NPTE Practice Test #1 Flashcards

Question

A research team compares the effects of exercise mode (concentric and eccentric strengthening) on patients with chronic Achilles' tendinopathy. Measurements of disability and performance are collected at baseline, after 12 weeks of treatment, and at 1 year post-treatment. Which is the best statistical test to use to determine which exercise mode is best at decreasing disability over time?

Answer 1

Two-way ANOVA with repeated measures on one factor. The study has two independent variables (exercise mode and time). Exercise mode is a between-subjects (nonrepeated) factor with two levels (concentric and eccentric). Time is a within-subjects (repeated) factor with three levels (baseline, 12 weeks, and 1 year). The two-way ANOVA with repeated measures on one factor (also called a two-way mixed model ANOVA) is used to compare each factor independently (main effects) as well as the effect of one factor on the other (interaction effect). Incorrect Choices: The one-way ANOVA is used to compare a single independent variable (between subjects factor) with at least three levels. A repeated measures ANOVA is used to compare a single independent variable (within-subjects factor) with at least three levels. A two-way ANOVA with repeated measures on both factors is used to compare two independent variables that are both within-subjects factors (all participants are exposed to all levels of each independent variable). Each independent variable would have to have at least two levels in this case. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall research guidelines in order to arrive at a correct conclusion. This necessitates deductive reasoning skill, where factual recall of information guides conclusions. For this case, the best statistical test is the two-way ANOVA with repeated measures on one factor. If answered incorrectly, review statistical tests information. One-way analysis of variance (ANOVA). Repeated measures ANOVA. Two-way ANOVA with repeated measures on both factors.

Answer 2

Anterior cerebral artery syndrome. These signs and symptoms are characteristic of anterior cerebral artery (ACA) syndrome, with contralateral hemiplegia and lower extremities more affected than upper extremities. Incorrect Choices: Posterior cerebral artery (PCA) syndrome typically presents with visual impairments, pain, and involuntary movements. Contralateral hemiplegia may also be present, but lacks specific findings with regards to greater impact on the upper or lower extremities. Middle cerebral artery (MCA) syndrome results in contralateral hemiplegia with greater involvement of the upper extremities than lower. Internal carotid lesions typically involve a massive infarction in the areas of the brain supplied by the MCA and ACA, producing significant edema with possible uncal herniation, coma, and death. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the symptoms presented and determine the specific type of stroke syndrome. Questions that require one to determine a diagnosis based on symptoms often necessitate analytical reasoning skill. In this case, the symptoms are consistent with anterior cerebral artery syndrome. Review types of stroke if answered incorrectly. Posterior cerebral artery stroke. Internal carotid syndrome. Middle cerebral artery syndrome.

Answer 3

Ineffective cough for secretion clearance. Both the MIP and MEP findings indicate significant ventilator muscle weakness. The patient will have difficulty drawing air in and forcefully expelling it, which are two phases of an effective cough. Therefore, the patient will have difficulty clearing their secretions. See Tables 5-1 and 5-2 for normal values of MIP and MEP. Incorrect Choices: A patient with Guillain-Barré syndrome will present as if they have a restrictive lung disease. The patient will have decreased costal expansion, but it will be symmetrical. Both increased I:E ratio and subcostal angle are findings consistent with someone with obstructive lung disease and lung hyperinflation, not restrictive lung disease. Type of Reasoning: ANALYTICAL This question provides pulmonary findings and the test-taker must determine the expected finding on examination. One must weigh the information presented to draw a reasonable conclusion, necessitates analytical reasoning skill. For this case, the MIP and MEP findings indicate ineffective cough for secretion clearance. If answered incorrectly review pulmonary guidelines, especially MIP and MEP if answered incorrectly. Asymmetrical decreased costal expansion. Increased inspiration: expiration (I:E) ratio. Increased subcostal angle.

Answer 4

A platelet count of 20,000. A patient with a platelet count of 20,000 is at increased risk for bleeding. Percussion may cause microtraumas and increased bleeding risk. Incorrect Choices: While dyspnea in Trendelenburg is uncomfortable, the position could be modified so that percussion and vibration can be completed. While an SaO2 range of 88% to 94% on room air is a consideration, it would not preclude this intervention. This should be monitored closely while considered positions maximize ventilation and perfusion. While this patient will require assistance for positioning, it doesn’t eliminate this treatment intervention. Pneumonia is an indication for manual airway clearance techniques. The therapist will need to complete the techniques in multiple postural drainage positions to optimize efficiency. Type of Reasoning: INDUCTIVE This question requires the test-taker to utilize clinical judgment in order to determine a best course of action. This requires inductive reasoning skill. In this case, a platelet count of 20,000 would curtail selection of the specific intervention approach. Review indications and contraindications for airway clearance techniques if answered incorrectly. Dyspnea when in the Trendelenburg position. SaO2 range of 88% to 94% on room air. Diagnosis of multilobe pneumonia.

Answer 5

Hip flexion, abduction, and internal rotation. The capsular pattern of the hip is limitation of flexion/internal rotation with some limitation of abduction. Additionally, according to the Hip Pain/Hip Osteoarthritis Clinical Practice Guideline (see Box 2-1), hip IR or flexion that is 15° less than the nonpainful side is strongly associated with hip OA. Incorrect Choices: The other patterns are not representative capsular patterns of the hip. Type of Reasoning: INFERENTIAL One must recall the capsular patterns of the hip in order to determine what is likely to be true for the patient in this question. This requires inferential reasoning skill, where one utilizes knowledge to determine likely symptoms or presentation of problems. In this case, the patient would likely show limitations in hip flexion, abduction, and internal rotation. Review capsular patterns of the hip if answered incorrectly. Hip flexion, adduction, and internal rotation. Hip extension, abduction, and external rotation. Hip flexion, abduction, and external rotation.

Answer 6

Myopathy. Myopathy typically impacts proximal muscles to a greater extent than distal muscles. Cholesterol lowering drugs (statins) are a risk factor for the development of myopathy. Incorrect Choices: Guillain-Barré syndrome (GBS) typically follows a respiratory illness or vaccination and causes rapid demyelination of multiple peripheral nerves resulting in rapid and acute proximal to distal weakness. Although myasthenia gravis causes fatigue and ultimately weakness in multiple muscles in the bilateral upper and lower extremities, it also presents with mild ptosis and involvement of ocular and/or oropharyngeal muscles. Amyotrophic lateral sclerosis may also cause fatigue/weakness, but it typically presents with asymmetric weakness and is defined by both lower and upper motor neuron involvement. Type of Reasoning: ANALYTICAL This question provides a group of symptoms and the test-taker must determine the most likely condition. This necessitates analytical reasoning skill, where information is analyzed to determine its meaning and significance, then draw a reasonable conclusion. For this case, the symptoms are consistent with myopathy. If answered incorrectly, review information on myopathy, especially signs and symptoms. Guillain-Barré syndrome. Myasthenia gravis. Amyotrophic lateral sclerosis.

Answer 7

Walking poles. Walking poles would provide immediate bilateral sensory feedback to assist in postural stability. It would also allow the patient to walk with a natural stride and upright posture. Incorrect Choices: A standard walker and bilateral ankle foot orthoses are too restrictive and would not adapt to unlevel surfaces. A standard cane is an option but would only provide unilateral sensory feedback and not promote upright posture. Type of Reasoning: Inductive Standard walker. Bilateral ankle foot orthoses. Single point cane.

Answer 8

The most recent pulmonary function test results. Recent pulmonary function test results will give the therapist information regarding the severity of the lung disease. This information will assist in determining how much the patient will progress. Incorrect Choices: While the current medication list will help determine how the patient is currently being managed, it doesn’t give any information about his or her function. The previous history of the disease will not translate well into what the patient’s function has been. It is possible that he or she has been quite functional despite terrible disease such that an acute exacerbation with little reserve will leave him or her quite limited. An acute asthma exacerbation will likely not appear on a chest x-ray, nor would chronic disease. Type of Reasoning: INDUCTIVE One must utilize clinical judgment in order to determine the most important information about a patient with asthma. Questions of this nature, where clinical judgment and knowledge are applied to patient cases, often necessitate inductive reasoning skill. For this situation, the most important information is the most recent pulmonary function test results. If answered incorrectly, review pulmonary rehab, including pulmonary testing information. A current medication list. A previous history of the disease. The most recent chest x-ray results.

Answer 9

Increased knee flexion resistance. Prosthetic causes of circumduction include a long prosthesis, locked knee unit, inadequate knee flexion, inadequate suspension, small or loose socket, and plantar flexed foot. Incorrect Choices: An unstable knee unit will cause forward flexion during stance. Inadequate socket flexion will result in lordosis during stance. A high medial wall or abducted hip joint will result in an abducted gait. Type of Reasoning: INFERENTIAL For this question, one must determine the reason for a specific gait deviation in order to arrive at a correct conclusion. One must apply knowledge of prosthetics in order to infer the most likely reason, which necessitates inferential reasoning skill. For this situation, the most likely cause is increased knee flexion resistance, which will not allow adequate knee flexion during swing phase. Review lower extremity prosthetics information if answered incorrectly. Unstable knee unit. Inadequate socket flexion. High medial wall or abducted hip joint.

Answer 10

Decreased or no breath sounds. The fractured ribs will cause the patient to have pain and therefore not take deep breaths. More importantly, the pneumothorax will cause an increasing positive pressure on the lung, not allowing it to inflate. The result will be minimal air movement and decreased or absent breath sounds. Incorrect Choices: Soft, rustling sounds are normal, vesicular breath sounds. These would not be present with these injuries. Crackles would indicate atelectasis or secretions, but it would not be possible to hear these sounds with these injuries because there is minimal air movement. Likewise, wheezes wouldn’t be possible to hear. Type of Reasoning: DEDUCTIVE One must recall the auscultation sounds with a pneumothorax in order to arrive at a correct conclusion. This necessitates the recall of factual information, which is a deductive reasoning skill. For this case, one would expect to hear decreased or no breath sounds. Review auscultation guidelines, especially with pneumothorax, if answered incorrectly. Soft, rustling sounds on inhalation. Crackles. Wheezes.

Answer 11

Decreased bone density. In addition to production of a thick and sticky mucus that blocks the airways, patients with CF also produce a thick mucus that can block the common bile duct leading to malabsorption of nutrients and resulting in decreased bone density. A resisted exercise program can assist with reversing the effects of the disease process. Incorrect Choices: CF primarily affects the respiratory and digestive systems. There is no evidence that carpal tunnel syndrome or other peripheral neuropathies are a common complication of cystic fibrosis. Patients with cystic fibrosis may present with polyarthralgias (joint swelling and stiffness) and joint contractures, but a strength training program would not be the best intervention to address these impairments. Type of Reasoning: INDUCTIVE For this question, the test-taker must recall the complications of cystic fibrosis and then prioritize which complication is most important to combat with a resistance training program. This necessitates clinical judgment and knowledge, which is an inductive reasoning skill. For this case, decreased bone density is most important. Review information on cystic fibrosis, especially musculoskeletal complications, if answered incorrectly. Carpal tunnel syndrome. Polyarthralgia. Joint contractures.

Answer 12

Lateral malleolus. The typical location of an arterial ulcer is the distal lower leg (toes, foot), the lateral malleolus, or the anterior tibial area. Incorrect Choices: The typical location of a venous ulcer is the distal lower leg and the medial malleolus. Type of Reasoning: INFERENTIAL One must determine what is likely to be true of a situation in order to arrive at a correct conclusion for this question. This necessitates inferential reasoning skill. The test-taker must utilize knowledge of arterial ulcers to determine what is likely to be true. In this case, the typical location of an arterial ulcer is on the lateral malleolus. Review information on arterial ulcers if answered incorrectly. Medial malleolus. Posterior tibial area. Medial distal tibia.

