PEAT 2 Flashcards

Question

A patient sustained a severe, traumatic brain injury 3 months ago. During the examination of passive range of motion, the physical therapist notices decreased passive knee extension and moderate hamstring spasticity. Palpation of the knee reveals a firm mass on the lateral aspect of the joint. The therapist should refer the patient to a physician for an evaluation of probable: A. osteogenic sarcoma B. patellar fracture C. osteomyelitis D. heterotopic ossification

Answer 1

D. Heterotopic ossification occurs in 10 percent to 20 percent of patients with traumatic brain injuries. The abnormal bone formation occurs in the soft tissue surrounding major joints. Patients with spasticity are at increased risk. Loss of range of motion is characteristic for this problem. Osteogenic sarcoma is less likely. A patellar fracture would not present as a lateral mass

Answer 2

C. Pain with resisted medial (internal) rotation and pain with passive lateral (external) rotation is indicative of subscapularis tendonitis. Bicipital tendonitis is suspected if resisted supination is painful when the patient's arm is at the side and the elbow is flexed to 90°. Painful resisted abduction and resisted lateral (external) rotation is indicative of supraspinatus tendinitis. Pain on resisted lateral (external) rotation is indicative of infraspinatus tendonitis.

Answer 3

A. The sartorius flexes, externally rotates and abducts the hip joint. With resisted hip flexion, the sartorius will be recruited to perform all three actions giving the observed substitution pattern. The tensor fascia late is a medial (internal) rotator and flexor of the hip, so substitution by it would involve medial (internal) rotation and abduction. The adductor longus would adduct the hip. Substitution by the semimembranosus would cause hip extension.

Answer 4

D. In order to best intervene with a patient who has had cardiac dysfunction, a full examination and evaluation is necessary to properly form a treatment plan. An important aspect of the examination is ascertaining the type of angina that the patient experiences so that the therapist will know how to prevent angina with exercise or recognize it if it does occur during the treatment session. The other options provided are all outcomes that would occur after the patient has completed a cardiac rehabilitation program.

Answer 5

D. Bell's palsy involves the facial nerve. The frontals is the only muscle listed that is innervated by the facial nerve. The sternocleidomastoid is innervated by the spinal accessory nerve, and the masseter and temporalis are innervated by the trigeminal nerve

Answer 6

A. The abdominal muscles are active during a sit-up (with the knees extended) up until the spine is completely flexed (head, shoulders, thorax lifted from surface). In order to come to a long-sitting position however, the hips must be flexed and the abdominals cannot perform this action because they do not cross the hip joint. Therefore, the hip flexors (iliopsoas among others) would have to complete this motion. The inability to achieve a long-sitting position would suggest weakness in the iliopsoas muscle.

Answer 7

C. The plantar grasp reflex is characterized by curling of the toes when a child is held supported in standing. The reflex is normal up to 9 months of age. Delayed integration of this reflex can result in delayed, independent ambulation.

Answer 8

C. Spinal shock occurs as a reaction to spinal cord injury and is characterized by an absence of all reflex activity below the level of the lesion. Depending on the extent of the lesion, the patient may lose all or some of their sensation and motor activity below the level of the lesion. Spasticity is associated with hyperreflexia and increased muscle tone. Spasticity would be expected to develop following the spinal shock stage. Decerebrate rigidity involves a sustained contraction of the upper and lower extremities in extension. With a lower motor neuron lesion, the loss of sensation and motor activity would be confined to a much smaller region (depending on the exact lesion) and would not affect all levels below the lesion.

Answer 9

C. Static alignment for knee stability is established by positioning of the knee so that the lateral reference line falls anterior to the knee joint.

Answer 10

B. Although protocols depend on the surgeon and the approach, it is generally recommended that anti-gravity hip abduction exercises not begin until 5 to 6 weeks post surgery. Patients are taught to avoid excessive hip flexion, usually beyond 80°. Bed mobility and ambulation would be started 1 or 2 days post operatively.

Answer 11

D. Posterior muscle tension is implicated in the development of tension headaches. Positive imagery is recommended as a self-treatment technique, but the awareness of tension and the appreciation of its absence are foundational. Massage and passive exercise may be relaxing, but the patient must be aware of the sensations of tension to prolong the benefit.

Answer 12

A. Infection control requires that the wound not be contaminated further, and that the health care workers protect themselves from disease by avoiding contact with body fluids. In this case the patient does not appear to be in life threatening danger, and so the wound should be attended to. Therefore, checking blood pressure would not be the first thing to do. Once the gloves are donned, cleaning the wound and covering it with a sterile dressing would be appropriate.

Answer 13

D. Patients should be encouraged to express their feelings. Comparisons to other patients who are dying, in an effort to assure the patient he is not alone, takes away from this patient's feelings. Denial of death would not be good for the patient, since he must ultimately cope with the inevitable. Pastoral counseling would be an option, but the therapist should be ready to listen to the patient, encourage expression of feelings and avoid denial.

Answer 14

D. Pronation of the foot can be caused by a variety of factors including calcaneal eversion and forefoot varus. Correction of the pronation by an orthosis could include a medial post (wedge) placed just proximal to the metatarsal heads or a medial post under the calcaneus. This approach involves bringing the ground up to meet the foot. A post under the fifth metatarsal head would accentuate the problem, as would a rearfoot post placing the calcaneus in an everted position. If the patient has excessive forefoot varus, a wedge may be placed in the instep in addition to the medial wedge proximal to the metatarsal heads to distribute the load; however a wedge in the instep by itself would not be the best intervention.

Answer 15

D. When the knee is extended the medial and lateral collateral ligaments are taut. During knee flexion the ligaments slacken. Therefore there is very little tibial rotation when the knee is extended (closed packed position) and approximately 40° of axial rotation with the knee flexed. Although the femoral condyles may glide posteriorly (depending on the direction of rotation) on the tibia and the hamstrings may rotate the tibia, the reason the motion is available is due to laxity in the collateral ligaments. Other ligaments such as the cruciates and the joint capsule may add to the stability in the closed packed position.

Answer 16

A. With this particular posture, the patient's scapula would be in a protracted (abducted) position; therefore the scapular protractors are already overactive and would require stretching not strengthening. The kyphosis suggests that the thoracic erector spine muscles are weak and need strengthening. The lumbar lordosis indicates shortened lumbar erector spine muscles. The forward head posture suggests that the cervical spine is flexed and the occiput is extended, therefore stretching of the suboccipital muscles would be indicated. A TEST-TAKING HINT: Although EXCEPT questions are rarely used on the NPE, be alert for this type of question and read the responses so that vou select the unrelated response.

Answer 17

D. Compression on the median nerve (carpal tunnel syndrome) is occurring, most likely as a result of swelling associated with the individual being in the eight month of pregnancy. In this case, rest and elevation would do the most to decrease the edema and relieve the symptoms. The wrist should not be positioned in full extension. Initial conservative treatment sometimes includes cock-up splinting to hold the wrist in neutral to 10° of extension, but not full extension. Although tendon gliding exercises may be used, heat would not be indicated since it may increase the edema. Resistive exercises for the wrist and fingers may aggravate the compression in the carpal tunnel.

Answer 18

A. A patient with COPD has premature collapse of the airways upon exhalation, which leads to air trapping and ultimately poor gas exchange. Breathing out through pursed-lips slows the airflow and creates a back pressure which helps to prevent the airways from collapsing while exhaling. By exhaling more fully through pursed-lips, more carbon dioxide is removed. By preventing airway collapse and air trapping in the lungs, the residual volume is actually decreased. Pursed-lipped breathing helps with ventilation, but does not necessarily assist with secretion mobilization.

Answer 19

C. The dermatome providing sensation to the little finger is innervated by the C8 nerve root. The triceps brachii is the only one of the muscles listed that is also innervated by the C8 nerve root. The biceps brachi, deltoid and brachioradialis are innervated by the C5, C6, and sometimes C7 nerve roots

Answer 20

D. Air is released during the stance phase of gait, which results in a negative pressure inside the socket to provide a suction suspension during the swing phase.

Answer 21

B. With venous insufficiency, the limbs would be edematous, the superficial veins would be dilated and if not corrected ulceration could develop. Options A and C are ruled out because they indicate no edema. Option D is not correct because the condition is relieved by sitting or leg elevation.

Answer 22

A. In order to improve knee flexion, the physical therapist needs to address patella tightness. During flexion at the knee, the posterior motion of the tibia causes the ligamentum patellae to pull the patella distally and posteriorly. Patellar mobilization in the distal direction would assist with increasing knee flexion.

Answer 23

C. The tibialis posterior plantar flexes and inverts the foot. This pattern requires the specific action of that muscle. The other patterns do not.

