PEAT #1

Question 1

A patient has an ankle-brachial index (ABI) of 1.5. Which of the following conditions affecting the lower extremity should a physical therapist suspect?

1.Arterial aneurysm

2.Arterial thrombosis

3.Arterial calcification

4.Arterial occlusive disease

Answer 1

1. With arterial aneurysm in the lower extremity, the affected artery is dilated (p. 632) and there is decreased blood flow and ischemia in the limbs. In this case, the ankle-brachial index should be less than 1.0.
2. Arterial thrombosis is an occlusive disease of the arteries. With occlusive diseases, the blood flow to the lower extremity decreases. Decreased blood flow to the lower extremities will result in an ankle-brachial index of less than 1.0. (p. 638)
3. Ankle-brachial index is a ratio of the systolic blood pressure at the ankle and the brachial systolic pressure. The normal value of the ankle-brachial index is 1.0, indicating similar blood flow in the ankle and brachial arteries. An ankle-brachial index greater than 1.1 relates to arterial calcification in the leg. With arterial calcification, the artery cannot be fully compressed for valid measurement of arterial pressure at the ankle. An ankle-brachial index greater than 1.1 is mostly found in patients who have diabetes. (p. 645)
4. The normal value of the ankle-brachial index is 1.0. With severe arterial occlusion, the ankle-brachial index will be less than 1.0. An ankle-brachial index of 1.1 or higher is not an indication of arterial occlusion. (pp. 641, 645)

Question 2

Which of the following exercises would be CONTRAINDICATED during pregnancy?

1.Standing push-ups

2.Modified squatting

3.Bilateral straight leg raises

4.Quadruped pelvic tilts

Answer 2

1. Exercises that are normally performed from a prone position should be modified in pregnancy. Standing push-ups will help maintain upper limb strength and promote good posture.
2. Modified squatting is incorrect because it is indicated for a pregnant woman. This exercise helps maintain lower limb strength for good body mechanics and also helps stretch the perineal area for increased flexibility during the delivery process.
3. Bilateral straight-leg raising places a great deal of stress on the abdominal muscles and low back. It may cause injury or diastasis recti and should not be included in a physical therapy program for pregnant women.
4. Quadruped pelvic tilt will help with correct posture and maintenance of mobility of the lumbar spine, as well as help to maintain the strength of abdominal muscles.

Question 3

Which of the following positions of the humerus is BEST for application of an ultrasound treatment to the supraspinatus tendon insertion?

1.Flexion and lateral (external) rotation

2.Extension and medial (internal) rotation

3.Abduction and lateral (external) rotation

4.Flexion and medial (internal) rotation

Answer 3

1. The correct way to expose the supraspinatus tendon is with extension and medial (internal) rotation. Flexion and lateral (external) rotation does not give access to the tendon.
2. Extension and medial (internal) rotation of the shoulder puts the supraspinatus tendon in the most accessible position.
3. The correct way to expose the supraspinatus tendon is with extension and medial (internal) rotation. Abduction and lateral (external) rotation does not give access to the tendon.
4. The correct way to expose the supraspinatus tendon is with extension and medial (internal) rotation. Flexion and medial (internal) rotation does not give access to the tendon.

Question 4

A patient is practicing moving from seated to standing position. Which of the following transfers to standing position would BEST facilitate motor learning of the task?

1.From a single chair at a self-selected speed, with minimal feedback of results

2.From a single chair at a variety of speeds, with maximum feedback of results

3.From a variety of chairs at a single speed, with maximum feedback of results

4.From a variety of chairs at a variety of speeds, with minimal feedback of results

Answer 4

1. Motor learning principles suggest that psychomotor skills are best learned when practice conditions allow errors to occur, when performers are encouraged to engage in active sensory encoding and retrieval processes, and when knowledge of results is used minimally. The conditions within this choice do not create variations within the task.
2. Motor learning principles suggest that psychomotor skills are best learned when practice conditions allow errors to occur, when performers are encouraged to engage in active sensory encoding and retrieval processes, and when knowledge of results is used minimally. The conditions within this choice do not vary the task and provide too much feedback.
3. Motor learning principles suggest that psychomotor skills are best learned when practice conditions allow errors to occur, when performers are encouraged to engage in active sensory encoding and retrieval processes, and when knowledge of results is used minimally. The conditions in this choice do not create variations within the task and provide too much feedback.
4. Motor learning principles suggest that psychomotor skills are best learned when practice conditions allow errors to occur, when performers are encouraged to engage in active sensory encoding and retrieval processes and when knowledge of results is used minimally. Such practice typically involves varying the task, varying the environment in which the task occurs, and providing minimal feedback of results.

Question 5

A patient who has right shoulder pain exhibits bruising, palmar erythema, and signs of confusion. Which of the following organs is MOST likely involved?

1.Liver

2.Pancreas

3.Kidney

4.Spleen

Answer 5

1. Right shoulder pain, bruising, palmar erythema, and confusion are all among the signs and symptoms of liver disease (p. 341).
2. Right shoulder pain, bruising, palmar erythema, and confusion are all among the signs and symptoms of liver disease (p. 341). Pancreatic pain is more likely to refer to the left, not right, shoulder (p. 329).
3. Right shoulder pain, bruising, palmar erythema, and confusion are all among the signs and symptoms of liver disease (p. 341). Renal pain may be referred to the shoulder; however, it is more commonly felt in the posterior subcostal region (p. 377). Associated symptoms include blood in the urine and fever/chills (p. 378).
4. Right shoulder pain, bruising, palmar erythema, and confusion are all among the signs and symptoms of liver disease (p. 341). Splenomegaly may occur as a result of chronic active hepatitis; however, a pathological condition of the spleen is not the primary cause of the other symptoms described (p. 345).

Question 6

Which of the following fall prevention strategies is MOST appropriate for a resident of a nursing home who has dementia, poor balance, and often wanders?

1.Place the patient in bed, with the side-rails up and secured.

2.Place the patient in a wheelchair with a seat belt that the patient is unable to remove independently.

3.Seat the patient in a geriatric recliner to reduce the likelihood of wandering.

4.Use an electronic monitor that will remotely alert staff when the patient gets out of bed.

Answer 6

1. The use of side-rails is a restraint. Their use on the bed of a mobile person may lead to a number of negative consequences, such as increasing the distance the patient could fall from the bed, creating an obstruction of vision, and creating a sense of being trapped. The use of side-rails with a patient who has dementia is a restraint and requires a physician’s order.
2. Lap cushions, trays, and seat belts are considered restraints if the patient is unable to remove them independently.
3. Geriatric recliners are considered restraints when they restrict a patient’s normal mobility.
4. The use of restraints has become a concern for nursing home caregivers, who must comply with Medicare guidelines and foster prevention of elder abuse. An electronic monitoring device is not a restraint. This option would facilitate safety through improved supervision and would allow the patient to maintain functional mobility.

Question 7

A physical therapist is reviewing the laboratory report of a patient who received a diagnosis of pneumonia 2 weeks ago. The patient’s white blood cell count is currently 9,000 cells/mm3. Which of the following conditions does this value indicate for the patient?

1.Anemia

2.Development of leukocytosis

3.Immunosuppression

4.Resolution of the pneumonia infection

Answer 7

1. Anemia would be diagnosed from iron and hemoglobin levels.
2. Leukocytosis is a total white blood cell count of greater than 11,000-15,000/mm3 (above normal range).
3. Immunosuppression causes leukopenia, which is a white blood cell count less than 4000/mm3.
4. The patient’s white blood cell count is within the normal range of 4500-11,000/mm3, so the infection has resolved.

Question 8

A 45-year-old patient reports general weakness and fatigue that developed over the past few months, along with increased pain bilaterally in the wrists and hands. The MCP and carpal joints are tender to touch, and the MCP joints appear slightly swollen. The patient MOST likely has which of the following conditions?

1.Osteoarthritis

2.Reiter syndrome

3.Rheumatoid arthritis

4.Carpal tunnel syndrome

Answer 8

1. Osteoarthritis often presents in the hands, but it is not often bilateral at the onset, nor present in multiple joints (Goodman, Pathology, pp. 1305-1306). Rheumatoid arthritis often presents with general fatigue, weakness, and bilateral symptomatic joints, most often presenting first in the hands and wrists (Goodman, Differential Diagnosis, pp. 448-449; Goodman, Pathology, pp. 1318-1321).
2. Reiter syndrome is a systemic disease that can cause pain in multiple joints; however, it is usually asymmetric, occurs after an infection, and presents over several weeks (Goodman, Differential Diagnosis, pp. 448-449). This is not consistent with the patient presentation in the scenario. Rheumatoid arthritis often presents with general fatigue, weakness, and bilateral symptomatic joints, most often presenting first in the hands and wrists (Goodman, Differential Diagnosis, pp. 438-441; Goodman, Pathology, pp. 1318-1321).
3. Rheumatoid arthritis often presents with general fatigue, weakness, and bilateral symptomatic joints, most often presenting first in the hands and wrists (Goodman, Differential Diagnosis, pp. 438-441; Goodman, Pathology, pp. 1318-1321).
4. While bilateral carpal tunnel syndrome is a possibility and would present with the wrist pain and perhaps tenderness of the carpal area, the metacarpophalangeal (MCP) joints would not be swollen or tender (Goodman, Pathology, p. 1670). Rheumatoid arthritis often presents with general fatigue, weakness, and bilateral symptomatic joints, most often presenting first in the hands and wrists (Goodman, Differential Diagnosis, pp. 438-441; Goodman, Pathology, pp. 1318-1321).

Question 9

A patient who is not able to walk has developed an ischial tuberosity pressure injury. The patient is able to perform independent intermittent catheterization and demonstrates independence in bed-to-chair transfers. Which of the following factors has MOST likely contributed to the formation of the pressure injury?

1.Friction

2.Infection

3.Tissue loading

4.Tissue maceration

Answer 9

1. Independence with transfers would decrease the risk of skin breakdown due to friction compared to the risk present from tissue loading (p. 145).
2. While the presence of infection may cause a wound to worsen, the infection is unlikely to be the causative factor for wound development. Since development of infection is dependent on the ability of microorganisms to attach to the host’s body, the likelihood that the attachment would occur without a pre-existing wound bed is less than the risk of wound development from tissue loading. Since the patient is not incontinent, risk of infection from urine is minimized. (pp. 145, 147)
3. In this patient, prolonged sitting due to the inability to walk leads to tissue loading and risk for skin breakdown on the ischial tuberosities (p. 145).
4. While maceration may contribute, patients who are nonambulatory are generally at risk for having issues with skin maceration in areas where skin is exposed to prolonged contact with urine or stools. Since the patient is independent with catheterization, the patient is unlikely to be experiencing prolonged contact with soiled clothing. (pp. 145-146).

Question 10

Changes in the level of which hormone are MOST likely to contribute to development of chondromalacia patella in a pregnant woman?

1.Calcitonin

2.Progesterone

3.Relaxin

4.Insulin

Answer 10

1. The role of calcitonin is to decrease plasma calcium concentration. There are no receptors on tendons that would alter their function in any way in response to changes in calcitonin levels. Calcitonin should not alter the way muscles and bones interact in a way that would cause chondromalacia, because any calcium changes in the muscle will occur in every muscle, so no imbalance should occur. (pp. 1012-1013)
2. The hormone progesterone is secreted by the placenta during pregnancy and has no known action on tendon laxity. It would not alter the way muscles and bones interact in a way that would cause chondromalacia. (p. 1061)
3. Chondromalacia is a roughening of the cartilage behind the kneecap, and relaxin causes an increase in tendon and ligament laxity, exacerbating any friction between the patella and the femur (p. 1062).
4. Insulin promotes glucose uptake. Although insulin receptors are found in most tissues, any insulin changes in the muscle or tendon will occur in every muscle or tendon, so no imbalance should occur in the interaction of muscles and bones such that chondromalacia would develop. (pp. 988-989)

Question 11

A physical therapist is reviewing the medical record of a patient in the intensive care unit. The patient was admitted the previous night through the emergency department after a motorcycle accident resulting in a fractured right femur. The therapist notes a physician’s order for a Doppler study of the left leg. The therapist should:

1.proceed with the evaluation and intervention without any restrictions.

2.withhold physical therapy until results of the study are obtained and interpreted by the physician.

3.proceed with the evaluation and limit intervention to transfer to a bedside chair.

4.obtain clearance from the nurse to provide intervention for the patient.

Answer 11

1. A physician’s order for a Doppler study indicates possible deep vein thrombosis. A complete physical therapy evaluation and treatment should be deferred until a deep vein thrombosis has been ruled out or therapeutic levels of a prescribed anticoagulant to treat a deep vein thrombosis have been reached.
2. A physician’s order for a Doppler study indicates possible deep vein thrombosis. Physical therapy should not be conducted until the Doppler study is completed and the results analyzed by the physician.
3. A physician’s order for a Doppler study indicates possible deep vein thrombosis. Transfer from bed to chair is contraindicated due to possible deep vein thrombosis.
4. The nurse alone should not be providing clearance; the Doppler study must be completed and the results interpreted by the physician.