Answer 13

Sacroiliac joints. The sacroiliac (SI) joints are most often affected in pregnancy, resulting in pain. Incorrect Choices: The other joints are not typically affected. Low back pain is common in pregnancy, largely resulting from the physical changes (added weight, poor muscle tone, increased lordosis, loose pelvic ligaments). Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the typical joints that are affected by pregnancy and may result in pain in order to arrive at a correct conclusion. This necessitates the recall of factual information, which is a deductive reasoning skill. For this scenario, the sacroiliac joints are typically affected by pregnancy. Review pregnancy and common physical changes if answered incorrectly. Glenohumeral joints. Hip joints. Lumbrosacral joints.

Answer 14

Starting at the proximal portion of the limb and working distally to move the lymph toward the thoracic duct. Manual lymphatic drainage is a component of a CDT plan for patients with lymphedema. Because of the very low forces present in the lymph system, lymph load in proximal areas must be relieved prior to progressing to areas where lymphedema is present. This proximal to distal approach maximizes any benefits that may occur from this treatment technique. Additionally, the anatomy of the lymph system requires movement of lower extremity lymph toward the thoracic duct. Only right upper quarter lymph would be directed toward the right lymphatic duct. Incorrect Choices: Intermittent pneumatic compression may be a treatment alternative when care is utilized to avoid damaging the lymph system by using low pressure, sequential compression. Additionally, the practice is limited to use in the upper extremity due to the unacceptable risk of causing genital lymphedema if performed in the lower extremity. Deep tissue friction massage is not indicated in patients with lymphedema. Aggressive manipulation of the integument may cause damage to lymphatic structures. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the symptoms presented in order to determine the most likely diagnosis. This requires analytical reasoning skill, where pieces of information are analyzed in order to draw a logical conclusion. In this situation, the symptoms are indicative of secondary lymphedema. Review secondary lymphedema if answered incorrectly. Starting at the distal portion of the limb and working proximally to move the lymph toward the right lymphatic duct. Following application of intermittent pneumatic compression to the right lower extremity. By performing deep tissue friction massage for several minutes on fibrotic areas prior to CDT.

Answer 15

Displace the rear axle forward for more efficient arm push. This patient is obese. A bariatric wheelchair with heavy-duty, extra-wide wheels is necessary. The rear axle is displaced forward compared to the standard wheelchair to allow for more efficient arm push. Incorrect Choices: Moving the front casters closer to the drive wheels would decrease stability (not increase). Friction rims and antitipping devices are adjustments that may be necessary for the patient with a spinal cord injury. Type of Reasoning: INDUCTIVE For this question, one must utilize knowledge of wheelchair prescription for patients with obesity in order to arrive at a correct conclusion. Clinical judgment coupled with knowledge of wheelchair prescription guidelines are required, which necessitates inductive reasoning skill. For this case, the therapist should recommend a wheelchair in which the rear axle is displaced forward for more efficient arm push. Review wheelchair prescription guidelines, especially for patient with obesity, if answered incorrectly. Move the small front casters closer to the drive wheels to increase stability. Add friction rims to increase handgrip function. Add an antitipping device to prevent falls going up curbs.

Answer 16

Prone, with a pillow under the hips and the bed flat. Prone with a pillow under the hips and the bed flat will raise the posterior basal segments up to facilitate drainage. This is an acceptable modified position for drainage of the posterior basal segment of the left lower lobe. Incorrect Choices: The side-lying position with the bed flat will drain the lingula more than the posterior basal segments. With the bed elevated in side-lying, the pillow position is just for comfort but will not facilitate drainage. Raising the bed up will cause drainage to go toward the base of the lungs, which would not be effective. If the head of the bed is elevated up in prone, drainage will also be more difficult. Type of Reasoning: DEDUCTIVE One must recall the proper positions for posterior basal segment drainage of the left lower lobe in order to arrive at a correct conclusion. This requires recall of facts and guidelines, which is a deductive reasoning skill. In this case, the therapist should position the patient in prone, with a pillow under the hips and the bed flat. Review postural drainage techniques if answered incorrectly. Side-lying on the right, with a pillow under the right hip and the bed flat. Side-lying on the right, with a pillow between the legs and the foot of the bed elevated 18 inches. Prone, with a pillow under the hips and the head of the bed elevated 18 inches.

Answer 17

- Stage I: skin is intact but red - Stage II: blister - Stage III: can see muscle - Stage IV: can see bone and tendons

Answer 18

Anterolateral rotary instability or ALRI. The pivot shift test is used to determine the presence of a rotary component to anterior knee instability. The Lachman’s test and anterior drawer test measure straight plane anterior instability. The pivot shift test provides additional information about the lateral stabilizers of the knee, such as the capsule and anterolateral ligament. The Slocum test is also used to identify ALRI. There is a modified pivot shift test used for the examination of suspected meniscal tears. See Box 2-5 for the Knee Ligament Sprains Clinical Practice Guideline. Incorrect Choices: A patellar tendon rupture is determined by observation and palpation of a defect in the tendon between the patella and tibial tuberosity. The mechanism of injury is a sudden eccentric loading contraction of the quadriceps femoris muscle, such as when landing from a jump or fall. Special tests used to assess the PCL or posterior instability of the knee include the posterior drawer and quad active test. Hyperextension or a dashboard injury are common mechanisms of injury for the PCL. Type of Reasoning: DEDUCTIVE This question requires the test-taker to recall the utility of the pivot shift test. This necessitates the recall of factual guidelines, which is a deductive reasoning skill. For this case, the test is used to determine the presence of anterolateral rotary instability or ALRI. If answered incorrectly, review the pivot shift test. Patellar tendon rupture. Posterior instability. Anteromedial instability or AMRI.

Answer 19

Dorsal translation of the metacarpal on the trapezium. The carpometacarpal joint of the thumb is considered a saddle joint in which the articular surface geometry is generally concave in one plane and convex in a plane perpendicular to the other. The proximal joint surface of the first metacarpal is generally convex in the palmar to dorsal direction and concave in the medial to lateral direction. The articular surface of the base of the first metacarpal typically presents as the convex member of this joint when movement occurs in palmar abduction. Thumb palmar abduction thus involves a convex metacarpal surface moving on the concave surface of the trapezium. Following the traditional concave/convex rules of motion, one would expect a combination of palmar roll and dorsal translatory motion of the metacarpal on the trapezium during palmar abduction. In this case, a therapist would be sure to evaluate dorsal glide of the metacarpal on the trapezium. Incorrect Choices: The other examples of joint play motion are not congruent with palmar abduction of the thumb. Type of Reasoning: DEDUCTIVE For this question, one must recall the translatory joint play motion of the CMC joint of the thumb in order to arrive at a correct conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, the expected motion is dorsal translation of the metacarpal on the trapezium. Review joint play of the CMC joint of the thumb if answered incorrectly. Palmar translation of the metacarpal on the trapezium. Ulnar translation of the metacarpal on the trapezium. Radial translation of the metacarpal on the trapezium.

Answer 20

Arrested growth. Supracondylar fractures are the most common pediatric elbow fracture, occurring most commonly between 3 and 10 years of age. Extension fractures account for about 95% of supracondylar fractures. The mechanism of injury is a fall on an outstretched hand with elbow hyperextended.Type IV is a fracture through all three elements of the bone: the growth plate, metaphysis, and epiphysis (10% incidence). Type IV growth plate fractures start above the growth plate, cross the growth plate, and exit through the joint cartilage. These injuries can affect the joint cartilage and may impair normal growth. See Table 2-31 for a review of Salter-Harris fracture classifications. Incorrect Choices: Nonunion of pediatric fractures is a rare complication. However, in one study of nonunion fractures, 47% were about the elbow, with most of the nonunions at the lateral condyle. Refractures of the forearm have an incidence of about 5%. Overall, the incidence of supracondylar-associated neurovascular injury is 12% and increases with displacement to between 19% and 49%. Excessive swelling and ecchymosis are a significant risk factor for compartment syndrome, and a thorough neurovascular exam should be performed and should focus on the brachial artery as well as the median and radial nerves. Type of Reasoning: INFERENTIAL This question requires the test-taker to determine the most likely consequence of a Salter-Harris type IV supracondylar humeral epiphyseal fracture. This requires knowledge of the Salter-Harris classification system in order to determine the most likely outcome. For this scenario, the most likely outcome is arrested growth. Review Salter-Harris fractures if answered incorrectly. Refracture at a future time. Nonunion. Severing of the radial nerve.

Answer 21

Hamstrings are fully ranged to 110 degrees in supine. Hamstrings need to be fully ranged to 110 degrees in the supine position. This allows for function in the longsitting position (e.g., dressing, leg management during transfers). Incorrect Choices: Ranging the hamstrings or low back extensors in long sitting will result in overstretched low back extensors (needed for stability in sitting). The long finger flexors are ranged into full extension with wrist flexion (not wrist extension). This allows the hand to be used functionally for tenodesis grasp. Type of Reasoning: INDUCTIVE One must utilize knowledge of spinal cord injury and selective stretching techniques in order to arrive at a correct conclusion. This necessitates clinical judgment, which is an inductive reasoning skill. In this case, the intervention that best demonstrates this is when the hamstrings are fully ranged to 110 degrees in supine. Review stretching techniques for spinal cord injury if answered incorrectly. Long finger flexors are fully ranged into extension with wrist extension. Low back extensors are fully ranged in longsitting. Hamstrings are fully ranged in longsitting.

Answer 22

Refer the patient to their primary care physician with possible pancreatitis. This question describes a patient with acute pancreatitis, likely due to taking excessive amounts of acetaminophen. The maximum daily dosage of acetaminophen is 3,000 mg. Drug toxicity can bring on an acute attack of pancreatitis. In addition to those described in the question stem, common clinical findings include epigastric pain radiating to the back; nausea, vomiting, and diarrhea; fever and sweating; tachycardia; malaise; bluish discoloration of the abdomen or flanks (called Cullen’s sign); and jaundice. Incorrect Choices: Nephrolithiasis, or kidney stones, have a different clinical presentation than what is described here. Pain typically occurs in the low back or under the lower ribs and radiates into the abdomen and groin. Painful urination, a persistent need to urinate, and cloudy or foul-smelling urine are all common symptoms of a kidney stone. Cryotherapy is an intervention that would be appropriate if the patient had back pain due to some type of musculoskeletal injury or dysfunction. Choice 4 fails to consider the patient’s gastrointestinal symptoms and the possibility that the excessive dosage of acetaminophen might have contributed to the current complaints. Type of Reasoning: EVALUATIVE For this question, one must determine a best course of action based on presenting patient symptoms. This necessitates evaluative reasoning skill, where information is weighed to determine the significance. For this situation, the therapist should refer the patient to their primary care physician for possible pancreatitis. If answered incorrectly, review signs and symptoms of pancreatitis. Refer the patient to their primary care physician with possible nephrolithiasis. Treat the patient with cryotherapy for pain relief and instruct the patient in a core strengthening program. Instruct the patient to rest and continue to take acetaminophen as needed for their pain.

