to a wound is the physician’s in collaboration with the wound care team. This is not an emergency situation.

Answer 32

A- Dorsal translation of the metacarpal on the trapezium. The carpometacarpal joint of the thumb is considered a saddle joint in which the articular surface geometry is generally concave in one plane and convex in a plane perpendicular to the other. The proximal joint surface of the first metacarpal is generally convex in the palmar to dorsal direction and concave in the medial to lateral direction. The articular surface of the base of the first metacarpal typically presents as the convex member of this joint when movement occurs in palmar abduction. Thumb palmar abduction thus involves a convex metacarpal surface moving on the concave surface of the trapezium. Following the traditional concave/convex rules of motion, one would expect a combination of palmar roll and dorsal translatory motion of the metacarpal on the trapezium during palmar abduction. In this case, a therapist would be sure to evaluate dorsal glide of the metacarpal on the trapezium. Incorrect Choices: The other examples of joint play motion are not congruent with palmar abduction of the thumb.

Answer 33

C- Sustaining pain levels of at least 2 out of 4 on the claudication scale during exercise. It has been established that in order to generate collateral circulation in patients with ischemia (i.e., claudication), patients need to exercise with at least moderate claudication pain. This level of blood and oxygen deprivation over time initiates the generation of collateral circulation. This correlates to 2 out of 4 on the claudication scale. Incorrect Choices: The ABI is not practical to assess during exercise because the patient cannot be moving during this test. While the RPE and HRmax are at moderate levels, this may not be at an intensity that elicits claudication symptoms.

Answer 34

B- Hamstrings are fully ranged to 110 degrees in supine. Hamstrings need to be fully ranged to 110 degrees in the supine position. This allows for function in the longsitting position (e.g., dressing, leg management during transfers). Incorrect Choices: Ranging the hamstrings or low back extensors in long sitting will result in overstretched low back extensors (needed for stability in sitting). The long finger flexors are ranged into full extension with wrist flexion (not wrist extension). This allows the hand to be used functionally for tenodesis grasp.

Answer 35

B- Mouth opening The muscles involved in opening include the lateral pterygoid, anterior head of the digastric muscle, and suprahyoid muscles. Incorrect Choices: The muscles that assist with mouth closing are the masseter, temporalis, medial pterygoid, and lateral pterygoid. The muscles that assist with protrusion are the temporalis, medial pterygoid, and lateral pterygoid. The muscles that assist with retrusion are the temporalis and suprahyoid muscles.

Answer 36

C- Medial cord brachial plexopathy The patient’s history and physical examination findings are most consistent with medial cord brachial plexopathy. This can occur secondary to a Pancoast tumor (tumor of the upper lobe of the lung). Smoking and a past history of cancer are risk factors for this type of tumor. Incorrect Choices: Isolated ulnar nerve involvement does not explain the patient’s weakness in other C8-T1 muscles that are not innervated by the ulnar nerves. It also does not explain the patient’s more proximal medial arm and forearm sensory loss. Medial and ulnar compression at the axilla are also not consistent with the patient’s symptoms, and specifically the involvement of the median nerve would result in weakness in forearm flexors and pronator teres (non C8-T1 muscles), as well as sensory loss of the right palmar hand, thumb, index, long and ring fingers. C8-T1 radiculopathy would explain the majority of the patient’s findings, but if these nerve roots were involved the patient would also have weakness of radial-C8 innervated muscles.

Answer 37

B- Systemic review and meta-analysis of RCTs Systematic review including meta-analysis of randomized controlled trials (RCTs) provides the best research evidence of effectiveness of an intervention. Incorrect Choices: Meta-analysis is not applied to cohort studies or multiple case studies. While an RCT can provide strong evidence of the effectiveness of an intervention, evidence derived from a meta-analysis that combines multiple RCTs is stronger.

Answer 38

C- Caregiver training for contact guarding during level walking and stairs. Caregiver training with safety instruction in contact guarding during level walking and stairs is the best choice to keep this patient functional in the home environment. Incorrect Choices: Manual balance perturbation training will likely result in a rigid response, decreasing use of normal synergistic movements. This patient should be kept safe and ambulatory for as long as possible and not be relegated to a wheelchair. A rolling walker is contraindicated for patients with a forward, flexed posture (typical in patients with Parkinson’s disease).

Answer 39

C- Slightly bluish, slate-colored discoloration. Slightly bluish, grayish, slate-colored discoloration of the skin along with clubbing of the nails is characteristic of chronic hypoxia. Incorrect Choices: Pallor (lack of skin color, paleness) is indicative of anemia, internal hemorrhage, or lack of sunlight exposure. Yellowish discoloration of the skin is indicative of jaundice (liver disease). Cherry-red discoloration of the skin is indicative of carbon monoxide poisoning.

Answer 40

A- Range of motion (ROM) exercises and prevention of deformity. Range of motion (ROM) exercises and prevention of deformity are important elements of the plan of care. Incorrect Choices: Lightweight splints are not an initial priority and can contribute to contracture development if worn too long. Furthermore, there are no reports of arthralgia in this case. Regular exercise is important but should not be aggressive (resistive training). Also, long-term use of corticosteroids puts this patient at risk for osteoporosis. Aerobic (treadmill) training might be indicated but is not an initial priority. Splints to provide joint protection are also not an initial priority.

Answer 41

B- Fasciculations with potential lower motor neuron (peripheral nervous system) involvement. The patient is having pronounced fasciculations in multiple muscles in the anterior, lateral, and posterior compartment of the leg, consistent with peripheral nervous system involvement. These findings should be correlated with lower extremity reflex, strength, and sensory testing to determine the most likely cause of peripheral nervous system pathology (e.g., radiculopathy, polyneuropathy, mononeuropathy, motor neuron disease). Incorrect Choices: Muscle spasticity would be velocity dependent and occur with movement (e.g., clonus, Hoffman’s sign, hyperreflexia) and less likely to be seen at rest. Myotonia is caused by dysfunction in the muscle membrane and is often associated with inherited myopathic disorders. Individuals with myotonia have difficultly relaxing the muscle (e.g., releasing their grip on objects). Fibrillations are not visible and can only be seen on needle EMG examination. Fibrillations are pathologic and consistent with peripheral nervous system damage to motor axons and/or the anterior horn cell.

Answer 42

A- Impaired auditory comprehension. Fluent aphasia is characterized by impaired auditory comprehension and fluent speech that is of normal rate and melody (e.g., Wernicke’s aphasia). Incorrect Choices: Nonfluent aphasia is characterized by speech that is slow, hesitant, awkward, interrupted, and produced with effort (e.g., Broca’s aphasia). Patients tend to have good awareness of their deficit and comprehension. Impaired articulation characterizes the patient with dysarthria (a motor speech disorder).

Answer 43

B- Crossed straight leg raise. This question requires knowledge of lumbar spine musculoskeletal special tests along with the application of their established sensitivity and specificity values. The crossed straight leg raise (SLR) is considered to be a highly specific test, which when positive helps to rule in the diagnosis of a herniated nucleus pulposus or lumbosacral radiculopathy. See Table 2-21 for a summary of the diagnostic accuracy of lumbar spine and pelvis special tests. Incorrect Choices: The SLR (Lasegue’s) test is a highly sensitive test and is therefore helpful in ruling out a lumbosacral radiculopathy when negative. The SLR test is an integral part of a comprehensive physical examination of a patient with LBP, but given its poor specificity, it is not helpful for ruling in a lumbar radiculopathy. The prone instability test is clinically useful for assessing lumbar spine instability. The femoral nerve traction test is helpful for assessing neurological dysfunction involving the femoral nerve and/or lumbar nerve roots L2–L4.

Answer 44

C- Full-thickness infraspinatus tear The finding of weak and pain-free resisted motion during the examination is suggestive of a complete muscle or tendon tear. The fact that this finding occurs with resisted external rotation indicates that the infraspinatus, a shoulder external rotator, is involved. The subscapularis is a shoulder internal rotator. Incorrect Choices: A key characteristic of adhesive capsulitis is that active and passive motions of the joint are both limited in the same directions. In this scenario, the patient had full passive shoulder external rotation, which is the motion that tends to be most significantly limited in patients with adhesive capsulitis. Other than the fall, none of the findings listed in the question stem are suggestive of shoulder instability.

Answer 45

B- External rotation lag sign. The external rotation lag sign is a good test to rule in full-thickness infraspinatus tears with an associated +LR of 7.2. This test is recommended with a moderate strength of evidence in the Rotator Cuff Disorders Clinical Practice Guidelines (see Box 2-2). The examination finding of weak and pain-free resisted external rotation is also suggestive of a complete tear. Incorrect Choices: The Jobe and full can tests are useful for ruling in a diagnosis of a full-thickness supraspinatus tear. The Hawkins-Kennedy test is a screening test that can be used to rule out a partial rotator cuff tear or rotator cuff tendinopathy.

Answer 46

B- Scalenes The phrenic nerve arises from the neck (C3–5) and innervates the diaphragm. The diaphragm is responsible for 45% of the air that enters the lungs during quiet breathing. During quiet breathing, the predominant muscle of respiration is the diaphragm. As it contracts, pleural pressure drops, which lowers the alveolar pressure and draws in air down the pressure gradient from mouth to alveoli. Expiration during quiet breathing is predominantly a passive phenomenon; as the respiratory muscles relax, the elastic lung and chest wall return passively to their resting volume. With paralysis of the diaphragm, the accessory muscles of respiration should be strengthened. These include the scalenes and sternocleidomastoid. Incorrect Choices: During active expiration, the most important muscles are those of the abdominal wall (including the rectus abdominis, internal and external obliques, and transversus abdominis), which drive intra-abdominal pressure up when they contract and thus push up the diaphragm, raising pleural pressure, which raises alveolar pressure, which in turn drives air out. These muscles do not substitute for diaphragmatic function.

Answer 47

B- Rhythmic stabilization during holding in kneeling. Rhythmic stabilization is a proprioceptive neuromuscular facilitation (PNF) technique designed to improve stability. The high kneeling position is a good choice to begin with for the patient with pronounced ataxia. The posture is upright; while the center of mass (COM) is lowered, the degrees of freedom are reduced by kneeling (foot and ankle control not required), and the base of support (BOS) is increased over standing. Incorrect Choices: Splinting and touch-down support are compensatory interventions not likely to improve recovery. Perturbed balance activities are contraindicated for the patient with poor postural stability and pronounced ataxia. Stabilizing reversals in side-lying are also not indicated, as the side-lying position does not require upright control.

Answer 48

C- Patellar tilt The patellar tilt test is a nonprovocative test used to identify reduced patellar mobility (positive test), which prompts a moderate change in the likelihood of patellofemoral pain being present. Specifically, the test is used to determine the structural tightness of the lateral patellar retinaculum. The test also assists in classifying patients into the category of patellofemoral pain with mobility impairments. See Box 2-8 for the Patellofemoral Pain Clinical Practice Guidelines. Incorrect Choices: The Thessaly test is a pain provocation test for meniscal injuries. The patellar apprehension test is utilized to determine if patellar instability is present. The Noble compression test is a provocative test for iliotibial band friction syndrome.

Answer 49

D- Myositis ossificans. Soft tissues that were injured in a traumatic event initially develop a hematoma and subsequently can develop into myositis ossificans. Myositis ossificans is a benign, ossifying soft-tissue lesion typically occurring within skeletal muscle, usually in adolescents and young adults. The most frequent symptoms and signs are pain and tenderness with a soft tissue mass. Approximately 80% of cases arise in the large muscles of the proximal extremities. Incorrect Choices: A stress fracture is an overuse injury. Bone is constantly attempting to remodel and repair itself, especially when extraordinary stress is applied. When enough stress is placed on the bone, it causes an imbalance between osteoclastic and osteoblastic activity, and a stress fracture may appear. Insidious onset of pain and swelling over the affected region is the most important complaint, initially during the activity. Neoplasms, or cancer of bone, change the appearance of bone on an x-ray. Bone may look ragged or may appear to have a hole in it. Hematomas look very different from tumors or bones on an x-ray because they are mostly fluid, and tumors and bones are solid.