Question 12

Which of the following dressings is MOST appropriate to use with an infected wound that also requires hemostasis?

1.Foam

2.Alginate

3.Transparent film

4.Hydrocolloid

Answer 12

1. A foam dressing is absorptive but also creates an occlusive environment for moist wound healing. In the case of infection, a less occlusive dressing would be a better choice. (pp. 563, 589-590)
2. An alginate dressing is best to use in this case because this type of dressing provides both hemostasis and is appropriate for use over an infected wound (pp. 565, 589).
3. A transparent film is not the best dressing to use in this case because it does not provide hemostasis or infection control. Films are more appropriate for friction reduction. (pp. 563, 589)
4. A hydrocolloid dressing is not the best dressing to use with an infected wound that also requires hemostasis because it is the most occlusive dressing type. An alginate dressing is better for hemostasis. (pp. 564, 589-590)

Question 13

Setting: Outpatient rehabilitation facility
Sex: Male
Age: 34 years
Presenting Problem / Current Condition
Left Achilles tendon repair with flexor hallucis longus tendon transfer, left fibularis (peroneus) brevis tendon repair, left anterior talofibular ligament repair with lateral ankle stabilization 6 weeks ago
Magnetic resonance imaging prior to surgery found complete disruption of the Achilles tendon located 6.5 cm above calcified insertion, longitudinal split tear of the fibularis (peroneus) brevis tendon inferior to the level of the lateral malleolus, complete tear of anterior talofibular ligament
Medical History
Degenerative arthritis of first MTP joint of the left foot
Other Information
Works as an electrician on a naval ship, requiring long periods of standing on a moving surface
Independent with all activities of daily living and ambulation without a device
Previously ran 3-5 miles/day (4.8-8.0 km/day)
Physical Therapy Examination
Pain (left ankle): 4/10
Active range of motion
Left ankle: dorsiflexion –5°, plantar flexion 5° to 30°, inversion 0° to 10°, eversion 0° to 10°
Left first MTP joint flexion/extension 0° to 10°
Left knee flexion/extension 5° to 125°
Right ankle and knee joints within normal limits
Left gastrocnemius atrophy
Genu valgus bilaterally, greater on the left than on the right
Femoral medial (internal) rotation on the left in standing and sitting position
Ambulates with an antalgic gait and decreased weight-bearing on the left
Physical Therapy Plan of Care
Therapeutic exercises
Gait training
Modalities
Manual therapy

Which of the following recommendations regarding orthoses is MOST appropriate for the patient?

1.The patient should use a wedge shoe.

2.The patient should use a removable cast boot.

3.The patient should use a posterior leaf spring orthosis.

4.No bracing or special shoes are necessary for the patient.

Answer 13

1. A wedge shoe has an elevated toe portion in relation to the heel so as to offload the forefoot. This type of shoe is used to offload neuropathic ulcerations which is not consistent this patient’s condition, therefore, this answer is incorrect.
2. The patient in the scenario had surgery 6 weeks ago. It is recommended that the patient wear a removable cast boot at all times except when bathing and/or performing exercises. Therefore this is the correct answer.
3. A posterior leaf spring orthosis is most often used for a patient who has dorsiflexion weakness and impaired motor control due to lower motor neuron flaccid paralysis of the dorsiflexors. The patient described in the scenario is post surgical intervention and demonstrates deficits consistent with this orthopedic injury, not due to a lower motor neuron injury. Therefore this answer is incorrect.
4. The patient in the scenario had surgery 6 weeks ago. It is recommended that the patient wear a removable cast boot at all times except when bathing and/or performing exercises. Therefore this is the correct answer.

Question 14

A patient has diplopia, dysphagia, and bilateral weakness of the lower extremities. The patient also has loss of vibratory sense, two-point discrimination, and position sense. There are no signs of personality changes or aphasia. Which of the following arteries is MOST likely affected?

1.Basilar

2.Anterior cerebral

3.Middle cerebral

4.Posterior cerebral

Answer 14

1. Vertebral (basilar) arteries supply the brainstem and cerebellum. Lesions of these arteries usually manifest as unilateral or bilateral weakness of extremities and loss of vibratory sense, two-point discrimination, and position sense. Diplopia, homonymous hemianopsia, dysphagia, dysarthria, nausea, and confusion may also occur.
2. The anterior cerebral artery supplies the superior surfaces of frontal and parietal lobes and the medial surfaces of the cerebral hemispheres, which control the motor and somesthetic cortex serving the legs. The frontal lobe controls the personality; since personality changes are not mentioned, this artery is not likely to be affected. Also, lesions of this artery are most likely to produce hemiparesis or hemiplegia, not bilateral weakness.
3. The middle cerebral artery supplies the frontal lobe, parietal lobe, and cortical surfaces of the temporal lobe and, therefore, affects higher cerebral processes of communication, language interpretation, and interpretation of space, sensation, form, and voluntary movement. Lesions of this artery are most likely to manifest as alterations in communication, cognition, mobility, and sensation. Contralateral hemianopsia and hemiplegia (greater in the face and arm rather than leg) is also likely to be observed. Also, lesions of this artery are most likely to produce hemiparesis or hemiplegia, not bilateral weakness.
4. The posterior cerebral artery supplies the medial and inferior temporal lobes, medial occipital lobe, thalamus, posterior hypothalamus, and visual receptive area. Lesions of this artery are most likely to manifest as contralateral hemiplegia (greater in the face and arm than in the leg), not bilateral weakness, ataxia/tremor, homonymous hemianopsia, cortical blindness, receptive aphasia, and memory deficits. Since ataxia and tremors are not mentioned as the presenting symptoms, this artery is not likely to be affected.

Question 15

A patient sustained a nondisplaced midshaft radial and ulnar fracture 12 weeks ago. The patient was casted in mid-range elbow flexion with the forearm in a neutral position. Which of the following muscle pairs would MOST likely demonstrate contractile tissue shortening following the cast removal?

1.Brachialis and flexor pollicis longus

2.Brachioradialis and triceps

3.Biceps brachii and triceps

4.Biceps brachii and brachioradialis

Answer 15

1. The brachialis as an elbow flexor is shortened. The pollicis longus attaches below the elbow and would not be restricted.
2. The brachioradialis flexes the elbow. The cast position shortened this muscle. The triceps would not be short.
3. The biceps brachii flexes the elbow and supinates the forearm. Although the biceps brachii would be shortened, the triceps would not be short.
4. The biceps brachii and brachioradialis flex the elbow and supinate the forearm. The cast position would shorten both muscles.

Question 16

A patient has nontraumatic neck and shoulder pain, decreased hand dexterity, paresthesia in the right upper extremity, hyperreflexia, and urinary retention with overflow incontinence. The patient MOST likely has which of the following conditions?

1.Central cord syndrome

2.Cervical transverse ligament tear

3.Cervical disc herniation

4.Cervical myelopathy

Answer 16

1. Central cord syndrome is caused by hyperextension injury (trauma) with bleeding into the central spinal cord (Umphred).
2. A transverse ligament tear would present with a history of trauma, heaviness of the head, lump in the throat, nausea, headache, and dizziness, not the signs and symptoms presented in the stem (Dutton, pp. 1222-1223).
3. Cervical disc herniation would present with signs and symptoms specifically limited to local findings for the level of involvement, for example, dermatome (anterolateral shoulder/arm), myotome (deltoid/biceps), and deep tendon reflex (biceps) signs associated with the right cervical spine C5 nerve root. (Dutton, pp. 1312-1314)
4. All of the signs and symptoms in the stem fit the clinical presentation of cervical myelopathy (Goodman).

Question 17

A patient who has a spinal cord injury reports having spastic (reflex) bowel function. Which of the following descriptions BEST characterizes the patient’s neurologic injury?

1.Injury above spinal segments S2–S4, leaving spinal defecation reflexes intact

2.Injury at or below spinal segments S2–S4, leaving spinal defecation reflexes intact

3.Injury above spinal segments S2–S4, abolishing spinal defecation reflexes

4.Injury at or below spinal segments S2–S4, abolishing spinal defecation reflexes

Answer 17

1. In spastic bowel dysfunction, the level of cord injury occurs above S2–S4, leaving the spinal defecation reflexes intact.
2. Spinal cord injuries at or below spinal segments S2–S4 result in flaccid bowel dysfunction, with loss of spinal defecation reflexes.
3. In spastic bowel dysfunction, the level of cord injury occurs above S2–S4, leaving the spinal defecation reflexes intact.
4. Spinal cord injuries at or below spinal segments S2–S4 result in flaccid bowel dysfunction, with loss of spinal defecation reflexes.

Question 18

A patient who has amyotrophic lateral sclerosis exhibits severe lower extremity weakness and moderate upper extremity weakness. The patient has been increasingly dependent for activities of daily living. Which of the following interventions is MOST appropriate for the patient?

1.Education in positioning principles

2.Fitting with ankle-foot orthoses

3.Education in manual wheelchair propulsion

4.Strength training of the upper extremities

Answer 18

1. The patient descriptors align with Stage 5 amyotrophic lateral sclerosis. A physical therapist should educate the family and patient on proper positioning and turning principles to avoid skin breakdown.
2. The patient descriptors align with Stage 5 amyotrophic lateral sclerosis. The patient would be unable to perform ambulation or mobility with or without orthoses due to severe lower extremity weakness. Orthotic support is more appropriate in Stage 2.
3. The patient descriptors align with Stage 5 amyotrophic lateral sclerosis. The patient would be unable to perform manual wheelchair propulsion due to moderate upper extremity weakness. Most patients are introduced to electronic or motorized mobility by Stage 4.
4. The patient descriptors align with Stage 5 amyotrophic lateral sclerosis. Upper extremity strength training is not appropriate in the setting of moderate weakness. Strength training is permissible in muscle groups with Fair plus (3+/5) strength during Stages 2 and 3 with caution to avoid excessive fatigue.

Question 19

A patient has higher than normal residual volume, absent or mucoid sputum, and spirometry measures that are unimproved with bronchodilators. The patient MOST likely has which of the following conditions?

1.Asthma

2.Pneumococcal pneumonia

3.Chronic bronchitis

4.Emphysema

Answer 19

1. Asthma is associated with sputum that is predominantly eosinophilic, and bronchodilators improve spirometry scores of patients who have asthma (Hillegass, pp. 207-209).
2. Pneumococcal pneumonia is associated with sputum that is most often pinkish, blood-flecked, or rusty and will show evidence of bacteria when cultured. Treatment is centered on antibiotics. Oxygen can be administered, but bronchodilators are not a treatment of choice. (Hillegass, pp. 142-143)
3. Chronic bronchitis is associated with sputum that is predominantly neutrophilic, and bronchodilators improve the spirometry scores of patients who have chronic bronchitis (Goodman).
4. Emphysema has the features of higher than normal residual volume (because of destroyed alveolar walls and enlarged air spaces), absent or mucoid sputum (as opposed to sputum with a lot of neutrophils), and spirometry measures that are unimproved with bronchodilators (unlike asthma, which improves with bronchodilators) (Hillegass, pp. 192-193, 197).

Question 20

A child who has athetoid cerebral palsy is MOST likely to exhibit which of the following characteristics?

1.Sustained limb posturing

2.Low frequency tremor

3.Rapid, jerky motions

4.Mixed muscle tone

Answer 20

1. Sustained limb posturing is characteristic of dystonia, not athetosis.
2. Tremor is characteristic of cerebellar involvement or Parkinson disease, not athetosis.
3. Rapid, jerky motions are characteristic of chorea, not athetosis.
4. Athetoid cerebral palsy is characterized by slow, involuntary, writhing, twisting, “wormlike” movements. Some muscles demonstrate tone that is too high, and others demonstrate tone that is too low.

Question 21

A patient has sustained a moderate ankle sprain with significant swelling greater than 1 inch (2.5 cm) throughout the ankle and into the foot. Which of the following wrapping techniques is MOST appropriate to control the edema?

1.Figure-8 compression wrap with consistent pressure on the limb distally and proximally

2.Spiral compression wrap with more pressure on the limb distally than proximally

3.Figure-8 compression wrap with more pressure on the limb proximally than distally

4.Spiral compression wrap with consistent pressure on the limb distally and proximally

Answer 21

1. To control edema, a compression wrap should be used with more pressure applied distally than proximally.
2. When applying compression wraps to control edema, a spiral wrap is used with more pressure applied distally than proximally.
3. In no case should a wrap be applied with the proximal pressure greater than the distal pressure.
4. When applying a compression wrap for joint support, the wrap is applied with even pressure distally to proximally. This patient needs edema control, for which more pressure distally than proximally is used.