Answer 23

Use of high-frequency chest wall oscillation. High chest wall oscillations (HFCWO) via a device such as the Vest Airway Clearance System allow for control of inspiratory and expiratory flow rates. The device can be used in any position regardless of the patient’s cognitive status. Incorrect Choices: The first two choices require a patient to consistently follow commands and potentially complete the activity alone, which would be difficult for a patient in this cognitive stage of recovery. Oscillatory positive expiratory pressure (PEP) using a FLUTTER device requires a patient to breathe through a mouthpiece with inspiration unimpeded and long exhalation against a back pressure, also impossible for this patient. Type of Reasoning: INDUCTIVE For this question, one must determine a best course of action for airway clearance, based on knowledge of effective airway clearance approaches. This necessitates inductive reasoning skill, where clinical judgment is paramount to arriving at a correct conclusion. For this situation, the best mode of airway clearance is high-frequency chest wall oscillation. Review airway clearance approaches if answered incorrectly. Active cycle of breathing. Autogenic drainage. Use of the FLUTTER device.

Answer 24

Increased skin temperature over long bones. Increased skin temperature over affected long bones is a common finding in individuals with Paget’s disease, a focal inflammatory condition that produces disordered bone remodeling. There is increased vascularity associated with the bone remodeling, leading to the increased skin temperature in affected areas. The bones that are most commonly involved are the pelvis, skull, femur, tibia, spine, shoulders, and ribs. Incorrect Choices: Pain, redness and swelling of the 1st metatarsal joint is a hallmark finding of gout. The combination of tachycardia, hyperreflexia, and decreased muscle strength is characteristic of Graves’ disease or hyperthyroidism. Kyphosis and easy bruising are common findings in Cushing’s syndrome, along with the telltale “moon face” and buffalo hump appearance of individuals with the disorder. Type of Reasoning: INFERENTIAL For this question, a diagnosis is provided and the test-taker must determine the likely symptoms consistent with this diagnosis. This requires inferential reasoning skill, where one infers or determines what is likely to be true of a situation. For this case, symptoms of increased skin temperature over long bones would corroborate a diagnosis of Paget’s disease. If answered incorrectly, review symptoms of Paget’s disease. Pain, redness and swelling of the 1st metatarsal joint. Tachycardia, hyperreflexia and decreased muscle strength. Kyphosis and easy bruising.

Answer 25

Crossed straight leg raise. This question requires knowledge of lumbar spine musculoskeletal special tests along with the application of their established sensitivity and specificity values. The crossed straight leg raise (SLR) is considered to be a highly specific test, which when positive helps to rule in the diagnosis of a herniated nucleus pulposus or lumbosacral radiculopathy. See Table 2-21 for a summary of the diagnostic accuracy of lumbar spine and pelvis special tests. Incorrect Choices: The SLR (Lasegue’s) test is a highly sensitive test and is therefore helpful in ruling out a lumbosacral radiculopathy when negative. The SLR test is an integral part of a comprehensive physical examination of a patient with LBP, but given its poor specificity, it is not helpful for ruling in a lumbar radiculopathy. The prone instability test is clinically useful for assessing lumbar spine instability. The femoral nerve traction test is helpful for assessing neurological dysfunction involving the femoral nerve and/or lumbar nerve roots L2–L4. Type of Reasoning: ANALYTICAL For this case, the test-taker must evaluate the symptoms presented and determine the special test that will rule in a diagnosis. This necessitates analytical reasoning skill, where symptoms are analyzed to draw reasonable conclusions. For this scenario, the therapist should conduct a crossed straight leg raise to rule in lumbosacral radiculopathy. If answered incorrectly, review information on special testing for lumbosacral radiculopathy. Straight leg raise. Prone instability test. Femoral nerve traction test.

Answer 26

Magnetic resonance imaging (MRI). MRI is highly sensitive for detecting MS plaques in the white matter of the brain and spinal cord. Lesions are seen as areas of increased signal intensity (bright spots). Contrast-enhanced scans are used for more long-term disease activity. Incorrect Choices: All other choices of diagnostic imaging techniques do not offer the same sensitivity and specificity for detecting plaques. Type of Reasoning: DEDUCTIVE One must recall the most effective diagnostic tool for MS in order to arrive at a correct conclusion. This requires the recall of factual information, which is a deductive reasoning skill. For this scenario, the most effective test is magnetic resonance imaging (MRI). Review diagnostic imaging techniques, especially for MS, if answered incorrectly. Positron emission tomography (PET). Computed tomography (CT). Transcranial sonography.

Answer 27

Scalenes. The phrenic nerve arises from the neck (C3–5) and innervates the diaphragm. The diaphragm is responsible for 45% of the air that enters the lungs during quiet breathing. During quiet breathing, the predominant muscle of respiration is the diaphragm. As it contracts, pleural pressure drops, which lowers the alveolar pressure and draws in air down the pressure gradient from mouth to alveoli. Expiration during quiet breathing is predominantly a passive phenomenon; as the respiratory muscles relax, the elastic lung and chest wall return passively to their resting volume. With paralysis of the diaphragm, the accessory muscles of respiration should be strengthened. These include the scalenes and sternocleidomastoid. Incorrect Choices: During active expiration, the most important muscles are those of the abdominal wall (including the rectus abdominis, internal and external obliques, and transversus abdominis), which drive intra-abdominal pressure up when they contract and thus push up the diaphragm, raising pleural pressure, which raises alveolar pressure, which in turn drives air out. These muscles do not substitute for diaphragmatic function. Type of Reasoning: INDUCTIVE One must utilize knowledge of accessory muscles of respiration in order to arrive at a correct conclusion. Based on this knowledge, one can determine the best muscles to focus on for intervention, which is an inductive reasoning skill. In this case, the scalenes should be the focus. Review accessory muscles for respiration if answered incorrectly. Tranversus abdominis. Internal obliques. External obliques.

Answer 28

Rhythmic stabilization during holding in kneeling. Rhythmic stabilization is a proprioceptive neuromuscular facilitation (PNF) technique designed to improve stability. The high kneeling position is a good choice to begin with for the patient with pronounced ataxia. The posture is upright; while the center of mass (COM) is lowered, the degrees of freedom are reduced by kneeling (foot and ankle control not required), and the base of support (BOS) is increased over standing. Incorrect Choices: Splinting and touch-down support are compensatory interventions not likely to improve recovery. Perturbed balance activities are contraindicated for the patient with poor postural stability and pronounced ataxia. Stabilizing reversals in side-lying are also not indicated, as the side-lying position does not require upright control. Type of Reasoning: INDUCTIVE One must utilize clinical judgment in order to determine the best intervention approach for this client. This necessitates inductive reasoning skill. For this scenario, the therapist should choose rhythmic stabilization during holding in kneeling to improve stability. Review intervention approaches for stability, especially rhythmic stabilization, if answered incorrectly. Lower extremity splinting and light touch-down hand support. Perturbed balance activities while standing on carpet. Stabilizing reversals during holding in side-lying.

Answer 29

Do not perform the treatment since it is contraindicated. All applications of electrical stimulation are contraindicated in the presence of a pacemaker. Consultation with the referring physician is necessary. Incorrect Choices: All other options resulting in the administration of electrical stimulation near or through a pacemaker are contraindicated. Type of Reasoning: EVALUATIVE This question requires the test-taker to weigh the potential courses of action and determine which response will have the most beneficial outcome. This necessitates evaluative reasoning skill. For this scenario, the therapist should not perform the electrical stimulation and should instead consult with the physician about alternative forms of therapy. Review contraindications for electrical stimulation if answered incorrectly. Perform the treatment since there is no contraindication. Refer the patient to another physical therapist who has greater expertise in using electrical modalities for patients with pacemakers. Administer the treatment with a waveform that does not penetrate as deep as interferential current.

Answer 30

Gait training with a cane to ensure safety. The first priority of the home physical therapist should be gait training with a cane to ensure safety. This compensatory strategy is necessary as this patient is demonstrating complications of diabetes, which are chronic and progressive. Incorrect Choices: Color-coding steps and installing nightlights may also be necessary compensatory strategies to modify the home environment. However, they are not the first priority. Ambulation practice without a cane will not ensure the safety of this patient. Type of Reasoning: INDUCTIVE This question requires clinical judgment in order to determine a best course of action for an elderly patient with a history of falls. This necessitates inductive reasoning skill coupled with knowledge of effective approaches for home safety and fall prevention. For this scenario, the therapist should focus on gait training with a cane to ensure safety. Review fall prevention and home safety guidelines if answered incorrectly. Color-coding raised surfaces, such as steps, with a sharp color contrast. Ambulation practice on changing floor to carpet surfaces in the home. Installing nightlights in strategic areas throughout the house and keeping them lit continuously.

Answer 31

Stabilize the patient and contact medical services immediately. This patient is exhibiting signs and symptoms of pulmonary embolism. This is an emergency medical situation and a cause of death in a substantial number of patients. Incorrect Choices: All other choices do not address the life-threatening and emergency nature of this situation. Type of Reasoning: EVALUATIVE For this question, one must determine the best course of action by weighing the options presented. This requires analysis of the symptoms in order to determine the severity of the situation to reach a sound conclusion, which is an evaluative reasoning skill. In this case, the therapist should stabilize the patient and contact medical services immediately. Review emergency procedures for pulmonary embolism if answered incorrectly. Return the patient to supine and monitor vital signs for the next 5 minutes. Allow the patient to rest for a few minutes and continue with the therapy session. Return the patient to supine and reschedule the therapy session for later in the afternoon.

Answer 32

Coma Recovery Scale-Revised. The Coma Recovery Scale-Revised examines multiple domains (auditory, visual, motor, verbal, communication, and arousal) of consciousness and function to include brain stem reflexes (pupillary light reflex, corneal reflex, spontaneous eye movements, oculocephalic reflex, and postural responses). It is recommended for use in multiple settings (acute care, inpatient/outpatient rehabilitation, long-term acute care/skilled nursing) and patients with various health conditions (TBI, stroke, brain tumor) that result in altered levels of consciousness. Incorrect Choices: The Glasgow Coma Scale (GCS) is typically used to assess acute concussions/TBIs, but is limited to assessing eye, verbal, and motor responses (see Table 3-14). The Rancho Los Amigos Levels of Cognitive Functioning (LOCF) is recommended for various settings and is used to delineate eight levels of cognitive and behavioral function in patients recovering from with moderate to severe TBI (See Table 3-15). Although commonly used, the GCS and Rancho Los Amigos LOCF do not specifically include assessment of brain stem reflexes. The Glasgow Outcome Scale-Extended is a structured interview that does not include physical examination items. It is most often used in research studies to classify global functional outcome states (death, vegetative, moderate/severe disability) for patients who have experienced a TBI. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the examination requirements presented and determine which formalized examination best meets these parameters. This requires analytical reasoning skill. For this case, the Coma Recovery Scale-Revised provides the needed measures of consciousness and formalized examination of brainstem reflexes. Review assessments for TBI, especially coma recovery and the Coma Recovery Scale-Revised, if answered incorrectly. Glasgow Coma Scale. Rancho Los Amigos Levels of Cognitive Functioning. Glasgow Outcome Scale-Extended.

