Things to know

Question 1

Diabetes mellitus

Answer 1

Diabetes mellitus is defined as a fasting plasma glucose level of greater than or equal to 126 mg/dL (6.9 mmol/L)

Question 2

Cushing syndrome

Answer 2

Cushing syndrome is the result of hypercortisolism due to the adrenal gland producing excess cortisol or excessive use of glucocorticoids that causes sodium retention and loss of potassium. Cushing syndrome is not diagnosed by using the fasting blood glucose levels

Question 3

Impaired glucose tolerance

Answer 3

Impaired glucose tolerance is defined as a fasting plasma glucose level greater than or equal to 100 mg/dL (5.6 mmol/L) but less than 125 mg/dL (6.9 mmol/L)

Question 4

Primary adrenal insufficiency

Answer 4

Although the adrenal glands produce glucocorticoids that stimulate gluconeogenesis and inhibit the effects of insulin, blood and urine hormonal assay levels are used to diagnose primary adrenal insufficiency, not a fasting plasma glucose. In addition, patients who have primary adrenal insufficiency present with nonspecific symptoms such as fever and weight loss, not polydipsia and polyuria

Question 5

Acetic acid wound cleanser

Answer 5

Acetic acid has been used as a topical solution to treat acute and chronic wounds. The cleanser may negatively affect new cells in the wound bed. Although it may have an antimicrobial effect, it may also have antimitotic (inhibiting mitosis) effects as well. It may adversely affect fibroblasts and epidermal keratinocytes during tissue repair, particularly affecting cells that fill and cover a wound. Acetic acid has been shown to be extremely cytotoxic to cells and caution is recommended in use of these to promote wound healing.

Question 6

Pulsatile lavage with suction

Answer 6

Pulsatile lavage with suction combines wound irrigation with suction and removes the irrigation fluid, wound exudate, and loose debris. It has been found to be advantageous over other interventions since it uses less water and requires less staff support, less cleanup, and less treatment time. It has been shown to increase healing time by rapid removal of contaminants, and it can be used to treat tunneling wounds using special cannula tips

Question 7

Wet-to-dry dressings

Answer 7

Wet-to-dry dressing has been used to debride wounds, but it has been found to remove not only necrotic tissue, but also rich endogenous fluids, fibrin, and other cells critical to wound healing. It is often uncomfortable for the patient, causing bleeding and trauma to the wound bed. There is considerable evidence that efficacy of wet-to-dry dressings has not been demonstrated.

Question 8

Sharp debridement

Answer 8

Sharp debridement is considered the reliable/valid (gold) standard of methods for removal of necrotic tissue, but it is not appropriate for wounds with tunneling (when the wound bed cannot be seen). When the purpose of the treatment is to remove excess exudate and debris from the wound, pulsatile lavage with suctioning would be indicated

Question 9

Erratic respiration in Parkinson

Answer 9

Erratic breathing is associated with Parkinson disease due to dyskinetic movement patterns of the muscles of respiration
Parkinson disease is characterized by restrictive lung dysfunction associated with rigidity and respiratory muscle weakness, both of which would produce decreased chest excursion and decreased inspiratory volume.

Question 10

S3 Heart Sound During exercise with onset of dyspnea. crackles

Answer 10

Presence of an S3 heart sound is the hallmark of cardiovascular pump failure. In patients who have pump failure, crackles (rales) are heard on inspiration and do not disappear with coughing. Crackles (rales) may be absent at rest and appear during exercise, indicating that the exercise intensity is too strenuous and is likely causing a transient pump failure. Exercise should be terminated, and dose must be adjusted prior to resuming exercise

Question 11

Normal Respitory Range

Answer 11

A normal range for an adult (age 18 years and older) is 12 to 20 breaths/minute.
A normal range for a child in elementary school (age 6-12 years) is 18 to 30 breaths/minute.
A normal range for a toddler (age 1-3 years) is 24 to 40 breaths/minute.
A normal range for an infant (age birth to 1 year) is 30 to 60 breaths/minute.

Question 12

Upper Cross Syndrome

Answer 12

Treatment for this posture would include cervical extensor and pectoralis major stretching, combined with scapular retraction and cervical retraction strengthening. Combining pectoralis major stretching and scapular retraction exercises is the best combination of interventions to correct this postur

Question 13

Lymphadema Stages

Answer 13

1. In Stage 0 lymphedema there are no clinical signs of edema although reduced lymph transport capacity is present.
2. Stage 1 lymphedema includes pitting edema, reversible with elevation, and edema that is increased with activity, heat, and humidity and is better in the morning.
3. Stage 2 lymphedema includes nonpitting edema that is irreversible along with fibrotic skin changes
4. In Stage 3 lymphedema, there is an increase in severe nonpitting fibrotic edema and atrophic changes in the skin, including hyperkeratosis, papillomas, and warts.

Question 14

Indication to Stop Therapy (DDX)

Answer 14

1. Dissecting aortic aneurysm is an absolute indication that treatment should be withheld.
2. Decompensated chronic heart failure is an absolute indication that treatment should be withheld.
3. Third degree heart block is an absolute indication that treatment should be withheld.

Question 15

Gait- Due to Femoral Nerve injury

Answer 15

The nerve that lies below the inguinal ligament is the femoral nerve. The femoral nerve provides innervation for the quadriceps musculature. When the quadriceps are weak, there will be a compensatory motion of the femur by action of the gluteus musculature to pull the femur posteriorly. This will result in the knee ground reaction force being in front of the knee axis, thus providing an extensor moment.

Question 16

Gait- transfemoral amputation reports buckling of the prosthetic knee while walking

Answer 16

1.A knee axis anterior to the trochanteric-knee-ankle (TKA) line creates a flexion moment at the knee, causing knee instability and possibly buckling
2. A prosthesis that is too long is likely to cause an abducted stance or circumduction in swing, not instability at the knee
3. A mechanical knee that has too much friction built in is likely to cause a circumducted gait, not instability at the knee
4. A socket with a high medial wall is likely to cause an abducted stance or lateral bend of the trunk, not instability at the knee

Question 17

Axillary Nerve

Answer 17

The axillary nerve innervates the deltoid and teres minor. The deltoid is primarily responsible for shoulder flexion, abduction, and extension. The teres minor is responsible for shoulder lateral (external) rotation and horizontal abduction

Question 18

2. Subscapular
3. Suprascapular
4. Long thoracic

Answer 18

2. The subscapular nerve innervates the teres major, which is responsible for shoulder extension, medial (internal) rotation, and adduction (p. 592).
3. The suprascapular nerve innervates the supraspinatus and infraspinatus. The infraspinatus is responsible for shoulder lateral (external) rotation and horizontal abduction. The supraspinatus is responsible for shoulder abduction and lateral (external) rotation. (p. 78, 593)
4. The long thoracic nerve innervates the serratus anterior, which is responsible for upward rotation and protraction of the scapula (p. 591).

Question 19

A patient has a right shoulder that is higher than the left, and a left iliac crest that is higher than the right. The patient also exhibits a right thoracic rib hump with forward bending of the trunk. Which of the following options BEST describes these findings?

1. Left thoracic functional scoliosis
2. Right thoracic functional scoliosis
3. Left thoracic structural scoliosis
4. Right thoracic structural scoliosis

Answer 19

1. The description in the stem indicates a structural scoliosis. A functional scoliosis is reversible, and, unlike a structural scoliosis, it can be changed with positional changes.
2. This description in the stem indicates a structural scoliosis. A functional scoliosis is reversible, and, unlike a structural scoliosis, it can be changed with positional changes.
3. The description in the stem indicates a right convexity, which would not be present with a left thoracic structural scoliosis.
4. Structural scoliosis involves irreversible lateral curvature with fixed rotation of the vertebrae. A right thoracic rib hump upon forward bending indicates a right thoracic structural scoliosis.

Question 20

Which of the following therapeutic activities is the MOST appropriate for an infant who has a C5–C6 brachial plexus injury?