Question 22

A patient who had a cerebrovascular accident exhibits a flexion synergy of the left upper extremity. To promote good upper extremity movement, a physical therapist should mobilize the patient’s scapula toward which of the following directions?

1.Upward rotation and retraction

2.Upward rotation and protraction

3.Downward rotation and retraction

4.Downward rotation and protraction

Answer 22

1. The flexion synergy of the affected upper extremity results in scapular retraction/elevation or hyperextension. The scapula should be mobilized in protraction (not retraction) to preserve the glenohumeral rhythm that prevents soft tissue impingement in the subacromial space during overhead movements of the arm.
2. Flexion synergy of the upper extremity includes scapular retraction/elevation or hyperextension. In the upper extremity, correct passive range of motion techniques require careful attention to lateral (external) rotation and distraction of the humerus, especially as ranges approach 90° of flexion or more. The scapula should be mobilized on the thoracic wall with an emphasis on upward rotation and protraction to prevent soft tissue impingement in the subacromial space during overhead movements of the arm.
3. The scapula should be mobilized on the thoracic wall with an emphasis on upward rotation (not downward rotation) and protraction (not retraction) to prevent soft tissue impingement in the subacromial space during overhead movements of the arm.
4. The scapula should be mobilized in upward rotation (not downward rotation) to preserve the glenohumeral rhythm that prevents soft tissue impingement in the subacromial space during overhead movements of the arm.

Question 23

Which of the following factors MOST contributes to adverse reactions to medications in aging adults?

1.Increase in hepatic blood flow

2.Increase in metabolic activity

3.Decrease in proportion of body fat

4.Decrease in total body water

Answer 23

1. With advanced age, functional liver tissue diminishes and hepatic blood flow decreases, not increases.
2. With advanced age, functional liver tissue diminishes and hepatic blood flow decreases. Consequently, the capacity of the liver to break down and convert drugs and their metabolites declines, not increases.
3. As people age, there is a decrease in lean body mass and an increase in the proportion of body fat.
4. A decrease in lean body mass and an increase in the proportion of body fat results in a decrease in body water. As a result, water-soluble drugs have a lower volume of distribution, which speeds up onset of action and raises peak concentration.

Question 24

Which of the following statements is the MOST appropriate example of patient care documentation?

1.Patient ambulated up and down stairs with a reciprocal stepping pattern without difficulty.

2.Patient ambulated up and down 6 steps using a right handrail and recip. stepping pattern with min assist.

3.Patient ambulated up and down 6 steps using a right handrail and a reciprocal stepping pattern with minimal assistance.

4.Patient ambulated up and down stairs using a right handrail and reciprocal stepping pattern with minimal assist.

Answer 24

1. Principles of documentation require that comments be clear, objective, and measurable. General statements that are too vague should be avoided.
2. The statement includes non-standardized abbreviations, such as “recip.” and “min,” which may not be facility-approved or widely recognized.
3. Principles of documentation require the use of objective statements that are clearly measurable. This statement also avoids non-standardized abbreviations and fully spells out terms.
4. Principles of documentation require that comments be clear, objective, and measurable. General statements that are too vague should be avoided.

Question 25

Which of the following options BEST describes a normal response to the cremasteric reflex test?

1.Skin tenses in the gluteal area.

2.Ipsilateral scrotum elevation

3.Contraction of the anal sphincter muscles

4.Umbilicus moves down and toward area being stroked.

Answer 25

1. Tensing of the skin in the gluteal area is due to the gluteal reflex, which is evoked by stroking the back. The gluteal reflex comes from nerve roots of L4–L5, S1–S3.
2. For the cremasteric reflex text, the patient lies in supine position while the examiner strokes the inner side of the upper thigh with a pointed object. The test result is negative if the scrotal sac on the tested side pulls up. Unilateral absence of this response indicates a lower motor neuron lesion between L1 and L2.
3. Contraction of the anal sphincter muscles is due to the superficial anal reflex. The examiner tests the superficial anal reflex by touching the perianal skin. A normal result is shown by contraction of the anal sphincter muscles. This reflex comes from the S2–S4 nerve roots.
4. Movement of the umbilicus down and toward the area being stroked is due to the superficial abdominal reflex. The examiner uses a pointed object to stroke each quadrant of the abdomen of the supine patient in a triangular fashion around the umbilicus. Absence of the reflex (movement of the skin) indicates an upper motor neuron lesion; unilateral absence indicates a lower motor neuron lesion from T7–L2, depending on where the absence in noted, as a result of segmental innervation.

Question 26

Which of the following actions should be done FIRST when teaching a new motor skill?

1.Provide frequent verbal feedback on performance.

2.Utilize massed practice.

3.Distribute written instructions with standardized formatting.

4.Identify and utilize learning preferences.

Answer 26

1. Frequent feedback is detrimental when learning a skill and would not be done first when teaching a new skill (p. 263).
2. Massed practice is less effective than distributed practice and would not be done first (p. 255).
3. It may be best to tailor written instructions to fit the patient’s learning needs (p. 212).
4. It is best to identify and use the patient’s preferred learning style (p. 24).

Question 27

A patient who has a long-term history of nonsteroidal antiinflammatory drug use reports back pain from the mid thoracic region to the right upper quadrant, including the posterior right shoulder. The patient also reports weight loss, loss of appetite, dark-colored stools, and episodes of epigastric pain within 3 hours of eating a meal. The patient reports an episode of vomiting material with a coffee-ground appearance prior to arriving for physical therapy. Which of the following gastrointestinal conditions is MOST likely responsible for these symptoms?

1.Peptic ulcer disease

2.Gastritis

3.Irritable bowel syndrome

4.Appendicitis

Answer 27

1. Patients who have a history of long-term nonsteroidal antiinflammatory drug use should be monitored for signs and symptoms of bleeding. Pain occurring within 1-3 hours of eating is typical in duodenal ulcers. The pain occasionally radiates to the mid thoracic back and right upper quadrant, including the right shoulder. Right shoulder pain alone may occur as a result of blood within the peritoneal cavity. Melena (dark, tarry stools) and coffee-ground vomitus are indicative of bleeding. Referral to a physician is warranted. (pp. 877-878)
2. Although gastritis is a common adverse effect of nonsteroidal antiinflammatory drugs and is associated with epigastric pain and loss of appetite, pain is much less common than with ulcer disease. Coffee-ground vomitus is not typically associated with gastritis. (pp. 875-876)
3. Irritable bowel syndrome typically presents with prolonged abdominal pain that is relieved by bowel movements. Changes in stool associated with irritable bowel syndrome include hard, loose, or watery stool, rather than melena (dark, tarry stools), alterations in stool frequency, or difficulty in having a bowel movement. Left lower quadrant pain with constipation and diarrhea are commonly associated with this condition. (p. 891)
4. An inflammation of the appendix typically presents with a classic sequence of abdominal pain with vomiting (not coffee-ground vomitus, which is indicative of bleeding), low-grade fever, anorexia, and nausea. Pain associated with appendicitis is constant and may shift within 12 hours to the right lower quadrant at the McBurney point. Melena (dark stools) and pain referred to the right shoulder are not typically associated with appendicitis. (pp. 904-905)

Question 28

Which of the following automatic postural responses will a patient MOST likely use to maintain equilibrium following a small perturbation on a stable surface from a posterior to anterior direction?

1.Hip strategy to control sway and move the body anterior to midline

2.Hip strategy to control sway and move the body posterior to midline

3.Ankle strategy to control sway and move the body anterior to midline

4.Ankle strategy to control sway and move the body posterior to midline

Answer 28

1. Use of a hip strategy is more appropriate for activities such as tandem and single limb stance (Umphred).
2. Use of a hip strategy is more appropriate for activities such as tandem and single limb stance (Umphred).
3. Small perturbations backward (anterior to posterior) would create a forward weight-shift, then a return to midline in response (O’Sullivan).
4. The ankle strategy is appropriate for small perturbations on a stable surface (Umphred). Small perturbations forward (posterior to anterior) would create a backward weight-shift, then a return to midline in response (O’Sullivan).

Question 29

A physical therapist is using exercise as an intervention for a patient with advanced ankylosing spondylitis. Which of the following types of exercise would be MOST important for the patient?

1.Aerobic exercise

2.Balance exercises

3.Light-weight resistance exercises

4.Short-duration, high-intensity exercise

Answer 29

1. Advanced ankylosing spondylitis would cause loss of chest wall excursion, which compromises breathing. Aerobic exercise done consistently would be most important in order to optimize efficiency of oxygen transport and maintain cardiopulmonary function. (pp. 1333, 1337)
2. Balance exercises would likely be used for a patient who has ankylosing spondylitis, but they would not be as important as maintaining cardiopulmonary function in those who have advanced stages of this disease. In addition, activities requiring high levels of balance might need to be avoided to reduce risk of falls. (p. 1337)
3. Stretching and aerobic exercise would be more important than light resistance exercise for a patient who has advanced ankylosing spondylitis and likely fusion of involved joints. Energy conservation would also take precedence over resistance exercise. (p. 1337)
4. High-intensity and high-impact exercise should be avoided by a patient who has advanced ankylosing spondylitis, because intense exercise can potentially exacerbate the inflammatory process and be potentially harmful. Low-intensity aerobic exercise is recommended instead. (p. 1337)

Question 30

A 43-year-old male patient reports the recent appearance of silver and scaly-appearing plaques on the scalp, elbows, and knees. If left unaddressed, which of the following complications is MOST likely to develop?

1.Bluish digits with cold exposure

2.Dermal reaction to sun exposure

3.Erosive arthritis in the DIP joints of the hands

4.Erosive arthritis in the hip joints

Answer 30

1. The stem describes a patient who recently developed psoriasis (pp. 449-450). Bluish discoloration of the digits with cold exposure is associated with Raynaud disease (p. 255).
2. The stem describes a patient who recently developed psoriasis (pp. 449-450). The dermal effects associated with systemic lupus erythematosus include a major skin reaction often resulting from exposure to sun. This may include a red, scaly rash. (p. 445).
3. The stem describes a patient who recently developed psoriasis, a systemic disease hallmarked by silver scaled papules and plaques in the scalp, elbows, knees, back, and buttocks. It is a systemic disease that can result in erosive arthritis, particularly in the DIP joints of the hands. (pp. 449-450)
4. The stem describes a patient who recently developed psoriasis, a systemic disease hallmarked by silver scaled papules and plaques in the scalp, elbows, knees, back, and buttocks. It is a systemic disease that can result in erosive arthritis, particularly in the DIP joints of the hands. Hip joints typically are not involved in psoriasis. (pp. 449-450)

Question 31

When treating a patient who has transient upbeating nystagmus and left ocular torsion, canalith repositioning maneuvers should be targeted to which of the following structures?

1.Right posterior semicircular canal

2.Right superior semicircular canal

3.Left posterior semicircular canal

4.Left superior semicircular canal

Answer 31

1. Debris in the right posterior semicircular canal produces symptoms of transient upbeating nystagmus and/or right ocular torsion.
2. Debris in the right superior semicircular canal produces symptoms of persistent downbeating nystagmus and/or right ocular torsion.
3. The canalith repositioning maneuver for the left posterior semicircular canal is performed to move free-floating debris in the posterior semicircular canal back into the vestibule, thus resolving the signs and symptoms of nystagmus and dizziness. Debris in the left posterior semicircular canal produces symptoms of transient upbeating nystagmus and/or left ocular torsion.
4. Debris in the left superior semicircular canal produces symptoms of persistent downbeating nystagmus and/or left ocular torsion.

Question 32

A patient who has chronic obstructive pulmonary disease is participating in a mild graded exercise program at a level of 2 metabolic equivalents (METs). The patient’s heart rate at rest is 80 bpm. During an incremental increase in exercise up to 4 metabolic equivalents (METs), the patient experiences an elevation in heart rate to 120 bpm. Which of the following actions is MOST appropriate?

1.Discontinue exercise while monitoring vital signs.

2.Continue the exercise session while monitoring vital signs.

3.Continue the exercise session and refer the patient to a physician to evaluate exercise response.

4.Discontinue the exercise session and refer the patient to an emergency department to evaluate exercise response.

Answer 32

1. This is a normal response in a patient who has chronic obstructive pulmonary disease and as such would not require discontinuation of the exercise session. Since elevated heart rates with increased hypoxemia are an expected compensatory response in patients who have pulmonary disease, there is no reason to cease exercise unless some other type of medical emergency exists.
2. During acute exercise, patients who have chronic obstructive pulmonary disease experience elevated heart rates and blood pressures with incremental exercise. The patient’s response is an expected compensatory response, and exercise can continue as prescribed with continued monitoring of vital signs.
3. Since elevated heart rates with increased hypoxemia are an expected compensatory response in patients who have pulmonary disease, there is no reason to refer the patient back to the physician unless there is some other type of medical emergency.
4. This is an expected compensatory response in a patient who has chronic obstructive pulmonary disease and as such would not require discontinuation of the exercise session. There is no reason to refer the patient to the emergency department unless there is some other type of medical emergency.