Answer 50

A- Hypotension and dizziness. All of these medications lower blood pressure. If the dosage is too great for patients, they will be hypotensive and likely feel dizzy. Incorrect Choices: Beta-blockers and calcium antagonists control arrhythmias. All medications stabilize blood pressure. If the dose of all these medications is too great, then the patient might experience extreme fatigue.

Answer 51

D- Erythrocyte sedimentation rate. Polymyalgia rheumatica is a systemic inflammatory disorder that primarily affects proximal muscles in the shoulder and pelvic girdles, and muscular arteries such as the temporal artery. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood tests are general markers of inflammation and are markedly elevated in patients with the disorder. In addition to those described in the question stem, common clinical findings include weakness, malaise, low grade fever, sweats, weight loss, and depression. Incorrect Choices: Myelin basic protein levels are determined following a lumbar puncture with aspiration of cerebrospinal fluid. Elevated myelin basic protein levels are suggestive of demyelinating diseases such as multiple sclerosis. Elevated serum acid levels are seen in patients with gout and may be seen in patients with other conditions such as diabetes, hypothyroidism, and obesity. Creatine kinase levels are used to help diagnose conditions associated with muscle damage such as rhabdomyolysis and myocardial infarction.

Answer 52

C- Coma Recovery Scale-Revised. The Coma Recovery Scale-Revised examines multiple domains (auditory, visual, motor, verbal, communication, and arousal) of consciousness and function to include brain stem reflexes (pupillary light reflex, corneal reflex, spontaneous eye movements, oculocephalic reflex, and postural responses). It is recommended for use in multiple settings (acute care, inpatient/outpatient rehabilitation, long-term acute care/skilled nursing) and patients with various health conditions (TBI, stroke, brain tumor) that result in altered levels of consciousness. Incorrect Choices: The Glasgow Coma Scale (GCS) is typically used to assess acute concussions/TBIs, but is limited to assessing eye, verbal, and motor responses (see Table 3-14). The Rancho Los Amigos Levels of Cognitive Functioning (LOCF) is recommended for various settings and is used to delineate eight levels of cognitive and behavioral function in patients recovering from with moderate to severe TBI (See Table 3-15). Although commonly used, the GCS and Rancho Los Amigos LOCF do not specifically include assessment of brain stem reflexes. The Glasgow Outcome Scale-Extended is a structured interview that does not include physical examination items. It is most often used in research studies to classify global functional outcome states (death, vegetative, moderate/severe disability) for patients who have experienced a TBI.

Answer 53

B- Mini-BEST The patient's past falls are a result of delayed reactive postural control (the ability to recover balance after an external perturbation). The Mini-BEST has strong psychometric properties and measures various domains of balance to include reactive postural control (see Table 3-9). The Mini-Best is also recommended by the APTA Neurology Section Parkinson's Disease EDGE Task Force (see Table 3-19). Incorrect Choices: The BBS, FGA, and TUG-Cog do not directly assess reactive postural control.

Answer 54

B- Crackers or bread. Slowly absorbed carbohydrates (crackers, bread, or pasta) can help prevent delayed-onset hypoglycemia. Incorrect Choices: Rapidly absorbed carbohydrates (e.g., fruit juice, candy, honey) are given during exercise to help prevent hypoglycemia. Foods with saturated fats (beef jerky, string cheese) should be limited. Carrot sticks and cherry tomatoes do not have major effects in preventing hypoglycemia.

Answer 55

D- Pressure-tolerant weight bearing is occurring. Pressure areas of the typical transtibial residual limb include the patellar tendon, the medial tibial plateau, the tibial and fibular shafts, and the distal end. Incorrect Choices: These are expected areas of redness. All other choices would not result in that pattern of redness.

Answer 56

C- Go upstairs foot-over-foot Going up stairs foot-over-foot (reciprocal stair climbing) is a developmental skill normally achieved by 2 years. Incorrect Choices: The ability to hop on one foot and stand on tiptoes is normally achieved by 4 years. The ability to jump with two feet is normally achieved by 3 years.

Answer 57

C- Percussion and shaking can be done in the area surrounding the chest tube. It is possible to complete manual techniques in the area of the chest tube. It is often the area in most need of airway clearance. It is important to consider pain management when doing this intervention. Incorrect Choices: Percussion and shaking are not contraindicated, but it is important to consider that this may be agitating to patients with a severe brain injury. Also, placing the patient in Trendelenburg should be avoided in the acute period to eliminate increases in intracranial pressure. Percussion and shaking can be completed bilaterally and with the chest tube in place. It is important to attend to patient comfort and chest tube positioning when in right side-lying.

Answer 58

C- A posterior rolling walker. A posterior rolling walker is used to promote an upright posture (eliminates the forward lean seen in use of the standard anterior walker). The addition of wheels improves walking speed and reduces energy expenditure. Incorrect Choices: All other choices do not achieve these same goals.

Answer 59

The attachments of the medial meniscus include the semimembranosus tendon, MCL and fibrous capsule, and medial meniscopatellar ligament. During open chain resisted knee flexion, the semimembranosus tendon will pull on the posterior aspect of the medial meniscus and in doing so may tear the surgical repair. Resisted knee flexion should be avoided for several weeks postoperatively until the repair site is stable. Incorrect Choices: Ankle pumps do not produce any adverse forces on the healing meniscus and are beneficial development postsurgically and during periods of immobilization for prevention of DVT. Isometric quad sets produce little tibiofemoral joint motion. Resisted knee extension produces some anterior meniscal motion via the medial meniscopatellar ligament, but the amount of translation is minimal and not harmful to the repair.

Answer 60

C- Time: >35 minutes; Intensity: 90%–95% of peak VO2; Frequency: 2–3 times/week; Duration: 8–12 weeks. Choice 3 incorporates all parameters suggested by the Clinical Practice Guideline for the Management of the Patient with Heart Failure (see Table 4-18). Incorrect Choices: A training period of 5–10 minutes is too short and 40%–50% of peak VO2 is not a sufficient intensity. A frequency of 5–7 times/week is too often and increases risk for injury. A duration of 4–6 weeks is too short to improve aerobic fitness.

Answer 61

C- Visual Analog Scale (Fatigue) and 2-minute walk test. The visual analog scale (Fatigue) measures self-report of fatigue for daily life, grooming, and household/occupational activities. Normative values for the 2-minute walk test have also been established for patients with multiple sclerosis. Incorrect Choices: None of the other options, except for the Fatigue Scale of Motor/Cognitive Function, directly measure the patient's primary impairment of fatigue. Additionally, secondary to the recent exacerbation it is important that the patient is not overexerted with more demanding (e.g., running) and increased duration activities (e.g., 6-minute walk test). Please see Table 3-18 for the APTA Neurology Section Multiple Sclerosis EDGE Task Force recommended examination items.

Answer 62

A- Double or blurred vision, decreased voice projection, and difficulty with repetitive sit to stand. Patients with myasthenia gravis (MG) typically have involvement of bulbar (extraocular, facial, and muscles of mastication) and proximal limb-girdle muscles. If overworked, patients will exhibit visual changes and difficulty with prolonged speaking, eating, or reading. They will also have weakness with repetitive testing of exercise of proximal limb muscles. Incorrect Choices: Shortness of breath, syncope, and cold distal extremities are more consistent with cardiovascular and respiratory conditions and not typically associated with MG unless it is severe (e.g., myasthenic crisis). Hyperreflexia and muscle spasm are more closely associated with upper motor neuron lesions and CNS involvement. Joint and muscle pain, inability to sleep, and irritability are more consistent with an active arthritic process or fibromyalgia.

Answer 63

B- Encourage expression of feelings and memories. When treating the patient with a terminal illness, the therapist should provide support and understanding of the grief process, encourage expression of feelings and memories, and respect privacy, cultural, or religious customs. Incorrect Choices: The therapist needs to maintain the boundaries of treatment and not discharge the patient. Keeping friends and relatives updated would violate the patient’s privacy unless specific permission is given by the patient. The patient should be kept involved in the decision planning in order to reduce anxiety.

Answer 64

D- Valgus position of the heel. Excessive foot pronation is known as pes planus or pes valgus—a “flat foot deformity.” The foot remains in pronation at the subtalar joint during weightbearing. The slight pronation of both the subtalar and transverse tarsal joints seen in normal stance is exaggerated. Incorrect Choices: The question asks what this observation during gait would reveal. Many patients have pronated feet without plantar fasciitis. Overpronation can cause stress or chronic inflammation on the plantar fascia ligament (plantar fasciitis) and lead to numerous related foot and ankle injury conditions. Over time, the force of the impact is absorbed into the tissues, which can lead to conditions such as Achilles tendinitis, bunions, heel spurs, metatarsalgia, Morton’s neuroma, plantar fasciitis (heel and arch pain), posttibial tendinitis, shin splints, and tarsal tunnel syndrome, as well as knee pain (chondromalacia, iliotibial band syndrome), hip pain, and lower back discomfort. Related conditions include corns, calluses, and hammertoes. Forefoot valgus and varus position of the heel are not congruent with foot pronation.

Answer 65

D- Passively extend the wrist and actively flex the MCP joints. Goals during the first few weeks include preventing tendon rupture and promoting tendon healing as well as edema and pain control. For scar management, perform active range of motion (AROM) flexion, isolated joint and tendon gliding (hook and straight fist). Perform passive extension via elastic recoil of the dynamic splint, 10 to 20 reps hourly. Begin active MP flexion to 30 to 40 degrees (via flexion block on dynamic splint). Progress MP flexion as tolerated. Perform wrist and digit passive range of motion (PROM) in extension and tenodesis out of splint 10 repetitions hourly. Avoid making a full fist as this may place too much stress on the repair. The wrist is splinted in 40 to 45 degrees extension with 0 to 20 degrees of MP flexion and 0 degrees of IP flexion. Incorrect Choices: One would not want any active extension as this could disrupt the repair. There are many different protocols, but many avoid any active extension until 4 weeks postop. Passively extending the wrist and MCP joints would be safe but would not help with preventing contractures of the repaired extensor tendons.

Answer 66

D- Dependent edema. If the right ventricle fails, the increased fluid will back up. Traveling backward from the right ventricle, the edema goes into the right atrium and then the periphery. This causes dependent edema. Incorrect Choices: An inability to lie flat occurs when there is edema in the lungs (paroxysmal noctural dyspnea). This doesn’t occur in isolated right ventricular failure. Exertional dyspnea occurs in right ventricular failure as a result of deconditioning after a period of time. It is not an early indication. Pulmonary edema results from increased intravascular pulmonary pressures. This doesn’t occur in right ventricular failure because there is a reduction in forward flow, and therefore there are lower pulmonary arterial pressures.

Answer 67

A- Do you have difficulty breathing? Symmetrical bilateral edema can signify congestive heart failure (CHF). Moderate to severe CHF can lead to pulmonary edema and subsequent shortness of breath. Intermittent compression may shift a significant amount of fluid from the periphery to the core circulation, thus increasing the load on the heart and immediate risk for a cardiac event. It is important to screen patients for shortness of breath as heart failure with pulmonary edema are contraindications to intermittent pneumatic compression. Incorrect Choices: A bull’s-eye rash is associated with Lyme’s disease and may cause joint pain and myalgia but would not result in bilateral lower extremity edema. Asking a patient if they experienced a fall and ankle sprain would explain unilateral localized pain and swelling but not bilateral edema. A gradual weight change over 1 year is less concerning than a rapid fluctuation in weight over days to weeks. Specifically, rapid weight changes are associated with high-risk health conditions (e.g., CHF, cancer, liver, or renal disease) that are recognized as contraindications to intermittent compression.

Answer 68

A- Prone, with no pillow under the hips or abdomen. Neutral or extended position of the spine allows for separation of the vertebral bodies while preventing excessive stress on the posterior structures. Incorrect Choices: All of the other choices place the person in a flexed position, which places greater stress on the posterior structures of the disc. In the early stages of treatment, a flexed position is inadvisable with a posterior herniation.