1. Open-hand batting of an object with finger extension and abduction
2. Reaching with shoulder medial (internal) rotation and forearm pronation
3. Reaching with shoulder lateral (external) rotation and forearm supination
4. Grasping an object with thumb (1st digit) adduction and metacarpophalangeal joint flexion

Answer 20

1. Weakness of finger extensors and intrinsic hand muscles that perform metacarpophalangeal abduction is more likely to be present in a C8–T1 brachial plexus injury (also known as Klumpke palsy) than in a C5–C6 brachial plexus injury.
2. An infant who has a C5–C6 brachial plexus injury (also known as Erb palsy) usually has the shoulder held in extension, medial (internal) rotation, and adduction and the forearm pronated. Reaching with shoulder medial (internal) rotation and forearm pronation will only reinforce the resting position and not address the weakness present in other muscle groups.
3. A C5–C6 brachial plexus injury (also known as Erb palsy) will result in weakness of the shoulder abductors, flexors, and rotators as well as the forearm supinators. Therefore, activities encouraging these motions should be emphasized during physical therapy.
4. Grasp is intact in infants who have a C5–C6 brachial plexus injury. Grasping an object with thumb (1st digit) adduction and metacarpophalangeal joint flexion is more appropriate for infants who have a C8–T1 injury resulting in intrinsic muscle weakness of the wrist and hand flexion.

Question 21

A woman in the 3rd trimester of pregnancy is performing pelvic floor exercises in supine position. She reports dizziness, nausea, and shortness of breath. Which of the following effects BEST describes the contribution of supine positioning to the patient’s symptoms?

1. Increase in inferior vena cava pressure and increase in venous return and cardiac output
2. Decrease in inferior vena cava pressure and increase in venous return and cardiac output
3. Increase in inferior vena cava pressure, leading to a decrease in venous return and cardiac output
4. Decrease in inferior vena cava pressure, leading to a decrease in venous return and cardiac output

Answer 21

1. Pressure in the inferior vena cava in supine position causes a decrease, not an increase, in venous return and cardiac output. This causes supine hypotensive syndrome, which presents as dizziness, nausea, and shortness of breath.
2. Pressure in the inferior vena cava rises, not decreases, in supine position. This causes supine hypotensive syndrome, which presents as dizziness, nausea, and shortness of breath.
3. Pressure in the inferior vena cava rises in late pregnancy, especially in supine position. This causes supine hypotensive syndrome, which presents as dizziness, nausea, and shortness of breath. Supine position causes a decrease in venous return and cardiac output.
4. Pressure in the inferior vena cava rises, not decreases, in supine position. This causes supine hypotensive syndrome. which presents as dizziness, nausea, and shortness of breath.

Question 22

A patient reports a snapping sensation over the lateral hip when running. Which of the following structures is MOST likely involved?

1. Iliopsoas
2. Iliotibial band
3. Acetabular labrum
4. Iliofemoral ligament

Answer 22

1. Slipping of the iliopsoas tendon over the osseous ridge of the lesser trochanter or anterior acetabulum is the most common cause of internal snapping. It occurs at approximately 45° of flexion when the hip is moving from flexion to extension, especially with the hip abducted and laterally (externally) rotated.
2. A tight iliotibial band riding over the greater trochanter of the femur may cause an external snap that tends to be felt more laterally during hip flexion and extension, such as occurs when running, especially if the hip is in medial (internal) rotation.
3. Acetabular labral tears can also cause a snapping hip sensation. There is generally sharp pain into the groin and anterior thigh, especially with pivoting movements. In this scenario, the snapping is felt over the lateral hip, so an acetabular labral tear is less likely. The pain can be reproduced passively when an extended hip is adducted and laterally (externally) rotated.
4. Internal snapping may be caused by the Iliofemoral ligament slipping and riding over the femoral head. This occurs at approximately 45° of flexion when the hip is moving from flexion to extension, especially with the hip abducted and laterally rotated.

Question 23

A patient who has hypothyroidism is MOST likely to exhibit which of the following symptoms?

1. Restlessness, increased appetite, diarrhea, muscle aches, intolerance to cold
2. Restlessness, increased appetite, constipation, muscle wasting, intolerance to heat
3. Lethargy, decreased appetite, diarrhea, muscle wasting, intolerance to heat
4. Lethargy, decreased appetite, constipation, muscle aches, intolerance to cold

Answer 23

1. Muscle aches and intolerance to cold are symptoms of hypothyroidism; restlessness, increased appetite, and diarrhea are symptoms of hyperthyroidism.
2. Constipation is a symptom of hypothyroidism; increased appetite, muscle wasting, and intolerance to heat are symptoms of hyperthyroidism.
3. Lethargy and decreased appetite are symptoms of hypothyroidism; diarrhea, muscle wasting, and intolerance to heat are symptoms of hyperthyroidism.
   **4. **A patient who has hypothyroidism (underproduction of thyroid hormone) has decreased cerebral blood flow leading to cerebral hypoxia and slowed neurologic functions, reduced peristaltic activity leading to constipation and decreased appetite, decreased muscle contraction/relaxation rate causing muscle aches, and decreased circulation to skin leading to cold intolerance.

Question 24

A patient who has an acute ankle sprain is being instructed in non-weight-bearing gait with crutches prior to discharge from the emergency department. Which of the following approaches by the physical therapist would MOST effectively facilitate learning?

1. Give verbal instructions in how to use the crutches.
2. Provide photographs of someone using crutches.
3. Have the patient verbally repeat the instructions and demonstrate use of the crutches.
4. Demonstrate use of the crutches and provide the patient with written instructions.

Answer 24

1. The therapist can best determine if the patient accurately understands the instructions only after the patient verbally repeats the instructions and demonstrates the use of crutches (O’Sullivan).
2. Providing a photograph does not demonstrate the motor task desired. It is better to have the patient watch a demonstration, but having the patient verbally repeat the instructions and demonstrate use of the crutches is best (O’Sullivan).
   3. When learning a new task, the patient is in the cognitive stage of learning. An effective training strategy in this stage is to have the patient verbalize task components and requirements (O’Sullivan). In the first stage, the goal of the learner is to understand the task dynamics (Shumway-Cook).
3. Demonstration is done so the patient has a reference of correctness, however asking the patient to verbalize components and requirements for the task is more effective than providing written instructions (O’Sullivan).

Question 25

Which of the following mechanisms BEST explains how a functional knee brace helps a patient who has anterior cruciate ligament deficiency to avoid knee instability at low external loads?

1. Restriction of anterior translation of the tibia on the femur
2. Improvement of knee proprioception
3. Enhancement of quadriceps contraction
4. Improvement of patellofemoral tracking

Answer 25

1. Functional knee braces have been shown to reduce anterior translation, especially at low external loads (Dutton; Beams).
2. Research has been inconsistent on the role functional knee braces play in improving proprioception. Neoprene knee braces have been shown to improve proprioception. (Dutton; Beams)
3. Research has been inconsistent on the role functional knee braces play in enhancing muscular response (Dutton; Beams).
4. Functional knee bracing has not been shown to improve patellofemoral tracking (Dutton).

Question 26

A patient reports an insidious onset of pain on the plantar surface of the foot, as well as forefoot burning, cramping, and numbness between the third and fourth metatarsal heads. The pain is reproduced when the metatarsal heads are squeezed together. The patient MOST likely has which of the following conditions?

1. Freiberg disease
2. Anterior tarsal syndrome
3. Morton neuroma
4. Sesamoiditis

Answer 26

1. Freiberg disease, which commonly involves avascular necrosis of the second metatarsal epiphysis, leads to collapse of the osteochondrotic deformity. Symptoms include pain localized to the metatarsal head and exacerbated with activity, range of motion limitations, joint swelling, and occasional plantar callosity under the second metatarsal head. Neurological signs, such as those described in the stem, are not attributable to Freiberg disease (p. 274).
2. Patients who have anterior tarsal syndrome report deep aching pain in the medial and dorsal aspect of the foot, burning around the nail of the great toe, and pins-and-needles sensations that are exacerbated with plantar flexion. These symptoms are not consistent with the description in the stem (p. 1169).
3. The symptoms described in the stem are consistent with Morton neuroma, a mechanical entrapment neuropathy of the interdigital nerve (p. 1168).
4. Sesamoiditis presents with pain on weight-bearing and swelling of plantar soft tissue. Passive dorsiflexion of the metatarsophalangeal joint while palpating the sesamoids exacerbates pain. Neurological signs, such as those observed in the patient described in the stem, are not commonly associated with this condition (p. 1167).