Question 33

A physical therapist reads about a clinically based study in which electrical stimulation was used for subjects with acute disc herniation. The author gives details about the parameters used and reports that the intervention had a statistically significant effect. External validity is LEAST threatened if the study findings are applied to which of the following groups?

1.Patients from the same population, when the same parameters are used, even if the stimulation device is not the same model

2.Patients from a similar population, when the same stimulation device model and the same parameters are used

3.Patients with a variety of diagnoses as long as they have low back pain

4.Patients with a similar physical therapy problem list as long as the same stimulation device model is used

Answer 33

1. External validity is the degree to which the results of a study can be generalized to another situation. In this option, the only change in the procedure is the model of the electrical stimulation machine. External validity should be maximized in this situation.
2. The generalizability (external validity) of the findings is only high for patients from the same population (those who have acute disc herniation).
3. The generalizability (external validity) of the findings is only high for patients from the same population (those who have acute disc herniation).
4. The generalizability (external validity) of the findings is only high for patients from the same population (those who have acute disc herniation).

Question 34

A patient has a lesion in the right middle cerebral artery. During examination, a physical therapist should expect to find:

1.impaired spatial perception.

2.ataxia of limbs and gait.

3.visual agnosia.

4.short-term memory loss.

Answer 34

1. A lesion of the right middle cerebral artery, which affects the right parietal lobe, typically produces impairment of spatial perception (p. 600).
2. Ataxia involving the limbs and gait occurs with damage to the cerebellum, involving the vertebrobasilar arteries (p. 603).
3. Visual agnosia occurs with damage to the left occipital lobe from a lesion of the posterior cerebral artery (p. 601).
4. A memory defect is a characteristic of damage to the inferomedial area of the temporal lobe either bilaterally or only on the dominant side of the brain (usually the left side). Damage to the posterior cerebral artery is implicated. (p. 601)

Question 35

A physical therapist is examining a patient who has a whiplash injury and a mid-cervical spine sprain. To determine the function of the patient’s longus colli and longus capitis, which of the following assessments should be included in the examination?

1.Axial extension

2.Craniocervical flexion

3.Cervical compression test

4.Neck flexion range of motion

Answer 35

1. Axial extension or chin retraction may assess the mobility of the upper cervical spine but not the function of the deep neck flexors. Axial extension causes excessive shear in the mid-cervical spine.
2. The longus colli and longus capitis are deep neck flexors. The craniocervical flexion test or the deep neck flexor endurance test is included in the examination of these muscles.
3. The cervical compression test is used to stress the ability of the neck to tolerate passive loading; it is not a test of muscle strength.
4. Neck flexion range of motion is not specific for the deep neck flexors and can be achieved with gravity assist (in sitting position) or with the superficial neck flexors such as the sternocleidomastoid.

Question 36

If treatment time and surface area are kept constant, which of the following ultrasound parameters would MOST likely deliver the GREATEST amount of energy through tissues?

1. 0.5 W/cm2 in continuous mode at 1 MHz
2. 0.8 W/cm2 in continuous mode at 3 MHz
3. 1.0 W/cm2 in 50% pulsed mode at 1 MHz
4. 1.2 W/cm2 in 25% pulsed mode at 3 MHz

Answer 36

1. Energy delivery to the tissues with the use of ultrasound is a function of various parameters, including intensity, frequency, and duty cycle. Continuous mode (or 100% duty cycle) produces thermal effects compared to pulse mode (p. 185). Research indicates that a frequency of 3 MHz results in a higher maximal temperature than 1 MHz despite delivering a lesser depth of penetration (p. 175). Furthermore, higher intensities produce higher temperature increases in tissues (p. 175).
2. Energy delivery to the tissues with the use of ultrasound is a function of various parameters, including intensity, frequency, and duty cycle. Continuous mode (or 100% duty cycle) produces thermal effects, compared to pulsed mode (p. 185). Research indicates that a frequency of 3 MHz results in a higher maximal temperature than 1 MHz despite delivering a lesser depth of penetration (p. 175). Furthermore, higher intensities produce higher temperature increases in tissues (p. 175).
3. Energy delivery to the tissues with the use of ultrasound is a function of various parameters, including intensity, frequency, and duty cycle. Pulsed mode (less than 100% duty cycle) produces nonthermal effects, compared to continuous mode (p. 185).
4. Energy delivery to the tissues with the use of ultrasound is a function of various parameters, including intensity, frequency, and duty cycle. Pulsed mode (less than 100% duty cycle) produces nonthermal effects, compared to continuous mode (p. 185).

Question 37

Which of the following ankle-foot orthoses is MOST appropriate for a patient who exhibits Trace (1/5) strength of the tibialis anterior muscle?

1.Posterior leaf spring

2.Floor reaction

3.Patellar tendon-bearing

4.Solid ankle

Answer 37

1. Trace (1/5) strength in the anterior tibialis indicates the ankle is unable to move into dorsiflexion, resulting in foot drop (Avers, pp. 284-285). The posterior leaf spring is designed to help lift the foot for adequate clearance during the swing phase of gait (O’Sullivan, p. 1293).
2. A floor (ground) reaction orthosis has an anterior shell that provides a posteriorly directed force to resist knee flexion during stance phase (O’Sullivan, p. 1296). This patient does not need assistance with knee control because the patient has weakness of the tibialis anterior, which affects dorsiflexion of the ankle (Avers, p. 284).
3. A patellar tendon-bearing orthosis is designed to lessen the load on the foot (O’Sullivan, p. 1296). This patient requires assistance with ankle dorsiflexion due to tibialis anterior weakness (Avers, p. 284).
4. A solid ankle-foot orthosis limits all foot and ankle motion (O’Sullivan, p. 1294). This patient requires only assistance with ankle dorsiflexion due to tibialis anterior weakness (Avers, p. 284).

Question 38

Which of the following combinations of activities would be MOST beneficial for maintaining bone density in a patient with osteoporosis?

1.Treadmill walking and balance training

2.Treadmill walking and resistance training

3.Swimming and balance training

4.Swimming and resistance training

Answer 38

1. Resistance training is an essential component of an exercise program for a patient who has osteoporosis (Moore) and is lacking from this option. Balance training, although helpful in preventing falls, is not most beneficial for maintaining bone density.
2. This question presents two comparisons and asks which is better: 1) treadmill walking or swimming and 2) resistance or balance training. The correct answer is treadmill walking and resistance training. Walking is a beneficial weight-bearing aerobic activity. Resistance training is important to maintain bone mineral density or prevent loss of bone mineral density. (Moore)
3. Swimming, because of the lack of a weight-bearing component, has limited value for a person who has osteoporosis (Goodman). Balance training, although helpful in preventing falls, is not most beneficial for maintaining bone density.
4. Swimming, because of the lack of a weight- bearing component, has limited value for a person who has osteoporosis (Goodman).

Question 39

A collegiate athlete reports right anterior groin pain first encountered after a rotational injury. The patient is also experiencing painful clicking. Hip range of motion is normal, but pain is provoked with combined end-range hip flexion, adduction, and medial (internal) rotation. Radiographs of the hip and pelvis are normal. Which of the following diagnoses is MOST likely?

1.Transient synovitis

2.Trochanteric bursitis

3.Anterior acetabular labral tear

4.Femoral head stress fracture

Answer 39

1. Transient synovitis is most likely to occur in children younger than the patient described in the stem. Transient synovitis is associated with an active antalgic gait and with pain that is aggravated by medial (internal) rotation but also by abduction, unlike the pattern found with anterior labral tears. (p. 1580)
2. Trochanteric bursitis is more likely to be associated with lateral hip/thigh pain aggravated by lying on the involved side. This condition is more likely to occur in patients age 40-60 years, not in the demographic group of the patient described in the stem. Pain often is enhanced with passive hip adduction and resisted lateral (external) rotation, abduction, and extension. (pp. 945-947)
3. The clinical presentation of anterior acetabular labral tears most often includes pain on passive adduction, flexion, and medial (internal) rotation. The description of mechanism of injury and clinical presentation in the stem are most typical of this injury. (pp. 936-938)
4. Femoral head stress fractures present with a pain pattern similar to the pattern presented in the stem, but pain is increased with weight-bearing. Examination results are often negative except for an empty end-feel with hip rotation and a noncapsular pattern. (p. 952)

Question 40

Pain associated with urinary calculi MOST often occurs because of blockage of which of the following structures?

1.Ureter

2.Urethra

3.Bladder

4.Kidney

Answer 40

1. Pain from urinary calculi results from the ureter contracting in the attempt to dislodge the calculi.
2. Pain from urinary calculi is more likely to result from obstruction in the ureter than from obstruction in the urethra.
3. Pain from urinary calculi results from obstruction in the ureter, not the bladder.
4. Pain from urinary calculi results from obstruction in the ureter, not the kidneys.

Question 41

A patient reports incontinence and a sensation of urgency to urinate with little output. Which of the following interventions is BEST to include in the therapeutic program?

1.Restriction of fluid intake

2.Scheduling an increased frequency of voiding

3.Detrusor contraction exercises

4.Relaxation training

Answer 41

1. Restricting fluid intake would result in dehydration, which is not a viable treatment option for incontinence.
2. The time intervals between voiding should be increased to suppress urges.
3. The detrusor muscle should be relaxed or inhibited in patients who have urge incontinence.
4. The patient is describing signs of urge incontinence with possible detrusor contractions. Relaxation training is helpful to decrease bladder contractions.

Question 42

A patient who had a cerebrovascular accident has not progressed with mobility during the past 2 weeks of treatment in a skilled nursing facility. The physical therapist’s prognosis is that the patient has residual deficits that will prevent the patient from becoming more independent. The family wants to take the patient home. Which of the following treatment plans is MOST appropriate for the patient?

1.Continue treatment for 2 weeks and then reassess to determine if the additional intervention has resulted in further improvement.

2.Recommend transferring the patient back to the hospital for reassessment for possible extension of the cerebrovascular accident.

3.Change the focus of the treatment to family or caregiver training in assisting the patient to ensure a safe discharge.

4.Discharge the patient to home at the current level of function and have the patient’s family monitor the patient for further improvement.

Answer 42

1. The patient is struggling to show improvements, and the therapist’s assessment is that the patient will have deficits that will prevent the patient from becoming more independent with mobility. Continuing treatment for 2 more weeks is not a good use of resources.
2. Recommending transfer back to the hospital is inappropriate because the patient does not show any significant decline warranting a hospital admission. The patient is struggling to show improvements, and the therapist’s assessment is that the patient will have deficits that will prevent the patient from becoming more independent with mobility.
3. A revision in the plan of care is indicated if the patient progresses more slowly than expected. Each modification must be evaluated in terms of overall effect on the plan of care. Family and caregiver education/training is a component of effective discharge planning. The caregiver should understand the proper use of any relevant assistive equipment and appropriate transfer and guarding techniques and should use correct body mechanics.
4. The family/caregiver and patient may be at risk for possible injury if not instructed in the proper body mechanics and transfer techniques.

Question 43

Which of the following modalities is MOST appropriate to administer to a patient who has hip joint pain secondary to a labral tear that occurred 6 months ago?

1.Traction

2.3-MHz thermal ultrasound

3.Ice pack

4.Sensory-level electrical stimulation

Answer 43

1. Traction is contraindicated in the presence of instability, which is implied by the diagnosis of a labral tear (p. 378).
2. Ultrasound with a 3-MHz frequency will only penetrate superficial tissue and will only cover a small area; therefore, it is not appropriate to treat the injury in question (p. 184).
3. Cryotherapy reduces chemical mediators being released in order to modulate pain. Ice packs are helpful in the initial, or acute, stage of healing but are not as effective in later stages of healing. (p. 4).
4. Sensory-level electrical stimulation can cover a large area and is effective for treating chronic pain (p. 7).

Question 44

A 16-year-old patient reports the insidious onset of middle to lower thoracic pain. The pain is worse with prolonged standing or sitting. The patient’s posture is characterized by excessive thoracic kyphosis and lumbar lordosis. Active rotation in sitting position is painful. Which of the following conditions is the MOST likely cause of the patient’s pain?

1.Annular disc tear

2.Compression fracture

3.Scheuermann disease

4.Spondylolisthesis

Answer 44

1. An annular disc tear is more common in an older population and more common in the lumbar region.
2. A compression fracture is more likely in older patients who have osteoporosis.
3. The stem describes the presentation of Scheuermann disease, which typically affects the T7–T10 region.
4. Spondylolisthesis may be present in the lumbar spine, but it is rare in the thoracic spine.

Question 45

When examining a patient’s pressure injury, a physical therapist notes that in the area of the wound, the patient has complete loss of skin and intact underlying fascia. The therapist should recognize this as a:

1.Stage 1 wound.