Answer 24

C. Pain that is experienced in the thoracic spine can be caused by a variety of pathologic conditions. Low back pain can be either mechanical or non-mechanical in nature. Pathology in the kidney may refer pain to the lumbar spine (ipsilateral flank), or upper abdomen. Pathology in the urinary bladder refers to the suprapubic or thoracolumbar region. The diaphragm is innervated by C3, C4, and C5 with the pain normally confined to the C4 dermatome. The negative MRI has ruled out possible involvement of the dura mater.

Answer 25

A. In order to optimally clear the congestion that has developed in his right lower lobe, the patient would need to be positioned on the left side to allow gravity to help drain the secretions to the proximal airways. This patient is also unconscious and intubated so in addition to drainage, manual hyperinflation is necessary to provide increased ventilation which would help to mobilize secretions followed by suctioning to clear the secretions. Suctioning first then hyperventilating while in left-sidelying is less effective than the order suggested in Option A. Positioning on the right side would not drain the right lower lobe and also since the patient is laying on the right side, the only place to percuss and vibrate would be the left side, which has no pathology. Finally positioning on the left side with deep breathing exercises will not be effective in mobilizing secretions, especially since the patient is unconscious and unable to actively perform deep breathing exercises.

Answer 26

B. Prolonged stretching does not depend on the length tension curve, but on the stress relaxation curve and Golgi tendon organ. Plyometrics is a form of exercise designed to enhance muscle speed and power. The theory behind plyometrics relies on the stretch reflex (active contraction of a muscle or active tension) and the natural elastic components of skeletal muscle and its surrounding connective tissue (passive tension). The graph shows that as the muscle is stretched, the passive components are stretched and add to the total amount of tension that can be developed in a muscle. During plyometric exercises, a muscle is quickly stretched activating the muscle spindle and the stretch reflex, as well as stretching the connective tissue elements surrounding the muscle fibers. This combination produces a quicker, more forceful, contraction by the muscle. Closed chain exercise use is not explained by the length tension curve. The hold relax technique is thought to be mediated via the Golgi tendon organ, not length tension.

Answer 27

D. The primary physical therapy goal in this case would be joint protection and the prevention of contractures and adhesions, usually through splinting. There is no evidence to suggest that physical therapy can prevent nerve degeneration and muscle atrophy, as they are the normal effects of a peripheral nerve lesion. Spasticity would not be present in a lower motor neuron injury

Answer 28

B. While all of the above would help prevent injury to a diabetic foot, the most important information to provide is about proper footwear. Ensuring properly fitting footwear would alleviate risk of skin breakdown as well as providing appropriate cushioning to the articular cartilage of the foot joints that are prone to injury from repetitive trauma and compression. Orthoses may not be necessary for all patients. Despite moisturizing the skin, if there is improper protection, skin breakdown can still occur. Exercising within appropriate parameters will not be beneficial if the patient's footwear is not supportive or properly fitting.

Answer 29

B. An intact circulatory system can sustain adequate blood flow to an elevated limb. A limb with arterial insufficiency may not be able to sustain adequate blood flow against gravity. The vasodilation, caused by local mechanisms, occurs in response to ischemia. An acute arterial occlusion creates a pallor, but because blood flow is blocked, the reactive hyperemia is impaired.

Answer 30

C. The gluteus maximus is a hip extensor that is more active during resisted motions or when the hip is in flexion, especially in functional activities such as stair climbing. In this case, the patient flexes the hip placing the gluteus maximus on stretch increasing its ability to produce tension. Therefore, the patient is leaning forward to maximize the ability of the gluteus maximus to extend the hip during the stair climbing activity. The other muscles listed would not benefit as much from the increased hip flexion.

Answer 31

C. A physical therapist would be required to perform the initial evaluation, plan of care, re-evaluations, modifications to the plan of care, and discharge plans for the patient. The patient who is stable and on an existing program would be the most appropriate patient to be delegated to the assistant. Therefore, the patient who has multiple sclerosis and who is on an established gait training program would be the most appropriate. The other three patients are receiving their initial treatments.

Answer 32

C. The medical record is owned by the hospital subiect to the patient's interest in the information it contains. Unless restricted by state or federal law or regulation, a hospital shall furnish to a patient, or a patient's representative parts of the hospital record upon request in writing by the patient or their representative. Option C is the only correct answer in this case, since it specifies that the patient must authorize the release of information.

Answer 33

B. The anterior tibialis shows poor (2/5) grade strength during the examination. Because this muscle is active during swing phase of gait and shortly after initial contact, one would expect to see gait deviations showing up at those times. Specifically, the anterior tibialis maintains dorsiflexion of the foot during swing phase and controls plantarflexion after initial contact. During swing phase, weakness of the anterior tibialis would cause the patient to increase the amount of hip and knee flexion to prevent toe drag. With weak hip abductors, the patient would be expected to have excessive pelvic rotation. To compensate the patient would laterally bend toward the weak (right) side during midstance to help prevent the excessive hip drop. Throwing the trunk backward after initial contact may be due to weakness of the hip extensors (gluteus maximus).

Answer 34

B. The patient's symptoms would be aggravated by exercises that cause increases in patellofemoral joint reaction forces. One of the goals of treatment would be to promote proper patellar tracking. Isometric exercises such as quadriceps setting and straight leg raises (SLR) are most often used for strengthening with a diagnosis of chondromalacia patella because they produce smaller patellofemoral joint reaction forces than some other forms of quadriceps exercises, and thus are less painful. The vasts medialis is one of the muscles active during quadriceps setting. This muscle tends to pull the patella medially during contraction and thus acts as a dynamic medial stabilizer, which promotes proper patellar tracking. The vastus medialis is not preferentially recruited during a straight leg raise, nor is it the only muscle responsible for terminal knee extension. Patello-femoral compression forces are generally less during a SLR than when doing extension exercises with the knee bent.

Answer 35

D. An outcome measure documents a desired performance or change in the patient's condition over time. This may include a description of the patient's function before, during and after intervention. Option D does not indicate a change or function, but is focused on attendance.

Answer 36

A. The rib cage would not be able to expand normally during inspiration due to weakness of the external intercostals muscles, which are innervated by thoracic nerve segments. With a spinal cord lesion at the C5-6 level, the diaphragm would still receive innervation from the phrenic nerve (C4). The anterior scalene (C4-6) would be partially innervated and the sternocleidomastoid (C2-3) would be fully innervated. The abdominal muscles would not be innervated since they receive their innervation from thoracic nerve segments. Paralysis of the abdominal muscles would cause the diaphragm to assume a low resting position.

Answer 37

A. Rheumatoid arthritis is a chronic inflammatory disease that affects many body systems including the joint spaces. Destruction and subluxation of joints can occur over time secondary to the inflammation that occurs in the synovium. Fatigue is a common symptom that accompanies rheumatoid arthritis. Therefore, the patient must get enough rest to avoid excessive fatigue and to protect the joints from overuse damage. Therefore education on energy conservation and joint protection is essential to minimize joint deformity. However, the patient must realize that some activity is good for them to prevent contractures and to maintain strength and endurance. Fatigue and joint pain can and often do co-exist in patients with rheumatoid arthritis. The pannus in the joints is actually increased with rest. Rest does not appear to change the activity of the antigen-antibody complex.

Answer 38

C. This patient would have functional use of the triceps and finger flexors and would, therefore, be independent for all wheelchair transfers to all surfaces. Coughing would not be limited and would not be a goal. Rolling would be easily achievable as a short-term goal. Ambulation with forearm crutches would not be a reasonable expectation for this patient.

Answer 39

A. Several things can be done to decrease the current density and the possibility of skin irritation. These include decreasing the intensity of the stimulation, increasing the inter-electrode distance and the use of larger electrodes.

Answer 40

B. The presence of dyspnea and the pink, frothy sputum would suggest the presence of congestive heart failure and resultant pulmonary edema. Congestive heart failure can occur from poor cardiac muscle function as a result of myocardial infarction. Pulmonary edema occurs from the backflow of blood from the heart into the pulmonary vessels, increasing pulmonary capillary pressure. The increase in pulmonary capillary pressure increases fluid movement into the alveoli, which are normally dry. This leads to the presence of pink, frothy sputum that can be expectorated along with shortness of breath (dyspne). Positions that increase blood flow to the heart, such as lying flat, will increase the signs and symptoms. Therefore, the patient should be positioned with the head up or as in this problem; the patient should be placed in a sitting position to help alleviate the symptoms. Laying the patient down flat, supine or with the legs elevated would exacerbate the patient's problems

Answer 41

C. Medical social services deal with home situations, financial supports and acts as a resource director on behalf of the patient. Social services would be the most appropriate choice to help arrange and coordinate rehabilitative services for this patient while they are at home. Although nurses, occupational therapists, physical therapists and physicians may all be involved with direct patient care, they would not be the most appropriate for this level of discharge planning.