Answer 69

B- Circumduction. Circumduction is the most likely compensatory gait deviation when tibial advancement is limited (e.g., spasticity of plantar flexors). Incorrect Choices: Trendelenburg gait is a lateral trunk lean that results from a weak or paralyzed gluteus medius on the stance side. An exaggerated flexion synergy results in flexion, abduction, and external rotation at the hip when the leg is lifted. An exaggerated extension synergy results in extension, adduction, and internal rotation (a scissoring pattern).

Answer 70

C- Pulmonary embolism due to use of birth control. Patients taking hormonal birth control are at increased risk for pulmonary embolism or deep venous thrombosis. If a patient taking hormonal contraceptives experiences a marked increase in their respiratory and heart rates, they should be referred for emergency medical treatment. Normal adult respiratory rates are 12–20 breaths per minute and the normal adult heart rate is 60–100 beats per minute. Incorrect Choices: It is highly unlikely that anxiety would cause a drop in SpO2. Pleural effusion due to lung cancer is very unlikely in a premenopausal woman with no history of smoking. A tension pneumothorax typically occurs as a result of trauma and does not usually result from exercise.

Answer 71

B- Remove the patient from the heat and immerse the patient in cold water. This patient has CNS dysfunction and heat induced symptoms consistent with heat stroke. It is important to recognize that profuse sweating may occur in patients with heat stroke and it is incorrect to assume that patients must be hot and dry. Finally, the best response for survival is to cool the patient on-site using full body immersion in cold water while protecting the airway. Incorrect Choices: Patients should not be transported until they have been cooled by cold water immersion. Spraying the patient with cold water is not the best way to cool on-site if immersion is available. Patients with symptoms consistent with heat stroke should not be provided oral fluids.

Answer 72

D- Psoriasis The image depicts psoriasis, an autoimmune disease characterized by erythematous plaques covered silver scales. Psoriasis causes dry and itchy skin as is commonly seen at the ears, scalp, knees, elbows, and genitalia. Incorrect Choices: Eczema, also known as dermatitis, results in itchy skin, but is not associated with silver plaques or joint pain. Fungal infections are characterized by a white coating (fungal spores) over the skin that causes erythema, itching, and pain. Scleroderma is a diffuse autoimmune disease that causes the skin and connective tissue throughout the body to be tight, firm, and inflamed. It is commonly seen in the fingers and toes and is also associated with Raynaud's phenomenon.

Answer 73

A- Motor aphasia. This patient’s involvement of the face and upper extremity greater than the lower extremity is highly suggestive of a middle cerebral artery (MCA) stroke. Various types of aphasia, including motor aphasia, are common in patients following a left MCA stroke. Incorrect Choices: Visual agnosia is seen in patients who have a posterior cerebral artery stroke. Urinary incontinence and lower greater than upper extremity involvement are associated with an anterior cerebral artery stroke. Although facial weakness is common following an MCA stroke, it typically only involves the lower half of the contralateral face. Complete hemifacial paralysis occurs with peripheral involvement of the facial nerve (CN 7) and is most commonly seen with Bell’s Palsy. For additional information see Chapter 3 Neurovascular syndromes: Cerebral and Brain Stem Strokes.

Answer 74

D- Static sitting with PT assisted weighting bearing of the right upper extremity. Secondary to the flaccid upper extremity and impaired sitting balance it is important to initially protect the upper extremity. Assessing the patient’s ability to maintain static sitting while the therapist also introduces weight-bearing into the involved extremity is initially warranted. Incorrect Choices: PT assisted sit to stand transfers are appropriate once the PT has assessed and determined the patient’s anticipatory postural control and ability to protect the involved extremity with position changes. Constraint induced movement therapy (CIMT) is not appropriate at this stage as the patient is reliant on the uninvolved extremity for stability. Additionally, the patient needs to demonstrate static sitting stability and awareness of the involved limb prior to initiating dynamic sitting activities (i.e., perturbation exercises).

Answer 75

B- Intense headache. Intense or increasing headache is a reason for concern following a stroke and/or administration of t-PA following an ischemic stroke. Changes in blood pressure are also associated with t-PA side effects and specifically bleeding causing an intracranial hemorrhage. See Table 3-14 for additional information on tissue plasminogen activator(t-PA) side effects and PT implications. Incorrect Choices: Answer choice # 1, 3, and 4 are not associated with t-PA side effects. Healthcare providers should consistently ask patients about headaches and monitor vital signs acutely in patients who have had a stroke and administration of t-PA.

Answer 76

A- Use frequent reinforcements for all desired behaviors. Behavioral modification is best achieved through use of positive reinforcements for all desired behaviors. Negative behaviors should be ignored, not reprimanded. Self-correction is not a form of behavior modification.

Answer 77

B- Grade I/II anterior-to-posterior. The therapist notes an empty end-feel during knee flexion suggesting that pain or muscle guarding is limiting the motion. No tissue resistance is encountered by the therapist during the passive range of motion assessment of the patient's knee. Grade I and II mobilization techniques are used to decrease pain and muscle guarding. This finding must be addressed first before considering the use of end-range mobilization techniques (grade III and IV) to improve motion. Based on the concave-convex rule, a posterior glide (anterior-to-posterior) would best facilitate knee flexion. See Table 2-1 for a review of the concave-convex rule application to peripheral joints. Incorrect Choices: Mobilizing the tibia in a posterior-to-anterior direction would be appropriate to improve limited knee joint extension. Grade III and IV joint mobilizations are used to improve motion by stretching tight joint capsules, ligaments, and other soft tissue structures at the end-range of motion.

Answer 78

A- Require longer periods of warm-up and cool-down. A patient recovering from cardiac transplantation will require longer periods of warm-up and cool-down because physiological responses to exercise and recovery take longer. Incorrect Choices: Low- to moderate-intensity resistance training can be performed. Aerobic exercise should be performed 4–6 times/week, while progressively increasing the duration of training from 15–60 minutes per session. (Source: ACSM Guidelines for Exercise Testing and Prescription)

Answer 79

D- Pool walking, slow walking, 30 minutes/session, 2–3 times/week. Low aerobics activities are best. Aquatic exercise (walking in a pool) has been shown to decrease pain and stiffness while increasing cardiovascular conditioning and strength. Exercise should start slow (mild intensity), 30-minute duration with rests as needed (interval training), 2–3 times per week. Incorrect Choices: All other choices are too aggressive (intensity, duration, frequency) and are likely to increase the patient’s symptoms, resulting in increased pain. It is particularly important to start slowly. Overdoing activities can make the patient feel worse and discontinue therapy.

Answer 80

A- Active range-of-motion (AROM) exercises and activities of daily living (ADLs) exercises. AROM and ADL exercises are beneficial and safe for this patient. Incorrect Choices: Exercise testing and training is contraindicated in patients with cancer whose platelets are <50,000, WBC <3,000, or Hemoglobin <10 g/dL. Additonal contraindications include significant bony metastases, severe cachexia, severe fatigue, or poor functional status.

Answer 81

C- Have the patient sit down and administer orange juice for hypoglycemia. Hypoglycemia or abnormally low blood glucose, results from too much insulin (insulin reaction). It requires accurate assessment of symptoms and prompt intervention. Have the patient sit down and give an oral sugar (e.g., orange juice). Incorrect Choices: Once the patient is stabilized, the physician should be notified. Emergency services are generally not needed. Profuse sweating does not usually accompany orthostatic hypotension.

Answer 82

A- 20 minutes of cryotherapy, every 2–3 hours, for 3 continuous days. This is an acute inflammatory condition. Cryotherapy is used to limit or reduce edema formation in acute situations. It should be applied as soon as possible and multiple times a day during the acute cycle. Under normal circumstances consistent vasoconstriction due to cryotherapy lasts up to about 20 minutes during the cooling cycle, which is why periods of cooling longer than 20 minutes are not recommended. Incorrect Choices: Thirty minutes of cryotherapy is longer than the recommended 15–20 minutes and has the potential for a hunting response. The hunting response is a phenomenon when tissue temperatures get too cold or persist too long, resulting in reflexive vasodilation. Additionally, icing two times a day is insufficient to control or prevent acute traumatic edema. Ultrasound is not recommended to limit edema formation, and three times a week of any modality is insufficient to control acute edema.

Answer 83

B- Is contraindicated during the first two months. Resistive training after cardiothoracic surgery is restricted to 5 to 8 pounds for the first 5 to 7 weeks. Moderate to heavy resistance exercises are contraindicated. Incorrect Choices: Resistance training can begin 5 weeks postsurgery, including 4 weeks of consistent participation in a supervised cardiac rehabilitation endurance training program. Once cleared, initial loads for the upper body should be 30%–40%, one repetition max, and 50%–60% for hips and legs. (Source: ACSM Guidelines for Exercise Testing and Prescription)

Answer 84

B- Cycling. The best choice is cycling, which does not involve the strenuous movements of the upper extremities that are required to perform the other activities. Incorrect Choices: Softball, bowling, and jogging are high-risk activities for patients with suspected lymphedema because of the strenuous nature and the frequent, sometimes aggressive rotational movements of the upper extremities. Softball and bowling require batting the ball and throwing from an over- or underhand position, with the potential for high centrifugal forces. Jogging is also not recommended for those at risk for developing lymphedema because of the forces placed on the upper extremity during arm carriage.

Answer 85

A- Sulfamylon. Sulfamylon penetrates through eschar and provides antibacterial control. Incorrect Choices: Silver nitrate and nitrofurazone are superficial agents that attack surface organisms. Panafil is a keratolytic enzyme used for selective debridement.

Answer 86

B- Cataracts. Cataracts which cause a clouding of the lens, result in a gradual loss of vision; central vision is lost first, then peripheral. Incorrect Choices: Glaucoma produces the reverse symptoms: loss of peripheral vision occurs first, then central vision, progressing to total blindness. Hemianopsia is a field defect in both eyes that often occurs following stroke. There was no mention of cerebrovascular accident (CVA) in the question.

Answer 87

C- Semmes-Weinstein monofilament testing. There is strong evidence to support the utilization of Semmes-Weinstein monofilament testing in patients with suspected CTS (see Box 2-3). Clinicians should assess the middle finger using a 2.83 or 3.22 monofilament as threshold normal for light-touch sensation and static 2-point discrimination. In patients with suspected moderate to severe CTS, clinicians should assess the thumb or index finger with a 3.22 monofilament as threshold for normal. Incorrect Choices: Allen’s test is a measure of arterial blood flow to the palm and hand. A positive Finkelstein’s test is diagnostic of de Quervain’s tenosynovitis. The Watson test is used to diagnose carpal bone (scaphoid) instability.

Answer 88

A- Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is commonly used to acutely assess patient’s level of consciousness and severity of TBI (see Chapter 3 and Table 3-14). Specifically, a <13 GCS score 2 hours after injury requires immediate emergency evaluation. Incorrect Choices: The Rancho Los Amigos Levels of Cognitive Functioning is recommended for various inpatient and rehabilitation settings for patients recovering from moderate to severe traumatic injury (see Table 3-15) but is not indicated in acute concussion assessment. The duration of post-traumatic amnesia (1–7 days = moderate TBI; >7 days = severe TBI) and alteration of consciousness (>24 hours = moderate/severe TBI) are also helpful in determining the severity of TBI, but this patient’s injury only happened 3 hours ago.

Answer 89

B- Type I error. A Type I error occurs when the conclusion is made that a difference between groups exists when no difference actually exists (a difference is observed in the average scores of the sample groups, when there is no difference between groups in the population). When multiple comparisons of the same data are made in a research study, the alpha level (which is the level of acceptable risk for making a Type I error) must be adjusted to account for the multiple comparisons. Several formulas exist to calculate the alpha level based on the number of comparisons being made. Incorrect Choices: Sampling error is the natural variation in the mean score of a sample with respect to the mean of the population. Residual error is the difference between individual scores and the predicted score of the dependent variable based on the score of the independent variable. Type II error is defined as stating there is no difference between groups when a real difference exists (no difference is observed in the average scores of the sample groups, when there is a difference between group scores in the population).