2.Stage 2 wound.

3.Stage 3 wound.

4.Stage 4 wound.

Answer 45

1. Stage 1 pressure injuries are characterized by nonblanchable erythema of intact skin. In this scenario, the skin is not intact.
2. Stage 2 pressure injuries are characterized by partial-thickness skin loss involving the epidermis, dermis, or both (e.g., abrasion, blister, or shallow crater).
3. Stage 3 pressure injuries are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia (deep crater with or without undermining).
4. Stage 4 pressure injuries are characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon or joint capsule).

Question 46

Setting: Acute care
Sex: Female
Age: 74 years
Presenting Problem / Current Condition
Coronary artery bypass graft 2 days ago
Medical History
Breast cancer with bilateral mastectomy 4 months ago; undergoing chemotherapy treatment
Hypertension
Type 2 diabetes
Other Information
Lives alone; spouse deceased
Walked 1 mile/day (1.6 km/day) and participated in tai chi 2 days/week
Independent with all activities of daily living and instrumental activities of daily living; did not use an assistive device
Medications: digoxin (Digitek), metformin (Glucophage), warfarin (Coumadin), furosemide (Lasix), simvastatin (Zocor)
Physical Therapy Examinations
Pain rating of 2/10 at rest around sternal incision
Vital signs
Blood pressure
(mm Hg) Heart rate
(bpm) Respiratory rate
(breaths/minute) Oxygen saturation
(on room air)
Resting supine 128/74 68 14 96%
Sitting 105/60 100 20 92%
Performed supine-to-sit transfer with moderate assistance of one person

At the completion of exercise, which of the following objective measures would be of MOST concern?

1.Blood pressure of 140/83 mm Hg

2.Mean arterial pressure of 60 mm Hg

3.Blood glucose of 95 mg/dL

4.Presence of a S2 heart sound

Answer 46

1. Blood pressure of 140/83 mm Hg is an incorrect answer because the total change in systolic pressure from baseline is less than 15 mm Hg and the change in diastolic pressure is less than 10, which are both acceptable changes (Hillegass, pp. 546-547).
2. Mean arterial pressure (MAP) of 60 mm Hg is the correct answer because a patient with a MAP this low will be unable to perfuse vital organs. This finding would be MOST concerning (Malone, p. 95).
3. Blood glucose of 95 mg/dL is an incorrect answer because blood glucose of 95 mg/dL is a normal finding and would not be concerning (Malone, p. 79).
4. Presence of a S2 heart sound is an incorrect answer because an S2 heart sound is a normal finding and would not be concerning (Malone, p. 203).

Question 47

A patient who has a hiatal hernia is receiving physical therapy. Which of the following exercises would MOST likely worsen the symptoms related to the hernia?

1.Wall sits

2.Overhead press

3.Bilateral leg lifts

4.Hamstring stretch

Answer 47

1. Wall sits are performed in an upright position and would not exacerbate a hiatal hernia.
2. An overhead press is typically performed in seated, semireclined, or standing position and would not exacerbate a hiatal hernia.
3. Individuals who have a hiatal hernia should avoid supine position and avoid the Valsalva maneuver. Bilateral leg lifts must be performed in supine position and require strong contractions of the stomach muscles, encouraging the Valsalva maneuver, which would worsen the hiatal hernia.
4. Hamstring stretching can be modified to be done in a position other than supine to avoid exacerbating a hiatal hernia.

Question 48

A physical therapist is teaching a patient pursed-lip breathing. This intervention will MOST likely result in which of the following changes?

1.Decreased ventilation-perfusion ratio

2.Increased partial pressure of arterial oxygen (PaO2)

3.Decreased respiratory rate

4.Increased strength of the ventilatory muscles

Answer 48

1. There is no evidence of a change in ventilation-perfusion ratio with pursed-lip breathing.
2. There is no evidence of a change in partial pressure of arterial oxygen (PaO2) with pursed-lip breathing.
3. The increase in exhalation time creates a decrease in respiratory rate.
4. There is no evidence of a change in strength of the ventilatory muscles with pursed-lip breathing.

Question 49

Which of the following findings is MOST commonly associated with patients who have chronic obstructive pulmonary disease?

1.Below normal diaphragmatic excursion of 0.4 to 0.8 inch (1 to 2 cm)

2.Above normal diaphragmatic excursion of 0.4 to 0.8 inch (1 to 2 cm)

3.Below normal diaphragmatic excursion of 1.2 to 2 inches (3 to 5 cm)

4.Above normal diaphragmatic excursion of 1.2 to 2 inches (3 to 5 cm)

Answer 49

1. Excursion is decreased in patients who have chronic obstructive pulmonary disease due to hyperinflation of the chest and a resultant flattened diaphragm. Normal excursion of the diaphragm is 1.2 to 2 inches (3 to 5 cm); therefore, 0.4 to 0.8 inch (1 to 2 cm) would be below the normal excursion value.
2. Excursion is decreased in patients who have chronic obstructive pulmonary disease due to hyperinflation of the chest and a resultant flattened diaphragm.
3. Normal excursion of the diaphragm is 1.2 to 2 inches (3 to 5 cm).
4. Excursion is decreased in patients who have chronic obstructive pulmonary disease due to hyperinflation of the chest and a resultant flattened diaphragm.

Question 50

What form of validity is measured by comparing results obtained with a test to results obtained using an already well-established and validated tool?

1.Face

2.Construct

3.Content

4.Criterion-related

Answer 50

1. Face validity is based on the validation of a test without comparison to an already validated test.
2. Construct validity is based on abstract concepts and is not observable or measurable.
3. Content validity of a test is measured to determine the extent of coverage of a concept. It is not determined by comparison with a reliable/valid (gold) standard.
4. Criterion-related validity of a new tool is tested by using practical and objective comparisons to a reliable/valid (gold) standard measure already in use.

Question 51

A patient has excessive ankle eversion when walking. Which of the following examination measures is MOST likely to determine the cause of the patient’s gait deviation?

1.Manual muscle test of the gastrocnemius and soleus

2.Manual muscle test of the tibialis anterior and tibialis posterior

3.Modified Ashworth Test of the tibialis posterior and flexor digitorum

4.Modified Ashworth Test of the tibialis anterior and extensor digitorum

Answer 51

1. Weakness in the gastrocnemius-soleus muscle results in excessive knee flexion during stance phase (Dutton, pp. 977-978).
2. Excessive ankle eversion during stance is most frequently associated with marked weakness of inverters such as the tibialis anterior and tibialis posterior (Dutton, p. 309), which may result from a malalignment such as a forefoot or rearfoot varus/valgus (Magee). Other causes of excessive eversion include plantar flexion contracture, fibular (peroneal) hypertonicity, and valgus deformity (Dutton, p. 314). A manual muscle test of the tibialis anterior and tibialis posterior muscles would best determine if these muscles are weak and in need of strengthening (Dutton, pp. 1136-1137).
3. The Modified Ashworth Test is used to examine spasticity (Umphred). However, excessive activation of the tibialis posterior muscle during walking (as would occur with spasticity) results in excessive inversion. The case describes excessive foot eversion.
4. The Modified Ashworth Test is used to examine spasticity (Umphred). Excessive activation of the tibialis anterior muscle during walking (as would occur with spasticity) results in excessive inversion. The case describes excessive foot eversion.

Question 52

A patient has a superficial partial-thickness burn. Which of the following signs would MOST likely be observed in the burned area?

1.Mixed red-white coloring

2.Marked edema

3.Intact blisters

4.Eschar

Answer 52

1. Mixed red-white coloring is evident with deep partial-thickness burns because the dermis is almost completely destroyed.
2. Marked edema is present with deep partial-thickness burns because of broken blisters and leakage of plasma fluid. Capillary destruction is marked.
3. Intact blisters are the most common sign of superficial partial-thickness burns. Damage is through the epidermis and into the papillary layer of the dermis.
4. Eschar is evident with full-thickness burns. It is a hard, devitalized tissue consisting of coagulated plasma and necrotic cells. Full-thickness burns destroy all of the epidermal and dermal layers and possibly the subcutaneous fat layer.

Question 53

Which of the following bladder management techniques is MOST likely to be used for a patient with bladder dysfunction due to a cauda equina lesion?

1.Sacral nerve modulation

2.Pelvic floor biofeedback

3.Pelvic floor strengthening exercises

4.Intermittent catheterization

Answer 53

1. Spinal cord lesions at the level of S2 and below lead to bladder areflexia and dysfunction of the external sphincter. Surgical interventions for neurogenic bladder exist; sacral nerve modulation is used for incomplete lesions. (Goodman, pp. 991-992) The patient has a complete lesion.
2. Spinal cord lesions at the level of S2 and below lead to bladder areflexia and dysfunction of the external sphincter (Goodman, p. 991). S2–S4 innervate muscles in the perineum and external sphincter; therefore, complete loss of innervation would lead to paralysis of the respective musculature (Moore). Biofeedback is for muscle identification would be an inappropriate intervention for this patient.
3. Spinal cord lesions at the level of S3 and below lead to bladder areflexia and dysfunction of the external sphincter (Goodman, p. 991). S2–S4 innervate muscles in the perineum and external sphincter; therefore, complete loss of innervation would lead to paralysis of the respective musculature (Moore). Strengthening exercises would be an inappropriate intervention for this patient.
4. Spinal cord lesions at the level of S2 and below lead to bladder areflexia and dysfunction of the external sphincter. Bladder tone is preserved, but bladder compliance decreases with time. Catheterization is a commonly employed intervention to avoid excessive bladder distention. (Goodman, p. 991)

Question 54

Which of the following tests is MOST accurate for assessing volume reduction in a patient who has lymphedema?

1.Water displacement

2.Limb circumference

3.Bioelectrical impedance

4.Optoelectronic volumetry

Answer 54

1. Water displacement has been regarded as the most sensitive and accurate standard for volume measurement.
2. Circumference measurements taken at various points of a body part are used most frequently to quantify lymphedema, but several problems exist, including limitations for acceptable differences between repeated circumferential measurement of the normal adult and control of intra- and interrater reliability. Circumferential measurement, although used clinically, is not considered a reliable/valid (gold) standard.
3. Single frequency bioelectrical impedance has become more frequently used in the clinical setting to measure limb fluid, but it is not considered the reliable/valid (gold) standard.
4. Optoelectronic volumetry calculates limb volume by using infrared light and has been conceptualized as a continuous variable, supporting a more robust test of the severity of lymphedema, but it is not considered a reliable/valid (gold) standard.

Question 55

Which of the following interventions would be MOST appropriate for a patient with a spinal cord lesion to the anterolateral sensory system?

1.Tactile stimulation using tuning forks and vibrators of varying frequencies

2.Active movement using visual feedback for facilitation of position sense

3.Sensory re-education utilizing objects of various sizes, shapes, and textures

4.Patient education concerning protection from hot/cold injuries

Answer 55

1. Use of tuning forks and vibrators would facilitate reeducation of vibratory sense. This sensory function is related to the dorsal column/medical lemniscus system and may not be affected in this patient.
2. Active movement with visual feedback would facilitate reeducation of proprioceptive sense. This sensory function is related to the dorsal column/medical lemniscus system and may not be affected in this patient.
3. Sensory reeducation focuses on all sensory modalities, but these techniques would emphasize reeducation of discriminative touch functions. These sensory functions are related to the dorsal column/medical lemniscus system and may not be affected in this patient.
4. With lesions to the anterolateral system, a patient may exhibit sensory deficits in both light touch and hot/cold discrimination. Failure to distinguish extremes in temperature could result in the patient sustaining thermal injuries. Instruction in techniques to protect against these injuries would be of primary importance.

Question 56

A non-English-speaking patient is accompanied to physical therapy by her young English-speaking grandson. The patient does not understand or speak enough English to fully participate in an initial examination. To provide the MOST appropriate services, the therapist should take which of the following actions?

1.Ask the grandson to translate and proceed with the examination.

2.Use a professional translator and proceed with the examination.

3.Ask a same-language-speaking member of the hospital’s staff to translate and proceed with the examination.

4.Use gestures, pictures, and simple terms in order to proceed with the examination.

Answer 56

1. Culturally and linguistically appropriate services require professional translators with knowledge of the patient’s language and knowledge of medical terms. The patient’s grandson should not be assumed to be an appropriate translator due to the sensitive topics to be covered.
2. Culturally and linguistically appropriate services require professional translators with knowledge of the patient’s language and knowledge of medical terms.
3. Culturally and linguistically appropriate services require professional translators with knowledge of the patient’s language and knowledge of medical terms. Although the person is a member of the hospital staff, the person may not have adequate knowledge of the medical terms involved in the patient’s care.
4. Use of gestures, pictures, and simple terms by the physical therapist may help avoid confidentiality issues but does not provide satisfactory communication between the therapist and the patient.