Answer 42

D. The open weeping rash may be infected. Skin infections are easily spread in a training room environment, and if not attended to correctly may infect more people. If an infection were suspected, the precise diagnosis would be made by means of a culture. Therefore, the most appropriate action would be to refer the patient to the team physician. Moist heat may increase the infection by increasing blood flow. An emergency room visit would not be indicated at this time. Occluding the wound with more pre-wrap creates an environment ideal for infection.

Answer 43

C. The previously amputated left limb must function as the main support limb. Any treatment strategy for ambulation must ensure that the left limb is functioning optimally. While the other factors are relevant, the previous ability of the patient to ambulate is the greatest concern.

Answer 44

A. Prone standers are used frequently for children who cannot achieve or maintain upright standing. The patient benefits from the physiologic changes associated with weight bearing and from the social and perceptual opportunity to see the environment from an upright position.

Answer 45

B. Pressure receptors (baroreceptors) are present in the carotid sinus and these receptors respond to changes in blood pressure. An increase in blood pressure that is sensed by these receptors will stimulate the parasympathetic system to decrease the rate and force of contraction of the heart in order to help lower the pressure. Repeated palpation in the carotid sinus area may simulate an increase in blood pressure and cause this reaction. Therefore increased heart rate and blood pressure are incorrect. Irregular heart rhythms generally result from electrolyte imbalance and/or ischemia to the conduction system of the heart.

Answer 46

A. The patient will be reluctant to move the limb because it is painful. ROM is essential to regain and maintain a functional ROM. In this case, the physical therapist's primary goal is to restore function with ROM exercises. Compression dressings, whirlpool, and splinting, are all acceptable aspects of care that help in the restoration of ROM. However, functional ROM would be the primary goal.

Answer 47

C. The most appropriate design would be a two-group pretest-posttest. Both groups are measured at the same times, but only the experimental group receives treatment. Gathering information from patient records may not provide the same accuracy as if the researcher had performed all of the measurements directly. Measuring ROM only on day 5 would not account for any pretest differences between groups.

Answer 48

A. The biceps brachi is both an elbow flexor and supinator, and it is most effective as a supinator with the elbow flexed to about 90° (approximately the muscle testing position). The brachialis does not cause supination (only flexion). The supinator does not flex the elbow. The brachioradialis would move the forearm to a midposition rather than fully supinating it. Therefore, when the elbow both flexes and supinates the biceps brachi would be the most likely muscle causing this action

Answer 49

C. All of these symptoms are indicative of reflex sympathetic dystrophy syndrome. Cervical disc disease does not produce swelling in the hand, color and temperature changes, or hyperhidrosis. Raynaud's phenomenon results in pain, pallor, and coolness, but no hyperhidrosis. Although carpal tunnel syndrome can also show sympathetic nervous system abnormalities, compression of the median nerve would refer symptoms to the lateral border of the hand (thumb area. With carpal tunnel syndrome, the patient may also display thenar muscle weakness.

Answer 50

C. The abductors are particularly active during the mid stance phase (single limb support) of gait to prevent the contralateral pelvis from excessive lateral tilting. Weakness of the hip abductors, particularly the gluteus medius, causes the hip to drop down on the side opposite the weakness. For example, weakness in the right gluteus medius would show up during stance phase on the right by excessive downward movement (lateral tilt) of the left pelvis. The hip adductors are active during terminal stance and through mid-swing and would not play a role in controlling the lateral rotation of the pelvis. The hip abductors show little activity during swing phase.

Answer 51

B. The structure indicated by the arrow is the greater tubercle. The arm is internally rotated in this radiograph.

Answer 52

C. Trunk ROM exercises and strengthening to minimize thoracic kyphosis are essential. Persons with ankylosing spondylitis tend to assume flexed postures. Disproportionately strong pectorals, hip flexors, or abdominals could worsen the kyphosis.

Answer 53

B. A brachial plexus injury that affects the C5 and C6 nerve roots is termed Erb-Duchenne paralysis. A lesion affecting the C8 and T1 roots is termed Klumpke's paralysis. Hemiplegia and spinal cord injury would be caused by trauma to the central nervous system and would not normally affect just the C5 and C6 nerve roots.

Answer 54

C. The occupational therapist would be the most appropriate members of the health care team to teach the patient the needed self-care skills. The occupational therapist would also be able to provide the patient with information regarding modifications to the home environment that would increase the patient's independence. The occupational therapist could teach the patient how to use adaptive devices and help with the fabrication of splints or self care aides.

Answer 55

C. The family should be involved in all stages of planning and treatment. Family involvement can shorten the rehabilitation process and the patient's return to the community. It is important to have the family involved early in the rehabilitation process rather than wait until the patient is ready to be discharged.

Answer 56

C. A complaint of heaviness likely reflects weakness. The complaint is not the fit or comfort of the prosthesis, so Option A is incorrect. The expense of obtaining a lighter prosthesis is not justified without determining if the solution is strengthening of muscle groups, which control the prosthesis. A fork strap attachment will assist with suspension, but will not reduce the weight of the prosthesis.

Answer 57

D. The history suggests that prolonged improper positioning of the cervical spine resulted in neck pain. A chronic forward head and kyphosis results in hyperextension in the upper cervical spine and excessive flexion in the upper thoracic spine. Further muscle length adaptation occurs with tight anterior muscles and stretched posterior muscles. Treatment should include correction of muscle weakness or imbalance. Rhomboid strengthening and axial neck extension are the only options that are both correct.

Answer 58

B. Macerated tissue results from excessive moisture. A more absorbent dressing would soak up the excessive moisture and prevent the maceration.

Answer 59

A. During Phase I (inpatient) cardiac rehabilitation, vital sign parameters with activity that warrant termination are: diastolic blood pressure of 110 mm Hg or greater, systolic blood pressure above 210 mm Hg or an increase greater than 20 mm Hg from resting and a heart rate that increases beyond 20 beats per minute above resting. The normal resting respiratory rate can range between 12 to 20 breaths per minute in adults, so an increase to 20 breaths per minute with low-level activity would not be a reason to terminate the activity

Answer 60

B. Because this patient has significant weakness in both lower extremities, a standing pivot transfer would not be safe. However, since the patient does have fair to normal upper extremity strength, and is not totally dependent, a hydraulic lift or two person lift would not be appropriate because it would not be enhancing the patient's functional skills. The most appropriate transfer method would be for the patient to use a sliding board transfer to her strongest (right) side.

Answer 61

B. Neurological changes that are age related include decreased pain and vibratory sensation. The other changes listed do not normally occur with aging in the absence of pathology.

Answer 62

B. Massaging the upper arm before the forearm helps reduce the proximal resistance of lymphatic flow, which will optimize the flow of fluid or edema from the distal areas. This has been referred to as the "uncorking effect". Local heat would cause vasodilation and may increase edema. Massaging the hand before the forearm would not allow the "uncorking effect" to occur. The massage strokes should be from distal to proximal (centripetal) direction

Answer 63

A. In order to cough effectively, the abdominal muscles must contract to expel air forcefully. This patient does not have this ability; therefore manual force against the abdomen would mimic the action of the abdominal muscles. The prone position would not assist the cough mechanism in this patient. Both pursed-lipped breathing and interrupting the expiratory air stream would decrease the force of exhalation and decrease cough effectiveness

Answer 64

B. The seat width should be slightly wider than the width of the widest body part, and the depth should come to within 1 inch of the popliteal fossa.

Answer 65

D. There is a normal, linear relationship between heart rate and exercise intensity in patients who are not on beta blocker medication or who are on non-rate responsive pacemakers. Therefore, teaching patients to take their pulse reliably before discharge is an important learning objective to ensure safety with exercise upon discharge. Ascending a flight of stairs before discharge is only appropriate if the patient needs to negotiate stairs at home, but not as important as pulse monitoring. Performing exercises without angina can be achieved by monitoring heart rate with exercise; therefore, taking a pulse is necessary. Returning to normal daily activity immediately after an MI is an unreasonable objective as it will take 6 to 8 weeks for the myocardium to heal; therefore, activity levels will need to be tempered in order to protect the heart while it is healing.

Answer 66

B. The QRS complex represents ventricular contraction. Atrial contraction is represented by the 'p' wave. When an area of the ventricle becomes irritable and develops an ectopic foci, the ventricle will depolarize prematurely before the normal conduction sequence (e.g., prior to SA node firing in the atria) and presents as a wide, irregularly spaced QRS complex. In normal ventricular depolarization, the QRS would be narrow and regularly spaced and atrial fibrillation would appear as the 'p' wave changes. Atrial repolarization occurs within the QRS complex and is not normally visible on EKG.