Answer 90

B- Watson. The Watson test is also known as the scaphoid shift test and is a test for scaphoid instability. To perform the test, the examiner applies a distal pull to the scaphoid while moving the wrist from ulnar to radial deviation. Axial compression of the thumb (1st metacarpal) along its longitudinal axis is also used as a provocative test for diagnosing scaphoid fractures. Incorrect Choices: Finkelstein’s is a provocative special test for DeQuervain’s tenosynovitis. The Allen test is used to determine the patency of the radial and ulnar arteries in the hand. Phalen’s test is designed to compress the median nerve in the carpal tunnel and is a sensitive test for carpal tunnel syndrome.

Answer 91

D- Immobilization. Timely intervention for a scaphoid fracture is critical. The patient should be immobilized and referred to a primary care provider or emergency room with the recommendation to order radiographs. Failure to properly manage a fractured scaphoid may result in avascular necrosis of the bone due to its poor vascular supply. A thumb-spica cast is typically indicated for 5–8 weeks and sometimes longer if the fracture involves the proximal pole of the scaphoid. Incorrect Choices: Range of motion and strengthening exercises would be appropriate after the cast has been removed, but not in the initial stages. Cryotherapy is indicated but only provides temporary, symptomatic relief and does not address the gravity of the injury.

Answer 92

B- Functional training activities with assistive devices as needed to support independence. Patients with ALS who have moderate weakness in various muscles in the distal lower extremities will require assistive devices/bracing to maintain independence. Strengthening and range of motion exercises should focus on functional activities and weak muscles (<3 out 5 manual muscle testing) should not be overworked. Additionally, use of an assistive device and bracing can assist in maintaining independence while avoiding fatigue. Incorrect Choices: Breathing exercises, stretching, and rolling are for patients in the later or end stage of ALS. Daily progressive resistive exercise is not indicated for denervated and weak muscles (<3 out of 5). Transfer and wheelchair training are the focus for patients who are no longer community ambulators.

Answer 93

A- Provide suggestions to nursing for positioning for optimal motor development. Excessive handling of a premature infant can cause oxygen desaturation. It is in the best interests of the infant to limit the number of handlers. The PT’s role should be to assist nursing in developing positioning schedules, positions for feeding, infant stimulation activities, etc. Incorrect Choices: At present, there is little information provided that would necessitate the PT or PTA to be a direct caregiver to this child.

Answer 94

B- Closed-chain functional strengthening of the quadriceps femoris and hamstrings, emphasizing regaining terminal knee extension. The evaluation is suggestive of an unhappy triad injury. Closed-chain exercises are emphasized during the subacute phase to enhance functional control of the muscles surrounding the knee. Terminal extension must be achieved during this stage if normal function is to occur. Incorrect Choices: Open-chain exercise does not promote regaining functional control for the muscle surrounding the knee. Focus on the hip abductors (rather than the hamstrings) will not promote regaining functional control of the knee joint.

Answer 95

This is an emergency situation. To ensure an open airway and prevent aspiration, position the patient in side-lying with the mouth pointing toward the ground. The patient should be protected from injury by loosening restrictive clothing and removing potentially harmful nearby objects. Incorrect Choices: Supine position can be life-threatening if the tongue falls backward to restrict the airway. The patient should not be restrained as this may increase the likelihood of injury or agitation. Rescue breathing is not indicated during an active seizure. Emergency care (EMS) is required if the patient has no known history of seizures, if the seizure lasts 5 minutes or longer, or if status epilepticus occurs. C- Position the patient in sidelying with the mouth pointing to the ground.

Answer 96

A- Involvement of muscles innervated by C5–C6 nerve roots. Erb paralysis is a brachial plexus injury involving the upper trunk C5–C6 nerves with paralysis of the shoulder and elbow muscles, commonly involving the suprascapular, musculocutaneous, and axillary nerves. The limb is held in a position of adduction, forearm pronation, and wrist and finger flexion (waiter’s tip position). Incorrect Choices: Erb’s paralysis involves C5–C6, so other options would not fit spinal nerves affected. Klumpke’s paralysis is a brachial plexus injury involving the lower trunk, C8 and T1 nerves, and muscles of the forearm and hand.

Answer 97

A- Use frequent reinforcements for all desired behaviors. Behavioral modification is best achieved through use of positive reinforcements for all desired behaviors. Incorrect Choices: Negative behaviors should be ignored, not reprimanded. Self-correction is not a form of behavior modification.

Answer 98

B- Grade I/II anterior-to-posterior. The therapist notes an empty end-feel during knee flexion suggesting that pain or muscle guarding is limiting the motion. No tissue resistance is encountered by the therapist during the passive range of motion assessment of the patient's knee. Grade I and II mobilization techniques are used to decrease pain and muscle guarding. This finding must be addressed first before considering the use of end-range mobilization techniques (grade III and IV) to improve motion. Based on the concave-convex rule, a posterior glide (anterior-to-posterior) would best facilitate knee flexion. See Table 2-1 for a review of the concave-convex rule application to peripheral joints. Incorrect Choices: Mobilizing the tibia in a posterior-to-anterior direction would be appropriate to improve limited knee joint extension. Grade III and IV joint mobilizations are used to improve motion by stretching tight joint capsules, ligaments, and other soft tissue structures at the end-range of motion.

Answer 99

A- Require longer periods of warm-up and cool-down. A patient recovering from cardiac transplantation will require longer periods of warm-up and cool-down because physiological responses to exercise and recovery take longer. Incorrect Choices: Low- to moderate-intensity resistance training can be performed. Aerobic exercise should be performed 4–6 times/week, while progressively increasing the duration of training from 15–60 minutes per session. (Source: ACSM Guidelines for Exercise Testing and Prescription)

Answer 100

D- Pool walking, slow walking, 30 minutes/session, 2–3 times/week. Low aerobics activities are best. Aquatic exercise (walking in a pool) has been shown to decrease pain and stiffness while increasing cardiovascular conditioning and strength. Exercise should start slow (mild intensity), 30-minute duration with rests as needed (interval training), 2–3 times per week. Incorrect Choices: All other choices are too aggressive (intensity, duration, frequency) and are likely to increase the patient’s symptoms, resulting in increased pain. It is particularly important to start slowly. Overdoing activities can make the patient feel worse and discontinue therapy.

Answer 101

A- Active range-of-motion (AROM) exercises and activities of daily living (ADLs) exercises. AROM and ADL exercises are beneficial and safe for this patient. Incorrect Choices: Exercise testing and training is contraindicated in patients with cancer whose platelets are <50,000, WBC <3,000, or Hemoglobin <10 g/dL. Additonal contraindications include significant bony metastases, severe cachexia, severe fatigue, or poor functional status.

Answer 102

C- Have the patient sit down and administer orange juice for hypoglycemia. Hypoglycemia or abnormally low blood glucose, results from too much insulin (insulin reaction). It requires accurate assessment of symptoms and prompt intervention. Have the patient sit down and give an oral sugar (e.g., orange juice). Incorrect Choices: Once the patient is stabilized, the physician should be notified. Emergency services are generally not needed. Profuse sweating does not usually accompany orthostatic hypotension.

Answer 103

A- 20 minutes of cryotherapy, every 2–3 hours, for 3 continuous days. This is an acute inflammatory condition. Cryotherapy is used to limit or reduce edema formation in acute situations. It should be applied as soon as possible and multiple times a day during the acute cycle. Under normal circumstances consistent vasoconstriction due to cryotherapy lasts up to about 20 minutes during the cooling cycle, which is why periods of cooling longer than 20 minutes are not recommended. Incorrect Choices: Thirty minutes of cryotherapy is longer than the recommended 15–20 minutes and has the potential for a hunting response. The hunting response is a phenomenon when tissue temperatures get too cold or persist too long, resulting in reflexive vasodilation. Additionally, icing two times a day is insufficient to control or prevent acute traumatic edema. Ultrasound is not recommended to limit edema formation, and three times a week of any modality is insufficient to control acute edema.

Answer 104

B- Is contraindicated during the first two months. Resistive training after cardiothoracic surgery is restricted to 5 to 8 pounds for the first 5 to 7 weeks. Moderate to heavy resistance exercises are contraindicated. Incorrect Choices: Resistance training can begin 5 weeks postsurgery, including 4 weeks of consistent participation in a supervised cardiac rehabilitation endurance training program. Once cleared, initial loads for the upper body should be 30%–40%, one repetition max, and 50%–60% for hips and legs. (Source: ACSM Guidelines for Exercise Testing and Prescription)

Answer 105

B- Cycling. The best choice is cycling, which does not involve the strenuous movements of the upper extremities that are required to perform the other activities. Incorrect Choices: Softball, bowling, and jogging are high-risk activities for patients with suspected lymphedema because of the strenuous nature and the frequent, sometimes aggressive rotational movements of the upper extremities. Softball and bowling require batting the ball and throwing from an over- or underhand position, with the potential for high centrifugal forces. Jogging is also not recommended for those at risk for developing lymphedema because of the forces placed on the upper extremity during arm carriage.

Answer 106

A- Sulfamylon. Sulfamylon penetrates through eschar and provides antibacterial control. Incorrect Choices: Silver nitrate and nitrofurazone are superficial agents that attack surface organisms. Panafil is a keratolytic enzyme used for selective debridement.

Answer 107

B- Cataracts. Cataracts which cause a clouding of the lens, result in a gradual loss of vision; central vision is lost first, then peripheral. Incorrect Choices: Glaucoma produces the reverse symptoms: loss of peripheral vision occurs first, then central vision, progressing to total blindness. Hemianopsia is a field defect in both eyes that often occurs following stroke. There was no mention of cerebrovascular accident (CVA) in the question.

Answer 108

C- Semmes-Weinstein monofilament testing. There is strong evidence to support the utilization of Semmes-Weinstein monofilament testing in patients with suspected CTS (see Box 2-3). Clinicians should assess the middle finger using a 2.83 or 3.22 monofilament as threshold normal for light-touch sensation and static 2-point discrimination. In patients with suspected moderate to severe CTS, clinicians should assess the thumb or index finger with a 3.22 monofilament as threshold for normal. Incorrect Choices: Allen’s test is a measure of arterial blood flow to the palm and hand. A positive Finkelstein’s test is diagnostic of de Quervain’s tenosynovitis. The Watson test is used to diagnose carpal bone (scaphoid) instability.

Answer 109

A- Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is commonly used to acutely assess patient’s level of consciousness and severity of TBI (see Chapter 3 and Table 3-14). Specifically, a <13 GCS score 2 hours after injury requires immediate emergency evaluation. Incorrect Choices: The Rancho Los Amigos Levels of Cognitive Functioning is recommended for various inpatient and rehabilitation settings for patients recovering from moderate to severe traumatic injury (see Table 3-15) but is not indicated in acute concussion assessment. The duration of post-traumatic amnesia (1–7 days = moderate TBI; >7 days = severe TBI) and alteration of consciousness (>24 hours = moderate/severe TBI) are also helpful in determining the severity of TBI, but this patient’s injury only happened 3 hours ago.

Answer 110

B- Type I error. A Type I error occurs when the conclusion is made that a difference between groups exists when no difference actually exists (a difference is observed in the average scores of the sample groups, when there is no difference between groups in the population). When multiple comparisons of the same data are made in a research study, the alpha level (which is the level of acceptable risk for making a Type I error) must be adjusted to account for the multiple comparisons. Several formulas exist to calculate the alpha level based on the number of comparisons being made. Incorrect Choices: Sampling error is the natural variation in the mean score of a sample with respect to the mean of the population. Residual error is the difference between individual scores and the predicted score of the dependent variable based on the score of the independent variable. Type II error is defined as stating there is no difference between groups when a real difference exists (no difference is observed in the average scores of the sample groups, when there is a difference between group scores in the population).