Question 27

A patient reports tingling and numbness in the palmar (volar) aspect of the right ring and little fingers (4th and 5th digits). The patient has a negative result on the test shown in the photograph. Which of the following test modifications is MOST likely to lead to the patient having a positive result on the test?

1. Flexing the wrist
2. Flexing the elbow
3. Abducting the shoulder
4. Rotating the neck

Answer 27

1. The neural entrapment suspected in the stem is that of the ulnar nerve. However, the photograph shows the upper limb tension test that is biased for the median nerve. The sequences of testing for the ulnar and median nerves are very similar except for the difference between elbow extension and elbow flexion. Wrist flexion will most likely reduce tension on both the median and ulnar nerves.
   2. The neural entrapment suspected in the stem is that of the ulnar nerve, whose sensory distribution is on the anterior and medial half of the ring finger (4th digit) and the anterior aspect of the little finger (5th digit). However, the photograph shows the upper limb tension test that is biased for the median nerve. The sequences of testing for the ulnar and median nerves are very similar except for the difference between elbow extension and elbow flexion. In order for the ulnar nerve to be subjected to tension, scapular depression, shoulder abduction, and lateral (external) rotation, elbow flexion, forearm pronation, wrist and finger extension, and contralateral cervical lateral flexion should be performed.
2. The neural entrapment suspected in the stem is that of the ulnar nerve. However, the photograph shows the upper limb tension test that is biased for the median nerve. The sequences of testing for the ulnar and median nerves are very similar except for the difference between elbow extension and elbow flexion. Further abducting the shoulder from its current position will not selectively test the ulnar nerve.
3. The neural entrapment suspected in the stem is that of the ulnar nerve. However, photograph shows the upper limb tension test that is biased for the median nerve. The sequences of testing for the ulnar and median nerves are very similar except for the difference between elbow extension and elbow flexion. Cervical rotation in either direction will most likely not influence the outcome of the test unless elbow flexion is also performed.

Question 28

A patient reports vertigo and nausea after rolling in bed. The symptoms last for 30 seconds. The patient has a positive response on the Hallpike-Dix test. To decrease symptoms, which of the following interventions would be MOST effective?

1. Habituation exercises
2. Brandt-Daroff exercises
3. Gaze stabilization treatment
4. Canalith repositioning treatment

Answer 28

1. The patient has symptoms that are consistent with benign paroxysmal positional vertigo due to canalithiasis (p. 332). Habituation exercises are most effective in patients who have vestibular hypofunction, not benign paroxysmal positional vertigo. (pp. 399-400).
2. The patient has symptoms that are consistent with benign paroxysmal positional vertigo due to canalithiasis (p. 332). Although Brandt-Daroff exercises are appropriate for the treatment of benign paroxysmal positional vertigo, they are nonspecific and the outcome is not as good as with the canalith repositioning for benign paroxysmal positional vertigo (p. 341).
3. The patient has symptoms that are consistent with benign paroxysmal positional vertigo due to canalithiasis (p. 332). Gaze stability exercises would be effective for patients with vestibular hypofunction resulting in impairments in gaze stability (pp. 397-399).
   4. The patient has symptoms that are consistent with benign paroxysmal positional vertigo due to canalithiasis, specifically, nausea and vertigo with movement, symptoms lasting 30 seconds or less, and a positive result on the Hallpike-Dix test (p. 332). Canalith repositioning treatment is the most appropriate evidence-based intervention for canalithiasis (pp. 332-335).

Question 29

A patient who has sacroiliac joint dysfunction will MOST likely experience pain during which of the following activities?

1. Sitting
2. Lying in prone position
3. Walking
4. Lying in supine position

Answer 29

1. Patients who have sacroiliac dysfunction often report pain that is aggravated by prolonged standing, asymmetrical weightbearing, or stair climbing; pain can also stem from running, long strides, or extreme postures (Frontera). Weakness or insufficient recruitment and/or unbalanced muscle function within the lumbar/pelvic/hip region can reduce the force-closure mechanism required for sacroiliac joint stability, which can result in a sustained counternutation of the sacrum. This “unlocks” the mechanism, rendering the sacroiliac joint vulnerable to injury. Regular weight-shifting occurs more frequently in walking than in sitting position (Dutton, p. 1538).
2. Weakness or insufficient recruitment and/or unbalanced muscled function within the lumbar/pelvic/hip region can reduce the force-closure mechanism required for sacroiliac joint stability, which can result in a sustained counternutation of the sacrum. This “unlocks” the mechanism, rendering the sacroiliac joint vulnerable to injury. There is little need for balanced sacral muscle activity in lying positions (Dutton, p. 1538).
3. Patients who have sacroiliac dysfunction often report pain that is aggravated by prolonged standing, asymmetrical weight-bearing, or stair climbing; pain can also stem from running, long strides, or extreme postures (Frontera). The following findings are likely to be present with a sacroiliac joint dysfunction: pain with walking, ascending or descending stairs; hopping or standing on the involved leg; pain with transitional movements such as rising to standing position from a sitting position or getting in and out of a car; and/or pain that is worsened with long periods of sitting or standing if lumbar lordosis is not maintained (Dutton, pp. 1539-1540). Unbalanced muscle function in the lumbar/pelvic/hip region during walking is most likely to cause pain in someone with sacroiliac joint dysfunction.
4. Weakness or insufficient recruitment and/or unbalanced muscled function within the lumbar/pelvic/hip region can reduce the force-closure mechanism required for sacroiliac joint stability, which can result in a sustained counternutation of the sacrum. This “unlocks” the mechanism, rendering the sacroiliac joint vulnerable to injury. There is little need for balanced sacral muscle activity in lying positions (Dutton, p. 1538).

Question 30

A patient had an uncomplicated total hip arthroplasty using a posterior approach 2 months ago. The patient wishes to return to sexual activity. Which of the following actions would be MOST appropriate for a physical therapist?

1. Educate the patient that sexual activity is not appropriate following a total hip arthroplasty.
2. Educate the patient about how to avoid contraindicated movements during sexual activity.
3. Refer the patient back to the orthopedic surgeon to discuss appropriate sexual positions.
4. Refer the patient back to the primary care physician to discuss alternatives to sexual activity.

Answer 30

1. A return to sexual activity after surgery is allowed as long as sufficient healing has occurred. The activity should be cleared by the orthopedic surgeon, and the precautions needed to protect the hip should be outlined. (Magee, pp. 701, 708)
   2. Posterior hip precautions after a total hip arthroplasty include avoiding hip flexion greater than 90°, medial (internal) rotation of the hip, and adduction of the hip (Magee, p. 698). Sexual activity that does not include these three contraindicated movements is appropriate for a patient after total hip arthroplasty with surgeon approval (Magee, p. 708). A physical therapist has a professional responsibility to educate a patient about the movement precautions related to the return to activities of daily living (including sexual activity) (Magee, p. 704; Pagliarulo).
2. It is within the scope of physical therapy practice to reeducate movement patterns and provide education on appropriate movement strategies for safety with activities of daily living (which includes sexual activity) (Magee, p. 704; Pagliarulo).
3. There is no indication in this case that a primary care physician would need to clear a return to sexual activity for a patient who has had uncomplicated total hip arthroplasty. The physical therapist’s scope of practice clearly includes this type of education. (Magee, p. 704; Pagliarulo)

Question 31

A patient who has upper motor neuron syndrome is MOST likely to exhibit which of the following signs?

1. Clonus
2. Severe muscular atrophy
3. Fasciculations and fibrillations
4. Hypoactive deep tendon reflexes

Answer 31

1. Clonus is characteristic of upper motor neuron syndrome (p. 377).
2. Severe muscular atrophy is characteristic of lower motor neuron syndrome (p. 378).
3. Fasciculations and fibrillations are characteristic of lower motor neuron syndrome (p. 378).
4. Hypoactive deep tendon reflexes are characteristic of lower motor neuron syndrome (p. 378).

Question 33

Which of the following tracts is being tested in the video? (stroking the foot of a baby- toes goe out)

1. Rubrospinal
2. Corticospinal
3. Spinothalamic
4. Vestibulospinal

Answer 33

1. The rubrospinal tract originates in the red nucleus of the midbrain and terminates in the anterior horn, where it synapses with lower motor neurons that primarily innervate the upper extremities.
   2. The corticospinal tract is the primary motor pathway and controls skilled movements of the extremities. A common indicator of corticospinal tract damage is the Babinski sign.
2. The spinothalamic tract relays sensory information. The dorsal or posterior columns carry information about position sense (proprioception), vibration, two-point discrimination, and deep touch.
3. The vestibulospinal tract assists in postural adjustments.