Answer 67

A. This stage of hemarthrosis will mean that there is still some bleeding into the joint space, but not as extensively, therefore the patient will benefit from range of motion exercise to prevent contracture. The patient may need active-assist, as there may still be pain or edema in the joint that prevents independent performance of range of motion. The mechanical trauma of weight bearing to tolerance at this stage may impinge and damaged the pathologic synovium within the joint. Resistive range of motion is more appropriate when pain and swelling have subsided and no bleeding is occurring. Continuous immobilization in the extended position will promote contracture in the edematous knee.

Answer 68

B. Lateral epicondylitis is caused by overuse of the wrist extensors that originate on the lateral epicondyle of the humerus, especially the extensor carpi radialis brevis. If the lateral epicondylitis is at a chronic stage, conditioning of the extensor muscles and sustained grip activities will be most effective in long term management. A forearm cuff is thought to decrease the muscle loading. Iontophoresis would not be appropriate for a home program. Friction massage of the brachioradialis would not be appropriate since the extensor carpi radialis brevis muscle is usually the one affected.

Answer 69

B. Contacting the patient's home health nurse is the appropriate first course of action because of the possible safety risk associated with the patient not taking their insulin. Injections and glucose testing would go beyond the scope of practice for physical therapy. Placing the responsibility on the family would not be appropriate because of the gravity of the situation.

Answer 70

A. The sitting position promotes visual attending, use of the upper extremities, and social interaction. A child who exhibits extensor posturing should be carried in a symmetric position that does not allow axial hyperextension and keeps the hips and knees flexed.

Answer 71

B. Caution should be used in patients who are taking tetracycline, because the drug will enhance the effects of the ultraviolet radiation. Ultraviolet is not contraindicated in these patients, however the dosage of the ultraviolet would probably have to be adjusted to some lower level. The penicillin allergy, calcium supplements and metal implants would not be affected by the ultraviolet light. It should be noted that although ultraviolet radiation therapy is not common in today's practice of physical therapy, therapists should nonetheless be aware of the precautions; and be able to advise patients who may be using ultraviolet radiation at home.

Answer 72

C. The position described creates the necessary force to move the lower body in this transfer given the level of the spinal cord injury. Finger extension against resistance would be difficult for a patient with C6 quadriplegia. The patient's hands would be kept near the thigh or hips with one hand on the mat and one on the wheelchair.

Answer 73

C. Cubital tunnel syndrome is ulnar nerve entrapment. The test as described is for the radial nerve. Tingling and paresthesias in the medial forearm and hand are typical findings with cubital tunnel syndrome. Pronator teres syndrome is compression of the median nerve. Although the patient may have pain on the radial side of the hand with pronator syndrome, it usually extends from the little finger (1st digit to the index finger (4th digit) and does not result in lateral elbow pain. The test described is for the radial nerve. Radial tunnel syndrome involves compression of the deep branch of the radial nerve and presents with symptoms similar to lateral epicondylitis, i.e. poorly localized pain over the radial aspect of the proximal forearm. Symptoms are reproduced in the above test position. Anterior interosseous syndrome is compression of the anterior interosseous nerve, which is a branch of the median nerve. The median, not the radial, nerve tension test will provoke symptoms of anterior interosseous nerve syndrome.

Answer 74

A. Tender points are the single most powerful way to distinguish the presence of fibromyalgia from other painful conditions in a patient. Non-restorative sleep, not loss of sleep, is a typical finding with fibromyalgia. Stretching exercises may be quite beneficial for patients with fibromyalgia. Visual disturbances and loss of balance do not typically occur with fibromyalgia, but may occur with myofascial pain syndrome.

Answer 75

D. Option A tests the integrity of the tibiofibular syndesmosis. With a positive test result, the patient will have reproduction of symptoms and in this case, anterior ankle pain. External rotation of the tibia may potentially compress the calcaneocuboid joint, but would not stress the ligaments. A 5th metatarsal fracture would not present with anterior ankle pain. Option D does not load the tibia and/or muscles enough to provoke pain from a stress fracture.

Answer 76

C. The joint indicated (subacromial) in the radiograph contains several soft tissue structures including the biceps brachi tendon, supraspinatus tendon, and subacromial bursa. The other structures listed are not located in this area.

Answer 77

C. A long distance runner presents to physical therapy with insidious onset of lower leg pain. The patient's examination results reveal weakness of toe flexion and ankle inversion. The physical therapist suspects vascular compromise associated with this presentation. Palpation at which of the following locations is MOST likely to reveal diminished arterial pulses in the patient?

Answer 78

D. Achilles' (S1- S2) testing will not access the involved level (L4). Sole of the foot sensation testing (L5, S1) will not access the involved level (L4). As the sign of the buttock test is for space occupying lesions in the pelvis, hip pathology, or something that is non-musculoskeletal, it is not indicated at this time, based on the information provided about the patient. This patient demonstrates foot slap gait that is most likely associated with progression of nerve root compromise (i.e. increased disc protrusion). The therapist must assess the level/degree of compromise of the involved level, L4. Strength testing of the tibialis anterior will offer the most important information, as it is innervated by the root most likely compromised. The scenario indicates peripheralization of symptoms, which is considered worsening of the condition

Answer 79

D. This injury was from a fall on an outstretched hand and is unlikely to be tendinitis. Colles' fractures do not present specifically with tenderness in the snuffbox. A triangular fibrocartilage complex injury is central/medial (ulnar side) and does not present with snuffbox pain. The location of option D describes the anatomical snuffbox. Tenderness with palpation in the anatomical snuffbox suggests a scaphoid fracture, especially from a fall on an outstretched hand injury.

Answer 80

B. Partial sit-ups encourage flexion, which is not indicated. This patient has an extension bias and prone opposite upper extremity/lower extremity is the easiest/safest exercise to initiate when extension is a favorable direction. Quadruped opposite arm and leg lifts on a therapy ball and bilateral bridging with feet on a therapy ball encourage flexion, which is not indicated.

Answer 81

D. Instructing the patient to walk a straight line while glancing left and right would address a vestibular problem, specifically oscillopsia, but would not help a patient with a primarily somatosensory deficit, as described in the question. Instructing the patient in exercises to strengthen the gastroc-soleus muscle group would not provide protection against falling, although it may be an appropriate adjunct in a comprehensive therapy program. Referring the patient to an orthotist for a custom ankle-foot orthoses fitting may be included at some point in the intervention scheme, but the most important factor is immediate protection from falling, which is best addressed with a cane. This patient has a somatosensory deficit and while introducing somatosensory challenges is appropriate, the most important thing to do is provide them with a cane for balance and upper extremity proprioceptive input.

Answer 82

C. In a normal distribution, the area between +/- 2 standard deviation units represents about 95% of the population. Greater than 50% of the scores fell between 33 and 55. Approximately 2.5% of the scores fell below 33 and approximately 2.5% of the scores fell above 55.

Answer 83

C. Since this is a temporary intervention, the cost of custom orthoses is not warranted. Also, there should not be unilateral intervention, to eliminate any problems associated with inducing a leg-length difference temporarily. Temporary heel lifts may be added to decrease stress on the Achilles during treatment of tendinitis, but these should be used bilaterally, because there may be problems in inducing a leg-length difference, even temporarily. Temporary heel lifts may be added to decrease stress on the Achilles' during treatment of tendinitis. These should be used bilaterally, as there may be problems in inducing a leg-length difference, even temporarily.

Answer 84

A. The data in the question are risk factors for osteoporosis and possible compression fracture. This patient could have weak bones due to long term steroid use, smoking, or being postmenopausal. Although lung cancer is likely with a history of smoking, lung cancer is unlikely because of the symptom onset after prolonged flexion and should not cause limited active range of motion. Coronary artery disease and an abdominal aortic aneurysm would not cause limited active range of motion or pain with deep breathing. The patient's history does not increase her likelihood for having an abdominal aortic aneurysm.

Answer 85

B. Option B's goal is the only goal that is objective, measurable, and functional. The goals in options A, C, and D lack function or specific measurable objective information.

Answer 86

D. The shoulder abduction, elbow extension, wrist extension position is for the median nerve. The shoulder flexion, elbow flexion, wrist extension position is for the ulnar nerve. Option C is incorrect, because the radial nerve stretch requires elbow extension, not flexion. Option D is the correct position for end-range gliding of the radial nerve.

Answer 87

A. A squat-pivot transfer avoids full lower extremity extension, thus minimizing lower extremity extensor tone. A sliding-board transfer is not appropriate with a high level of ataxia in the upper extremities. A standing-pivot transfer is not appropriate because it may increase the extensor tone in the lower extremities. A dependent tuck transfer does not encourage active patient participation or promote independence.