Answer 33

The Mini-BEST (Balance Evaluation System Test). The patient's past falls are a result of delayed reactive postural control (the ability to recover balance after an external perturbation). The Mini-BEST has strong psychometric properties and measures various domains of balance to include reactive postural control (see Table 3-9). The Mini-Best is also recommended by the APTA Neurology Section Parkinson's Disease EDGE Task Force (see Table 3-19). Incorrect Choices: The BBS, FGA, and TUG-Cog do not directly assess reactive postural control. Type of Reasoning: INDUCTIVE For this question, the test-taker must utilize knowledge of examination approaches for patients with Parkinson's disease in order to arrive at a correct conclusion. This requires clinical judgment, which is an inductive reasoning skill. For this case, the Mini-BEST would best assess the patient's current balance and fall risk. If answered incorrectly, review balance and fall risk assessments, especially the Mini-BEST. Berg Balance Scale (BBS). Functional Gait Assessment (FGA). Timed Up & Go with Cognitive Task (TUG-Cog).

Answer 34

Crackers or bread. Slowly absorbed carbohydrates (crackers, bread, or pasta) can help prevent delayed-onset hypoglycemia. Incorrect Choices: Rapidly absorbed carbohydrates (e.g., fruit juice, candy, honey) are given during exercise to help prevent hypoglycemia. Foods with saturated fats (beef jerky, string cheese) should be limited. Carrot sticks and cherry tomatoes do not have major effects in preventing hypoglycemia. Type of Reasoning: INFERENTIAL This question requires one to recall slowly absorbed carbohydrates in order to arrive at a correct conclusion. This necessitates the recall of factual information, which is a deductive reasoning skill. For this situation, crackers or bread should be chosen to prevent delayed-onset hypoglycemia after exercise. Review dietary recommendations to prevent hypoglycemia if answered incorrectly. Fruit juice or candy. Beef jerky and string cheese. Carrot sticks and cherry tomatoes.

Answer 35

Forceful passive range of motion (PROM), especially if spasticity is present. Forceful PROM in the presence of spasticity increases the risk of developing HO (osteogenesis typically occurring in the soft tissues adjacent to large joints). Incorrect Choices: Joint mobility can usually be successfully maintained with all other choices. Type of Reasoning: INFERENTIAL For this question, the test-taker is provided with a condition and must determine the greatest risk factor associated with the condition. This requires one to determine what is likely to be true of a situation, which necessitates inferential reasoning skill. For this scenario, forceful passive range of motion (PROM), especially with spasticity present, presents the greatest risk for developing HO. Review risk factors for development of HO if answered incorrectly. Prolonged positioning with resting splints. Prolonged stretching using tilt table standing. Joint mobilization with PROM.

Answer 36

Platform crutches. Platform crutches allow weightbearing on the forearms and are used for patients who are unable to bear weight through their hands, as in this case. Incorrect Choices: All other choices allow weightbearing through the hands, placing stress on the distal radius. Type of Reasoning: INDUCTIVE For this question, one must determine the best assistive device for a patient with a trimalleolar ankle fracture on the right and a fracture of the left distal radius. This necessitates clinical judgment, which is an inductive reasoning skill. Based on the patient’s injuries, platform crutches are the best choice. Review indications for platform crutches if answered incorrectly. Axillary crutches. Forearm crutches. Lofstrand crutches.

Answer 37

Taught to family members in order for them to participate in the care of the patient. Passive range of motion (PROM) exercises can be taught to family members in order for them to participate in the care of the patient. Incorrect Choices: Other rehab staff, not only PTs or PTAs (e.g., rehabilitation aides, nursing assistants), can also be taught PROM techniques to maintain the joint mobility of the patient with marked spasticity. The RN is not typically engaged in this type of care of the patient. Type of Reasoning: EVALUATIVE This question requires one to weigh the potential courses of action in order to determine which action will have the best therapeutic outcomes. This requires evaluative reasoning skill. For this situation, the therapist should teach family members PROM exercises so they can participate in the care of the patient. Review traumatic brain injury information and participation of family in the plan of care. Performed only by the physical therapist since the patient is unable to follow verbal commands. Performed only by the physical therapist (PT) or physical therapist assistant (PTA) to minimize the possibility of pathological fractures. Taught to all registered nurses (RNs) who might participate in the care for the patient.

Answer 38

Go up stairs foot-over-foot. Going up stairs foot-over-foot (reciprocal stair climbing) is a developmental skill normally achieved by 2 years. Incorrect Choices: The ability to hop on one foot and stand on tiptoes is normally achieved by 4 years. The ability to jump with two feet is normally achieved by 3 years. Type of Reasoning: DEDUCTIVE One must recall motor skill development in toddlers in order to arrive at a sound conclusion for this question. This necessitates the recall of factual information, which is a deductive reasoning skill. For this situation, going up stairs foot-over-foot is a normal developmental milestone for a 2-year-old child. Review motor skill milestones, especially stair negotiation, if answered incorrectly. Hop on one foot. Stand on tiptoes. Jump with two feet.

Answer 39

Time: >35 minutes; Intensity: 90%–95% of peak VO2; Frequency: 2–3 times/week; Duration: 8–12 weeks. Choice 3 incorporates all parameters suggested by the Clinical Practice Guideline for the Management of the Patient with Heart Failure (see Table 4-18). Incorrect Choices: A training period of 5–10 minutes is too short and 40%–50% of peak VO2 is not a sufficient intensity. A frequency of 5–7 times/week is too often and increases risk for injury. A duration of 4–6 weeks is too short to improve aerobic fitness. Type of Reasoning: INDUCTIVE This question requires one to determine through clinical judgment the best high-intensity interval training program for a patient with compensated Class III heart failure. This requires knowledge of cardiac rehabilitation guidelines, which is an inductive reasoning skill. For this situation, the best program would be >35 minutes; intensity: 90%–95% of peak VO2 with a frequency 2–3 times/week and a duration of 8–12 weeks. If answered incorrectly, review high-intensity interval training programs, especially for compensated Class III heart failure. Time: 5–10 minutes; Intensity: 40%–50% of peak VO2; Frequency: 2–3 times/week; Duration: 4–6 weeks Time: 5–10 minutes; Intensity: 90%–95% of peak VO2; Frequency: 5–7 times/week; Duration: 4–6 weeks. Time: >35 minutes; Intensity: 40%–50% of peak VO2; Frequency: 5–7 times/week; Duration: 8–12 weeks.

Answer 40

Visual Analog Scale (Fatigue) and 2-minute walk test. The visual analog scale (Fatigue) measures self-report of fatigue for daily life, grooming, and household/occupational activities. Normative values for the 2-minute walk test have also been established for patients with multiple sclerosis. Incorrect Choices: None of the other options, except for the Fatigue Scale of Motor/Cognitive Function, directly measure the patient's primary impairment of fatigue. Additionally, secondary to the recent exacerbation it is important that the patient is not overexerted with more demanding (e.g., running) and increased duration activities (e.g., 6-minute walk test). Please see Table 3-18 for the APTA Neurology Section Multiple Sclerosis EDGE Task Force recommended examination items. Type of Reasoning: INDUCTIVE For this question, the test-taker must utilize clinical judgment to determine the best examination item for a patient with multiple sclerosis. This necessitates inductive reasoning skill. In this case, one must be familiar with the examinations presented in order to choose the examination that will best assess the patient's symptoms. For this scenario, the Visual Analog Scale (Fatigue) and 2-minute walk test are best. If answered incorrectly, review information on assessments for multiple sclerosis, especially the Visual Analog Scale (Fatigue) and the 2-minute walk test. 12-item Multiple Sclerosis Walking Scale and Dynamic Gait Index. Multiple Sclerosis Quality of Life Measure and Timed Up & Go. Fatigue Scale of Motor/Cognitive Function and 6-minute walk test.

Answer 41

Double or blurred vision, decreased voice projection, and difficulty with repetitive sit to stand. Patients with myasthenia gravis (MG) typically have involvement of bulbar (extraocular, facial, and muscles of mastication) and proximal limb-girdle muscles. If overworked, patients will exhibit visual changes and difficulty with prolonged speaking, eating, or reading. They will also have weakness with repetitive testing of exercise of proximal limb muscles. Incorrect Choices: Shortness of breath, syncope, and cold distal extremities are more consistent with cardiovascular and respiratory conditions and not typically associated with MG unless it is severe (e.g., myasthenic crisis). Hyperreflexia and muscle spasm are more closely associated with upper motor neuron lesions and CNS involvement. Joint and muscle pain, inability to sleep, and irritability are more consistent with an active arthritic process or fibromyalgia. Type of Reasoning: INFERENTIAL This question requires the test-taker to infer or determine what is likely to be true for symptoms that are consistent with exacerbation of myasthenia gravis. This necessitates inferential reasoning skill. For this situation, double or blurred vision, decreased voice projection, and difficulty with repetitive sit to stand would indicate an exacerbation of myasthenia gravis. Review information on myasthenia gravis, especially response to exercise, if answered incorrectly. Dyspnea, syncope, and cold hands and feet. Hyperreflexia, muscle spasms, and an inability to stand on one foot with eyes open. Increased muscle and joint pain, inability to sleep, and irritability.

Answer 42

Passively extend the wrist and actively flex the MCP joints. Goals during the first few weeks include preventing tendon rupture and promoting tendon healing as well as edema and pain control. For scar management, perform active range of motion (AROM) flexion, isolated joint and tendon gliding (hook and straight fist). Perform passive extension via elastic recoil of the dynamic splint, 10 to 20 reps hourly. Begin active MP flexion to 30 to 40 degrees (via flexion block on dynamic splint). Progress MP flexion as tolerated. Perform wrist and digit passive range of motion (PROM) in extension and tenodesis out of splint 10 repetitions hourly. Avoid making a full fist as this may place too much stress on the repair. The wrist is splinted in 40 to 45 degrees extension with 0 to 20 degrees of MP flexion and 0 degrees of IP flexion. Incorrect Choices: One would not want any active extension as this could disrupt the repair. There are many different protocols, but many avoid any active extension until 4 weeks postop. Passively extending the wrist and MCP joints would be safe but would not help with preventing contractures of the repaired extensor tendons. Type of Reasoning: DEDUCTIVE For this question, one must recall the protocol for range of motion after extensor tendon repair. This requires the recall of protocol guidelines, which is factual information and necessitates a deductive reasoning skill. For this scenario, the therapist should instruct the patient to passively extend the wrist and actively flex the MCP joints. Review extensor tendon repair range of motion guidelines if answered incorrectly. Actively extend the wrist and passively flex the MCP joints. Actively extend the wrist and MCP joints. Passively extend the wrist and MCP joints.

Answer 43

Dependent edema. If the right ventricle fails, the increased fluid will back up. Traveling backward from the right ventricle, the edema goes into the right atrium and then the periphery. This causes dependent edema. Incorrect Choices: An inability to lie flat occurs when there is edema in the lungs (paroxysmal noctural dyspnea). This doesn’t occur in isolated right ventricular failure. Exertional dyspnea occurs in right ventricular failure as a result of deconditioning after a period of time. It is not an early indication. Pulmonary edema results from increased intravascular pulmonary pressures. This doesn’t occur in right ventricular failure because there is a reduction in forward flow, and therefore there are lower pulmonary arterial pressures. Type of Reasoning: DEDUCTIVE For this question, one must recall the early signs of right ventricular failure in order to arrive at a correct conclusion. This requires the recall of factual information, which is a deductive reasoning skill. In this case, an early sign is dependent edema. Review signs and symptoms of right ventricular failure if answered incorrectly. Paroxysmal nocturnal dyspnea. Exertional dyspnea. Pulmonary edema.