Question 57

Setting: Outpatient rehabilitation
Sex: Female
Age: 82 years
Presenting Problem / Current Condition
Frequent falls (three in the past month)
Difficulty crossing a street quickly
Medical History
Atrial fibrillation
Hypertension
Spinal stenosis
Other Information
Lives alone in a one-story home
Ambulates household distances with a straight cane
Physical Therapy Examination(s)
Vital signs at rest in seated position: blood pressure 132/80 mm Hg, heart rate 72 bpm, oxygen saturation 98% on room air
Edema present in bilateral lower extremities
Lower extremity muscle strength Good (4/5) bilaterally throughout
Dynamic Gait Index score: 12

Which of the following additional outcome measures is MOST appropriate to include in the patient’s evaluation?

1.Stair Climb Test

2.6-Minute Walk Test

3.Fullerton Advanced Balance Scale

4.Activities-Specific Balance Confidence Scale

Answer 57

1. This is the incorrect answer because this measure is designed to assess lower extremity power of the lower extremities. The patient has had repeated falls and would benefit from an appropriate falls outcome measure. The patient does not necessarily need power in the lower extremities to cross a street safely (Avers, p. 148).
2. This is the incorrect answer because the six minute walk test is a submaximal measure of aerobic capacity. The patient is having the most difficulty with balance and gait. The patient is a household ambulator and will likely not be able to complete the Six Minute Walk Test and will not provide valuable information to help the patient cross the street safely (Avers, p. 149).
3. This is the incorrect answer because the Fullerton is a balance test for higher-functioning older adults and would likely be too challenging for this patient as the patient is a household ambulator who uses a cane for mobility (Avers, p. 155).
4. This is the correct answer because a score of 12 on the DGI indicates a fall risk in older adults. The patient also has a history of recurrent falls. A self-report specific balance measure would be beneficial to gain a better understanding of when and why falls are occurring. (Avers, p. 144).

Question 58

Setting: Outpatient rehabilitation
Sex: Female
Age: 82 years
Presenting Problem / Current Condition
Frequent falls (three in the past month)
Difficulty crossing a street quickly
Medical History
Atrial fibrillation
Hypertension
Spinal stenosis
Other Information
Lives alone in a one-story home
Ambulates household distances with a straight cane
Physical Therapy Examination(s)
Vital signs at rest in seated position: blood pressure 132/80 mm Hg, heart rate 72 bpm, oxygen saturation 98% on room air
Edema present in bilateral lower extremities
Lower extremity muscle strength Good (4/5) bilaterally throughout
Dynamic Gait Index score: 12

The patient appears to have new shortness of breath and reports having slept in a recliner last night. Which of the following findings is MOST likely to be present upon auscultation?

1.Stridor

2.Diminished or absent breath sounds

3.S3 heart sound

4.S4 heart sound

Answer 58

1. This is the incorrect answer because stridor indicates an upper airway obstruction (food particle in airway or acute airway inflammation). The patient is showing signs of possible acute congestive heart failure (Malone, p. 278).
2. This is the incorrect answer because diminished or absent breath sounds are consistent with an infection such as pneumonia, or a lung pathology such as fibrosis. The patient in this question is experiencing signs consistent with possible congestive heart failure (Frownfelter, pp. 207-208).
3. This is the correct answer because the patient is showing signs consistent with possible acute congestive heart failure (bilateral lower extremity edema, dyspnea, and dyspnea in supine). Patients with heart failure can have a S3 heart sound (Frownfelter, pp, 79-80, 209).
4. This is the incorrect answer because the S4 heart sound signifies rapid ventricular filling after atrial contraction and is consistent with a presentation of systemic hypertension, cardiomyopathy or coarctation of the aorta (Frownfelter, p. 209). The patient in this question is experiencing symptoms most likely related to congestive heart failure due to the bilateral lower extremity edema.

Question 59

Setting: Outpatient rehabilitation
Sex: Female
Age: 82 years
Presenting Problem / Current Condition
Frequent falls (three in the past month)
Difficulty crossing a street quickly
Medical History
Atrial fibrillation
Hypertension
Spinal stenosis
Other Information
Lives alone in a one-story home
Ambulates household distances with a straight cane
Physical Therapy Examination(s)
Vital signs at rest in seated position: blood pressure 132/80 mm Hg, heart rate 72 bpm, oxygen saturation 98% on room air
Edema present in bilateral lower extremities
Lower extremity muscle strength Good (4/5) bilaterally throughout
Dynamic Gait Index score: 12

Which of the following recommendations regarding assistive devices should the physical therapist make to the patient?

1.Use a wheelchair.

2.Use a front-wheeled walker.

3.Continue use of the straight cane.

4.Discontinue assistive device use.

Answer 59

1. This is the incorrect answer because therapists want to recommend the least restrictive assistive device. The patient lives alone and would benefit from continued independence and safe walking to reduce mortality and morbidity (Avers, p. 208).
2. This is the correct answer because the patient has been having frequent falls with the straight cane and needs more stability. The patient also has spinal stenosis which favors spinal flexion. A rolling walker will provide the patient with some degree of spinal flexion (Avers, p. 208, Dutton, Chapter 28).
3. This is the incorrect answer because although the aim is to provide the least restrictive assistive device, the patient is having frequent falls and has a low DGI score. Continued use of the straight cane could result in more falls (Avers, p. 208).
4. This is the incorrect answer because the patient is having frequent falls and scored low on the DGI. The patient most likely needs a more supportive assistive device to lower fall risk and maintain independence (Avers p. 208).

Question 60

Setting: Outpatient rehabilitation
Sex: Female
Age: 82 years
Presenting Problem / Current Condition
Frequent falls (three in the past month)
Difficulty crossing a street quickly
Medical History
Atrial fibrillation
Hypertension
Spinal stenosis
Other Information
Lives alone in a one-story home
Ambulates household distances with a straight cane
Physical Therapy Examination(s)
Vital signs at rest in seated position: blood pressure 132/80 mm Hg, heart rate 72 bpm, oxygen saturation 98% on room air
Edema present in bilateral lower extremities
Lower extremity muscle strength Good (4/5) bilaterally throughout
Dynamic Gait Index score: 12

Which of the following types of exercise would be MOST appropriate?

1.Step aerobics

2.Walking on a treadmill

3.Biking on a recumbent bike

4.Flutter kicking in prone position in a pool

Answer 60

1. Step aerobics is a high-risk activity for patients who have lower extremity edema. The patient is also at high risk for falls, and, therefore, this is not the best choice. (Zuther, p. 270)
2. This is not the best answer because the patient is a household ambulator and has a risk of falls (based on history and DGI) and will likely tire quickly on the treadmill (Avers).
3. Use of a recumbent bike encourages a flexed posture, which is beneficial for individuals with spinal stenosis. A recumbent bike also encourages higher positioning of the legs, which is better for lower extremity edema. Biking will stimulate diaphragmatic breathing, which promotes the return of lymph and venous fluid to the blood circulation. Biking is likely to be able to be performed by the patient. (Zuther, pp. 269-270)
4. This is a plausible answer as the hydrostatic pressure from the pool can provide compression and unweight heavy legs. However, the patient has spinal stenosis and would likely not tolerate the prone position as this increases spinal extension, which can exacerbate symptoms. (Dutton)

Question 61

A patient who has right hemiparesis following a cerebrovascular accident is habitually positioned in right sidelying position. Which of the following problems may result from this positioning and should be of GREATEST concern to the physical therapist?

1.Left gaze preference

2.Chronic right shoulder pain

3.Trunk shortening on the right

4.Skin breakdown on the medial aspect of left knee

Answer 61

1. Unilateral gaze preference is associated with unilateral neglect and results from the lesion itself, not patient positioning. A patient with visual unilateral neglect often avoids crossing the midline visually (p. 1198). This condition is much more common in patients who have left hemiplegia than in patients who have right hemiplegia (p. 1198).
2. Hemiplegic shoulder pain is a common complication after stroke. Poor positioning of the more affected upper extremity has been implicated in producing joint microtrauma and pain. Prolonged soft tissue injury can result in complex regional pain syndrome. (pp. 646-647)
3. Sidelying on the right side should produce elongation of the trunk on the right, not shortening of the trunk.
4. Risk factors for skin breakdown include decreased sensation and abnormal patterns of movement, neither of which should be present on the less involved (left) side in this case (pp. 622-623).

Question 62

A patient who has a C6 spinal cord injury (ASIA Impairment Scale A) is MOST likely to exhibit which of the following movement patterns during inhalation?

1.Inward motion of the abdomen and inward motion of the upper chest

2.Inward motion of the abdomen and outward motion of the upper chest

3.Outward motion of the abdomen and inward motion of the upper chest

4.Outward motion of the abdomen and outward motion of the upper chest

Answer 62

1. A patient who has a C6 spinal cord injury retains full use of the diaphragm but lacks innervation to abdominal and intercostal musculature. The patient will display outward, not inward, motion of the abdomen and inward motion of the upper chest.
2. A patient who has a C6 spinal cord injury retains full use of the diaphragm but lacks innervation to abdominal and intercostal musculature. The patient will display outward, not inward, motion of the abdomen and inward, not outward, motion of the upper chest.
3. A patient who has a C6 spinal cord injury retains full use of the diaphragm but lacks innervation to abdominal and intercostal musculature. The patient will display outward motion of the abdomen and inward motion of the upper chest. The outward motion of the abdominal area is caused by the diaphragm contracting and pushing abdominal contents forward and outward, and the inward motion of the upper chest is due to the lack of structural support from paralyzed thoracic musculature.
4. A patient who has a C6 spinal cord injury retains full use of the diaphragm but lacks innervation to abdominal and intercostal musculature. The patient will display outward motion of the abdomen and inward, not outward, motion of the upper chest.

Question 63

A patient has jaundice, dark urine, and ascites. Which of the following findings is MOST likely to be present during the physical therapy examination?

1.Asterixis

2.Pronator drift

3.Hoffman sign

4.Rebound tenderness

Answer 63

1. Jaundice, darkened urine, and ascites are all clinical signs of liver disease. Asterixis, or liver flap, is also likely to be present as a result of ammonia imbalance, which causes this neurologic symptom. (Goodman, p. 341)
2. Pronator drift is more likely to be observed in the presence of an upper motor neuron disorder. Upper motor neuron signs/symptoms are associated with central nervous system conditions, such as cerebrovascular accident, spinal cord injury, and multiple sclerosis. (Fruth, pp. 397, 400)
3. A positive result on the Hoffman Test, or Hoffman sign, is associated with corticospinal tract disorders. A positive result may be found contralateral to the area of a brain lesion or bilaterally in the presence of injury or compression of the spinal cord. (Fruth, p. 402)
4. Jaundice, ascites, and darkened urine are common clinical signs of liver disease. Rebound tenderness is most likely to be associated with appendicitis and peritonitis. (Goodman, pp. 319-320)

Question 64

A patient displays an irregular heart rhythm, increased respiratory rate, and acetone-like breath odor after performing 15 minutes of intense exercise. Which of the following conditions is MOST likely present?

1.Thyroid hypersecretion

2.Pituitary hypersecretion

3.Pancreatic hyposecretion

4.Adrenal hyposecretion

Answer 64

1. Also known as thyrotoxicosis, thyroid hypersecretion is associated with an enlarged thyroid gland, also known as a goiter. Patients exhibit hypermetabolism and sympathetic overactivity. Patients report fatigue, tremor, heat intolerance, increased sweating with warm moist skin, weight loss, palpitation with tachycardia, diarrhea, and muscle weakness and atrophy. They do not display an abnormal vital sign response to exercise, nor do they have acetone breath. (pp. 484-486)
2. Giantism and acromegaly can result from excessive secretion of growth hormone. This can result from a pituitary tumor or from a hypothalamic abnormality that leads to increased growth hormone release (pp. 479-480). Pituitary hyperactivity does not result in an abnormal vital sign response to exercise and does not cause the acetone breath associated with ketoacidosis.
3. Patients who have diabetes potentially have a lack of insulin secretion or effectiveness, leading to disruption of glucose metabolism. Results of acute metabolic changes related to glucose metabolism include hyperglycemia (high blood glucose), electrolyte disturbances that are manifested by acidosis that triggers an increased respiration rate, irregular heart rate, and increased fatty acid metabolism resulting in acetone breath. (p. 522)
4. People who have hyposecretion of adrenal hormones have Addison disease. Addison disease is characterized by the inability to withstand food deprivation, hyperpigmentation, dehydration, and postural hypotension (p. 498). A patient who has adrenal insufficiency should not exhibit any of the signs or symptoms described in the stem.

Question 65

Where on the forearm should a physical therapist place electrodes for biofeedback therapy in order to facilitate hook grasp?