Answer 88

B. Sensory level interferential current at 80 to 100 Hz does not address the problem itself, but may address any related pain. Iontophoresis with acetic acid can address the cause of calcific tendinitis, not just the symptoms. High volt pulsed electrical stimulation at 200 pps does not address the problem itself, but may address any related pain. Diathermy with a parallel treatment set up is not the best choice, as deep heat will not address the pathology.

Answer 89

B. Decreasing the electrode size will increase current density and make the treatment more intense and uncomfortable. Decreasing the pulse width will make the treatment more comfortable, still affecting large fibers (A beta) without stimulating the A delta and C fibers (pain). Increasing the pulse rate while using pulsed current will not make the treatment any more comfortable. It has been proposed that a higher frequency is more comfortable with alternating current, but this is not true with pulsed current. Only switching to a monophasic current will not affect this patient's comfort.

Answer 90

D. The medial knee is the L3 dermatome. The medial ankle is L4 dermatome. The plantar foot is S1 or S2. A posterolateral disc bulge at L4- L5 will most likely affect the L5 nerve root and the dermatome for the L5 nerve root. The L5 dermatome includes the dorsal aspect of the great toe. The dorsal area of the great toe is consistently included in the L5 dermatome

Answer 91

B. The 10-m walk for time test addresses speed more than endurance. By definition, the 6-minute walk test is the only option that addresses endurance. The timed up and go test does not measure endurance. A Maximum VO2 assessment does not directly measure functional endurance.

Answer 92

C. Option A is not a more difficult activity than the one the patient is currently able to perform. It is not challenging the patient. Option B addresses balance, but is not a functional activity. Option C is correct, as it challenges the patient, addresses endurance, and is safe for this patient. Option D progresses endurance, not balance

Answer 93

A. Lumbar stenosis by definition causes lower extremity symptoms with extension activities and stenosis is more common in an older population. Gluteal artery claudication would cause buttock pain, not calf pain. This patient is relatively too old for a herniated nucleus pulposus. Most herniated nucleus pulposus do not cause bilateral symptoms. Nothing given in the patient's history would increase the likelihood of a deep vein thrombosis.

Answer 94

C. Vital capacity is measured from maximum inhalation to maximum exhalation. Inspiratory capacity measures volume with maximal inhalation. Tidal volume measures total volume of air moved during either inhalation or exhalation over a specific period of time (usually 1 minute and then divided by the ventilatory rate. Inspiratory reserve volume measures inspiratory volume beyond normal inspiration.

Answer 95

D. One continuous ramp that is 60 ft (18 m) long is too long of a run without a level area to rest. One continuous ramp that is 30 ft (9 m) long is too steep a slope. Two ramps, each 60 ft (18 m) long and connected by a level area is too long of a run without a level area to rest and unnecessarily long. The rise should not be greater than 30 in (76 cm) for any 1 run and should be 1 ft (.3 m) in length per each 1 in (2.5 cm) rise.

Answer 96

C. A high percentage of true positives would be a measure of sensitivity. A high percentage of false positives would indicate low sensitivity. True negatives is correct as 0.88 is high and specificity is to correctly identify true negatives. A high percentage of false negatives would indicate low, not high, specificity

Answer 97

A. Atelectasis occurs when 1 or more segments or lobes of the lung is collapsed. It often occurs following thoracic or upper abdominal surgery, when the patient has a reduced total lung capacity, functional residual capacity, and residual volume. Bronchietasis is an abnormal dilation of the bronchi and bronchioles and results in increased residual volumes. The primary symptom of chronic bronchitis is chronic productive cough and results in increased residual volume. Emphysema usually results in significantly increased residual volumes.

Answer 98

A. The latissimus dorsi depresses the shoulder girdle and can be short in patients with depressed scapulae. The upper trapezius, if short, would elevate the scapula. The rhomboids, if short, would adduct and downwardly rotate the scapula. The teres major, if short, would abduct the scapula.

Answer 99

C. The sensory distribution for the lateral sural cutaneous nerve includes the upper portion of the lateral lower leg, but does not extend into the foot. The L4 nerve root usually covers the anterior knee and down into the medial lower leg and foot. The information given in the question includes the sensory distribution of the superficial peroneal nerve. The S1 nerve root extends into the lateral portion of the foot, not the top portion of the foot.

Answer 100

D. A deep vein thrombosis corresponds to the leg pain and possibly swelling, but not shortness of breath. A myocardial infarction corresponds to shortness of breath, but typically does not result in swelling acutely. A myocardial infarction could result in the development of congestive heart failure, which would result in these symptoms, but this is a secondary result, not a primary result. A pulmonary embolism would result in shortness of breath, usually not changed by position, and typically cardiac arrest. Typical signs of congestive heart failure include dyspnea, paroxysmal nocturnal dyspnea, orthopnea, and peripheral

Answer 101

B. These patients require maximal assistance for floor-to-wheelchair transfers as they don't typically have the trunk control required to perform this task. Typically with C7 spinal cord injury, patients are able to perform wheelchair mobility on smooth surfaces independently. They may require an upright wheelchair to assist with trunk control. These patients usually are independent with supine-to-sit transfers; by rolling from side to side and getting their arms behind them, they are able to come to long sitting. They do not have the trunk control to perform a wheelie, which is required for ascending a curb in a wheelchair.

Answer 102

C. Motor weakness in a peripheral nerve distribution is usually associated with multiple sclerosis, not Guillain-Barre Syndrome. Although Guillain-Barre Syndrome does affect the peripheral nerves, it tends to affect multiple nerves, not just a single peripheral nerve distribution. Rapid development of progressive motor weakness is very characteristic of Guillain-Barré Syndrome. Guillain-Barré Syndrome affects multiple peripheral nerves.

Answer 103

A. The functional position of the wrist and hand describes the position from which the optimal function is most likely to occur. This position is described as: (1) slight wrist extension, (2) slight ulnar deviation, (3) fingers flexed at the MCP, PIP and DIP joints and (4) thumb slightly abducted.

Answer 104

C. Dialing 911 is not the first step and may not be indicated until further assessment is completed after the seizure. There is no need to try and keep the patient from biting her tongue or to insert an object into the mouth, which could cause damage to the patient's teeth. During a seizure, injury should be prevented. Rolling the patient on her side will help prevent aspiration. Option D is not an appropriate response to the patient having a seizure

Answer 105

A. The restocking of treatment booths with supplies is the only option which does not involve direct patient contact or care, and thus is the MOST appropriate activity to delegate to a volunteer. Although volunteers may at times be involved with patient care activities (i.e.,transporting patients), the patients in the above situations pose a potential risk and would require supervision by someone other than a volunteer.

Answer 106

B. Prednisone is a glucocorticoid that exhibits these side effects. The primary side effect of penicillin is an allergic reaction such as skin rashes and difficulty breathing. The primary side effect of aspirin is gastritis. The primary side effect of gold therapy is diarrhea, irritation of oral mucosa and skin rashes.

Answer 107

A. The optimal exercise duration for achieving a weight loss with a walking program is 40 to 60 minutes of continuous aerobic activity. Therefore once a patient is safely tolerating 15 minutes, the best progression is to increase the duration while maintaining the same intensity or walking speed. Increasing walking speed should only be performed once the patient can consistently tolerate 20 to 30 minutes of exercise. Decreasing the duration while increasing the frequency of exercise would not accomplish the goal 40 to 60 minutes of continuous exercise. A patient who has been walking for only 15 minutes 3 times per week would not be ready to begin jogging and jogging 1 time per week would be too low of an exercise frequency in general to achieve any training benefit

Answer 108

B. Walking on the toes tests superficial posterior compartment, not superficial anterior compartment. The physical therapist must rule out an acute anterior compartment syndrome and the dorsalis pedis pulse is the only test given in the options that will give the therapist information about the function of the anterior compartment. Eversion strength would be involved in lateral compartment syndrome, not anterior compartment syndrome. Achilles' reflex tests deep posterior compartment (tibial nerve), not anterior compartment

Answer 109

D. Excessive femoral anteversion could cause toeing in, during standing. Anterior rotation of the innominate would cause shortening of the extremity. Pelvic tilt may cause a leg-length discrepancy with the longer leg being on the side of the tilt. When the malleoli are aligned in supine and then change with long sitting it is indicative of innominate rotation. In this case when the right malleolus shifted inferiorly (gets longer) it indicates a posterior rotation of the pelvis on the side of the longer leg.

Answer 110

B. A nerve root impingement commonly gives radicular pain. One of the most common causes of a capsular pattern in the shoulder is traumatic arthritis following injury to the shoulder. The capsular pattern may gradually develop over time. A painful arc is often associated with a non-capsular pattern such as seen with bursitis or tendonitis at the shoulder. A torn rotator cuff is associated with weakness and loss of active shoulder elevation.