Answer 44

Refer the patient to a physician. This case represents the typical presentation for juvenile rheumatoid arthritis (JRA). The following are common symptoms of JRA: swollen, stiff, painful joints usually worse in the morning; fatigue; fever; swollen lymph nodes; and poor weight gain/slow growth. Additionally, the physical therapist was unable to identify specific impairments that would be potentially contributing to the patient’s complaints, warranting referral to physician for additional testing. Incorrect Choices: The other choices do not address the findings of swollen, painful joints. The FIM evaluates functional performance (eating, dressing, grooming). Clubbing is seen with hypertrophic osteoarthropathy. Dupuytren’s contracture involves flexion contractures of the fourth and fifth digits of the hand, MP, and proximal interphalangeal (PIP) joints. Type of Reasoning: EVALUATIVE For this question, one must weigh the potential courses of action and determine which decision will best aid in establishing a diagnosis. This necessitates evaluative reasoning skill where one weighs the merits of each potential course of action to seek resolution. For this situation, the therapist should refer the patient to a physician. Review diagnostic approaches for JRA if answered incorrectly. Administer the Functional Independence Measure (FIM). Examine for clubbing at the distal interphalangeal joints. Examine for Dupuytren’s contracture.

Answer 45

The pacemaker will sense a lack of depolarization and initiate a contraction if the heart rate drops too low. A dual sensing pacemaker is implanted to assess depolarization of the atrium or the ventricle. If the depolarization does not occur within the set time limits of the device, the pacemaker will initiate depolarization, which results in a ventricular contraction. Incorrect Choices: The pacemaker has no effect on the heart rhythm in this case. The beta-blocker may lead to the patient converting to normal sinus rhythm, or more likely, the patient will remain in atrial fibrillation and the medication works to maintain the heart rate within a normal range (60–100 beats per minute). There is not any increased risk associated with exercise and a pacemaker. The hemodynamic response should be the same as any patient on a beta-blocker. Type of Reasoning: INFERENTIAL For this question, one must determine what is likely to be true for a patient with atrial fibrillation and a permanent pacemaker in place. This requires inferential reasoning skill, where one must predict outcomes based on information presented. For this situation, the patient’s pacemaker will sense a lack of depolarization and initiate a contraction if the heart rate drops too low. Review pacemaker guidelines if answered incorrectly. The pacemaker placement will have eliminated the atrial fibrillation, and the patient will have a regular heart rate. The patient could experience sudden cardiac death if they exercise. The patient’s hemodynamic response will be an unreliable measure of exercise tolerance and should not be measured.

Answer 46

Vomit that looks like coffee grounds. Gastric ulcers cause a mixture of dried and new blood that often looks like coffee grounds. Symptoms of gastric ulcers include epigastric pain that is often described as gnawing or burning. Incorrect Choices: Esophageal dysfunction (e.g. gastroesophageal reflux disease) may present as atypical head, neck, and chest pain that mimics a heart attack. Diffuse right shoulder pain is associated with liver or gall bladder dysfunction. Visible blood in the feces occurs with disorders of the descending colon and rectum (e.g., colon cancer, diverticulitis, hemorrhoids). Type of Reasoning: Inferential Atypical head, neck, and chest pain. Diffuse right shoulder pain. Visible blood in the feces.

Answer 47

Positive family history of the disorder. Lymphedema is divided into two broad categories: primary (congenital or hereditary) and secondary (acquired) lymphedema. Primary lymphedema occurs due to a genetic condition that affects the development of lymph nodes and vessels. Incorrect Choices: Secondary lymphedema occurs “secondary” to an obstruction of the lymphatic system from surgery, infection, trauma, or radiation. Secondary lymphedema often develops after surgery to remove lymph nodes in patients with cancer. Burns that cover large portions of the body, including the extremities, can impede lymph flow. Filariasis is a parasitic infection spread via mosquitoes and is the leading cause of lymphedema worldwide. Type of Reasoning: Deductive Surgical removal of axillary lymph nodes. Burns covering over 60% of the body. Recent diagnosis of filariasis.

Answer 48

Manual wheelchair. Bilateral L3 neurologic levels would allow a patient to have partial function of the quadriceps and hip adductors but would result in complete paralysis and sensory loss below the knees. The most realistic device for community ambulation would be a wheelchair. Most patients with a complete L3 neurologic level would be able to ambulate short distances with the assistance of bilateral KAFO and a walker or forearm crutches. Incorrect Choices: An AFO would be unrealistic for this patient for community ambulation, as the patient lacks any sensation or strength distal to the knees. Standard crutches are also not recommended for long-term use as forearm crutches in a trained patient provide similar stability and less pressure on the shoulders over time. Type of Reasoning: Deductive Loftstrand (forearm) crutches and ankle foot orthoses. Standard walker and ankle foot orthoses (AFO). Standard crutches with knee/ankle foot orthoses (KAFO).

Answer 49

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

Answer 50

Proximal muscle weakness. Hypothyroidism can have numerous musculoskeletal effects, including myalgia (muscle pain) and proximal muscle weakness. Incorrect Choices: Additional musculoskeletal effects include stiffness (not joint laxity) and delayed relaxation (decreased) deep tendon reflexes. Type of Reasoning: INFERENTIAL For this question, the test-taker must determine what is most likely to be true based on knowledge of hypothyroidism. Questions of this nature, where one must infer information, require inferential reasoning skill. In this case, one should infer that proximal muscle weakness is most likely to be present. If answered incorrectly, review information on hypothyroidism. Distal muscle weakness. Joint laxity. Increased deep tendon reflexes.

Answer 51

Chest wall mobility and prevention of scar contracture. Prevention of scar contracture and preservation of chest wall mobility and normal neck range of motion (ROM) are the initial major goals to focus on with this patient. Incorrect Choices: Return to preburn function and ADLs is an important treatment goal but is not the initial focus. Pain and infection management are important goals of the medical team and are typically managed by the medical team. Type of Reasoning: INDUCTIVE For this question, the test-taker must use clinical judgment to determine a best course of action, which necessitates inductive reasoning skill. Knowledge of effective treatment approaches for burns is paramount to arriving at a correct conclusion. In this case, chest wall mobility and prevention of scar contracture should be the initial focus of the therapist. Review treatment approaches for burns, especially in children, if answered incorrectly. Return to preburn function and activities of daily living. Pain management. Infection management.

Answer 52

Impaired sensory integrity. Changes in skin composition associated with aging include decreased sensitivity to touch, decreased perception of pain and temperature, and increased risk of injury. Incorrect Choices: Perception of pain is decreased (not increased). The dermis thins, and elasticity is decreased (not increased). The elderly often exhibit low-grade inflammation; acute inflammatory responses are commonly caused by tissue injury or infections. Type of Reasoning: INFERENTIAL For this question, the test-taker must recall the effects of aging and then determine the most likely effect that relates to the skin. This requires inferential reasoning skill. For this situation, the most likely skin effect is impaired sensory integrity. Review effects of the aging process, especially those that affect the skin, if answered incorrectly. Increased perception of pain. Increased skin elasticity. Increased acute inflammatory response.

Answer 53

Rising of the abdomen due to no abdominal muscle tone on the abdominal viscera. The abdominal musculature provides external stability to the abdominal viscera. Without this, the viscera are displaced with respiration. Incorrect Choices: With an ASIA A injury, the muscle weakness would be symmetric. The diaphragm is innervated by C3–5 nerve roots, so it will be functioning in this patient. Muscle weakness will cause a restrictive disorder (inability to generate negative pressure), not an obstructive disorder (air trapping). Type of Reasoning: INFERENTIAL One must determine what is most likely to be true for patients with cervical spinal cord injury in order to arrive at a correct conclusion. Questions that ask one to predict possible outcomes often necessitate inferential reasoning skill. For this case, the therapist should anticipate rising of the abdomen due to no abdominal muscle tone on the abdominal viscera. Review cervical spinal cord injury effects on respiration if answered incorrectly. Asymmetric lateral costal expansion due to ASIA A injury. An increased subcostal angle due to air trapping from muscle weakness. No diaphragmatic motion since the diaphragm is below the level of the lesion.

Answer 54

A waist size greater than 40 inches. Criteria for diagnosis of metabolic syndrome include abdominal obesity (waist circumference >40 inches in men or >35 inches in women). Incorrect Choices: Other criteria include elevated triglycerides (150 mg/dL or higher); low HDL levels (<40 mg/dL in men or <50 mg/dL in women); and a fasting plasma glucose level >110 mg/dL. Type of Reasoning: DEDUCTIVE This question requires the test-taker to recall the guidelines for risk of developing metabolic syndrome. This is factual information, which is a deductive reasoning skill. For this situation, a waist size greater than 40 inches would be a risk factor. Review metabolic syndrome guidelines if answered incorrectly. An HDL level lower than 45 mg/dL. Triglyceride levels greater than 100 mg/dL. Fasting blood glucose less than 100 mg/dL.

Answer 55

Hypertension and hyperinsulinemia. Obesity is associated with hypertension, dyslipidemia, hyperinsulinemia (type 2 diabetes), and hyperglycemia. The presence of these comorbidities increases risk, resulting in the need for additional medical screening before exercise testing. Incorrect Choices: Hyperpituitarism, hormone-related cancer, and hypotension are not associated with obesity. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the clinical manifestations associated with a high BMI (obesity). This is factual information, which necessitates deductive reasoning skill. In this case, the clinical manifestations include hypertension and hyperinsulinism. Review obesity guidelines if answered incorrectly. Hyperpnea and hyperpituitarism. Hormone-related cancer. Hypolipoproteinemia and hypotension.

Answer 56

Legg-Calvé-Perthes disease. Legg disease is an idiopathic childhood hip disorder initiated by disruption of blood flow to the femoral head, leading to avascular necrosis. Age of onset is between 2–13 years and is four times more likely in boys than girls. Characteristic clinical examination findings are gradual onset and limited range of motion in abduction and extension (due to collapse of subchondral bone at the femoral neck/head). The gait deviation is called a psoatic limp due to weakness of the psoas major muscle. The patient moves in hip external rotation, flexion, and adduction along with exaggerated trunk and pelvic movements. Incorrect Choices: Slipped capital femoral epiphysis (SCFE) is also a common hip disorder observed in adolescents. However, the age of onset in males is usually 10–17 years (average 13 years). Patients with SCFE demonstrate a Trendelenburg gait and limited range of motion in abduction, flexion, and internal rotation. Hip dysplasia is an abnormality in the size, shape, orientation, or organization of the femoral head and/or acetabulum that can result in hip subluxation or dislocation. Hip dysplasia is more common in females than males. Legg-Calvé-Perthes disease is often misdiagnosed as growing pains in early stages. However, children experiencing growing pains typically present with increased pain at night and do not commonly exhibit loss of range of motion or a dysfunctional gait. Type of Reasoning: ANALYTICAL This question requires the test-taker to analyze pieces of information in order to draw a reasonable conclusion. This type of reasoning process is analytical, where the test-taker weighs the individual symptoms to determine a likely diagnosis. The symptoms presented in this situation are most likely consistent with Legg-Calvé-Perthes disease. Review information on Legg-Calvé-Perthes disease if answered incorrectly. Hip dysplasia. Growing pains. Slipped capital femoral epiphysis.

Answer 57

Lower trapezius, latissimus dorsi, and pectoralis major. The muscles needed for crutch use include the shoulder depressors and extensors along with elbow extensors. Incorrect Choices: All other choices include muscles that enhance shoulder elevation or abduction. Type of Reasoning: INDUCTIVE For this question, one must utilize clinical judgment to determine the most important muscles to strengthen for crutch use. This requires inductive reasoning skill. For this scenario, the therapist should focus on strengthening the lower trapezius, latissimus dorsi, and pectoralis major. Review muscles needed for crutch use if answered incorrectly. Upper trapezius, rhomboids, and levator scapulae. Deltoid, coracobrachialis, and brachialis. Middle trapezius, serratus anterior, and triceps.