Answer 111

B- Watson The Watson test is also known as the scaphoid shift test and is a test for scaphoid instability. To perform the test, the examiner applies a distal pull to the scaphoid while moving the wrist from ulnar to radial deviation. Axial compression of the thumb (1st metacarpal) along its longitudinal axis is also used as a provocative test for diagnosing scaphoid fractures. Incorrect Choices: Finkelstein’s is a provocative special test for DeQuervain’s tenosynovitis. The Allen test is used to determine the patency of the radial and ulnar arteries in the hand. Phalen’s test is designed to compress the median nerve in the carpal tunnel and is a sensitive test for carpal tunnel syndrome.

Answer 112

D- Immobilization. Timely intervention for a scaphoid fracture is critical. The patient should be immobilized and referred to a primary care provider or emergency room with the recommendation to order radiographs. Failure to properly manage a fractured scaphoid may result in avascular necrosis of the bone due to its poor vascular supply. A thumb-spica cast is typically indicated for 5–8 weeks and sometimes longer if the fracture involves the proximal pole of the scaphoid. Incorrect Choices: Range of motion and strengthening exercises would be appropriate after the cast has been removed, but not in the initial stages. Cryotherapy is indicated but only provides temporary, symptomatic relief and does not address the gravity of the injury.

Answer 113

B- Functional training activities with assistive devices as needed to support independence. Patients with ALS who have moderate weakness in various muscles in the distal lower extremities will require assistive devices/bracing to maintain independence. Strengthening and range of motion exercises should focus on functional activities and weak muscles (<3 out 5 manual muscle testing) should not be overworked. Additionally, use of an assistive device and bracing can assist in maintaining independence while avoiding fatigue. Incorrect Choices: Breathing exercises, stretching, and rolling are for patients in the later or end stage of ALS. Daily progressive resistive exercise is not indicated for denervated and weak muscles (<3 out of 5). Transfer and wheelchair training are the focus for patients who are no longer community ambulators.

Answer 114

A- Provide suggestions to nursing for positioning for optimal motor development. Excessive handling of a premature infant can cause oxygen desaturation. It is in the best interests of the infant to limit the number of handlers. The PT’s role should be to assist nursing in developing positioning schedules, positions for feeding, infant stimulation activities, etc. Incorrect Choices: At present, there is little information provided that would necessitate the PT or PTA to be a direct caregiver to this child.

Answer 115

B- Closed-chain functional strengthening of the quadriceps femoris and hamstrings, emphasizing regaining terminal knee extension. The evaluation is suggestive of an unhappy triad injury. Closed-chain exercises are emphasized during the subacute phase to enhance functional control of the muscles surrounding the knee. Terminal extension must be achieved during this stage if normal function is to occur. Incorrect Choices: Open-chain exercise does not promote regaining functional control for the muscle surrounding the knee. Focus on the hip abductors (rather than the hamstrings) will not promote regaining functional control of the knee joint.

Answer 116

C- Position the patient in sidelying with the mouth pointing to the ground. This is an emergency situation. To ensure an open airway and prevent aspiration, position the patient in side-lying with the mouth pointing toward the ground. The patient should be protected from injury by loosening restrictive clothing and removing potentially harmful nearby objects. Incorrect Choices: Supine position can be life-threatening if the tongue falls backward to restrict the airway. The patient should not be restrained as this may increase the likelihood of injury or agitation. Rescue breathing is not indicated during an active seizure. Emergency care (EMS) is required if the patient has no known history of seizures, if the seizure lasts 5 minutes or longer, or if status epilepticus occurs.

Answer 117

A- Involvement of muscles innervated by C5–C6 nerve roots. Erb paralysis is a brachial plexus injury involving the upper trunk C5–C6 nerves with paralysis of the shoulder and elbow muscles, commonly involving the suprascapular, musculocutaneous, and axillary nerves. The limb is held in a position of adduction, forearm pronation, and wrist and finger flexion (waiter’s tip position). Incorrect Choices: Erb’s paralysis involves C5–C6, so other options would not fit spinal nerves affected. Klumpke’s paralysis is a brachial plexus injury involving the lower trunk, C8 and T1 nerves, and muscles of the forearm and hand.

Answer 118

A- Skilled nursing facility. A skilled nursing facility is the best facility because the patient continues to require nursing care for the open wounds. Initiation of physical therapy when this patient is able is also available. Incorrect Choices: Discharge to home would be premature because the patient is unable to transfer. Custodial care involves medical or nonmedical care that does not seek a cure. A rehabilitation hospital is not appropriate at this time, because the patient cannot actively participate in rehabilitation 3 hours/day.

Answer 119

C- Central sensitization. Central sensitization (CS) occurs with increased excitatory and decreased inhibitory neural signaling in the central nervous system resulting in hypersensitivity. This process occurs even though there is no current evidence of actual or threatened tissue damage in the periphery (nociceptive pain) or a lesion or disease in the somatosensory system causing the pain (neuropathic pain). This patient exhibits various signs and symptoms of central sensitization to include intense and nonlocalized pain, sporadic pain at rest, allodynia, and secondary hyperalgesia. Incorrect Choices: Nociceptive pain is typically associated with an acute or ongoing disease process that activates peripheral nociceptors. Nociceptive pain is localized to the area of tissue damage and has a linear relationship with the level of activity and specific aggravating factors. Neuropathic pain involves damage to the somatosensory system and is associated with radiating pain, numbness, or tingling in a dermatomal or specific nerve distribution. Peripheral sensitization may enhance or prolong pain in the injured area and contribute to central sensitization, but it is not associated with secondary hyperalgesia.

Answer 120

C- Orthostatic hypotension and dizziness. Thiazide diuretics are used to manage mild to moderate hypertension. Adverse side effects include orthostatic hypotension and dizziness, along with drowsiness, lethargy, and weakness. These represent a safety risk during functional training and gait. Incorrect Choices: BP is lowered and is more stable, not less. Hypokalemia (not hyperkalemia) can occur, resulting in increased PVCs. Muscle cramps and weakness can occur. Joint pains are likely caused by a comorbid condition.

Answer 121

D- Within a few days after surgery to preserve tendon gliding. Early passive and active assistive exercises promote collagen remodeling to allow free tendon gliding. Incorrect Choices: When rehabilitation is delayed by several weeks, adhesions form, which restrict free tendon gliding. Early initiation of strengthening exercises is contraindicated.

Answer 122

C- Visual confrontation test with a moving finger. Visual field is examined using the confrontation test. The patient sits opposite the therapist and is instructed to maintain his/her gaze on the therapist’s nose. The therapist slowly brings a target (moving finger or pen) in the patient’s field of view alternately from the right or left sides. The patient indicates when and where he/she first sees the target. Incorrect Choices: Distance acuity vision is tested using a Snellen eye chart at a distance of 20 feet. Ocular pursuit is tested using a penlight moved in an H pattern to the extremes of gaze. Convergence is tested using a penlight and ruler; the patient keeps the penlight in focus as it moves inward from a distance of 4 or 6 inches.

Answer 123

B- Barreled chest with a decreased thoracic excursion. A patient with severe COPD (GOLD 4) will have lost much of the elastic recoil properties of the lung. The usual elastic properties of the lung tissue help to pull the thorax into the normal chest wall configuration of health. Without these elastic recoil properties the patient’s thorax will “barrel” in appearance, meaning it is larger and rounder than what you would normally expect. As the thorax has moved into an inspiratory position at rest, there is less movement available, so a decreased thoracic excursion would be expected. Incorrect Choices: Pectus excavatum (funnel chest) is not an acquired chest wall deformity that results in decreased thoracic excursion. Pectus carinatum (pigeon breast) is not an acquired chest wall deformity that results in a decreased thoracic excursion. While the barreling of the chest of COPD often has a kyphosis associated with it, the second hallmark to the chest wall deformity of COPD is a decrease in excursion.

Answer 124

D- 1.5 mm of downsloping ST segment depression. The upper limit for exercise intensity prescribed for patients post-MI is based on signs and symptoms. Of the choices, only ST segment depression (>1.0 mm of horizontal or downsloping depression) is a significant finding, representative of myocardial ischemia. Incorrect Choices: Both HR and BP are expected to rise (the levels of 140 and 140/80 are not significant for most patients). The appearance of a single PVC is also not significant because single PVCs can occur in individuals without a cardiac history.

Answer 125

D- Contact the referring provider secondary to concerns of central nervous system pathology and the need for further testing. This patient has red flag findings of persistent down-beating nystagmus and inability to walk more than a few steps. The findings of persistent and sustained down-beating nystagmus with lateral gaze raises concerns of various CNS pathologies (infract, cerebellar tumor, or Chiari malformation), all which require further evaluation and imaging (MRI). Incorrect Choices: The findings of persistent and sustained down-beating nystagmus with lateral gaze and increasing headaches warrants immediate discussion with the referring provider prior to other treatments. The patient’s collective findings are not consistent with BPPV, Ménière’s disease, or unilateral hypofunction.

Answer 126

C- Mobility combined with mechanical compression. According to the Venous Thromboembolism Clinical Practice Guideline published by Hillegass et al. (see Box 4-3), there is strong evidence for physical therapists to promote a culture of mobility coupled with mechanical compression (graded compression stockings) for patients with a DVT that have been initiated on an anticoagulant. Incorrect Choices: Bed rest places a patient at further risk for a DVT or pulmonary embolism. It may be helpful to have a patient use an assistive device if they are experiencing pain associated with the newly diagnosed DVT, but evidence suggests that movement is beneficial and there is no indication to prevent weight-bearing on the affected limb.

Answer 127

B- Increased subcostal angle. This film demonstrates a patient with hyperinflated lungs as evidenced by the flattened diaphragm, blunted costophrenic angle, and increased amount of air. This will cause the subcostal angle to increase significantly. Incorrect Choices: Hyperinflated lungs are indicative of obstructive disease. The I:E ratio will increase in this case as the patient has difficulty getting air out. There is no evidence of secretions in this film, which would alter the resonance of mediate percussion, so it can be assumed that this finding would be normal. Lateral costal expansion would be decreased in this patient due to the hyperinflated lungs.

Answer 128

D- Rectus capitis posterior major and minor. Forward head posturing or forward translation of the occiput in relation to the neck and trunk is associated with extension of the occipital axial joint and flexion of the lower and mid cervical spines. Chronic extension of the occipital axial joint will lead to shortening of the suboccipital extensor muscles (rectus capitis posterior major and minor), and localized stretching of these muscles would be indicated as part of a therapeutic intervention to reduce forward head posturing. Incorrect Choices: Muscles anterior to the axis for mid and lower cervical flexion and extension will be chronically overlengthened, and therefore further stretching of these would not be indicated. Forward head posturing is also associated with forward scapular posturing, and therefore further stretching of scapular adductors (middle trapezius and rhomboid muscles) would not be indicated.

Answer 129

B- Lung hyperinflation. The findings on the PFTs are consistent with severe obstructive lung disease. The FEV1, the amount of air a patient can get out in 1 second, is markedly reduced, indicating obstruction. The FEF 25%–75% is very low, indicating difficulty getting air out of the small airways. Lung hyperinflation on a chest film is a hallmark finding in obstructive lung disease. Incorrect Choices: A blunted costophrenic angle is seen with a pleural effusion or infiltrate. Pulmonary congestion is a finding consistent with volume overload and heart failure. A tracheal deviation would most likely be seen with a traumatic event. Any of these findings would demonstrate a restrictive pattern on PFTs, which would primarily include a decreased FVC.

Answer 130

C- L4 nerve root compression. The positive findings are consistent with an L4 nerve root compression. Incorrect Choices: Weakness of only one muscle group is not a common finding for DJD or SI dysfunction. L5 nerve root compression would result in hamstring weakness.