Answer 111

D. Although all of options are involved in the decision making process, the determination of contraindications is the first thing to consider, since all other options are unnecessary if the patient has other pathologies that could be a contraindication.

Answer 112

A. Tightness of the hamstrings causes excessive lumbar flexion, because tight hamstrings restrict the amount of hip flexion. Weak gluteals allow more hip flexion. Weak abdominals show up in antigravity flexion of the trunk, not passive forward bending. Hip flexor flexibility is not a factor in forward bending.

Answer 113

C. Active range of motion is not allowed until approximately 6 weeks. Supraspinatus strength testing is not allowed due to the active range of motion restriction. After open surgical repair of the rotator cuff, passive range of motion is allowed to tolerance generally around 100° of elevation. Full range of motion would not be achieved by this time; the cuff is still protected from stresses

Answer 114

B. The patient has too much eversion during the midswing phase. This is probably caused by too much activity in the extensor digitorum longs or extensor hallucis longus. To correct the situation, the tibialis anterior should be facilitated since it dorsiflexes and inverts but doesn't cause eversion. The fibularis brevis, an everter, would cause plantarflexion of the foot rather than dorsiflexion. The flexor hallucis longs does not dorsiflex the ankle.

Answer 115

D. The presence of clonus would be on the right side, not the left side. Spasticity would be on the right side, not the left side. This is a case of hemisection of the spinal cord, Brown-Sequard syndrome. The lesion is on the right side of the spinal cord and it is an upper motor neuron lesion (Babinski's sign) with damage to the corticospinal tract, posterior columns, and lateral spinothalamic tract. Upper motor neuron spinal cord lesions present with hyperactive tendon reflexes (in this case on the right side), clonus, and spasticity ipsilateral to the side of the lesion. Pressure sensation is lost on the ipsilateral side and pain and temperature are lost contralateral to the side of the lesion due to the crossing of those fibers in the spinal cord.

Answer 116

B. Trigeminal neuralgia causes facial pain. All of the signs and symptoms in the question are indicative of a partial nerve lesion affecting the facial nerve. This type of lesion is Bell's Palsy. A left cerebrovascular accident affects only the lower facial muscles below the eye. Damage to the oculomotor nerve causes paralysis of 1 or more of the muscles that moves the eyeball.

Answer 117

C. Complete severance of the spinal cord causes motor and sensory loss on both sides of the body. A lesion of the anterior horn cells causes a lower motor neuron problem and hyporeflexia. The signs and symptoms presented in the question point to a hemisection of the spinal cord on the left side, which gives rise to ipsilateral motor and proprioception loss and contralateral loss of pain and temperature. Also present are hyperreflexia and a positive Babinski's sign on the left side. A lesion of the central spinal cord usually spares the motor tracts.

Answer 118

D. Closed chain exercises may produce more force in the quadriceps. They also produce more hamstring force than open chain exercises. They cause co-contraction of agonist and antagonist muscles, disallowing isolated contraction of the quadriceps. Closed kinetic chain exercises for the knee are generally thought to produce a co-contraction of the quadriceps and hamstrings, an effect which is not associated with open chain knee extension exercises. The co-contraction causes the hamstrings to restrict anterior displacement of the tibia on the femur (anterior drawer effect) and puts less strain on the anterior cruciate ligament.

Answer 119

C. Neither options A, B, nor D is safe or appropriate. When descending stairs, it is generally best for the therapist to be positioned below the patient as protection from falling. However, the patient should always descend stairs leading with the involved leg, the right leg in this case, and the cane.

Answer 120

D. Left hemiparesis occurs with a blockage of the right middle cerebral artery. Hemineglect syndrome is much more common in right cerebral hemisphere lesions. Left homonymous hemianopia occurs with a blockage of the right middle cerebral artery. Complete blockage of the left middle cerebral artery would most likely cause a problem with expressive speech (Broca's aphasia) especially in a right-handed individual.

Answer 121

A. All of the questions are important in history taking; however the suspected diagnosis is Bell's Palsy caused by a lesion of the facial nerve. The patient would most likely have weakness in the muscles of facial expression including smiling. Asking the patient to smile would most likely show an asymmetrical smile with weakness on the right side. Jaw pain and inability to chew food would be more likely due to a lesion of the trigeminal nerve. Inability to swallow may be caused by damage to cranial nerves IX, X or XII.

Answer 122

B. Although all of the options are steps in the cardiopulmonary resuscitation guidelines, based on the presented signs and symptoms, activation of the emergency response system is the first thing the therapist should do, as the patient is located within a hospital setting.

Answer 123

A. A prosthesis that is too short causes a patient to laterally bend towards the prosthetic side during stance phase. Each of the conditions given in options B, C, and D would make the prosthesis seem too long and none would cause the problem described.

Answer 124

C. Regarding options A, and B, for larger perturbations, individuals utilize hip and knee muscles to recover the balance. Regarding option C, for slight perturbations, most individuals use an ankle strategy. Ankle musculature is used to control the perturbation and recover the balance. Regarding option D, if the perturbation is strong enough to cause the individual's center of mass to move outside the base of support, a stepping strategy would be employed by taking a step and increasing the size of the base of support.

Answer 125

C. Normally, heart rate monitoring is the best method for monitoring exercise intensity. However, since the heart rate is controlled, it should not be used. Blood pressure is a measure of intensity, but is not practical in this case. The effect of the propranolol (Inderal), a beta blocking agent, is to control heart rate and decrease the workload on the heart. Perceived exertion (Borg's scale) is the preferred method to monitor exercise intensity for a patient taking beta blocking agents. Respiration rate may not be an accurate indicator of exercise intensity and cardiac workload.

Answer 126

D. A well-written goal includes an audience (who), behavior (what will be done), condition (under what circumstances), and degree (amount of change). The only option that includes all of these conditions is, "The patient (who) will demonstrate thenar muscle strength (behavior) of Good (4/5) grade (degree) and be able to hold objects in hand while at work (condition). Options A, B, and C, are each missing 1 or more of the required elements.

Answer 127

B. Strength increase in muscle is due to a number of factors including neurological adaptation and muscle fiber hypertrophy with an increase in actin and myosin. Hyperplasia in humans is still controversial. Long-term changes in muscle strength are due to all of the above factors. However, short-term changes, such as 1 week, are most likely to due to neurological factors such as more efficient motor unit recruitment, autogenic inhibition, and more efficient co-activation of muscle groups.

Answer 128

C. The quadratus lumborn, internal obliques, and external obliques are all innervated below the level of the lesion. Internal obliques are innervated below the level of the lesion. Sitting push-ups are often used as preparation for gait training and transfers. The push-ups are done to strengthen the muscles that "hike the pelvis" or lift the buttocks from the mat in a seated position. In a patient with a complete spinal cord injury at the T6 level the only muscle group that is still capable of lifting the pelvis is the latissimus dorsi, which is innervated by the cervical roots C6 - C8. The therapist is attempting to strengthen these muscles because they are capable of lifting the pelvis in the absence of the erector spine and abdominal musculature, which are innervated below the level of the lesion.

Answer 129

B. Since the symptoms are centrally located, there is no need to use sidelying. Spinal stenosis involves a narrowing of the spinal canal. The canal is opened somewhat during sitting or positions of lumbar flexion. The canal is narrowed during lumbar extension. The best position for this patient is supine with the knees flexed. Left side lying with the knees straight and prone with no pillows under the hips promote extension. The canal is narrowed during lumbar extension.

Answer 130

D. A patient must give informed consent regarding information about the treatment. The best alternative for the therapist is to have the niece visit directly with the aunt or have the niece attend a treatment session with the aunt's permission. Informed consent can only be given by the patient, unless the patient is incapable of doing so. In this case, there is nothing to suggest that the patient is unable to give her own consent.

Answer 131

A. The facial nerve, while primarily motor, does carry some sensations, particularly taste sensation from the anterior two-thirds of the tongue. Abnormal tone is associated with a supranuclear (central) lesion. Supranuclear lesions produce contralateral voluntary lower facial paralysis, so weakness would be on the other side. A Bell's phenomenon is not present with central lesions. Posis or sagging of the eyelid occurs with weakness of the levator palpebrae muscle. The levator palpebrae muscle is innervated by the oculomotor nerve (III). Pain and temperature sensation from the face (jaw) is carried by the trigeminal nerve (V).