Question 34

Damage to which of the following structures would MOST likely result in the deformity shown in the photograph?

1. Ulnar nerve
2. Median nerve
3. Upper trunk of brachial plexus
4. Lateral cord of brachial plexus

Answer 34

**1. **Clawing of the ring and little fingers (4th and 5th digits) results from unopposed action of extensor musculature combined with paralysis of the intrinsic muscles of the hand, which occurs when there is involvement of the ulnar nerve (Goodman, pp. 1676-1677).
2. Compression of the median nerve at the wrist can cause carpal tunnel syndrome, which may cause pain, sensory changes, and atrophy of the thenar musculature (Goodman, pp. 1668-1669).
3. Damage to the upper trunk of the brachial plexus results in Erb palsy, which causes the wrist and fingers to be flexed in a “waiter’s tip” position (Palisano).
4. Damage to the lateral cord of the brachial plexus would have an effect on the musculocutaneous and median nerves and the muscles innervated by them (Palisano).

Question 35

A 4-year-old child shows no interaction with peers and has increased sensitivity to sound and touch, and poor eye contact. Which of the following techniques would be BEST for physical therapy in the child’s preschool?

1. Change activities frequently.
2. Provide structured routines.
3. Allow the child to select activities freely.
4. Incorporate high levels of sensory stimulation.

Answer 35

1. Children with autism spectrum disorders respond best with a high degree of structure and predictable routines.
2. The child demonstrates the signs of autism spectrum disorder. Young children with autism spectrum disorder have been shown to prefer and thrive in structured, predictable environments.
3. While it is important to allow for free movement and improvisational activities, children who have autism spectrum disorders respond best with a high degree of structure. For low-functioning children (as described in the stem), more prompting may be required to optimize outcomes.
4. Odd or exaggerated responses to sensory stimuli are common in autistic children. Too much sensory stimulation may be overwhelming.

Question 36

A patient has an irregularly shaped, heavily exudating, superficial ulcer on the medial aspect of the distal leg. Which of the following conditions is MOST likely the cause of this wound?

1. Type 2 diabetes
2. Chronic venous insufficiency
3. Arterial occlusive disease
4. Secondary lymphedema

Answer 36

1. Although type 2 diabetes contributes to both arterial and venous disease (p. 512), it is the sensory changes and repeated stress/pressure on insensate areas that causes ulceration (pp. 515-516). Diabetic ulcers are typically round and deep and have minimal drainage (p. 642). The stem states that the wound is irregular in shape, heavily exudating, and superficial.
2. Venous wounds are typically irregular in shape and highly exudative and frequently develop at the medial distal leg (pp. 642, 655-656).
3. Arterial ulcers are typically round in appearance and dry (p. 642). The stem indicates that this wound is irregular in shape and heavily exudating.
4. Wounds that develop as a result of progressive secondary lymphedema are usually a result of cracking of dry skin from chronic fibrosis (p. 682). This wound is irregular in shape and heavily exudating.

Question 37

A patient who has chronic obstructive disease has a respiratory rate of 30 breaths/minute and exhibits prominent use of the upper trapezius and sternocleidomastoid muscles during inspiration. Which of the following interventions is MOST appropriate for the patient?

1. Incentive spirometry
2. Pursed-lip breathing
3. Segmental breathing
4. Glossopharyngeal breathing

Answer 37

1. Incentive spirometry is commonly performed by postoperative patients to reduce the incidence of respiratory complications. This patient is not post surgery, and incentive spirometry does not address the increased respiratory rate.
   2. Pursed-lip breathing slows the respiratory rate. The patient has a rapid respiratory rate and overuse of the inspiratory accessory muscles and would, therefore, benefit from techniques to slow down respiration.
2. Segmental breathing is used to augment localized lung expansion. Although this patient has signs and symptoms of respiratory distress, segmental breathing will not address the elevated respiratory rate.
3. Glossopharyngeal breathing is used in patients who have high-level tetraplegia to improve respiratory capacity and increase vital capacity. This patient does not have a loss of vital capacity, but rather has an increased respiratory rate and overuse of the accessory inspiratory muscles.

Question 38

A patient who has a chronic T4 spinal cord injury (ASIA Impairment Scale A) has the vital signs shown in the table. The patient MOST likely has which of the following conditions?

1. Spinal shock
2. Autonomic dysreflexia
3. Orthostatic hypotension
4. Pulmonary embolism

Answer 38

1. Spinal shock is a period of areflexia immediately following an acute spinal cord injury. It is characterized by the absence of reflex activity, which impairs autonomic regulation and results in hypotension and the loss of the ability to sweat. (O’Sullivan)
   2. The table shows the patient’s systolic blood pressure rising greater than 20 to 30 mm Hg during the therapy intervention. A rise in systolic blood pressure of 20 to 30 mm Hg is one of the diagnostic indicators of an episode of autonomic dysreflexia. Autonomic dysreflexia typically affects patients who have a spinal cord injury above T6 and commonly occurs more than 3-6 months after the injury. (O’Sullivan)
2. The table does not indicate the drop in blood pressure necessary for the clinical diagnosis of orthostatic hypotension. A decrease of 20 mm Hg in systolic blood pressure or a decrease of 10 mm Hg for diastolic blood pressure would indicate orthostatic hypotension. (Goodman, p. 160)
3. A pulmonary embolism would typically present with sudden chest pain, tachycardia, tachypnea, and an oxygen saturation less than 95%. This patient’s heart rate, oxygen saturation, and respiratory rate are not consistent with a pulmonary embolism. (Goodman, p. 291)

Question 39

A patient who has type 1 diabetes is unable to tolerate walking due to metatarsal and distal toe ulcers, despite using a walker. Which of the following types of footwear is MOST appropriate?

1. Heat-moldable healing shoe
2. Heel relief shoe
3. Postoperative shoe
4. Heel rocker shoe

Answer 39

1. The heat-moldable healing shoe can be molded directly to the shape of the patient’s foot and is commonly used after amputation or skin grafting. This type of shoe does not alleviate weight-bearing on the metatarsal heads. (Hamm, pp. 217-218)
2. The goal of off-loading is to reduce pressure and shear forces on the area of ulcers (Baranoski). Off-loading the heel would place more weight-bearing on the forefoot, which is where the ulcers are located.
3. A postoperative shoe, especially without a total contact molded insole, does not offload the metatarsals as well as a heel rocker shoe does (Hamm, pp. 219-220).
4. The heel rocker shoe is designed to provide extreme forefoot relief by transferring the patient’s weight to the heel area. It can be used to facilitate wound healing for metatarsal and distal toe ulcers. (Hamm, p. 221)

Question 40

During weight bearing, initial compensation for fixed forefoot valgus is provided by:

1. rearfoot supination.
2. rearfoot pronation.
3. medial (internal) tibial rotation.
4. ankle dorsiflexion.

Answer 40

**1. **Excessive midtarsal or subtalar supination is the common compensation for forefoot valgus (p. 1146).
2. Rearfoot pronation is the compensatory motion for forefoot varus (p. 1146).
3. Medial (internal) tibial rotation is the compensatory motion for functional forefoot valgus (p. 328).
4. Increased ankle dorsiflexion would have no effect on the rotary component of forefoot varus or valgus. Primary motions of the talocrural joints are dorsiflexion and plantar flexion. The talocrural joint laterally (externally) rotates with supination and medially (internally) rotates with pronation. (pp. 1103-1105)

Question 41

A 3-month-old child has asymmetrical thigh folds, uneven knee heights, and asymmetrical hip abduction range of motion. The child MOST likely has which of the following conditions?