Answer 58

Aggressive quadriceps femoris stretching. Aggressively stretching a muscle following direct trauma that results in formation of a hematoma may induce myositis ossificans, which is a painful condition of abnormal calcification within a muscle belly. The quadriceps, brachialis, and biceps brachii muscles are the most frequent locations for myositis ossificans. While flexibility exercises in a pain-free range are appropriate, aggressive stretching exercises into the painful range should be avoided. Incorrect Choices: Quadriceps setting exercises, gentle knee and hip range of motion exercises, and ice baths are all appropriate choices of interventions after a muscle contusion that do not increase the risk of developing myositis ossificans. Type of Reasoning: INDUCTIVE For this question, the test-taker must recall intervention approaches that should be avoided after muscle contusion. This requires inductive reasoning skill, where one utilizes clinical judgment and knowledge of intervention guidelines to arrive at a correct conclusion. For this case, the therapist should avoid aggressive quadriceps femoris stretching in order to avoid inducing myositis ossificans. If answered incorrectly, review intervention guidelines for patients with muscle contusions. Isometric quadriceps femoris exercises. Knee and hip range of motion in a pain-free range. Ice baths.

Answer 59

Neutral-positioned wrist orthosis. The special test shown in this video is Phalen’s test. If the test reproduces the patient’s paresthesias in the right palm (median nerve distribution), it increases the likelihood of a diagnosis of carpal tunnel syndrome (CTS). There is moderative evidence (Grade B) to recommend the use of a wrist orthosis, particularly worn at night, for symptom relief and functional improvement in patients with CTS. See Box 2-4 for the CTS Clinical Practice Guideline. Incorrect Choices: The Clinical Practice Guideline recommends that each of the other modalities listed as answer choices should NOT be used to treat CTS. Type of Reasoning: Inductive Thermal ultrasound to the anterior wrist. Laser therapy to the anterior wrist. Iontophoresis to the carpal tunnel region.

Answer 60

Airway clearance and secretion removal. The patient has signs and symptoms consistent with pneumonia. It is most important to assist with secretions clearance to assist with recovery from the infection and to improve gas exchange. Incorrect Choices: Quitting smoking is an appropriate goal for this patient but would be best timed after the acute period has passed. It isn’t stated that the patient’s breathing pattern is impaired and therefore it is not imperative to address it at this time. If there is an increased work of breathing, it will be rectified by clearing the secretions. Patients with a history of chronic obstructive pulmonary disease (COPD), which is presumed in this case due to the long history of tobacco use, do benefit from inspiratory muscle training (IMT). However, this is best timed after the acute infection has resolved. Type of Reasoning: INDUCTIVE This question requires one to utilize clinical judgment to consider a best course of action for a patient with pneumonia. Knowledge of effective intervention approaches for pneumonia is paramount to arriving at a correct conclusion and requires inductive reasoning skill. For this case, the therapist should focus on airway clearance and secretion removal initially. Review intervention approaches for pneumonia if answered incorrectly. Getting the patient to quit smoking. Breathing reeducation to increase efficiency of ventilation. Graded inspiratory muscle training.

Answer 61

Axillary nerve injury. Injury to the axillary nerve is a well-documented complication of glenohumeral dislocation, reported in as many as 40% of cases. The incidence of concomitant axillary nerve injuries increases with age. Patients with this injury typically present with numbness or paresthesias in the lateral shoulder region and weakness with shoulder abduction. Incorrect Choices: Thoracic outlet syndrome occurs with compression of neurovascular structures in the region of the scalene triangle, between the clavicle and 1st rib, or between the pectoralis minor and thoracic wall. Pain and paresthesias may be present and are typically reported in the medial forearm and hand. A radiculopathy that involves the C7 and C8 nerve roots would primarily affect forearm and intrinsic hand muscles and the patient would present with pain and paresthesias along the C7 and C8 dermatomes. Radial tunnel syndrome is an entrapment neuropathy of the lateral elbow region causing pain and paresthesia in the posterolateral forearm and dorsum of the hand. Type of Reasoning: ANALYTICAL This question requires the test-taker to analyze the presenting symptoms and determine the likely diagnosis that is consistent with the findings. This requires analytical reasoning skill where pieces of information are weighed for their significance and flowing from that, a reasonable conclusion of what the information means. In this case, the findings are consistent with axillary nerve injury. Review information on axillary nerve injury if answered incorrectly. Thoracic outlet syndrome. C7–C8 radiculopathy. Radial tunnel syndrome.

Answer 62

The patient has neck pain. Health care providers can communicate information relevant to mutual patients, but not communicate information that is irrelevant to another provider's care. In this example, the patient's neck pain is most likely to be irrelevant information to the social worker relative to the other items. Incorrect Choices: The information regarding being laid off, need for housing assistance, and the patient's age are valuable background information for the social worker. This information is sensitive but must be shared to allow the social worker to have a basic understanding of why assistance is needed. Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the information presented and then apply knowledge of the HIPAA to arrive at a correct conclusion. This requires weighing the information for its merits, which is an evaluative reasoning skill. For this case, it would be most likely inappropriate to share that the patient has neck pain. If answered incorrectly, review HIPAA guidelines. The patient was laid off. The patient needs housing assistance. The patient is 17 years old.

Answer 63

To evacuate air and/or blood from the intrapleural space. A chest tube has been inserted into the intrapleural space. It would be attached to a vacuum line with a water seal interspersed. Air, blood, or other fluid is evacuated from the pleural space following a pneumothorax, cardiothoracic surgery, pleural effusion, or other condition to allow the lung to fully expand. The water seal prevents any air from back flowing into the thoracic cavity. Chest physical therapy is permitted in this area. Incorrect Choices: Supplemental O2 is provided by use of a nasal cannula, mask, or manual resuscitator bag. Mechanical ventilation is a means to replace spontaneous breathing. Moistened and heated O2 is administered via endotracheal, nasotracheal, or tracheal means. A chest tube is not applicable for these purposes.A Swan-Ganz catheter, also known as a pulmonary catheter, is a thin tube inserted directly into the pulmonary artery. It can measure pulmonary artery pressure, cardiac output, and oxyhemoglobin saturation. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the information in the picture in order to make a determination of the primary purpose of the tubing inserted into the patient. This requires analytical reasoning skill, where determining a correct answer through the review of pictures, charts, and graphs is utilized. For this case, the tubing is placed to evacuate air and/or blood from the intrapleural space. Review ICU guidelines, especially types of drainage tubes, if answered incorrectly. To provide moistened room air directly to the patient. To provide heated and moistened pure O2 directly to the patient. To measure pulmonary artery pressure and cardiac output via a Swan-Ganz catheter.

Answer 64

S1 radiculopathy. This patient’s complaint of pain and numbness is along the S1 dermatome. Additionally, the diminished Achilles tendon reflex is an S1 reflex. These findings are consistent with compression of the S1 nerve root. Incorrect Choices: The patient profile and examination findings do not include any items that are suggestive of L5 radiculopathy, spinal instability or lumbar facet dysfunction. Type of Reasoning: Analytical L5 radiculopathy. Spinal instability. Lumbar facet dysfunction.

Answer 65

Gastrocnemius. The gastrocnemius muscle is innervated by the S1-2 spinal nerve root levels. This is the only S1-innervated muscle listed in the answer choices. Incorrect Choices: The nerve root innervation levels for the other answer choices are iliopsoas (L2-3), quadriceps femoris (L3-4) and tibialis anterior (L4-5). Type of Reasoning: Inferential Iliopsoas Quadriceps femoris. Tibialis anterior.

Answer 66

Posterior cruciate ligament. The PCL is the primary restraint to posterior displacement of the tibia on the femur. The scenario describes one of the three most common mechanisms of injury of the PCL. This occurs when the knee is flexed, and an object forcefully strikes the proximal anterior tibia and displaces it posteriorly. The most common causes of PCL injury are motor vehicle accidents (dashboard injury) and athletics. Incorrect Choices: The usual mechanism of injury for the ACL is noncontact deceleration that produces a valgus twisting injury (e.g., athlete quickly pivoting in the opposite direction). Other mechanisms of injury of the ACL include hyperextension and severe medial tibial rotation.The medial patellofemoral ligament is typically injured during a lateral patellar dislocation. The most common mechanism for a patellar dislocation is a powerful contraction of the quadriceps in combination with sudden flexion and external rotation of the tibia on the femur. This question describes trauma to the tibia, not the patella.Injuries of the popliteal artery are rare and typically result from severe trauma resulting in (1) a dislocation of the tibia on the femur or (2) a fracture of the distal femur with posterior displacement of the short distal fragment. Type of Reasoning: INFERENTIAL For this question, the test-taker must draw from knowledge of anatomy, coupled with an understanding of the mechanism of injury in order to determine which structure was most likely injured. This requires inferential reasoning skill, where one must determine what is likely to be true of a situation. For this case, the posterior cruciate ligament was likely injured. Review mechanisms of injury of the PCL if answered incorrectly. Anterior cruciate ligament. Medial patellofemoral ligament. Popliteal artery.

Answer 67

Refuse to treat the patient and immediately consult with the patient’s primary care provider for further evaluation. This question describes a patient with a possible thoracic aortic aneurysm (TAA). Although less prevalent than abdominal aortic aneurysms, a TAA should still be treated as an emergency situation. Patients often describe the pain of an aneurysm as throbbing or pulsating, and the pain location of a TAA is typically between the shoulder blades or substernal. Risk factors for aortic aneurysms include connective tissue disorders such as Marfan’s syndrome. Patients with Marfan’s syndrome are tall and thin and often have deformities of the sternum. Incorrect Choices: There are no indications in this scenario that the patient’s back pain is musculoskeletal in nature. Each of the incorrect choices describe intervention options for a musculoskeletal problem and ignore the fact that what is described is a potential emergency situation. If there had been a fracture of a thoracic vertebra, changes in positions and activities certainly would have provoked the patient’s symptoms. Type of Reasoning: EVALUATIVE One must determine a best course of action based on presenting signs and symptoms in order to arrive at a correct conclusion. This requires evaluative reasoning skill where one must weigh the merits of a course of action to make sound decisions. For this situation, the therapist should refuse to treat the patient and immediately consult with the patient’s primary care provider for further evaluation. Review symptoms of thoracic aortic aneurysm if answered incorrectly. Treat the patient with grades III and IV mobilizations of the thoracic spine and costovertebral joints. Begin the patient on a strengthening program targeting the chest, back, and core muscles. Recommend an x-ray to rule out a fracture of the thoracic spine and sternum.

Answer 68

Short stretch bandages with multilayered foam padding applied distal to proximal. The best choice for compression treatment following manual lymphatic drainage utilizes short stretch bandages with multilayered foam padding applied distal to proximal. Short stretch bandages have low resting and high working pressures and do not create a barrier to lymph flow at rest. However, when exercising, compression against the bandage increases to provide a more effective and consistent change in pressure during the contraction cycle, enhancing lymph flow. Bandages should be applied from distal to proximal, with higher pressure distally to avoid constricting lymph flow to the torso. Incorrect Choices: Elastic bandages are not appropriate for this treatment because of the excessive pressures placed on the lymphatic and vascular systems. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall how to correctly apply compression bandaging for lymphedema in order to draw a correct conclusion. This requires the recall of factual guidelines, which is a deductive reasoning skill. For this scenario, the best method of application is using short stretch bandages with multilayered foam padding applied distal to proximal. If answered incorrectly, review lymphedema treatment guidelines, especially bandaging. Elastic bandages with multilayered foam padding applied distal to proximal. Elastic bandages with multilayered foam padding applied proximal to distal. Short stretch bandages with multilayered foam padding applied proximal to distal.