1.Proximal anteromedial

2.Proximal posterolateral

3.Distal anteromedial

4.Distal posterolateral

Answer 65

1. For best biofeedback results, electrode placement should be as close to the muscle as possible (Prentice). Hook grasp requires finger flexion (Lippert, p. 215). The finger flexors are located proximal to the anterior forearm (Lippert, pp. 201-202).
2. The proximal posterolateral forearm is the location of the finger extensors (Lippert, pp. 204-205).
3. No muscles originate from the distal anterior, medial forearm area (Lippert, pp. 201-206).
4. The distal posterolateral forearm is the location of thumb and index finger (1st and 2nd digit) extensors (Lippert, pp. 203-205).

Question 66

After undergoing a reverse total shoulder arthroplasty, a patient is MOST likely to dislocate the shoulder in which of the following positions?

1.Lateral (external) rotation and abduction with flexion

2.Medial (internal) rotation and abduction with flexion

3.Lateral (external) rotation and adduction with extension

4.Medial (internal) rotation and adduction with extension

Answer 66

1. Lateral (external) rotation and abduction with flexion is not the most likely position to dislocate the reverse total shoulder arthroplasty. Combined medial (internal) rotation and adduction with extension is more likely to cause dislocation.
2. Abduction and flexion are not most likely to cause dislocation. Combined medial (internal) rotation and adduction with extension is more likely to cause dislocation.
3. Lateral (external) rotation is not most likely to cause dislocation. Combined medial (internal) rotation and adduction with extension is more likely to cause dislocation.
4. Patients are most likely to dislocate a reverse total shoulder arthroplasty by performing medial (internal) rotation and adduction in conjunction with extension. This position allows the prosthesis to escape anteriorly and inferiorly.

Question 67

A physical therapist is treating an infant who has a Pavlik harness for developmental dysplasia of the hip. The infant should wear the harness:

1.during rest only.

2.during activity only.

3.2–4 hours/day.

4.18–23 hours/day.

Answer 67

1. Wearing the harness during rest only is inadequate. It should be worn 18–23 hours/day.
2. Wearing the harness during activity only is inadequate. It should be worn 18–23 hours/day.
3. Wearing the harness for 2–4 hours per day is inadequate. It should be worn 18–23 hours/day.
4. The harness must be worn 18–23 hours/day.

Question 68

Which of the following functional tests would be MOST appropriate to verify that a patient lacks figure-ground discrimination?

1.Have the patient find an object, such as a toothbrush, among similarly shaped objects.

2.Have the patient locate a white button on a white shirt.

3.Ask patient to identify an object, such as a key, with eyes closed.

4.Ask the patient to reach for a bright blue paper located on a white desk.

Answer 68

1. Having a patient find an object among similarly shaped objects is a better test for form discrimination rather than figure-ground discrimination as it assesses whether subtle differences in shape can be perceived (p. 1208). Finding a toothbrush amongst an array of utensils of various shapes and sizes would be a better test for figure-ground discrimination (p. 1208).
2. An impairment in figure-ground discrimination is the inability to visually distinguish a figure from the background in which it is embedded. A functional test that can be given to the patient to assess figure-ground discrimination is to ask a patient to point out a white button on a white shirt. Compensatory techniques to be used with patients who lack figure-ground perception are placing red tape over the Velcro strap of the shoe to aid the patient in locating it or using bright red tape to mark the edges on stairs. (pp. 1207-1208)
3. Tactile agnosia is the inability to recognize forms by handling them, although tactile sensation may be intact. If a patient is handed an object while the patient’s vision is occluded, the patient will fail to recognize the object. This would not be the best test for an impairment of figure-ground discrimination. (p. 1213)
4. A patient who has depth and distance perception problems may have difficulty grasping an object. The impaired patient will overshoot or undershoot the object. This would not be the best test for an impairment of figure-ground discrimination. (pp. 1210-1211)

Question 69

Which of the following joint mobilization techniques would MOST effectively increase elbow joint flexion?

1.Humeroulnar distraction

2.Humeroradial posterior glide

3.Radioulnar anterior glide

4.Radioulnar posterior glide

Answer 69

1. The purpose of humeroulnar distraction is to increase flexion (or extension) of the elbow joint.
2. The purpose of humeroradial posterior glide is to increase extension, not flexion, of the elbow joint.
3. The purpose of radioulnar anterior glide is to increase supination of the forearm, not elbow joint flexion.
4. The purpose of radioulnar posterior glide is to increase pronation of the forearm, not elbow joint flexion.

Question 70

A physical therapist is treating a patient with bicipital tendonitis. The therapist has determined that iontophoresis with medication for a total treatment dosage of 80 milliampere-minutes is most appropriate. Which of the following current parameters should a physical therapist use when applying the iontophoresis to achieve the BEST results?

1.3–4 milliamperes, direct current

2.8–10 milliamperes, direct current

3.3–4 milliamperes, pulsed current

4.8–10 milliamperes, pulsed current

Answer 70

1. Direct current is indicated with a maximum safe amplitude of 4 milliamperes.
2. Direct current is indicated, but an amplitude of 8–10 milliamperes is too high.
3. Pulsed current is not the correct type of electrical current to use with iontophoresis. Direct current should be used.
4. Pulsed current is not the correct type of electrical current to use with iontophoresis. Direct current should be used. The amplitude of 8–10 milliamperes is too high.

Question 71

A physical therapist is assisting with bed mobility for a patient who is receiving antibiotics for vancomycin-resistant Enterococcus (VRE). Which of the following precautions and personal protective equipment are indicated for physical therapy intervention?

1.Contact precautions; the therapist should wear a mask.

2.Contact precautions; the therapist should wear a gown.

3.Droplet precautions; the therapist should wear a mask.

4.Droplet precautions; the therapist should wear a gown.

Answer 71

1. Vancomycin-resistant Enterococcus (VRE) requires contact precautions. Contact precautions require a gown. A mask is not needed unless droplet precautions are necessary.
2. Contact precautions are followed for vancomycin-resistant Enterococcus (VRE). A gown is needed for contact precautions.
3. Vancomycin-resistant Enterococcus (VRE) requires contact precautions. A gown is needed for contact precautions.
4. A gown is appropriate; however, the therapist should follow contact precautions, not droplet precautions.

Question 72

After beginning an initial interview with a patient, a physical therapist discerns that the patient is becoming angry. The patient declares that numerous other clinicians have asked the same questions and demands that the therapist contact the physician. What is the MOST appropriate FIRST response by the therapist?

1.Validate the patient’s feelings of anger.

2.Attempt to change the direction of the examination questions.

3.Step out of the area and allow the patient to calm down.

4.Explain to the patient the importance of collecting the same information.

Answer 72

1. The first step in dealing with an angry patient who is not disruptive or a security risk is to validate the patient’s feelings by listening and by acknowledging the patient’s anger over the situation. This may diffuse the anger, allowing the therapist to carry on with the examination.
2. Attempting to change the direction of the questions is better used for a patient who is emotionally labile or excessively talkative. It does not acknowledge the patient’s anger and thus may not diffuse the patient’s anger.
3. Leaving the area would be appropriate if a patient is disruptive and appears to have violent intent. Stepping out of the area does not acknowledge the patient’s anger.
4. Explaining the importance of collecting the same information may be an appropriate second step, but it does not acknowledge the patient’s anger and thus may not diffuse the situation.

Question 73

A patient who is a secretary has a well-healed fracture of the right scaphoid. The findings upon the initial physical therapy examination include 55° of wrist flexion and 45° of wrist extension with pain at end-range. Which of the following additional findings would result in the GREATEST delay in return to work?

1.Passive pronation and supination limited to 65° on the right

2.Pain with light touch and increased sweating of the right hand

3.Subjective pain of 3/10 with right wrist movement and 1/10 at rest

4.Grip dynamometer strength of 72 lb (32.7 kg) on the right and 80 lb (36.3 kg) on the left

Answer 73

1. Most activities of daily living are performed at 50° of pronation and supination. Pronation and supination limited to 65° on the right would not delay return to work. (Magee, pp. 451-452)
2. One of the complications after an upper extremity trauma is the advent of complex regional pain syndrome. This complication often presents with burning pain with any movement of the body part, excessive sensitivity to light touch or minor stimulation, temperature changes, localized sweating, localized changes of the skin, or trophic changes of the skin, hair, and nails. Of the four options, this complication would result in longest delay in recovery and return to work. (Dutton)
3. The functional position of the wrist is between 20° and 35° of wrist extension, which this patient has (Magee, p. 445). The patient’s pain is at end-range of wrist motion, and the patient should not have to push the wrist to end-range for most functional activities.
4. The grip strength on the right is 90% of the grip strength on the left. Although the right hand remains 10% weaker, this is an adequate strength for activities of daily living. (Magee, p. 455)

Question 74

A patient with low back pain has L4 nerve root impingement. The patient will MOST likely demonstrate which of the following gait deviations?

1.Trendelenburg gait

2.Foot slap

3.Posterior thrust of the trunk at heel strike (initial contact)

4.Toe walking

Answer 74

1. Trendelenburg gait is attributed to weakness in the gluteus medius muscle or L5 nerve root involvement (Magee, pp. 585, 1009).
2. The L4 nerve root is the main segmental innervation to the tibialis anterior. The L4 nerve root is also the myotome for ankle dorsiflexion. Impingement of the L4 nerve root would result in foot slap. (Magee, p. 585; O’Sullivan, p. 239)
3. Backward trunk lean reduces demands on a weakened stance limb gluteus maximus (O’Sullivan, p. 242). The gluteus maximus is innervated by the inferior gluteal nerve (L5–S2) (Magee, pp. 585, 1008-1009).
4. Causes of toe walking include a tight Achilles tendon, clubfoot, cerebral palsy, or limb length discrepancies (Magee, p. 1009; O’Sullivan, p. 239). It is not associated with L4 impingement.

Question 75

Which of the following conditions is MOST likely to be associated with systemic lupus erythematosus?

1.Uveitis

2.Urethritis

3.Photosensitivity

4.Psoriasis

Answer 75

1. Uveitis is commonly found in patients who have ankylosing spondylitis (p. 1134).
2. Urethritis is commonly found in patients who have Reiter syndrome (p. 1344).
3. Skin rashes, fever, fatigue, malaise, photosensitivity, dyspnea, cough, and peripheral neuropathies are all common findings in patients who have systemic lupus erythematosus (pp. 307-308).
4. Psoriasis is commonly seen in patients who have psoriatic arthritis (pp. 1341-1342).

Question 76

Setting: Outpatient
Sex: Male
Age: 22 years
Presenting Problem / Current Condition
Insidious onset of right medial elbow pain 1 month ago
Unable to perform overhead throwing of a baseball without pain
Medical History
Right shoulder impingement 1 year ago
Asthma
Other Information
Professional overhead throwing athlete (baseball pitcher)
Independent with all essential activities of daily living
Physical Therapy Examination
Active and passive range of motion of right wrist flexion/extension, elbow flexion/extension, and forearm pronation/supination pain free and within normal limits
Resisted right wrist flexion, ulnar deviation, and pronation grossly pain-free with Good (4/5) strength
Tenderness to palpation at the right medial elbow in 50° of elbow flexion
Sensation intact throughout the right upper extremity
Physical Therapy Plan of Care
None; this is the first visit

The patient is MOST likely to have a positive result on which of the following tests?

1.Milking Maneuver Test

2.Golfer’s Elbow Test

3.Varus Stress Test

4.Elbow Flexion Test

Answer 76

1. This is the correct choice for the following reasons. The most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 20 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Additionally, there is tenderness to palpation with the elbow between 30°–60° of flexion, which is the correct position to palpate the ulnar collateral ligament (Dutton, p. 691). The Milking Maneuver Test is a special test for the medial collateral ligament of the elbow. The patient sits with the elbow flexed to 90° or more and the forearm supinated. The examiner grasps the patient’s thumb under the forearm and pulls it, imparting a valgus stress to the elbow. Reproduction of symptoms (apprehension, medial joint pain, gaping, and/or instability) indicates a positive test and a partial tear of the medial collateral ligament. Thus, the milking maneuver is likely to be positive in this case.
2. This is an incorrect test for the following reasons: While medial elbow tendinopathy (Golfer’s Elbow) is similar in presentation. This is an unlikely diagnosis in this case for the following reasons. While medial elbow tendinopathy may present with tenderness to palpation at the medial elbow, symptoms are typically exacerbated by either resisted wrist flexion and or pronation and passive wrist extension and/or supination (Dutton, p. 724). Both findings are not present in this case making medial elbow tendinopathy an unlikely diagnosis. The Golfer’s Elbow Test is typically performed for medial epicondylitis by passively extending the elbow and wrist (Magee, p. 453). In this case, the wrist and elbow active and passive range of motion are pain-free. Thus, this is the incorrect choice.
3. This is an incorrect test for the following reasons. The Varus Stress Test assess the lateral collateral ligaments of the elbow (Dutton, p. 691), not the medial collateral ligaments of the elbow. The most common mechanism of injury for the lateral collateral ligament is from a fall on outstretched hand (FOOSH) injury or from an elbow dislocation. Also, the patient may report painful catching, clicking or a feeling of instability during elbow flexion/extension particularly around 40° of elbow flexion with forearm supination (Dutton, p. 717). None of these features are present in this case and thus should not be considered a potential diagnosis to test for making this an incorrect choice.
4. This is an incorrect test for the following reasons: This test helps to determine if cubital tunnel syndrome is present (Magee, p. 456). Symptoms of cubital tunnel include paresthesia involving the fourth and fifth digits, accompanied by pain that may extend proximally or distally on the medial aspect of the elbow, pain or paresthesia worse at night; decreased sensation in the ulnar distribution of the hand; progressive inability to separate the fingers; loss of grip power and dexterity; and atrophy or weakness of the ulnar intrinsic muscles of the hand (late sign) are signs of cubital tunnel (Dutton, p. 725). Since none of these findings are present, this diagnosis of cubital tunnel, and a subsequent positive Elbow Flexion Test are unlike making this an incorrect choice.