1. Osteochondritis dissecans
2. Legg-Calvé-Perthes disease
3. Slipped capital femoral epiphysis
4. Developmental dysplasia of the hip

Answer 41

1. Osteochondritis dissecans is characterized by localized necrosis of the subchondral bone and typically occurs in patients between the ages of 12 and 20 years (Palisano, p. 325).
2. Legg-Calvé-Perthes disease typically occurs in children between the ages of 4 and 8 years. The primary symptom is antalgic limping with hip abductor weakness. (Palisano, p. 320)
3. Slipped capital femoral epiphysis occurs in children ages 10-15 years. It is characterized by severe pain and restricted abduction and medial (internal) rotation. (Palisano, p. 323)
4. The child has classic signs of hip dysplasia, which are asymmetrical gluteal folds, asymmetrical knee height, and asymmetry of hip abduction range of motion (Palisano, p. 310; Tecklin).

Question 42

Which of the following hematological conditions is MOST likely to be found in a patient who has chronic kidney disease?

1. Anemia
2. Leukopenia
3. Neutropenia
4. Polycythemia

Answer 42

1. Anemia is a significant hematologic problem associated with chronic kidney disease due to decreased erythropoietin production, decreased red blood cell lifespan, and reduced iron absorption (Goodman, Pathology, p. 969; Goodman, Differential Diagnosis, pp. 214, 365).
2. Leukopenia is a reduction of leukocytes and can occur in many forms of bone marrow failure such as after chemotherapy or radiation or as a result of severe infections and autoimmune diseases. It is not associated with chronic kidney disease. (Goodman, Differential Diagnosis, pp. 217-218, 365)
3. Neutropenia can be congenital or acquired and is associated with decreased circulating neutrophiles. Acquired neutropenia may be caused by medications, infectious agents, and carcinomas (Goodman, Pathology, p. 720). Neutropenia is not associated with chronic kidney disease.
4. Polycythemia is a myeloproliferative disorder in which bone marrow stem cells produce excessive red blood cells. Decreased, not increased, red blood cell production is associated with chronic kidney disease. (Goodman, Differential Diagnosis, pp. 215, 365)

Question 43

Which of the following heart valves is being auscultated in the photograph?

1. Mitral
2. Aortic
3. Tricuspid
4. Pulmonary

Answer 43

1. The mitral valve is auscultated at the fifth intercostal space along the midclavicular line.
2. The aortic valve is auscultated at the second intercostal space, right sternal border.
3. The tricuspid valve is auscultated at the fourth intercostal space, left sternal border.
4. The pulmonary valve is auscultated at the second intercostal space, left sternal border

Question 44

The exercise shown in the photograph is MOST likely to be prescribed for a patient who has which of the following findings?

1. Decreased strength of the flexor carpi ulnaris
2. Decreased strength of the extensor carpi ulnaris
3. Diminished sensation in the lateral deltoid region
4. Diminished sensation in the palm and thumb, index finger, and middle finger (1st, 2nd, and 3rd digits)

Answer 44

1. The flexor carpi ulnaris muscle is innervated by the ulnar nerve (p. 86), not radial nerve, which is being stretched in the photograph.
2. The intervention in the photograph is a radial nerve stretch. A possible finding with a radial nerve mobility issue is decreased strength of the extensor carpi ulnaris muscle, which is innervated by this nerve. (p. 83)
3. Diminished sensation in the lateral deltoid region is indicative of an axillary nerve issue (p. 81), not an impairment of the radial nerve, which is being stretched in the photograph.
4. Decreased sensation in the palm and first three digits is indicative of median nerve involvement (p. 84), not impairment of the radial nerve, which is being stretched in the photograph.

Question 45

Which of the following research designs is LEAST valid and generalizable?

1. Small case series
2. Clinical case report
3. Clinical observation
4. Randomized controlled trial

Answer 45

1. Although data from small case series are very useful, subjects in these series are not randomly assigned to experimental and control groups, thereby limiting the generalizability of the data (pp. 314, 317).
2. Clinical case reports are nonexperimental. Findings from clinical case reports are not sufficient to conclude that a treatment approach is valid. (p. 317)
   **3. **Clinical observation is a preliminary step used to formulate a theory, which then can be used to design formal research (p. 310). Clinical observation is not as generalizable as a randomized controlled trial.
3. The research method that is best suited to determine efficacy is the randomized controlled trial, in which researchers control for a variety of factors that would interfere with an understanding of the impact of the treatment of interest (p. 49).

Question 46

A patient reports pain and swelling in the medial aspect of the elbow and tingling in the ring and little fingers (4th and 5th digits). Examination reveals a positive result on the elbow flexion test. The patient MOST likely has which of the following conditions?

1. C5 radiculopathy
2. Medial epicondylalgia
3. Cubital tunnel syndrome
4. Olecranon bursitis

Answer 46

1. A C5 radiculopathy can present with neurological symptoms from the superior aspect of the shoulder to the lateral aspect of the arm. The patient may also have decreased strength of the deltoid muscle with a potential loss of the brachioradialis reflex. (pp. 1282, 1288, 1313)
2. In medial epicondylalgia, pain will be in the anterior medial elbow region, there will be pain with pronation and wrist flexion, and there is no numbness or tingling (pp. 740-741, 760).
3. The symptoms described in the stem are classic signs of cubital tunnel syndrome, which is entrapment of the ulnar nerve. This condition results in symptoms of tingling in the ring and little fingers (4th and 5th digits). (p. 738)
4. Olecranon bursitis would likely cause pain and swelling in the posterior aspect of the elbow (p. 740)

Question 47

Manual muscle testing of a patient’s pelvic floor muscles reveals a grade of Poor (2/5). Which of the following positions is BEST to begin strengthening?

1. Supine
2. Standing
3. Seated
4. Walking

Answer 47

1. A grade of Poor (2/5) is defined as full excursion in a gravity-eliminated position. Supine position would be a gravity-eliminated position that is best to begin strength training.
2. Standing is an against-gravity position for the pelvic floor muscles and would not be optimal to begin strengthening given the extent of weakness.
3. Sitting is an against-gravity position for the pelvic floor muscles and would not be optimal to begin strengthening given the extent of weakness.
4. Walking is an against-gravity position for the pelvic floor muscles and would not be optimal to begin strengthening given the extent of weakness.

Question 48

Which of the following heart sounds heard in a 70-year-old adult MOST likely indicates ventricular failure?

1. S1
2. S2
3. S3
4. S4

Answer 48

1. S1 is a normal sound heard when mitral and tricuspid valves close.
2. S2 is a normal sound heard when aortic and pulmonic valves close.
3. S3 is normal in children and young adults, but is abnormal if heard in those over the age of 40 years. In patients who have heart failure, it is indicative of ventricular failure or lack of ventricular compliance.
4. S4 is an abnormal sound that may occur with cardiomyopathies and coarctation of the aorta but not with left ventricular failure.

Question 49

The patient who had a right cerebrovascular accident 3 days ago is preparing to perform a transfer. The patient’s posture while sitting on the edge of a bed is shown in the photograph. Which of the following interventions would MOST effectively address the impairment shown in the photograph?

1. Ask the patient to find midline and acknowledge success with the task.
2. Provide strengthening exercises for the lateral trunk musculature.
3. Verbally instruct the patient to correct the trunk posture to an erect position.
4. Bring the patient into the vertical position by applying manual pressure on the left side of the trunk.

Answer 49

1. The photograph depicts a patient who has pusher syndrome (ipsilateral pushing), which results from a perceptual problem with the somatosensory cortices. Finding midline, reaching across midline, and acknowledging success promotes relearning of the somatosensory system to begin to inherently correct to a vertical position.
2. The photograph depicts a patient who has pusher syndrome (ipsilateral pushing). Pusher syndrome (ipsilateral pushing) does not stem from a motor problem that could be addressed by strengthening.
3. The photograph depicts a patient who has pusher syndrome (ipsilateral pushing). Verbal instruction will not eliminate the problem because this does not provide the patient an opportunity to have a successful movement pattern to facilitate relearning of the somatosensory system.
4. The photograph depicts a patient who has pusher syndrome (ipsilateral pushing). The patient would resist the movement pattern described, because pusher syndrome (ipsilateral pushing) does not result from a motor problem.

Question 50

The test shown in the photograph is used to identify which of the following conditions?