Answer 69

Right TMJ, inferior glide manipulation. Right TMJ, inferior glide. In the photo, the chin has deviated to the right at terminal opening. The active range of motion (AROM) will be limited with ipsilateral opening and a lateral deviation to the side of restriction for patients with a TMJ capsular pattern of restriction. Incorrect Choices: The left TMJ incorrectly states the capsular pattern. Additionally, superior glide manipulation on the right would compress the joint, not affording a stretch to the capsule tightness. Type of Reasoning: INDUCTIVE This question requires clinical judgment in order to determine a best intervention approach for a patient with TMJ dysfunction. Knowledge of effective intervention approaches for the TMJ is paramount to arriving at a correct conclusion, necessitating inductive reasoning skill. For this case, the BEST intervention approach is right TMJ, inferior glide manipulation. Review intervention approaches for the TMJ if answered incorrectly. Left TMJ, superior glide manipulation. Left TMJ, inferior glide manipulation. Right TMJ, superior glide manipulation.

Answer 70

Hyponatremia. Metabolic abnormalities seen in adrenal insufficiency include hyponatremia (decreased sodium concentration in the blood) secondary to renal loss of sodium ions. A decrease in cortisol results in an inability to regulate potassium and sodium. Symptoms include general fatigue and anorexia. Incorrect Choices: Patients with adrenal insufficiency will be hyperkalemic, hypoglycemic, and may have acidosis. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the metabolic abnormalities that are often associated with adrenal insufficiency in order to arrive at a correct conclusion. This necessitates the recall of factual information, which is a deductive reasoning skill. For this case, hyponatremia is often associated with adrenal insufficiency. Review signs and symptoms of adrenal insufficiency if answered incorrectly. Hypokalemia. Hyperglycemia. Alkalosis.

Answer 71

Avoid direct contact with the patient’s blood or blood-contaminated equipment by wearing gloves. Hepatitis B is transmitted in blood, body fluids, or body tissues. Precautions should include avoiding direct contact with blood or blood-contaminated equipment. Incorrect Choices: This is not an airborne infectious disease. The patient does not need to wear a mask or have specific no-touch tissue receptacles. Contact with body surfaces with no blood droplets or open wounds should also not be an issue. Type of Reasoning: DEDUCTIVE For this question, one must recall the guidelines for standard precautions. This is factual information, which is a deductive reasoning skill. For this case, in addition to wearing a protective gown, the therapist should avoid direct contact with the patient’s blood or blood-contaminated equipment by wearing gloves. Review standard precautions, especially for hepatitis B, if answered incorrectly. Avoid direct contact with any part of the patient. Have the patient wear a mask to minimize droplet spread of the organisms from coughing. Provide tissues and no-touch receptacles for disposal of tissues.

Answer 72

Standing, forward bend test. Screening is most commonly done on adolescents. Females achieve adolescence about two years before males and are afflicted with scoliosis requiring treatment three to four times more frequently than males. The forward bend test is the standard screening test for scoliosis. During the test, the child will bend forward with feet together, knees straight, and arms hanging free. The therapist observes child from the back, looking for a difference in the shape of the ribs on each side. A spinal deformity is most noticeable in this position. Incorrect Choices: All other choices are not appropriate for examining for scoliosis (e.g., backward extension, trunk rotation, forward bending in longsitting). Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the guidelines for conducting a scoliosis screening test in order to arrive at a correct conclusion. This necessitates factual recall of testing guidelines, which is a deductive reasoning skill. For this situation, the standard screening test is standing, forward bend test. Review scoliosis screening guidelines if answered incorrectly. Longsitting, forward bend test. Sitting, rotation test to the right and left. Standing, backward extension test.

Answer 73

Stop and start the flow of urine every time you go to the toilet. Kegel exercises (pelvic floor exercises) should not include stopping and starting the flow of urine every time one goes to the toilet. This can be used once as a test to find if the correct muscles are contracting. Continued use can result in bladder complications (e.g., infection, overuse). Incorrect Choices: Proper instructions for Kegel exercises include: lie down, sit, or stand with your legs slightly apart and relax your thighs, buttocks, and abdomen muscles. Tighten the ring of muscle around your front and back passages, drawing the pelvic floor muscles up inside. Hold for 5–10 seconds and relax. Repeating the exercise 10 times, three times a day is the recommended intensity and frequency. Type of Reasoning: INDUCTIVE This question requires one to recall Kegel exercise guidelines in order to determine an approach that is NOT appropriate to provide as part of instruction for exercise. This requires inductive reasoning skill, where clinical judgment is paramount to arriving at a correct conclusion. For this case, it is NOT appropriate to stop and start the flow of urine every time when going to the toilet. Review Kegel exercise guidelines if answered incorrectly. Squeeze the muscles around the vagina, imagining you are stopping the flow of urine, hold for 5–10 seconds, then relax. Repeat the exercises 10 times, three times a day. Start in supine position and progress to sitting and standing practice.

Answer 74

Weakness of the rectus abdominis and oblique muscle groups. During a dynamic activity such as the performance of a bilateral active straight leg raise, the weight of the limbs lifted produces an anterior torque on the pelvis. During this dynamic activity, excessive lordosis typically is associated with excessive anterior pelvic rotation. Normally muscles that control anterior pelvic rotation (posterior pelvic rotators) act to counter the anterior torques produced by the mass of the lower limbs lifted off the table, helping to prevent unwanted sagittal plane movements of the lumbar spine. Contractile activities of the anterior trunk muscles (rectus and obliques) provide a posterior rotation moment on the pelvis, helping to stabilize the pelvis. Fatigue weakness of the anterior trunk muscles in this patient could result in poor control of sagittal plane rotation of the pelvis, leading to the observed increasing lumbar lordosis. Incorrect Choices: The quadratus lumborum acts as a stabilizer and an extensor of the lumbar spine in the sagittal plane, and one would not suspect weakness as the cause of the observed excessive lordosis. Lack of hamstring lengthening could not directly produce the observed increasing lordosis. While the rectus femoris and sartorius are capable of anterior pelvic rotation when the lower limbs are fixed, they offer no direct force to produce unwanted anterior pelvic rotation and subsequent lordosis in this case in which the limbs have been lifted off the table. Type of Reasoning: INFERENTIAL For this question, one must infer, or draw a reasonable conclusion, for an increasing lumbar lordosis during bilateral straight leg raising. Questions that require one to determine what is most likely to be true often necessitate inferential reasoning skill. For this case, the cause is most likely fatigue weakness of the rectus abdominis and oblique muscle groups. Review causes of lumbar lordosis if answered incorrectly. Muscle imbalance between the rectus femoris and the sartorius muscles. Weakness of both quadratus lumborum muscles. Excessive elastic shortening of the ipsilateral hamstring muscle group.

Answer 75

Tone is normal in both upper and lower extremities. A full-term infant in the NICU can have low Apgar scores, respiratory distress, or any one of a number of specific diagnoses (none listed in this case). Initial tone and posturing involve some flexion of the limbs. At 1 month, decreased flexion can be expected. Incorrect Choices: All other choices indicate that the flexor tone and posturing noted in a newborn’s upper and lower limbs are abnormal. Type of Reasoning: ANALYTICAL For this question, one must analyze the description of posture in an infant and make a determination of what the posturing indicates. This requires analytical reasoning skill. For this case, the posturing indicates that tone is normal in both upper and lower extremities. Review posturing in infants if answered incorrectly. Upper extremity tone is abnormal. Lower extremity tone is abnormal. Tone is abnormal in both upper and lower extremities.

Answer 76

Weakness or severe spasticity of the quadriceps. Weakness or severe spasticity of the quadriceps is the most likely cause of genu recurvatum. Incorrect Choices: Spasticity of the hamstrings or pretibial muscles is unlikely and would cause the knee to buckle. Weakness of the gastrocnemius-soleus would cause lack of push-off, while weakness of the pretibial muscles would cause a drop foot. Type of Reasoning: INFERENTIAL For this question, one must determine the most likely cause of genu recurvatum and use this knowledge to arrive at a correct conclusion. Questions of this nature often require inferential reasoning skill. For this case, the cause is most likely due to weakness or severe spasticity of the quadriceps. Review gait patterns, especially genu recurvatum, if answered incorrectly. Severe spasticity of the hamstrings or weakness of the gastrocnemius-soleus. Weakness of the gastrocnemius-soleus or spasticity of the pretibial muscles. Weakness of both the gastrocnemius-soleus and pretibial muscles.

Answer 77

Lymphedema. Stemmer sign is assessed by pulling up on the skin at the base of the second toe or finger, which the clinician is doing in this picture. If the skin is unable to be pulled up, then it is a sign of lymphedema, usually primary but also advanced secondary. Incorrect Choices: A bunion is diagnosed by the metacarpophalangeal (MCP) joint angle. A fracture is diagnosed by radiology. A hammer toe is usually diagnosed by visual inspection of the foot. Type of Reasoning: ANALYTICAL For this question, one must utilize knowledge of Stemmer’s sign and analyze the information present in the picture in order to arrive at a correct conclusion. Questions that accompany pictures often necessitate analytical reasoning skill. For this situation, the picture depicts an examination for the presence of lymphedema. Review Stemmer’s sign if answered incorrectly. Metatarsalgia. Hammer toe. Fracture of the second toe.

Answer 78

Wrist and finger flexion. Klumpke paralysis involves muscles innervated by the lower roots of the brachial plexus (C8–T1 nerves). Paralysis affects the intrinsic hand muscles (interossei, thenar, and hypothenar muscles), flexors of the wrist and fingers (flexor carpi ulnaris and ulnar half of flexor digitorum profundus), and forearm pronators. Typical presentation is an intrinsic minus or claw hand. Horner’s syndrome can also be present with involvement of T1 affecting the dilators of eye and eyelid elevation. Incorrect Choices: Shoulder and elbow movements are not impaired with Klumpke’s paralysis. Type of Reasoning: INFERENTIAL This question requires one to determine the expected motion impaired by Klumpke’s paralysis. This necessitates understanding of the diagnosis and muscles innervated by the lower roots of the brachial plexus in order to arrive at a correct conclusion. For this scenario, one would expect wrist flexion to be impaired. Review Klumpke’s paralysis and movements impaired by the injury if answered incorrectly. Shoulder elevation. Elbow extension. Elbow supination.

Answer 79

Acute appendicitis. Pain and tenderness with palpation over McBurney’s point are associated with acute appendicitis. McBurney’s point is located half the distance between the anterior superior iliac spine (ASIS) and the umbilicus in the right lower abdominal quadrant. Incorrect Choices: A positive Murphy’s sign (pain and tenderness over the costovertebral angle) is associated with acute cholecystitis or acute pyelonephritis. Hiatal hernia pain is usually sharp and localizes to the lower esophagus/upper stomach area. Gastroesophageal reflux disease (GERD) produces persistent burning pain in the esophagus, throat, or chest. Type of Reasoning: DEDUCTIVE This question requires factual recall of information in order to arrive at a correct conclusion. This is a deductive reasoning skill. One must recall what pain and tenderness of McBurney’s point indicates. In this case, it is indicative of acute appendicitis. Review testing guidelines for acute appendicitis if answered incorrectly. Hiatal hernia. Acute cholecystitis. GERD.