Answer 132

C. The left tensor fascia lata would be chronically stretched, rather than shortened. The piriformis is an extensor and external rotator of the hip, so not as likely to be affected. The right leg is shorter, so in standing, the patient's right hip should be lower than the left. This relatively places the right lower extremity in abduction and the left lower extremity in adduction. This chronic posturing would mostly likely cause tightness in the right hip abductors and the left hip adductors. Of all the options, the right gluteus medius muscle is the most likely to be tight, because it is a right hip abductor. The right adductors would be in a chronically lengthened position, so not as likely to be affected

Answer 133

D. Normal sitting requires about 105° of hip flexion, so an elevated chair would not be necessary. Reaching would not be as restricted as donning socks. The reacher wouldn't be very effective in assisting with shoes and socks, and has a tendency to be overused. Stair climbing requires about 60° to 70° of hip flexion, and step height modification would not be needed. To reach to the foot, approximately 120° of hip flexion is required. If a modified procedure is chosen with the foot across the opposite thigh, at least 110° of hip flexion is still required. With only 105° of hip flexion, the patient would have most difficulty putting on socks.

Answer 134

C. Supine knee extension with hip flexion places a stretch on the sciatic nerve, which involves lower lumbar nerve roots (L4-S3). Knee flexion with hip flexion would not place a stretch on the femoral nerve. An upper lumbar radiculitis involves the nerve roots that form the femoral nerve (L2-L4). The femoral nerve can be stretched or provoked, by extending the hip while flexing the knee. Prone hip extension would place a stretch on the femoral nerve, but there would be less stretch with the knee in extension than in flexion.

Answer 135

B. Peripheral neuropathies are not characteristic of ankylosing spondylitis. The symptoms and signs of morning stiffness, loss of spinal mobility, and ankylosis of the sacroiliac joints, are most suggestive of ankylosing spondylitis, a disease more frequently found among adult males. Because of the involvement of the costochondral joints, chest wall expansion is frequently restricted. Swelling of peripheral joints is not characteristic of ankylosing spondylitis. The straight leg raise test is suggestive of nerve root compression. Nerve root compression is not characteristic of ankylosing spondylitis.

Answer 136

D. Regarding the patient being hypertensive, the opposite is likely. Orthostatic hypotension is a potential side effect. Arrhythmias are not listed as a recognized side effect of opioids. Regarding developing diarrhea, gastrointestinal motility is decreased, so the opposite effect of constipation is a frequent problem. Opioids tend to make the medullary chemoreceptors less responsive to carbon dioxide, thus slowing down respiratory rate and inducing a relative hypoxia and hypercapnia. The respiratory response to exercise may be blunted.

Answer 137

B. Regarding option A, a ratio of 75% is considered normal. Regarding option B, the patient has a mild disease. Advanced obstructive disease can have values of 25%. Nonetheless, the patient has mild morbidity, so special precautions should be used. Regarding option C, the patient has a mild disease and is not yet showing signs of morbidity, so special precautions should not be necessary. There would be no need to limit heart rate to 60% if the patient tolerates it. A forced vital capacity of 60% is a mild loss. Avoidance of aerobic exercise should not be required, and special physician approval related to a value of 65% should not be necessary.

Answer 138

C. An abnormal lymph node should feel firm, not soft. An elevated skin temperature is not an expected accompanying feature of an abnormal lymph node. An abnormal lymph node may feel firm and nontender, but an elevated skin temperature is not an expected accompanying feature of an abnormal lymph node. An abnormal lymph node can range in feeling from firm to hard, be mobile or nonmobile, and be tender or nontender. Again, an abnormal lymph node can range in feeling from firm to hard, but would not feel soft.

Answer 139

D. Standing-pivot transfer requires standing, which the patient is not able to perform safely. Manual-pivot transfer involves the assistance of another person, so would not allow for independence. Mechanical-lift transfer involves the assistance of another person, so would not allow for independence. Sliding transfer is the safest independent technique since the patient cannot stand without minimal assistance.

Answer 140

A. Approximation reinforces stability and standing is appropriate, because the patient has the most difficulty in this position. Rhythmical stabilization would be appropriate to address a loss of balance in sitting, but this patient's major problem is in standing balance. Resistive exercises to antigravity muscles may improve endurance for patients who are walking, but would not address the postural instability. Opening or closing the eyes has no effect on the ability to maintain standing balance in patients with cerebellar disease.

Answer 141

B. Regarding effective pain modulation, ramps are used to obtain a more gradual activation of muscle, rather than as a method of pain modulation. Ramp controls are usually not available on stimulators designed specifically for pain control. The waveform shown is monophasic with a ramp-up and ramp-down surge of the amplitude. The gradual rise and fall in the stimulus pulse amplitude allows the gradual recruitment of nerve fibers, creating a more comfortable initiation of contraction for the patient. The declining ramp at the end of the contraction allows a smooth gradual drop in the force produced by the muscle, also enhancing comfort. The gradual onset of muscle stimulation produces contractions that more closely mimic those produced in functional activities during voluntary muscle activation. Regarding frequency and motor unit recruitment, the waveform shown has a change in amplitude, not frequency. The waveform also has a change in amplitude, not pulse width.

Answer 142

D. Sensory level stimulation will likely be insufficient to provide pain relief, because the analgesia isn't as long lasting as motor-level stimulation. Clinic-based treatment would limit the frequency of treatment and therefore, the overall effectiveness. The patient has a chronic problem, so will most likely require a motor-level stimulation, because it provides a longer-lasting analgesia. A portable stimulator is preferable because it will enable the treatment to continue on to a home program outside the clinic.

Answer 143

C. Urinary frequency is not a side effect of opioids. Hypertension is a potential side effect of stronger opioids such as morphine. Constipation is a frequent side effect of opioid analgesics, because they decrease gastrointestinal motility. Diaphoresis is a symptom of narcotic withdrawal, but is not expected in a patient who is still taking the medication.

Answer 144

B. Option A's choice may create a barrier to communication, because the response is defensive. Option B's response indicates that the therapist is concerned with the relative's feelings and provides the relative with the opportunity to express any concerns. Passage of the licensure examination may not convince the relative of competency and does not promote communication between the therapist and the relative. The approach of option D does not encourage the patient's relative to express concerns.

Answer 145

A. Elevation and pressure is the correct next step in controlling bleeding. Removal of the dressing and bandage would potentially irritate the wound and increase the hemorrhage. Elevation and pressure should be applied first, before additional dressings, bandages, and pressure to the brachial artery. While calling the patient's physician to arrange transportation for medical care may be necessary, it does not immediately control the bleeding.

Answer 146

A. Approximately 60% of Guillain-Barré Syndrome cases are associated with recent upper respiratory infections or other infections. Regarding a recent accident, traumatic causes of symptoms would help to rule out, rather than rule in the diagnosis. Guillain-Barré Syndrome is acute and does not usually recur. Therefore, this question would also help to rule out, rather than rule in the diagnosis. This question is too general and does not help to further the diagnostic suspicions

Answer 147

B. While sensory testing is important in an initial exam, impaired sensation is less likely to occur in congestive heart failure by itself (as written in the question). Right-sided congestive heart failure results in dependent edema; measurements of pitting edema are appropriate to determine the severity of congestive heart failure and aid the therapist in treatment planning. Manual muscle testing is also appropriate for an initial exam. However, with acute congestive heart failure, resisted manual muscle testing is generally avoided until the congestive heart failure is more stable. Reflex testing is also important in an initial exam, but again, since this patient only has congestive heart failure, then reflexes are less likely to be impaired.

Answer 148

C. Since the patient is non-weight-bearing, transfer abilities and gait examination are less likely to yield information regarding the cause of foot pain. With regard to capillary refill in toes, complications of cast fixation may include swelling and, if severe, compartment syndrome. Improperly fitted casts and/or patients leaving limbs in a dependent position can result in painful swelling that creates occlusion to distal blood flow. Testing capillary refill is an easy test to examine distal extremity perfusion. Blood pressure changes could cause changes in perfusion to distal extremities, but it would be very difficult to measure lower extremity blood pressure with the cast on.

Answer 149

B. While nasotracheal suctioning is a viable option to clear a patient's secretions, it is usually the last resort when a patient does not have an artificial airway. So if option a manual costophrenic assist doesn't work, then suctioning may be needed. Any patient who has been on mechanical ventilation will likely have some respiratory muscle deconditioning. However, with superimposed neuromuscular disease, the respiratory muscle weakness will be further exacerbated. Therefore, providing manual assist at the lower ribs during cough will assist the patient in successfully clearing secretions. Supplemental oxygen can help a patient's ventilatory muscle endurance but does not ensure that the patient will be able to generate enough force during the cough. Inspiratory muscle training would be beneficial for this patient, but not at this acute stage status, post recent ventilation wean. Once secretions are under control, then muscle training can begin.

Answer 150

A. The electrocardiogram change shows 3 mm ST depression, which is indicative of cardiac ischemia and an indication to stop exercise and notify medical staff. Continuing gait training would endanger the patient. Stopping and resting is a plausible option. However, the medical staff should be alerted to this situation first. Continuing gait training, despite some standing rests could allow the ischemia to progress and endanger the patient.