1. Hip osteoarthritis
2. Iliopectineal bursitis
3. Acetabular labral tear
4. Femoral shaft stress fracture

Answer 50

1. The fulcrum test is not used to assess for hip osteoarthritis. The FABER (flexion, abduction, and lateral (external) rotation test), or Patrick test, would be more likely to elicit symptoms related to this condition.
2. The fulcrum test shown in the photograph is not used to identify iliopectineal bursitis. Resisted hip flexion and passive hip extension would be more likely to elicit symptoms related to this condition.
3. The fulcrum test shown in the photograph is not used to identify acetabular labral tears. The scour test would be used to test for this condition.
4. The test shown in the photograph is the fulcrum test, which is used to detect femoral shaft stress fractures. A positive test result is indicated by the patient’s report of pain or apprehension when pressure is applied.

Question 51

A patient who has generalized deconditioning is in physical therapy for a general exercise prescription to optimize function. The patient’s past medical history is significant for primary lymphedema in the right lower extremity. Which of the following exercise recommendations is the BEST low-risk option for the patient?

1. Jogging
2. Swimming
3. Tennis
4. Stair stepper

Answer 51

1. Jogging is among the activities considered to be associated with medium or higher risk for patients who have lymphedema, regardless of the pace (Goodman; Zuther).
2. Swimming is among the beneficial forms of exercise with low risk for patients who have lymphedema (Goodman; Zuther).
3. Tennis is considered a high-risk activity for patients who have lymphedema. Tennis involves ballistic movements of the upper and lower extremities. (Goodman)
4. Use of a stair-stepper machine is considered a higher risk activity that can exacerbate lymphedema (Goodman).

Question 52

Which of the following interventions would be MOST appropriate for a patient who has a positive sulcus sign?

1. Pectoral strengthening
2. Rotator cuff strengthening
3. Acromioclavicular joint mobilization
4. Sternoclavicular joint mobilization

Answer 52

1. Pectoral strengthening would not address the instability of the glenohumeral joint.
2. A positive sulcus sign is indicative of inferior glenohumeral instability (p. 645). Rotator cuff strengthening will increase the stability of the glenohumeral joint and the ability of the humeral head to stay in the glenoid fossa (pp. 669-672).
3. Acromioclavicular joint mobilization would not address the instability of the glenohumeral joint.
4. Joint mobilization of the sternoclavicular joint would not address the instability of the glenohumeral joint.

Question 53

Which of the following positions would be MOST appropriate for a patient who sustained burns to the axilla, elbow, and volar (palmar) surface of the hand?

1. Wrist in extension and digits in slight flexion
2. Elbow in slight flexion and forearm in supination
3. Shoulder in abduction and lateral (external) rotation
4. Shoulder in extension and lateral (external) rotation

Answer 53

1. The recommended functional position of the wrist is from neutral to 30° of extension, but the proximal and distal interphalangeal joints should be in extension while the metacarpals are in slight flexion.
2. The recommended position would be elbow extension and the forearm in supination or neutral position.
3. Shoulder abduction and lateral (external) rotation is the recommended position because it promotes stretching of the axillary region of the shoulder, which often becomes contracted following a burn.
4. Shoulder abduction and lateral (external) rotation would be a better position for this patient.

Question 54

A patient has an acute lumbar disc herniation and lumbar spondylolisthesis. Which of the following interventions is MOST appropriate?

1. Passive trunk extension
2. High-velocity manipulation
3. Active trunk flexion exercises
4. Spinal stabilization exercises

Answer 54

1. Although passive trunk extension is indicated for individuals who have an acute lesion and an extension bias (such as a herniated lumbar disc), trunk extension is contraindicated in spondylolisthesis (pp. 455, 462, 473).
2. High-velocity manipulation is contraindicated for patients who have a herniated disc, as well as for patients who have spondylolisthesis (pp. 464, 473).
3. Although trunk flexion is indicated for individuals who have spondylolisthesis, active trunk flexion is contraindicated for patients who have an acute disc lesion, such as a herniated disc (pp. 464-465, 473).
4. Spinal stabilization exercises are indicated to increase trunk stability for patients who have an acute herniated disc and for patients who have spondylolisthesis (pp. 465, 473).

Question 55

Radiographic imaging of a patient who has severe neck pain reveals bony growths in the intervertebral foramen between C2 and C3. Which of the following muscles would MOST likely be affected by this condition?

1. Diaphragm
2. Supraspinatus
3. Latissimus dorsi
4. Serratus anterior

Answer 55

1. The diaphragm is innervated by the phrenic nerve (C3–C5) (p. 172).
2. The supraspinatus is innervated by the suprascapular nerve (C5–C6) (p. 704).
3. The latissimus dorsi is innervated by the thoracodorsal nerve (C6–C8) (p. 700).
4. The serratus anterior is innervated by the long thoracic nerve (C5–C7) (p. 698).

Question 56

Which of the following tests is MOST appropriate to perform when assessing the effect of a child’s disability on the child’s caregivers?

1. School Functional Assessment
2. Pediatric Evaluation of Disability Inventory
3. Bruininks-Oseretsky Test of Motor Proficiency
4. Peabody Developmental Motor Scale

Answer 56

1. The School Functional Assessment is used to assess and monitor the performance of children in functional tasks and activities in elementary school social and academic settings. It does not have a section on caregivers’ need for assistance.
2. The Pediatric Evaluation of Disability Inventory (PEDI) is a 197-item inventory that is used to detect the functional limitations on participation of the patient and the need for assistance by the caregivers.
3. The Bruininks-Oseretsky Test of Motor Proficiency is a test of fine manual control, manual coordination, body coordination, strength, and agility. It does not have a section on caregivers’ need for assistance.
4. The Peabody Developmental Motor Scale can be used to assess changes in gross and fine motor skills and is appropriate for children up to age 5 years. It does not have a section on caregivers’ need for assistance.

Question 57

To improve sitting posture and lower extremity dressing ability for a patient who has tetraplegia, which of the following procedures would be MOST appropriate for a physical therapist to perform?

1. Stretch the lower trunk muscles and the hamstrings.
2. Allow the hamstrings and the lower trunk muscles to tighten.
3. Allow the hamstrings to tighten and stretch the lower trunk muscles.
4. Allow the lower trunk muscles to tighten and stretch the hamstrings.

Answer 57

1. Although the hamstrings must be sufficiently long to allow 100° of straight leg raise, individuals who have tetraplegia benefit from having tight lower trunk muscles to improve sitting stability.
2. Although individuals who have tetraplegia will benefit from tightness in the lower trunk muscles, the hamstrings must be sufficiently long to allow a 100° straight leg raise to improve the ability to sit in long sitting position and to dress the lower extremities.
3. Individuals with tetraplegia benefit from tightness of the lower trunk muscles to improve stability in sitting position. Hamstring length to allow 100° straight leg raise improves the ability to long sit and dress lower extremities.
4. Individuals who have tetraplegia benefit from having tight lower trunk muscles to improve stability in sitting position and hamstring length to allow 100° of straight leg raise to improve the ability to sit in long sitting position and to dress the lower extremities.

Question 58

In a patient who has glenohumeral joint effusion, which of the following patterns of motion loss is MOST likely to occur?

1. Maximal loss of lateral (external) rotation, moderate loss of abduction, and minimal loss of medial (internal) rotation
2. Maximal loss of lateral (external) rotation, moderate loss of medial (internal) rotation, and minimal loss of abduction
3. Maximal loss of medial (internal) rotation, moderate loss of abduction, and minimal loss of lateral (external) rotation
4. Maximal loss of medial (internal) rotation, moderate loss of lateral (external) rotation, and minimal loss of abduction

Answer 58

1. Joint effusion contributes to capsular pattern range of motion loss. In the glenohumeral joint, the capsular pattern of range of motion loss is maximum loss of lateral (external) rotation, moderate loss of abduction, and minimal loss of medial (internal) rotation.
2. A capsular pattern of loss is expected with joint effusion; therefore, abduction loss is expected to be worse than medial (internal) rotation loss.
3. A capsular pattern of loss is expected with joint effusion; therefore, lateral (external) rotation loss is expected to be worse than losses in medial (internal) rotation and abduction.
4. A capsular pattern of loss is expected with joint effusion; therefore, lateral (external) rotation and abduction losses are expected to be worse than medial (internal) rotation loss.

Question 59

A patient underwent surgical repair of a superior labrum tear in the shoulder 1 week ago. Which of the following resisted motions should be AVOIDED during physical examination of the patient?