Answer 131

B- Stage 2 The patient’s signs and symptoms are most consistent with stage 2 of the Hoehn-Yahr Classification of Disability Scale and corresponding minimal bilateral or midline involvement with no balance impairment. Incorrect Choices: Stage 1 of the Hoehn-Yahr Classification of Disability Scale is defined as minimal or absent disability with only unilateral symptoms. In stage 3 an individual with Parkinson’s disease (PD) has clear balance impairments and restrictions on activity. In stage 4 patients with PD will exhibit severe symptoms (resting tremor, bradykinesia, rigidity, and postural instability) and can only complete standing and walking with assistance. The criteria for stage 5 include confinement to a bed or wheelchair.

Answer 132

C- Low-grade fever Cellulitis is a rapidly spreading, acute infection of the skin and subcutaneous tissues. Small breaks in the skin allow organisms such as staphylococcus to invade the dermis and hypodermis. Patients with cellulitis often present with fever, chills, and local swelling, tenderness, erythema, and warmth. Cellulitis may result in lymphangitis. The involvement of the lymphatic system is often first observed as a red streak under the skin radiating from the infection site in the direction of regional (proximal) lymph nodes. Incorrect Choices: Ecchymosis, or the discoloration/bruising, results from actual tissue damage and bleeding and is often seen after trauma to the musculoskeletal system. A ligament torn after a lateral ankle sprain would result in ecchymosis in the involved area. There was no history of trauma in this case. The tibialis posterior pulse is palpated behind the medial malleolus. The swelling caused by cellulitis on the dorsolateral foot would not occlude the tibialis posterior pulse. Stemmer’s sign is a special test that is used to help establish the diagnosis of lower extremity lymphedema.

Answer 133

C- Nitroglycerin Of the medications listed, nitroglycerin has the greatest risk of causing dizziness or weakness due to postural hypotension. Fall risk is increased even with small doses of nitroglycerin. Incorrect Choices: Colace (docusate sodium), an anticonstipation agent, can result in mild abdominal cramps and nausea. Coumadin (warfarin sodium) is an anticlotting medication. Adverse effects can include increased risk of hemorrhage, which indirectly can result in lightheadedness. Dosages are carefully monitored. Albuterol, a bronchodilator, can cause tremor, anxiety, nervousness, and weakness.

Answer 134

D- Postural stability exercises in supine and sitting with a focus on maintaining proper postural alignment. The trunk impairment scale score indicates the patient can maintain static posture for a short duration (at least 10 seconds). Initially, this patient will be able to work on postural stability exercises (e.g., pelvic tilts) in supine and sitting with a focus on increasing sitting tolerance while maintaining proper postural alignment. Once the patient's sitting tolerance has improved, dynamic sitting balance exercises can be introduced. Incorrect Choices: The TIS score reinforces that this patient has significant impairments with dynamic and coordinated sitting balance activities (e.g., trunk rotation and functional reach) and will initially require moderate to maximal levels of assistance with sit to stand transfers. It is important to improve sitting balance and tolerance prior to sustained or repetitive standing transfers and activity. At this stage, an electric wheelchair with cushions to maintain postural alignment is too restrictive and may impede the patient from improving static sitting tolerance.

Answer 135

D- Weightbearing as tolerated with range of motion as tolerated. The 2017 JOSPT Knee Ligament Sprain Clinical Practice Guideline (see Box 2-5) recommends immediate mobilization within 1 week after ACL reconstruction to increase joint range of motion, reduce joint pain, and reduce the risk of knee extension ROM loss. The use of an immediate postoperative knee brace does not appear to be safer or more effective than using no knee brace at all following an ACL reconstruction. The 2017 recommendation is to elicit and document patient preferences regarding bracing. Incorrect Choices: The 2010 and 2017 JOSPT Knee Ligament Sprain Clinical Practice Guideline reports that immobilization results in an increased risk for scar tissue and capsular restrictions and increased pain. Immediate weight-bearing is associated with no detrimental effects regarding stability or function. Immediate weightbearing may decrease anterior knee pain and provides a compressive stimulus to the tibiofemoral joint, increasing activation of the quadriceps muscle.

Answer 136

A- C5 neurologic level; ASIA B.

Answer 137

C- Unstable knee unit. An unstable knee unit will result in the knee buckling in stance and the patient forward bending and loading into the walker to compensate. Incorrect Choices: If the prothesis is too long it will result in a long limb with the typically compensations of vaulting or circumduction but not excessive forward trunk lean. If the walker is set too high the patient will maintain an upright posture and typically compensate by increasing elbow flexion. Weakness in the gluteus maximus will result in increased lumbar and trunk extension during stance.

Answer 138

C- Central Cord Syndrome. Central Cord Syndrome most often occurs with neck hyperextension and in adults over the age of 50. The patient's signs and symptoms, to include pronounced upper extremity weakness and "cape-like" loss of pain and temperature sensation, are consistent with damage to the ventral horn and spinothalamic tracts at the level of the cervical spine. Incorrect Choices: Anterior cord syndrome is more common with neck flexion injuries and results in damage to the corticospinal and spinothalamic tracts, thus causing more pronounced lower extremity symptoms, to include upper motor neuron signs below the level of the lesion. Brown Sequard Syndrome is defined by the classic ipsilateral loss of motor and medium to large sensory fiber (vibration, proprioception, fine touch) function and contralateral loss of pain and temperature. Medial medullary syndrome is most often the result of a stroke and presents with weakness in the tongue (cranial nerve XII) and hemiplegia (see Tables 3-12 and 3-22 for additional information).

Answer 139

C- Symptoms are intermittent. Acutely ill, hospitalized elderly patients frequently exhibit delirium, a fluctuating attention state. Patients demonstrate a fluctuating course with symptoms of confusion that alternate with lucid intervals. Sleep/wake cycles are disrupted and confusion is typically worse at night. Incorrect Choices: All other choices are signs of chronic dementia.

Answer 140

A- Presence of atelectasis. The prevention (or presence of) atelectasis is a primary indication for the use of incentive spirometry. Atelectasis is a complete or partial collapse of a lung that occurs when the tiny alveoli become deflated or filled with fluid. It is one of the most common pulmonary complications following thoracic or abdominal surgery. Incentive spirometry, or sustained maximal inspiration, along with deep breathing exercises and early mobilization are often prescribed following these surgeries to prevent or treat pulmonary complications. Incorrect Choices: Incentive spirometry is contraindicated for patients who show signs of cognitive impairment, confusion, and delirium, leading to the inability to understand or demonstrate proper use of the equipment. Ascites is the abnormal build-up of fluid within the abdomen and is not typically an indication for incentive spirometry. The most common causes of ascites are liver disease (cirrhosis) and chronic renal failure. Coughing is the best way to clear the lungs of sputum. There are several types of exercises used to help patients strengthen their cough including graded coughing, huffing, and sniffing.

Answer 141

C- Use an AFO with heel pressure relief. The AFO helps to prevent plantarflexion contractures, while the heel pressure relief prevents further damage to the heel and promotes healing. Incorrect Choices: This pressure ulcer, based on the examination findings, is stable and needs to be monitored, not debrided. Arterial bypass grafts are needed if circulation is compromised. There is no indication that this is the case.

Answer 142

B- Deep vein thrombosis. One of the most common side effects of Raloxifene is deep vein thrombosis and therefore poses an increase for the risk of stroke. Incorrect Choices: Side effects of depressed heart rate, elevated blood pressure, and altered balance reactions are not commonly reported.

Answer 143

D- Poor head and fine motor control. Most power wheelchairs require good head control to use a head rest control system or good fine motor skills to use a joy stick. Although there are other ways to propel a power chair, this is the best reason to NOT recommend a power chair. Incorrect Choices: Studies have found that children as young as 18 months of age can operate a power wheelchair, so age is not a factor here. Most children with power wheelchairs have quadriplegia and don’t have a good prognosis for community ambulation. Without knowing any more about their abilities, it cannot be said that quadriplegia is a reason not to use a power chair. A child being nonverbal does not preclude them from using a power wheelchair. Just because a child is nonverbal does not mean that they cannot understand what is spoken to them or that they are cognitively impaired. Even if cognitive impairments were a factor, children with mild cognitive impairments can operate power mobility devices.

Answer 144

B- Stretching of the quadriceps femoris muscle. Osgood disease is a painful condition resulting from inflammation of the tibial tubercle at the insertion of the patellar tendon. The disorder is typically seen in adolescent athletes during periods of rapid growth. Physical therapy interventions should include flexibility exercises and activity modification to prevent excessive stress to the inflamed site. Medications such as acetaminophen and NSAIDs may also be helpful. Incorrect Choices: Repetitive stresses to inflamed musculoskeletal tissues should be avoided. This includes quadriceps strengthening exercises. Graded mobilizations of the knee may be helpful if the therapist identifies joint mobility dysfunctions, but it is not the best intervention for this condition. Transcutaneous electrical stimulation will provide short-term symptomatic relief only.

Answer 145

C- Calcium alginate dressings. Wounds with moderate to high exudate benefit from calcium alginate dressings. The dressings absorb large amounts of exudate (up to 20 times their weight) and form a gel, which maintains the moist wound environment while maintaining good permeability to oxygen. Incorrect Choices: Gauze and semipermeable film dressings require a secondary dressing and offer poor conformability to deep wounds. Hydrogel dressings are not recommended for wounds with heavy exudate.

Answer 146

A- Centralized gnawing pain with loss of postural control during lifting activities. Discal degeneration without nerve root compression would likely be exhibited as a centralized gnawing pain with loss of proprioception. Incorrect Choices: Because there is no nerve compression, there will not be any type of radicular pain and/or decrease in specific muscle function (beyond the lumbar spine region), so one should not see a decrease in the function of the gluteus medius.

Answer 147

C- Involve the patient in decision-making and monitor for safety. As patients with TBI recover, structure and guidance must be gradually reduced and patient involvement in decision-making increased. Safety must be maintained while increasing levels of independence are fostered. Patients at stage VII exhibit purposeful and appropriate responses in familiar settings, and moving to level VIII requires patient opportunities to take part in decision making in a structured and safe environment. Incorrect Choices: A high degree of structure, assistance, and maximum supervision is not therapeutic at this stage of recovery.

Answer 148

B- Use of a toe wedge. A festinating gait is an abnormal and involuntary increase in the speed of walking in an attempt to catch up with a displaced center of gravity due to the patient’s forward lean. The most appropriate intervention would be to use a toe wedge, which would help to displace the patient’s center of gravity backward. Incorrect Choices: Increasing cadence or stride length would serve only to increase, not decrease, the problem, as will the use of a heel wedge.

Answer 149

A- High-intensity workloads for short durations. High exercises at fast contraction speeds for shorter durations (<20 repetitions) are needed to train the highly adaptable fast-twitch IIa fibers. Incorrect Choices: Performing workloads at low intensity and slow contraction speeds will challenge slow-twitch (type I) fibers. High-intensity workloads at long durations are contraindicated.

Answer 150

C- Chronic exertional compartment syndrome. Chronic exertional compartment syndrome is the result of transiently elevated anterior compartment pressure that restricts blood flow to muscles. Patients are tender in the anterolateral leg region with tautness of the anterior compartment. A rearfoot strike running pattern may be associated with chronic exertional compartment syndrome due to increased muscle activity of the tibialis anterior. Treatment may require a change in footwear, training surface, or run-retraining. Incorrect Choices: Acute compartment syndrome typically results from trauma, and patients present with similar but more severe symptoms. Patients frequently demonstrate numbness and tingling in the deep fibular nerve distribution. Medial tibial stress syndrome and stress fractures of the tibia/fibula are also chronic overuse injuries, but there is bony tenderness associated with both of these conditions. The distal posteromedial tibia is tender in patients with medial tibial stress syndrome.

Answer 151

B- Anterior drawer test. The anterior drawer test assesses the integrity of the ATFL. After an acute injury, the combination of palpation tenderness, hematoma, and a positive anterior drawer stress test is highly specific (95%) for the diagnosis of lateral ankle ligament injuries. See Box 2-13 for recommendations based on the Ankle Ligament Sprains Clinical Practice Guideline. Incorrect Choices: The talar tilt assesses the integrity of the calcaneofibular ligament. Thompson’s test assesses the integrity of the Achilles tendon. Morton’s test is used to determine if there is a possible metatarsal stress or a neuroma in the forefoot.