Answer 151

C. Pain relief upon forward bending or sitting and pain relief upon standing are more diagnostic for lumbar origin of pain. Regarding cramping pain that occurs at a predictable distance walked, common presentation and clinical manifestations of pain caused by vascular limitation is cramping in nature and occurs in predictable exertion levels. Numbness and tingling that occurs at a predictable distance walked are more in line with a neurologic cause of pain rather than a vascular cause

Answer 152

B. Option A's exercise prescription would not provide enough overload to gain benefits. There is good evidence that inspiratory muscle training is safe and provides beneficial results for patients with respiratory muscle weakness. Option B's prescription was culled from the literature by Massery & Cahalin and is thus published in Cahalin's textbook. Option C's prescription would not provide enough overload either. The intensity is too great to begin with, while the frequency is too little to gain benefits.

Answer 153

C. Neither the standing, sitting upright, nor semi-upright position promotes reflux. Supine position could facilitate relaxation of the lower esophageal sphincter and promote reflux from the stomach into the esophagus.

Answer 154

D. The traditional position to drain the right middle lobe is left sidelying, not right sidelying. Option B is the traditional drainage position for right middle lobe, but does not take into account the intracranial pressure issues. Option C is the traditional drainage position for right middle lobe, but does not take into account the intracranial pressure issues; it should be left sidelying. Again, the traditional position to drain the right middle lobe is left sidelying with one-quarter turn towards supine, head of bed down approximately 20°. However, because of the recent craniotomy, the patient's increased intracranial pressure is a major issue to monitor and keep stable. Therefore, this traditional position should be modified to flat sidelying.

Answer 155

D The cardiologist is not the best referral, as this appears to be an integumentary problem unrelated to the cardiac condition. A physical therapist should not recommend any over the counter medications, as it is outside the scope of practice of a physical therapist. Any pharmaceutical education or advice, except "as prescribed by your physician", is outside the physical therapist's scope of practice. A pharmacist is the most appropriate heath care professional of those given to assist this patient.

Answer 156

C. Elevating the legs in the presence of arterial insufficiency decreases blood flow, which increases pain. Purple or brown pigmentation of the skin on the legs is associated with venous insufficiency, not arterial insufficiency. The patient has intermittent claudication caused by arterial insufficiency. Placing the patient's legs in the dependent position facilitates blood flow and reduces pain. Pain with exercise indicative of intermittent claudication, not deep vein thrombosis associated with a positive Homan's sign.

Answer 157

A. Excessive drop in blood pressure is indicative of patient intolerance to upright posture. Systolic blood pressure may increase slightly and heart rate may increase slightly. Oxygen saturation of 93% is within the acceptable range

Answer 158

C. Since the patient is non-weight-bearing bilaterally, the standing-pivot transfer is contraindicated. Since the caregiver is elderly, neither a 1-person nor a 2-person lift, is a safe choice. Since the caregiver is elderly and the patient is non-weight-bearing bilaterally, the sliding-board transfer is the best choice of the options given.

Answer 159

С. The reservoir must be placed below the level of the heart. Notifying the nurse would be sufficient. Notifying the physician is unnecessary.

Answer 160

D. The patient is too ill for either the VO2 max treadmill test or the 2-step test. The submaximal exercise test is not as sensitive or specific a test as the 6-minute walk test. The 6-minute walk test is designed for acutely ill cardiopulmonary patients.

Answer 161

C. Neither dorsal glide, ventral glide, nor cranial glide, would improve abduction. The radiograph shows limitation of glenohumeral motion causing the reduction in shoulder abduction. Caudal glide assists with improving abduction.

Answer 162

B. A standard walker on stairs is not as safe as crutches. As the patient was previously active, has stairs at home, and must be non-weight-bearing on one lower extremity, axillary crutches would provide the greatest safety margin and independence. A quad cane would not be sufficient, since the patient is non-weight-bearing on one lower extremity. The patient would not be able to be non-weight-bearing on 1 lower extremity with 2 straight canes.

Answer 163

C. A right cerebrovascular accident affects the left shoulder, not the right shoulder. The upper trapezius is controlled by spinal accessory nerve (XI ), not the vagus nerve (X). The spinal accessory nerve (XI) (supplied by the corticobulbar tract) was apparently not affected by the stroke and accounts for the patient's ability to shrug a flaccid arm. The deltoid does not shrug the shoulder

Answer 164

C. The oculomotor nerve (III) controls the inferomedial eye muscles. The trochlear nerve (IV) controls inferolateral eye movement. The abducens nerve (VI) controls lateral eye movement. Damage to this nerve causes the eyeball to deviate medially due to weakness of the lateral rectus muscle. The vagus nerve (X) does not control the eye muscles.

Answer 165

D. Homonymous hemianopsia describes a visual impairment. There is no evidence of visual limitations. Astereognosis is the inability to recognize an object by handling the object without looking at the object. Unilateral neglect describes the inability to register and integrate stimuli from one side of the body. Constructional apraxia describes a cognitive dysfunction in which a patient does not know what to do with the blocks.

Answer 166

C. Regarding option A, commonly, passive and active ranges of motion are not equally limited and are more likely to be problematic for shoulder abduction. An empty end feel is more likely. Regarding option B, range of motion is more limited secondary to muscle weakness. Also, a hard end feel would not be present. Examination findings of shoulder flexion limitation equal in both passive and active range of motion and accompanied b a hard end feel are indicative of adhesive capsulitis. Commonly passive range of motion is not limited and does not have a hard end feel present.

Answer 167

D. Unresolved edema is not indicated and would be more prevalent in lymphedema. A venous filling time of less than 15 seconds is suggestive of arterial insufficiency. Intermittent claudication is related to activity, not to dependency tests. A venous filling time of less than 15 seconds is suggestive of venous insufficiency.

Answer 168

A. Excessive prosthetic plantarflexion can cause insufficient knee flexion. A stiff heel cushion can cause excessive knee flexion and therefore buckling. A low prosthetic shoe heel can cause delayed knee flexion. Excessive prosthetic foot inset can cause excessive lateral thrust

Answer 169

A. Patients with fibromyalgia are not able to tolerate strengthening programs that involve either high repetitions or high resistance; therefore, only low resistance and low repetitions would be potentially beneficial for this patient population

Answer 170

A. Ahistory of mechanical locking is a common symptom of knee medial meniscus tear. Pain is commonly increased with weight-bearing, not decreased weight-bearing. Swelling would more likely be evident anteriorly, not posteriorly. Quadriceps atrophy is more likely, not hamstrings atrophy.

Answer 171

B. Although the Romberg Test is a measure of the role of vision in balance, it alone would not be the most appropriate measure for functional balance. The Berg Balance Scale is an objective measure of static and dynamic balance abilities and consists of 14 commonly performed functional tasks; therefore, it is the most appropriate tool to use as a measure of intervention effectiveness. The Fugl-Meyer Assessment is appropriate for cortical strokes and would not be the most appropriate for a cerebellar stroke. It is not as comprehensive in balance tasks as the Berg Balance Scale. The Barthel Index is a more global instrument and is not as focused on functional balance as the Berg Balance Scale.

Answer 172

C. Neither practice and feedback of examination skills, role playing the interview process, nor self-paced performance, involves active learning with other people in everyday situations. Readings do not meet the learning needs of active experimentation nor concrete experience. Each of the other options involves active learning with other people in everyday situations. Active learning relies on feeling and intuition rather than logic and reasoning.

Answer 173

D. Contract-relax stretching for tight structures is not recommended for soft tissues compromised by rheumatoid arthritis. Grade IV mobilization techniques are contraindicated for soft tissues compromised by rheumatoid arthritis. The elimination of functional activities is not required. Strengthening exercises are the most appropriate intervention for a patient with rheumatoid arthritis in remission.

Answer 174

A. Left hamstrings contracture is a fixed, mechanical limitation. It is the most likely cause of the gait impairment, as it directly affects both the knee joint during the midstance phase and the step length. It is the only option that can contribute to both of the gait impairments. Neither right illiopsoas weakness, left hip flexion contracture weakness, nor right quadriceps weakness, contributes to both gait impairments.

Answer 175

C. Nerve conduction above and below the local nerve compression is usually normal. Latency is typically increased, not decreased, across the carpal tunnel compression site. Nerve conduction above and below the local nerve compression is usually normal.

Answer 176

A. The fact that the patient has normal muscle strength of the hip external rotators along with limitation of range of motion indicates either tightness of the internal rotators or hip capsule tightness. The gluteus medius and minimus are internal rotators of the hip. The trunk shift is a normal substitution pattern found in individuals that are lacking hip range of motion. The problem is related to the hip, not the trunk. The patient's piriformis shows normal strength, so it is not weak.