1. Forearm pronation
2. Forearm supination
3. Scapular retraction
4. Scapular protraction

Answer 59

1. Forearm pronation is performed by the pronator teres. This muscle originates from the medial epicondyle of the humerus and attaches to the upper portion of the radius (Dutton, pp. 716-717). The pronator teres has no anatomical connection to the labrum at the shoulder. Therefore, resisted forearm pronation has no effect on the repaired labrum tear.
2. Resisted forearm supination is performed by active contraction of the biceps brachii and supinator muscles (Dutton, p. 718). The long head of the biceps brachii has firm attachments to the superior labrum of the shoulder (Dutton, p. 595). Resisted contraction of the biceps brachii during the first 3-6 weeks post surgery, when the labrum tear has not yet fully healed, can place excessive strain on the labrum and can cause severe damage to the repaired labrum. Therefore, resisted forearm supination should be avoided during the first 6 weeks, which is the time needed for proper healing of the labrum (Dutton, pp. 653-654).
3. Scapular retraction is performed by the middle trapezius, rhomboids, and lower trapezius muscles (Magee, pp. 272, 279). None of these muscles have any anatomical connections to the labrum at the glenohumeral joint. Therefore, resisted shoulder retraction has no effect on the repaired labrum tear at the shoulder joint.
4. Resisted scapular protraction occurs at the scapulothoracic joint and has no direct effect on the labrum within the glenohumeral joint (Magee, p. 272).

Question 60

A patient reports experiencing pain that is worse when stepping out of bed or after prolonged walking. The test shown in the photograph has a positive result. The patient MOST likely has which of the following conditions?

1. Metatarsalgia
2. Morton neuroma
3. Plantar fasciitis
4. Sever disease

Answer 60

1. Metatarsalgia is characterized by pain on the plantar surface of the foot, but pain is generally localized to the metatarsals and is predicted by compression force to the metatarsals (Dutton, p. 1166).
2. Morton neuroma is characterized by pain on the plantar surface of the foot, but pain is generally localized to the metatarsals and is predicted by compression force to the metatarsals (Dutton, pp. 1168-1169).
3. Plantar fasciitis is characterized by morning pain and pain with prolonged walking and is predicted by a positive result on the windlass test, which is shown in the photograph (Dutton, p. 1093; Magee).
4. Generally, Sever disease is characterized by pain in the heel and with a stretch of the posterior lower leg muscles (Dutton, p. 1583).

Question 61

The operative report for a patient who had a total hip arthroplasty includes reattachment of the greater trochanter with wire. Which of the following exercises is CONTRAINDICATED for the operative extremity during the acute phase of healing?

1. Active hip flexion to 80° in supine position with the knee flexed
2. Active hip abduction to 40° in sidelying position with the knee extended
3. Active assisted hip extension to neutral in sidelying position with the knee flexed
4. Active assisted hip adduction to neutral in supine position with the knee extended

Answer 61

1. Hip flexion up to 90° is permitted with total hip arthroplasty involving trochanteric osteotomy (p. 734). Active hip flexion within precautions is a common exercise in acute rehabilitation after total hip arthroplasty.
2. A transtrochanteric surgical approach for total hip arthroplasty involves osteotomy of the greater trochanter at the gluteus medius and minimus insertion, anterior capsulotomy and dislocation, and reattachment of the greater trochanter with wire. Abduction precautions are necessary while these structures heal (p. 730). After trochanteric osteotomy, no resisted abduction and no active isotonic hip abduction against gravity are allowed until the osteotomy has healed (p. 734).
3. Hip extension to neutral is permitted with a total hip arthroplasty involving trochanteric osteotomy (p. 734). Assistance to support the lower extremity is important to minimize active hip abduction in the sidelying position.
4. Hip adduction to neutral is permitted with total hip arthroplasty involving trochanteric osteotomy (p. 734). This hip movement is functionally important for sit-to-supine transfers.

Question 62

A patient reports pain, tingling, and paresis in the anterior chest, scapula, and lateral aspect of the forearm into the hand. Overhead activities aggravate the symptoms. In sitting position, the patient is assessed by extending and laterally (externally) rotating the shoulder, which causes a diminished radial pulse. The findings would be confirmed by a positive result on which of the following tests?

1. Roos
2. Clunk
3. Speed
4. O’Brien

Answer 62

1. Pain and paresthesias, especially with overhead activity, are consistent with thoracic outlet syndrome (Dutton). The special test described in the stem is the Adson test; the result indicates that the patient has thoracic outlet syndrome (Magee, p. 344). Roos test will rule in thoracic outlet syndrome (Magee, pp. 345-346).
2. The clunk test is performed to confirm a tear of the glenoid labrum (Magee, p. 299). The special test described in the stem is the Adson test; the result indicates that the patient has thoracic outlet syndrome (Dutton; Magee, p. 344).
3. The Speed test is performed to confirm biceps tendinitis or partial rupture of the tendon (Magee, p. 299). The special test described in the stem is the Adson test; the result indicates that the patient has thoracic outlet syndrome (Dutton; Magee, p. 344).
4. The O’Brien test is performed to identify superior labral tears or proximal biceps impairment (Magee, p. 299). The special test described in the stem is the Adson test; the result indicates that the patient has thoracic outlet syndrome (Dutton; Magee, p. 344).

Question 63

Which of the following skin findings is MOST consistent with a Stage 3 pressure injury?

1. Visibly exposed bone or tendon that is directly palpable
2. A shallow, open ulcer with a red wound bed without slough
3. Visible subcutaneous fat, but no visible bone or tendon
4. Purple-colored skin or the presence of a blood-filled blister

Answer 63

1. An exposed bone or tendon that is visible or directly palpable describes a Stage 4 pressure injury.
2. A shallow open ulcer with a red or pink wound bed without slough describes a Stage 2 pressure injury.
3. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed in a Stage 3 pressure injury. In this stage, there is full-thickness tissue loss. The bone/tendon is not visible or directly palpable.
4. A purple localized area of discolored intact skin or a blood-filled blister due to damage to the underlying soft tissue from pressure and/or shear describes a suspected deep tissue injury.

Question 64

A patient who has low back pain and a medical history of chronic obstructive pulmonary disease and heart failure has been referred for physical therapy. Which of the following interventions requires the MOST patient monitoring?

1. Aquatic therapy
2. Supine lumbar traction
3. Core strengthening
4. Lumbar soft-tissue mobilization

Answer 64

1. In patients who have heart failure, the concern is that the increase in cardiac volume that occurs during immersion may overwhelm the pumping ability of the heart (Cameron, pp. 345-346). Patients who have chronic obstructive pulmonary disease must be carefully monitored while immersed due to the additional respiratory challenge (Cameron, p. 346).
2. Contraindications for lumbar traction include spinal infection, rheumatoid arthritis, osteoporosis, and spinal cord pressure secondary to discal herniation. The only form of lumbar traction contraindicated for patients who have cardiac and pulmonary insufficiency is inverted traction. (Cameron, pp. 379-383)
3. Strengthening is not contraindicated for patients who have heart failure or chronic obstructive pulmonary disease (O’Sullivan, pp. 513, 566).
4. Massage therapy is not contraindicated for patients who have heart failure or chronic obstructive pulmonary disease (Behrens).

Question 65

A patient sustained a forced flexion injury to the middle finger (3rd digit) 1 day ago. The patient is unable to actively extend the PIP joint. The PIP joint can be fully extended passively and has a normal end-feel into extension. Which of the following structures is MOST likely injured?

1. Volar plate of the PIP joint
2. Tendon of the flexor digitorum profundus
3. Central tendon of the extensor digitorum
4. Terminal tendon of the extensor digitorum

Answer 65

1. Volar plate injuries result from a PIP extension force rather than a PIP flexion force, which was the mechanism of injury described in the stem. An injury to the volar plate would result in excessive passive PIP extension with an empty end-feel due to pain, swelling, and guarding.
2. Injury to the flexor digitorum profundus, which inserts into the volar aspect of the distal phalanx, would result in the inability to actively flex the DIP. There would be full passive extension of the DIP unless swelling or pain from the acute injury limited range of motion (empty end-feel).
3. The most likely injury is an injury to the central slip of the extensor digitorum (either an insertional avulsion fracture or pure tendon Injury). This injury results in the inability to actively extend the PIP joint due to loss of ability to generate extension force to the middle phalanx. Full passive extension of the PIP would remain intact in an acute injury unless swelling or pain from the acute injury limited range of motion (empty end-feel) or, in a chronic injury, where a flexion contracture of the PIP could develop.
4. A lesion of the terminal tendon, which inserts into the proximal portion of the distal phalanx, would result in the inability to actively extend the DIP.