Answer 152

C- Household ambulation with an RGO and walker. A child with a high-level myelomeningocele will be able to ambulate for limited (household) distances with an RGO and walker. Physiological benefits include improved cardiovascular and musculoskeletal functions. Incorrect Choices: The child will not be able to be a community ambulator because of the high-energy expenditure necessary with this level of lesion. An RGO is the best choice. The hips are joined by metal cables that prevent inadvertent hip flexion (possible using KAFOs) during a reciprocal two- or four-point gait.

Answer 153

B- Respiratory alkalosis. This arterial blood gas shows an increased pH, which is an alkalosis. When looking at arterial blood gas values, carbon dioxide can be viewed essentially as an acid. If the carbon dioxide level is low, then you have less acid, or a resulting alkalosis. This is, therefore, a respiratory alkalosis. Incorrect Choices: Because the blood pH is higher than normal (7.35–7.45), the condition is an alkalosis, not an acidosis. If the increased pH was due to a metabolic disorder, a high bicarbonate value would be anticipated. As the HCO3 is normal (24 mEq/dL), the alkalosis is not from a metabolic cause.

Answer 154

A- Diminished executive function and cognition. Diffuse Lewy Body Disease (DLBD) is a one of the most prevalent causes of major neurocognitive disorders. The presenting feature of DLBD is dementia, or the inability to plan, sequence, and organize thoughts and decisions. Dementia can also result in changes in mood or behavior (see Table 10-3 for the differences in the most common types of neurocognitive disorders). Incorrect Choices: Extrapyramidal motor findings (e.g., bradykinesia, rigidity, resting tremor), festinating gait, and autonomic dysfunction can occur with DLBD, but most often manifest after impairments in executive function and cognition. This is a key differential from Parkinson's disease (PD), where patients start with motor dysfunction and may or may not exhibit cognitive dysfunction in the later stages. Patients with DLBD and PD may have pain, but the pain is typically in the later stages of the disease and not limited to the joints (may also have muscular pain from rigidity and inactivity). Finally, dysphagia and incontinence are most closely associated with end-stage Alzheimer's or Parkinson's disease.

Answer 155

D- Focus on knowledge of results and visual inputs. During the early stage of motor learning (cognitive stage), learners benefit from seeing the whole task correctly performed. Dependence on visual inputs is high. Developing a reference of correctness (knowledge of results) is critical to ensure early skill acquisition (cognitive mapping). Incorrect Choices: Focus on proprioceptive inputs is important during the middle (associative) stage of motor learning. Delayed feedback may be used during later learning.

Answer 156

A- Daily walking, using interval training for 10- to 15-minute periods. An appropriate initial exercise prescription for a patient with a history of CHF and claudication pain in the right calf should include low-intensity exercise (walking), low to moderate duration (10–15 min), and higher frequencies (daily). The exercise session should carefully balance activity with rest (interval or discontinuous training). Incorrect Choices: All other choices include durations that are too long (60, 40, or 30 min) and do not provide adequate rest periods.

Answer 157

C- Cervical flexor muscle endurance testing. The Neck Pain Clinical Practice Guidelines (see Box 2-14) suggest using the cervical deep neck flexor muscle endurance testing as part of a comprehensive physical examination for neck pain patients with movement coordination impairments (including whiplash-associated disorder). Incorrect Choices: All of the other listed tests and measures may be included as part of a comprehensive examination of the patient with neck pain. Spurling’s test is recommended as a priority for patients with neck pain and radiating upper extremity pain. Cervical mobility testing is recommended as a priority for those who have neck pain with associated headaches. The cervical flexion-rotation test is recommended as a priority for individuals who have neck pain and mobility deficits. See Box 2-14 for the different categories of neck pain and appropriate examination techniques for each type.

Answer 158

D- Bridging, pelvic elevation. The typical lower extremity synergies are effectively broken up using bridging (combines hip extension from the extensor synergy with knee flexion from the flexion synergy). Incorrect Choices: Supine hip extension with adduction and foot tapping in the sitting position are in-synergy activities (lower extremity flexion and extension synergies). Supine, lower extremity PNF D2F with knee flexing and D2E with knee extending moves the lower extremity in a pattern closely aligned with the typical flexion and extension synergies.

Answer 159

B- Biceps brachii. The dermatome at the lateral shoulder is C5, and the peripheral nerve field is the axillary nerve. Therefore, the sensory loss that the patient is experiencing could be the result of a lesion to either the nerve root or peripheral nerve. The axillary nerve is supplied by the C5 and C6 nerve roots. To prove that the patient has a C5 problem, the therapist must identify weakness in a C5 muscle that is not also innervated by the axillary nerve. The biceps brachii and brachialis are two strong C5 muscles and are easily tested with resisted elbow flexion. Incorrect Choices: Weakness found in the teres minor and middle deltoid would support the colleague’s argument. Weakness in the triceps brachii would not prove helpful for either therapist in this case as it is innervated by the C6–C8 nerve root levels.

Answer 160

C- Interval walking program at 50% of age predicted heart rate maximum. For patients with moderate to severe aortic stenosis, low-intensity exercise should be prescribed due to the risk of adverse events with higher intensity activities. Incorrect Choices: The intensity of all other activities is too high for a patient with moderate to severe aortic stenosis due to the increased risk of adverse events.

Answer 161

A- Moro and Startle reflex. The Moro reflex would occur if the child looks up quickly, with neck extension, shoulders abducted, and elbows extended. The startle reflex results in the same response, but a result of a loud noise, sudden quick movement in the visual field or sudden bright light. Both of these could cause the child to fall backward. These primitive reflexes may not be integrated. Incorrect Choices: Although the palmar reflex could be slightly problematic in using an open hand to weight bear on UEs while seated, children could adapt to sitting with hands fisted. The Landau reaction is extension of the neck, trunk, and hips when a child is held in a suspended vertical position, so not related to sitting. Body-on-body righting is a reaction that results in rolling with the rotation of the head. The Tonic labyrinthine reflex would result in flexor tone in prone and extensor tone in supine.

Answer 162

A- Mole (cherry angioma). The image depicts a mole (cherry angioma), and it is a benign collection of capillaries. They are common and occur in almost half of all adults over 30 years of age. Incorrect Choices: Unlike a mole, skin cancer (basal cell, squamous cell, or melanoma) typical has a combination of Asymmetry, irregular Border, multiple Colors, increased Diameter (>6 mm), and/or is Evolving (A, B, C, D, Es of skin examination).

Answer 163

C- Stretching exercises. Based on the Adhesive Capsulitis Clinical Practice Guideline (see Box 2-2), there is moderate evidence to support stretching exercises (both supervised and home-based) in patients with adhesive capsulitis. Incorrect Choices: There is currently weak evidence for the use of modalities (diathermy, ultrasound) and joint mobilization. While physical therapists may use these interventions to treat patients with adhesive capsulitis, based on the evidence the BEST choice is stretching exercises.

Answer 164

C- Stage II Stage II lymphedema is described as spontaneously irreversible and is characterized by an increase in swelling that is not reduced overnight or by elevation of the affected limb. Clinical fibrosis may be present. See Chapter 4 for a full description of the stages of lymphedema. Incorrect Choices: Stage 0 is described as a preclinical or latent stage during which the patient is at risk for development of lymphedema. The patient may complain of achiness and heaviness of the affected limb although edema is not yet evident. In Stage I pitting edema is present and is reversible with elevation. The affected area may be a normal size in the morning but swelling increases with activity, heat, and humidity. Stage III is also called elephantiasis. Severe nonpitting fibrotic edema is present along with atrophic changes (deep skin folds, discoloration, hardening of dermal tissue). These changes may limit mobility of the affected limb and the patient.

Answer 165

B- Stemmer’s sign. The presence of Stemmer’s sign is a highly specific test for lymphedema and is a characteristic finding of Stage II. To perform the test, the therapist gently pinches and lifts the skin at the base of the second toe on its dorsal side. A positive test is present when the skin cannot be lifted or separated from the underlying tissue. The ability to pinch and lift the skin is a negative test result. Incorrect Choices: Homan’s sign is a special test that may be used when deep vein thrombosis (DVT) is suspected. The examiner gently dorsiflexes the ankle and/or squeezes the calf to reproduce the patient’s symptoms. The test’s diagnostic accuracy is limited and cannot be relied upon. Absent pulses indicate some type of insult or compromise to the artery being tested (such as the dorsalis pedis artery). Diminished or absent distal pulses may be suggestive of chronic arterial insufficiency. Temporary pallor and cyanosis of the toes along with changes in skin temperature are also suggestive of peripheral vascular disease. These findings are often seen in Raynaud’s phenomenon or Raynaud’s disease, due to episodic vasoconstriction of small arteries and arterioles in response to cold temperatures or emotional stress.

Answer 166

B- Initiate functional training consistent with the level of injury. A functional neurologic disorder (conversion disorder) represents a real loss of function for the patient. The symptoms are real and varied. The condition may be triggered by stress, psychological, or physical trauma. The therapist should treat this patient the same as any patient with spinal cord injury with similar functional deficits. Early intervention is crucial. Incorrect Choices: A psychologist or psychiatrist is best able to help the patient understand the cause of the patient’s paralysis. The therapist should be empathetic; however, counseling should not be the main focus of intervention in PT. Confrontation (using E-Stim to prove the patient has functioning muscles) is contraindicated.

Answer 167

A- Hire the more qualified female and provide aide assistance or lift equipment when heavy lifting is required. The Age Discrimination and Employment Act of 1967 prohibits employers from discriminating against persons 40–70 years of age in any area of employment. The 1973 Rehabilitation Act prohibits employment discrimination based on disability and requires reasonable accommodation in the workplace by removing barriers unless there would be “undue hardship” for the employer. Title VII of the Civil Rights Act of 1964 might also come into play since one provision prohibits discrimination based on gender. The female candidate is clearly the more qualified and would be the best hire in this case. Incorrect Choices: Although asking about age is not permissible in the hiring process, familiarity with the candidate or a review of a résumé could unintentionally make the candidate’s age obvious. Ruling out the female from the interview process with age and back pain as factors is clearly discriminatory. The male candidate may have potential; however, consideration of both age and back pain history, whether discussed or not, is discriminatory. The older candidate may be familiar with the caseload, department systems, and all other things being equal, is the stronger candidate if reasonable accommodations can be made.

Answer 168

D- Ibuprofem. Ibuprofen and many other NSAIDs (nonsteroidal anti-inflammatory drugs) can have deleterious effects on the entire GI tract when taken long term and in high doses. The most common clinical effect is on the gastro-duodenal mucosa, where erosions and ulcerations can occur and may progress to bleeding and perforations. Other signs and symptoms of a peptic or duodenal ulcer include night pain that typically occurs after midnight, vomiting, anorexia, and bloody stools. Incorrect Choices: Oxycodone is a narcotic or opioid medication and typically prescribed for short-term management of significant postoperative pain. Common side effects of opioid administration include sedation, dizziness,nausea, constipation, physical dependence, and respiratory depression. Baclofen is a muscle relaxant and may be prescribed for acute episodes of spinal pain when significant muscle guarding or spasm is present. The most common side effects include fatigue, drowsiness, dry mouth, depression and decreased blood pressure. Celebrex is an NSAID but it is a cyclooxygenase-2 (COX-2) inhibitor and much more gastroprotective than Ibuprofen and many other NSAIDS that are not COX-2 inhibitors. COX-2 inhibitors provide benefit in reducing ulcer formation and bleeding, although they do not completely eliminate the risk.