Question 77

Setting: Outpatient
Sex: Male
Age: 22 years
Presenting Problem / Current Condition
Insidious onset of right medial elbow pain 1 month ago
Unable to perform overhead throwing of a baseball without pain
Medical History
Right shoulder impingement 1 year ago
Asthma
Other Information
Professional overhead throwing athlete (baseball pitcher)
Independent with all essential activities of daily living
Physical Therapy Examination
Active and passive range of motion of right wrist flexion/extension, elbow flexion/extension, and forearm pronation/supination pain free and within normal limits
Resisted right wrist flexion, ulnar deviation, and pronation grossly pain-free with Good (4/5) strength
Tenderness to palpation at the right medial elbow in 50° of elbow flexion
Sensation intact throughout the right upper extremity
Physical Therapy Plan of Care
None; this is the first visit

Results of which of the following imaging modalities at the elbow would MOST likely confirm the suspected diagnosis?

1.Lateral radiograph

2.Computed tomography

3.Magnetic resonance imaging

4.Dual-energy x-ray absorptiometry (DXA)

Answer 77

1. This is an incorrect choice for the following reasons: First, the following structures are typically viewed on a lateral radiograph of the elbow: Olecranon, radius, distal humerus, and anterior fat pad (McKinnis, p. 568). Radiographs remain the initial imaging choice following traumatic elbow injuries to establish the initial injury, any associated fractures or displacement (Dutton, p. 705) which is an unlikely diagnosis in this case. Most fractures and dislocations at the elbow result from falls on an outstretched hand with or without an abduction or adduction component, or a force applied through a flexed elbow. Fractures of the radial and ulnar shafts are more often caused by direct trauma, often associated with violent blows, motor vehicle accidents, or falls from heights (McKinnis, p. 584). None of these mechanisms of injury are present in this case. While radiographs may reveal intra-articular loose bodies in the joint (McKinnis, p. 574), joint locking and twinges that typically indicate a loose body is moving within the joint are not present (Dutton, p. 170). Magnetic resonance imaging (MRI) is the most likely test reveal injuries to the ligament (McKinnis, p. 574).
2. This is an incorrect choice for the following reasons: Computed tomography (CT scan) may be indicated to identify occult fractures, osteochondral lesions, or the specific location of loose bodies or heterotopic ossification. Most fractures and dislocations at the elbow result from falls on an outstretched hand with or without an abduction or adduction component, or a force applied through a flexed elbow. Fractures of the radial and ulnar shafts are more often caused by direct trauma, often associated with violent blows, motor vehicle accidents, or falls from heights (McKinnis, p. 584). This mechanism of injury is not present in this case, and the MRI has been shown to be the most specific tool for diagnosing an ulnar collateral ligament injury (Dutton, p. 705) makings this an incorrect choice.
3. This is the correct choice for the following reasons. The most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 22 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Additionally, there is tenderness to palpation with the elbow between 30°–60° of flexion, which is the correct position to palpate the ulnar collateral ligament (Dutton, p. 691). Magnetic resonance imaging (MRI) has been reported to be highly specific (100% specificity, 57% sensitivity) for detecting ulnar collateral ligament tears (Dutton, p. 705). Indications for MRI of the elbow include suspected ligament injuries (McKinnis, p. 578).
4. This is an incorrect answer. A density dual-energy X-ray absorptiometry (DEXA) scan is used to detect osteopenia or osteoporosis (Goodman, p. 825). While Osteoporosis is a common condition in post menopausal females and half of women older than 50 years of age with osteoporosis will experience fractures due to loss of bone density, this individual does not appear to have signs of a fracture and is not of the most common gender and/or age range for suspected bone mineral density loss. Thus, the most pressing and overwhelming concern is the ulnar collateral ligament which is best visualized with an MRI (McKinnis, p. 578).

Question 78

Setting: Outpatient
Sex: Male
Age: 22 years
Presenting Problem / Current Condition
Insidious onset of right medial elbow pain 1 month ago
Unable to perform overhead throwing of a baseball without pain
Medical History
Right shoulder impingement 1 year ago
Asthma
Other Information
Professional overhead throwing athlete (baseball pitcher)
Independent with all essential activities of daily living
Physical Therapy Examination
Active and passive range of motion of right wrist flexion/extension, elbow flexion/extension, and forearm pronation/supination pain free and within normal limits
Resisted right wrist flexion, ulnar deviation, and pronation grossly pain-free with Good (4/5) strength
Tenderness to palpation at the right medial elbow in 50° of elbow flexion
Sensation intact throughout the right upper extremity
Physical Therapy Plan of Care
None; this is the first visit

Which of the following interventions would be MOST appropriate for the patient?

1.Resisted supination with a hammer

2.Resisted elbow flexion with a dumbbell

3.Resisted concentric wrist flexion with a dumbbell

4.Resisted eccentric wrist extension with a resistance band

Answer 78

1. This choice is incorrect for the following reasons. First, there are no impairments in supination noted in the case. Second, the supinator has not been documented to have a stabilizing role at the medial elbow. Supination with a dowel or hammer strengthens the supinator (Kisner, p. 649), which does not provide an essential role in the rehabilitation of UCL injuries. Emphasis is placed on the forearm flexors, ulnar deviators, and pronators, in order to enhance their role as secondary stabilizers of the medial joint. Strengthening exercises for the following groups may be included: wrist curls and pronation (Dutton, p. 716). Thus this is not an efficacious choice for this case.
2. This choice is incorrect for the following reasons. First, there are no impairments in elbow flexion strength noted in the case. Second, the elbow flexor has not been documented to have a stabilizing role at the medial elbow. Elbow flexion with a dumbbell strengthens the elbow flexors (Kisner, p. 614), which does not provide an essential role in the rehabilitation of UCL injuries. Emphasis is placed on the forearm flexors, ulnar deviators, and pronators, in order to enhance their role as secondary stabilizers of the medial joint. Strengthening exercises for the following groups may be included: wrist curls and pronation (Dutton, p. 716). The most common clinical utility for resisted elbow flexion is for weakness of the elbow flexors (Kisner, p. 614). Thus this is not the most efficacious choice for this case.
3. This is the correct answer for the following reasons. First, the most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 20 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Additionally, there is tenderness to palpation with the elbow between 30°-60° of flexion, which is the correct position to palpate the ulnar collateral ligament (Dutton, p. 691). The most likely differential diagnosis for this case is medial elbow tendinopathy (Golfer’s elbow). This is an unlikely diagnosis in this case for the following reasons: While medial elbow tendinopathy may present with tenderness to palpation at the medial elbow, symptoms are typically exacerbated by either resisted wrist flexion and or pronation and passive wrist extension and/or supination (Dutton, p. 724). Both findings are not present in this case making medial elbow tendinopathy an unlikely diagnosis. Physical therapy treatment for UCL injuries includes the following: Rest and activity modification for about 2–4 weeks, range-of-motion exercises, modalities. Strengthening and stretching of the flexor carpi ulnaris, pronator teres, and flexor digitorum profundus are initiated once the acute inflammatory stage has subsided. Emphasis is placed on the forearm flexors, ulnar deviators, and pronators, in order to enhance their role as secondary stabilizers of the medial joint. Strengthening exercises for the following groups may be included: wrist curls and pronation (Dutton, p. 716). Thus, wrist curls is a prioritized intervention.
4. This choice is incorrect for the following reasons. First, there are no impairments in extension strength noted in the case. Second, the wrist extensor has not been documented to have a stabilizing role at the medial elbow. Eccentric wrist extension with a dumbbell strengthens the wrist extensors (Kisner, p. 650), which does not provide an essential role in the rehabilitation of UCL injuries. Emphasis is placed on the forearm flexors, ulnar deviators, and pronators, in order to enhance their role as secondary stabilizers of the medial joint. Strengthening exercises for the following groups may be included: wrist curls and pronation (Dutton, p. 716). The most common clinical utility for eccentric wrist extension is for lateral epicondylalgia. There is emerging evidence and moderate research support that suggests eccentric resistance training is effective in the treatment of lateral epicondylalgia (Kisner, p. 644). Thus this is not the most efficacious choice for this case.

Question 79

Setting: Outpatient
Sex: Male
Age: 22 years
Presenting Problem / Current Condition
Insidious onset of right medial elbow pain 1 month ago
Unable to perform overhead throwing of a baseball without pain
Medical History
Right shoulder impingement 1 year ago
Asthma
Other Information
Professional overhead throwing athlete (baseball pitcher)
Independent with all essential activities of daily living
Physical Therapy Examination
Active and passive range of motion of right wrist flexion/extension, elbow flexion/extension, and forearm pronation/supination pain free and within normal limits
Resisted right wrist flexion, ulnar deviation, and pronation grossly pain-free with Good (4/5) strength
Tenderness to palpation at the right medial elbow in 50° of elbow flexion
Sensation intact throughout the right upper extremity
Physical Therapy Plan of Care
None; this is the first visit

Use of which of the following devices would be MOST effective at preventing further injury in this case?

1.Cock-up splint at the wrist

2.Hinged brace at the elbow

3.Counterforce brace at the elbow

4.Forearm-based immobilization orthosis at the wrist

Answer 79

1. This is an incorrect choice for the following reasons: The most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 20 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Additionally, there is tenderness to palpation with the elbow between 30°–60° of flexion, which is the correct position to palpate the ulnar collateral ligament (Dutton, p. 691). A wrist cock-up splint is indicated for a number of conditions including Posterior Interosseous Nerve Syndrome (Dutton, p. 728) and extensor tendon repairs (Magee, p. 399), but has no reported functional benefit in an injury to the ulnar collateral ligament making this an incorrect choice.
2. This is the correct choice for the following reasons. The most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 20 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Additionally, there is tenderness to palpation with the elbow between 30°–60° of flexion, which is the correct position to palpate the ulnar collateral ligament (Dutton, p. 691). The most effective brace to prescribe for this condition is a hinged elbow brace. During the inflammatory phase, the intervention includes immobilization of the elbow positioned at 90° of flexion in a well-padded posterior splint for 3–4 days followed by a hinged elbow brace initially set at 15°–90° (Dutton, p. 717). Thus, the hinged elbow brace is the correct choice for a patient with an ulnar collateral ligament injury.
3. This is an incorrect choice for the following reasons: While medial elbow tendinopathy (Golfer’s elbow) is similar in presentation. This is an unlikely diagnosis in this case for the following reasons. While medial elbow tendinopathy may present with tenderness to palpation at the medial elbow, symptoms are typically exacerbated by either resisted wrist flexion and or pronation and passive wrist extension and/or supination (Dutton, p. 724). Both findings are not present in this case making medial elbow tendinopathy an unlikely diagnosis. The Golfer’s elbow test is typically performed for medial epicondylitis by passively extending the elbow and wrist (Magee, p. 453). In this case, the wrist and elbow active and passive range of motion are pain-free. Thus, this is an unlikely diagnosis. The most likely brace prescribed for medial epicondylitis is a counterforce brace. A counterforce brace may be beneficial in patients who are rehabilitating but still involved in activities that may aggravate the symptoms (Magee, p. 307). The use of a counterforce brace is not indicated for an ulnar collateral ligament tear as there is no mechanism in which this brace could have a positive impact making this an incorrect choice.
4. This is an incorrect choice for the following reasons: A forearm-based wrist immobilization orthosis is fabricated with a to obtain a rigid support to be used during the proliferative stage of healing of an open reduction internal fixation. All forearm and wrist motions are significantly limited with this device (Chui, p. 386). The most likely diagnosis in this case is an injury to the ulnar collateral ligament for the following reasons: This patient is 20 years old and plays baseball which is a common population for ulnar collateral ligament injuries. Pain is located at the medial (ulnar) side of the elbow anatomically where the UCL is located (Dutton, p. 705). Immobilization of the wrist and forearm will not aid in this patient’s recovery, thus this is an incorrect choice.

Question 80

All incorrect questions complete