Question 66

At the beginning of a running warm-up, a patient reports the onset of heartburn and difficulty swallowing. The patient denies shoulder pain or nausea. Which of the following conditions is the MOST likely cause of the symptoms?

1. Myocardial ischemia
2. Gastroesophageal reflux disease
3. Peptic ulcer disease
4. Cholelithiasis

Answer 66

1. Myocardial ischemia is the result of an acute coronary syndrome or the blockage of blood in the coronary arteries. It presents with chest pain that worsens with activity and refers to the shoulder, neck, and jaw. It is typically associated with nausea, sweating, and apprehension. (p. 871)
2. Heartburn is the principal symptom of gastroesophageal reflux disease. Other common symptoms can include difficult and painful swallowing. Gastroesophageal reflux disease is due to transient relaxation of the lower esophageal sphincter causing (acidic) gastric contents to flow back up into the esophagus and causing irritation to the mucosal lining and, hence epigastric pain. It can be exacerbated by ballistic activities, such as running, and although it can be associated with nausea, it is not associated with shoulder pain thus making this the most correct answer. (p. 871)
3. Peptic ulcer disease presents with epigastric pain and nausea or vomiting. Pain is not usually referred however occasionally, ulcer pain radiates to the midthoracic back and right upper quadrant, including the right shoulder (p. 878). Peptic ulcer disease is not always associated with an increase in activity.
4. Cholelithiasis presents with right upper quarter pain or epigastric pain and usually with nausea or vomiting (p. 871).

Question 67

Which of the following modifications can the physical therapist in the photograph perform that will MOST likely increase the amount of tension on the neural tract being tested?

1. Abduct and laterally (externally) rotate the hip.
2. Plantar flex the ankle of the raised leg.
3. Instruct the patient to flex the cervical spine.
4. Instruct the patient to extend the cervical spine.

Answer 67

1. The hip should be adducted and medially (internally) rotated to increase the neural tension (Magee).
2. Dorsiflexing the ankle of the raised leg will increase neural tension, and plantar flexion will decrease it (Magee).
3. Flexing the cervical spine will increase tension of the neural tract from above and likely provoke symptoms (Dutton).
4. Flexing the cervical spine will increase tension, while extending the cervical spine will release the tension in the neural tract, making symptom provocation highly unlikely (Dutton).

Question 68

A wound on a patient’s lower limb due to arterial insufficiency is MOST likely associated with which of the following characteristics?

1. Significant edema, palpable pedal pulses, and substantial drainage
2. Significant edema, palpable pedal pulses, and a shallow wound bed
3. Intermittent claudication, absent pedal pulses, and a deep wound bed
4. Intermittent claudication, absent pedal pulses, and substantial drainage

Answer 68

1. Significant drainage and edema are more characteristic of venous insufficiency.
2. Significant edema is more characteristic of venous insufficiency.
3. A wound due to arterial insufficiency is typically associated with intermittent claudication, absent pedal pulses, and a deep wound bed due to decreased oxygenated blood flow in the area or limb.
4. Significant drainage is more characteristic of venous insufficiency.

Question 69

A teenager with idiopathic scoliosis has been wearing a well-fitting thoracolumbar orthosis. Brace tolerance is good, but the patient stands with the trunk flexed forward on the lower extremities. This standing posture is MOST likely caused by which of the following conditions?

1. Excessive lumbar lordosis
2. Shortened hamstrings
3. Tight hip flexors
4. Leg length discrepancy

Answer 69

1. Excessive lumbar lordosis may be present, but it is not the cause of the problem. The orthosis would prevent lumbar lordosis. (p. 720)
2. Shortened hamstrings would contribute to flat back posture, not excessive trunk flexion (p. 718).
3. Tight hip flexors can cause trunk flexion because the orthosis prevents lumbar lordosis and anterior pelvic tilt from occurring (p. 720).
4. Leg length discrepancy would likely not cause forward trunk flexion in this patient; it causes lateral pelvic titling (p. 720).

Question 70

A patient has an acute onset of low back pain and left lower extremity pain. Further testing reveals left lower extremity pain reproduced at 40° with a straight leg raise test and an Achilles reflex of 1+. The patient MOST likely has which of the following conditions?

1. Lateral disc herniation
2. Large central disc herniation
3. Left lateral spinal stenosis
4. Right lumbar structural scoliosis

Answer 70

1. Disc herniations are associated with acute pain in the back and leg (unilaterally) (Magee, p. 560). Lower extremity symptoms elicited with straight leg raise testing are suggestive of a lateral disc herniation (Magee, p. 604).
2. A large central disc herniation would be more likely to reproduce pain in the back during the straight leg test. Lower extremity symptoms elicited with straight leg raise testing are suggestive of a lateral disc herniation. (Magee, p. 604).
3. Spinal stenosis is associated with an insidious, not acute, onset as well as bilateral, not unilateral, symptoms (Magee, p. 560).
4. Scoliosis is associated with insidious onset and would not be associated with a positive result for the straight leg test (Magee, p. 560).

Question 71

A patient is attempting to roll from supine to right sidelying position by reaching for and grasping the hospital bed rail. The patient is having difficulty executing the task due to weakness in the left upper extremity. Which of the following proprioceptive neuromuscular facilitation patterns for the left upper extremity would MOST effectively assist with rolling?

1. Shoulder flexion, adduction, and lateral (external) rotation
2. Shoulder extension, adduction, and medial (internal) rotation
3. Shoulder flexion, abduction, and lateral (external) rotation
4. Shoulder extension, abduction, and medial (internal) rotation

Answer 71

1. Shoulder flexion, adduction, and lateral (external) rotation (along with finger flexion within the pattern) would allow the patient to reach for the rail across the body and grasp the rail to pull to assist with rolling to sidelying position.
2. Shoulder extension, adduction, and medial (internal) rotation (along with finger flexion within the pattern) would direct the upper extremity across the body toward the hip, which would not direct the patient’s hand toward the rail to assist with rolling to sidelying position.
3. Shoulder flexion, abduction, and lateral (external) rotation (along with finger extension within the pattern) would not direct the upper extremity across the body and would not facilitate rolling to sidelying position and grasping the rail.
4. Shoulder extension, abduction, and medial (internal) rotation would move the upper extremity down by the posterior aspect of the hip, which would not assist with rolling from supine to sidelying position.

Question 72

An 80-year-old patient has a recent history of frequent falls when walking to the bathroom in the evening. The Clinical Test for Sensory Interaction in Balance reveals normal body sway with eyes open on firm and compliant surfaces and increased body sway with eyes closed and when wearing the visual-conflict dome. Which of the following modifications between the bedroom and the bathroom would be MOST appropriate?

1. Install a low-pile carpet.
2. Install a carpet with a mixed color pattern.
3. Place colored tape lines on the path.
4. Place nightlights​ along the path.

Answer 72

1. Even though the use of lower-pile carpet can be an appropriate home modification to prevent falls, there is no indication that this patient is falling because of an inability to navigate more compliant surfaces such as higher-pile carpet. The results of the Clinical Test for Sensory Interaction in Balance indicate normal body sway on compliant surfaces. (O’Sullivan, pp. 328, 388; Shumway-Cook, pp. 280-282)
2. Carpet with mixed-color patterns may be visually confusing and impair judgment of spatial distances (O’Sullivan, p. 328).
3. Even though placing colored tapes on the borders of stairs is considered an appropriate home modification for an individual who is visually impaired, placing tape lines along a level surface is more commonly used as a strategy to encourage larger stride lengths and would not be as effective as nightlights at night for an individual who is visually dependent for balance (O’Sullivan, pp. 329, 789).
4. Providing adequate lighting is an appropriate home modification to help prevent falls, especially for an individual who is visually dependent for balance, as evidenced by frequent night-time falls and supported by the results of the Clinical Test for Sensory Interaction in Balance (Johansson; O’Sullivan, p. 328; Shumway-Cook, pp. 280-282).