Answer 169

C- Cuff weights and other exercise apparatus should be disinfected immediately on removal from the patient’s room. All medical/exercise equipment used in the patient’s room needs to be disinfected immediately unless left in the patient’s room as dedicated equipment or is disposable. Health-care providers (HCP) need to observe contact precautions when working with the patient. This includes cleaning their hands with soap and water or an alcohol-based hand rub before and after caring for the patient. They are also required to wear personal protective equipment (gloves and a gown) during patient interaction. Incorrect Choices: A mask is not needed as C. diff is not airborne. Required PPE includes both gloves and a gown. PPE is donned before entering the room and removed before leaving the room. Equipment and devices including stethoscopes, pulse-oximeters, walkers, goniometers, weights, and so on can be used as long as they are disinfected once removed from the patient’s room.

Answer 170

D- Cholescintigraphy. Cholescintigraphy also known as hepatobiliary iminodiacetic acid (HIDA) scan, is an imaging test used to view the gallbladder, liver, bile ducts, and small intestines. The examination findings in this patient are consistent with gall bladder disease (biliary dyskinesia). Symptoms can include weight gain as the gallbladder does not drain bile properly, which leads to improper fat digestion. Other symptoms can include upper abdominal pain after eating, nausea, bloating, and indigestion. Incorrect Choices: An electrocardiogram (ECG or EKG) records electrical activity in the heart. It is used to detect arrhythmias or other types of heart disease (such as a heart attack). The patient history in this scenario is not consistent with cardiac disease. A barium swallow test is a radiological test done to visualize the esophagus, stomach, and duodenum and may help detect ulcers, hernias, diverticulitis, swallowing difficulty diagnosis, or tumors. Most of these conditions would be accompanied by a history of weight loss, not weight gain as mentioned in the question stem. An x-ray would rule out a possible scapular fracture. If the patient in this scenario had a scapular fracture, a history of trauma along with bruising and swelling in the shoulder and upper back would have been described. Shoulder movements would have likely reproduced the patient’s pain.

Answer 171

B- Active eccentric contractions in the pain-free range. For a muscle that is chronically inflamed, focus should be placed on eccentric contractions, because there is less effort and stress placed on the contractile units than with concentric contractions at the same level of work. The exercise should be performed in the pain-free portion of the range. Incorrect Choices: Isokinetic, isometric, and isotonic exercises do not allow for pain-free muscle contractions and can cause further inflammation of the muscle.

Answer 172

C- Decrease the US intensity. Acoustical energy is reflected from the bone into the bone-tissue interface, resulting in rapid tissue temperature elevation and stimulation of the highly sensitive periosteum of the bone. A reduction in intensity is indicated if a strong ache is felt. Incorrect Choices: The question assumes that the treatment size of the area is correct. Increasing the size of the treatment area would minimize the ability to elevate the tissue temperature. Thus, the patient would not experience a strong ache from rapid tissue temperature elevation. Adding more transmission medium would encourage transmission of acoustical energy and thus potentiate the rapid tissue temperature elevation, contributing to the patient’s symptom. The frequency has to do with the depth of penetration of the US energy, not the rate/speed at which the tissue temperature is being elevated.

Answer 173

A- Perform careful ROM of the shoulder internal rotators. Internal rotation ROM does not create the peel back mechanism that increases stress to the repair. Given the nature of this repair, an understanding of the postoperative precautions is paramount to a successful surgical outcome. Early rehabilitation within the postoperative precautions correlates to a quicker overall recovery and improved outcomes. Incorrect Choices: Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii that results in instability of the biceps-labral anchor. The surgery requires reattachment of the labrum and biceps anchor. Given the repair of the biceps, contraction and stretching of the biceps should be avoided during the maximum protection phase. In addition, external rotation ROM/stretching should be avoided given the peel back mechanism and increased stress to the repair.

Answer 174

D- Tachycardia at a relatively low intensity of exercise with ST segment depression. The typical exercise ECG changes in the patient with CAD include tachycardia at low levels of exercise intensity. The ST segment becomes depressed (>1 mm is significant). In addition, complex ventricular arrhythmias (multifocal or runs of PVCs) may appear and are associated with significant CAD and/or a poor prognosis. Incorrect Choices: The other choices do not accurately describe the expected ECG changes with exercise. Chronotropic incompetence is indicated by an HR that fails to rise; bradycardia (slowing of HR) is not expected. ST segment elevation with significant Q waves can occur and is indicative of aneurysm or wall motion abnormality.

Answer 175

D- Potassium Lasix is not a potassium sparing diuretic and patients taking potassium are at risk for eliminating too much potassium. Low potassium can lead to muscle cramps, fatigue, and cardiac arrhythmias. Incorrect Choices: The other electrolytes are not affected by Lasix.

Answer 176

B- Discontinue the examination and place the patient in a cervical collar. The procedure shown here is the modified Sharp-Purser test. It is a test for upper cervical spine instability and includes assessing the integrity of the transverse ligament. If the test is positive, the physical examination should be terminated, and no interventions should be attempted other than stabilizing the patient’s spine with a cervical collar. Causes of upper cervical spine instability include trauma, RA, Down syndrome, ankylosing spondylitis, long-term corticosteroid use and connective tissue disorders such as Ehlers-Danlos syndrome. Incorrect Choices: Each of the other choices place the patient at risk for serious injury and possibly even death.

Answer 177

C- Place a BP cuff on the involved extremity and inflate the cuff until the bleeding stops. A radial arterial line is a catheter placed in the artery itself. If it becomes dislodged during treatment, the artery is now open to bleeding. This arterial bleeding needs to be stopped immediately, although it is not considered a cardiac emergency. Place a BP cuff above the site of bleeding and inflate the cuff to above systole to stop the bleeding or place enough manual pressure on the site to stop the bleeding. Then call for help. Incorrect Choices: Elevating the site of bleeding above heart level will not be as effective, because this is an arterial bleed. As long as the heart is pumping with adequate pressure, the site will continue to bleed. This is not a cardiac emergency. Never replace any line that has become disconnected. The line is no longer sterile and should not be reinserted into the patient. A new, sterile catheter will need to be used if the radial line is to be replaced.

Answer 178

D- Only muscles on the lower half of the left side of the face. A stroke that involves the internal capsule would result in a supranuclear palsy, which affects only the contralateral lower half of the face. The specific pathway that is affected is the corticobulbar tract, which contains upper motor neurons (UMN) that project from the motor cortex to the nucleus of the facial nerve (cranial nerve VII) in the brainstem. The muscles in the upper half of the face are spared because both the right and left cerebral cortex project to the lower motor neurons (LMNs) in the facial nucleus that the innervate muscles of the forehead. In contrast, the LMNs that innervate muscles of the lower half of the face receive input from the contralateral motor cortex only. Therefore, a stroke that affects the internal capsule (corticobulbar tract) prevents input from the motor cortex to the contralateral facial nucleus, causing paresis or paralysis of the muscles of the lower half of the face only. Incorrect Choices: A lesion that affects all muscles on the left side of the face is consistent with an LMN or peripheral nerve lesion, such as Bell’s palsy or trauma to the left facial nerve. A complete LMN lesion to the right CN VII would prevent motor commands from reaching all ipsilateral facial muscles, resulting in facial paralysis of those muscles. A lesion that affects the left internal capsule or corticobulbar tract would affect only muscles on the lower half of the right side of the face.

Answer 179

C- Right hemothorax. A right hemothorax (blood was in the pleural space) takes up space in the right hemithorax, shifting the trachea to the left. Incorrect Choices: A left pneumothorax and a left pleural effusion take up space in the left thorax. The air (pneumothorax) or the sterile fluid (effusion) in the pleural space would push contents of the left hemithorax, including the trachea, to the right. A lung collapse, or a volume loss phenomenon, on the right would pull the trachea over toward the right.

Answer 180

A- High-detection sensitivity with recording electrodes placed far apart over the muscle belly. Initially high-detection sensitivity is needed to detect low-amplitude signals generated by a small number of motor units such as in a weak extensor carpi radialis longus. Electrode placement: If the patient has poor muscle control, moving the electrodes apart can help sample a larger portion of the muscle. As the patient is able recruit more motor units the electrodes can be moved closer together to decrease potential cross-talk from other motor units. Therapists can get the electrodes too far apart and should limit the distance to only the area they intend to sample. Incorrect Choices: Low-detection sensitivity may not pick up the necessary motor unit signals. Electrode placement should be placed over the motor units, not the musculotendinous junctions.

Answer 181

D- Document the findings and consult with the primary physician immediately after treatment. This patient is most likely experiencing jaundice as a result of liver dysfunction. The therapist’s best course of action is to document the findings and consult with the primary physician immediately, preferably by phone. Incorrect Choices: All other choices delay consulting with the primary physician. The symptoms indicate liver dysfunction and jaundice, which warrant immediate contact with the physician.

Answer 182

B- True negatives. Specificity is defined as the true negative rate of a disorder in a population or study sample. A highly specific test is used to help rule in a disorder or condition, as it rarely misclassifies those without the disorder as actually having it. That is, a highly specific test will have very few false positives associated with it. “SpPIn” is a useful clinical-decision making mnemonic that applies to specificity: tests that are highly specific (“Sp”), when positive (“P”) will rule in (“In”) the condition of interest. Incorrect Choices: Sensitivity is defined as the true positive rate. A highly sensitive test is useful for ruling out a condition, as it rarely misclassifies those with the disorder as not having it. A highly sensitive test will have very few false negatives associated with it. Tests that are highly sensitive are useful screening tool for excluding conditions. “SnNOut” is another useful clinical-decision making mnemonic that applies to sensitivity: tests that are highly sensitive (“Sn”), when negative (“N”) will rule out (“Out”) the condition of interest.

Answer 183

C- One pupil larger than the other. A dilated pupil that is not reactive to light suggests a moderate to severe traumatic brain injury (TBI) and warrants immediate triage to an emergency room. Incorrect Choices: Brief confusion and ringing in the ears that quickly resolves is more consistent with mild TBI. A bump or tenderness at the site of injury or one episode of vomiting without other symptoms does not require immediate triage to an emergency room, but patients should be followed for any signs of progression of symptoms (headaches, confusion, drowsiness, or agitation). Repeated vomiting does require triage to the emergency room, emphasizing the need to follow patients closely who have one immediate episode of vomiting.

Answer 184

B- Bladder incontinence. This patient’s involvement of the lower extremity greater than the upper extremity is highly suggestive of an anterior cerebral artery (ACA) stroke. Bladder incontinence is common in patients with an ACA stroke and relates to the ACA vascular zone and proximity of the genitalia and lower extremity on the motor homunculus. Incorrect Choices: Diverse types of aphasia, to include expressive aphasia, are common in patients following a left middle cerebral artery stroke. Homonymous hemianopsia can occur with occlusion of the posterior cerebral artery or middle cerebral artery. Horner’s syndrome is the result of damage to the sympathetic tract. There are several causes (e.g., neck trauma, tumor, stroke) of Horner’s syndrome to include a lateral medullary stroke (i.e., Wallenberg’s syndrome). For additional information see Chp-3 Neurovascular syndromes: Cerebral and Brain Stem Strokes.

Answer 185

D- Moderate to high intensity overground ambulation. Moderate to high intensity overground ambulation is a highly recommended task specific intervention (Level I-II evidence) to improve locomotion in patients >6 months post stroke. For additional information please see Chapter 3- APTA Neurology CPG- Recommendations to improve locomotion. Incorrect Choices: Virtual reality standing balance exercises and strength training have shown to improve locomotion, but are not task specific. Body weight support treadmill training is not recommended by the APTA Neurology Clinical Practice Guideline and is too restrictive for this patient.

Answer 186

C- Seat height. Wheelchair seat height and depth are key measurements that influence the patient’s ability to rest their foot comfortably on the floor. This is critical for this patient as they will not be able to propel themselves with their arms without proper adjustment of the seat height and depth. Incorrect Choices: Armrest height, seat width, and back height will be important for patient comfort but do not directly influence this patient’s ability mobility. See the wheelchair section of Chapter 12 (Functional Training, Equipment, Devices, and Technology) for additional information.