Answer 80

Heart rate to be low at rest and rise minimally with exercise. A beta-blocker will decrease the sympathetic response to activity. This will decrease the heart rate at rest and will blunt the heart rate response to activity. Incorrect Choices: The heart rate response to exercise will be blunted. The blood pressure will rise with exercise, just not to the expected levels. The systolic blood pressure will be lowered at rest and will increase with activity, but not to normal levels. Type of Reasoning: INFERENTIAL For this question, one must determine what is most likely to be true of a situation, which is an inferential reasoning skill. One must utilize knowledge of beta-blockers and exercise with beta-blocker use in order to arrive at a correct conclusion. For this situation, one would expect heart rate to be low at rest and rise minimally with exercise. If answered incorrectly, review beta-blocker effects during exercise. Heart rate to be low at rest and rise continuously to expected levels as exercise intensity increases. Systolic blood pressure to be low at rest and not rise with exercise. Systolic blood pressure to be within normal limits at rest and progressively fall as exercise intensity increases.

Answer 81

Fugl-Meyer Assessment of Motor Performance. The Fugl-Meyer assessment of motor performance is the best option and contains specific tests to assess upper and lower extremity function, strength, coordination, sensation, and range of motion. Incorrect Choices: The Berg Balance Scale, FIM, and the NIH Stroke Scales assess function across multiple areas and domains but are not specific to sensory and motor impairments. Please see Box 3-1 and Table 3-13 for additional information. Type of Reasoning: INDUCTIVE For this question, the test-taker must utilize clinical judgment to determine a best course of action. This necessitates inductive reasoning skill. In this case, one must be familiar with the examinations presented in order to choose the examination that will best assess the patient's primary impairments. For this scenario, the Fugl-Meyer Assessment of Motor Performance is best. If answered incorrectly, review information on CVA assessment, especially the Fugl-Meyer Assessment of Motor Performance. Functional Independence Measure (FIM). Berg Balance Scale. NIH Stroke Scale.

Answer 82

All four limbs in extension. With decerebrate posturing (decerebrate rigidity), the upper and lower extremities are held rigidly in extension. Incorrect Choices: In decorticate posture, the upper extremities are held rigidly in flexion while the lower extremities are extended. With opisthotonos, extreme hyperextension of the neck and spine is evident, with both lower extremities flexed and the heels touching the buttocks. All limbs flexed is not typically found in the comatose patient. Type of Reasoning: DEDUCTIVE This question requires the test-taker to recall factual guidelines related to posturing with individuals who are comatose. Recall of facts and guidelines often necessitates deductive reasoning skill. For this case, decerebrate posturing would present as all four limbs in extension. Review various types of posturing with coma if answered incorrectly. The upper extremities in flexion and the lower extremities in extension. Extreme hyperextension of the neck and spine with both lower extremities flexed and the heels touching the buttocks. All four limbs in flexion.

Answer 83

Use a pumice stone to gently remove calluses. Foot care precaution for patients with diabetic polyneuropathy should include the use of a pumice stone to gently file calluses. Other advice includes examining footwear for proper fit to prevent callus and corn development. Additionally, patients should never use anything sharp or chemicals to debride corns or calluses. Incorrect Choices: It is important to moisturize but not between the toes as it contributes to skin maceration. It is best to buy shoes at the end of the day when the feet are larger. Buying shoes at the beginning of the day could result in an improper fit. Finally, heating pads and hot water bottles are contraindicated in someone with polyneuropathy. If the patient’s feet are cold, it is recommended they wear socks. Type of Reasoning: INDUCTIVE For this question, the test-taker must utilize knowledge of diabetic foot care in order to determine the best foot care precaution information to share with the patient. This necessitates clinical judgment, which is an inductive reasoning skill. For this case, the therapist should share with the patient use of a pumice stone to gently remove calluses. If answered incorrectly, review diabetic foot care information. Apply moisturizing cream daily in-between the toes and on the heels. It is best to shop for new shoes at the beginning of day. Keep your feet warm at night with a heating pad or hot water bottle.

Answer 84

Turning head while walking. The Berg Balance Test (BBT) is a test of static and dynamic balance in sitting and standing. It includes transitional items of sit-to-stand and stand-to-sit. It does not include items on gait. Turning while walking is an item on both the Tinetti Performance-Oriented Mobility Assessment and the Dynamic Gait Index. Incorrect Choices: All other choices are items on the BBT. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the features of the Berg Balance Test in order to arrive at a correct conclusion. This is factual recall of information, which is a deductive reasoning skill. In this case, the BBT does not examine turning while walking. Review the BBT if answered incorrectly. Sit-to-stand transitions. Functional reach in standing. Tandem standing.

Answer 85

Dorsiflexion and eversion. The term “clubfoot” (talipes equinovarus) refers to the way the foot is positioned at a sharp angle to the ankle, like the head of a golf club. It describes a range of foot abnormalities usually present at birth in which the infant’s foot is twisted into an equinovarus deformity. Stretching should be opposite the direction of the deforming position; therefore, stretch is into dorsiflexion and eversion. Incorrect Choices: All other choices would not be beneficial when stretching a clubfoot. Type of Reasoning: INDUCTIVE This question requires one to determine a best course of action using clinical judgment, based on knowledge of clubfoot. Questions of this nature, where clinical judgment is utilized to reach a sound conclusion, often necessitate inductive reasoning skill. In this case, the therapist should recommend stretching in the opposite direction of the deforming position, which is dorsiflexion and eversion. Review clubfoot and treatment guidelines if answered incorrectly. Plantarflexion and inversion. Plantarflexion and eversion. Dorsiflexion and inversion.

Answer 86

Emphysema. Pursed lip breathing gives increased resistance to the airways on exhalation. The resistance causes increased pressure, which helps to prevent airway collapse (likely sequelae given the pathophysiology of emphysema). This occurs via collateral ventilation through pores of Kohn and canals of Lambert. Incorrect Choices: Circumferential thoracic burn is a restrictive disorder, and pursed lip breathing will not have any effect on this. Asbestosis is an interstitial lung disease where there are fibrotic changes within the lung tissue. Pursed lip breathing will have no effect on this patient’s breathing pattern. Rib fractures are also a restrictive disorder. In order to improve the breathing pattern, it would be most beneficial to control pain. Pursed lip breathing will have little effect. Type of Reasoning: INFERENTIAL This question requires one to utilize knowledge of pursed lip breathing in order to determine a best course of action in choosing this approach for a specific diagnosis. This requires clinical judgment, which is an inductive reasoning skill. For this situation, pursed lip breathing is most appropriate for emphysema. If answered incorrectly, review pursed lip breathing guidelines and intervention approaches for emphysema. Circumferential thoracic burns. Asbestosis. Rib fracture.

Answer 87

Forearms supinated with wrists extended and fingers flexed. The patient with tetraplegia at the C6 level does not have triceps to assist in transfers. Independent transfers can be achieved using muscle substitution and positioning to lock the elbow. The hands are positioned anterior to the hips; the shoulders are externally rotated with the elbows and wrists extended, forearms supinated, and fingers flexed. Strong contraction of the anterior deltoid, shoulder external rotators, and clavicular portion of the pectoralis major flexes and adducts the humerus, causing the elbow to extend. Incorrect Choices: Fingers are always flexed (not extended) to preserve tenodesis grasp. Forearms are supinated (not pronated) and the wrist is extended (not flexed). Type of Reasoning: INDUCTIVE This question requires one to determine, through clinical judgment, what would be the best UE joint positioning for a patient with C6 tetraplegia in order to perform a transfer using a transfer board. This necessitates clinical judgment and use of knowledge of transfers with tetraplegia, which is an inductive reasoning skill. For this case, the therapist should ensure the forearms are supinated with wrists extended and fingers flexed. Review transfer guidelines for patients with tetraplegia if answered incorrectly. Forearms pronated with wrists and fingers extended. Forearms pronated with wrists and fingers flexed. Forearms supinated with wrists and fingers extended.

Answer 88

Weakness with shoulder abduction and lateral rotation. The suprascapular nerve innervates the supraspinatus and infraspinatus, which are tested with the actions of shoulder abduction and lateral rotation, respectively. There is no cutaneous nerve field for the suprascapular nerve. Incorrect Choices: The long head of the triceps brachii (radial nerve) and posterior deltoid (axillary nerve) muscles are tested with shoulder extension. The subscapularis muscle produces medial rotation and is innervated by the upper and lower subscapular nerve. Combined shoulder adduction and medial rotation are produced by the pectoralis major (medial and lateral pectoral nerves), latissimus dorsi (thoracodorsal nerve), and teres major (upper and lower subscapular nerve) muscles. See Table 2-4 for a review of upper extremity muscles and their innervation. Type of Reasoning: INFERENTIAL For this question, the test-taker must infer what is likely to be true of a clinical situation in order to arrive at a correct conclusion. This requires inferential reasoning skill. For this case, weakness with shoulder abduction and lateral rotation would support a diagnosis of suprascapular nerve injury. If answered incorrectly, review information on suprascapular nerve injury. Weakness with shoulder extension. Weakness with shoulder medial rotation. Weakness with shoulder adduction and medial rotation.

Answer 89

Stress fracture. Symptoms of a stress fracture may include pain and swelling, particularly with weight bearing on the injured bone. Stress fractures should be considered in patients who present with tenderness or edema after a recent increase in activity or repeated activity with limited rest. The differential diagnosis varies based on location but commonly includes tendinopathy, compartment syndrome, and nerve or artery entrapment syndrome. Incorrect Choices: Bone tumor is a possibility but not the most characteristic in this scenario. Pain may be increased at night. In this case there was pain at night but not increased. Activity may also increase the amount of pain. There may also be swelling with a bone tumor. Imaging is required.Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome can be either acute or chronic. Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. There may be pain, decreased pulses, paresthesias, pallor, and paralysis. Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. However, the patient usually complains of a bursting type of pressure and pain, and that was not the case here.Shin splints (medial tibial stress syndrome) is a common condition that can be distinguished from tibial stress fractures by nonfocal tenderness (diffuse along the mid-distal, posteromedial tibia) and a lack of edema. Type of Reasoning: ANALYTICAL This question requires one to determine the most likely diagnosis based on a description of symptoms. Questions of this nature often necessitate analytical reasoning skill, where information is analyzed in order to draw reasonable conclusions. For this scenario, the symptoms are most consistent with a stress fracture. Review signs and symptoms of stress fractures if answered incorrectly. Bone tumor. Anterior compartment syndrome. Shin splints.

Answer 90

Chronic venous insufficiency. Lower extremity edema is usually due to incompetent valves, which causes the edema. Long-standing edema causes staining of the legs because of increased iron from pooling blood. Incorrect Choices: While lower extremity edema would be present in acute venous insufficiency, there is not any time for leg staining. Acute arterial insufficiency would cause significant pain, pale or cyanotic skin, and decreased or absent pulses. Chronic arterial insufficiency would cause pain, decreased or absent pulses, and dependent rubor along with trophic changes (nail changes, loss of hair, and pale, shiny skin). Type of Reasoning: ANALYTICAL For this question, one must analyze the symptoms presented and make a determination of the most likely diagnosis. This necessitates analytical reasoning skill, where symptoms are assessed to determine a sound conclusion. For this situation, the symptoms are consistent with chronic venous insufficiency. If answered incorrectly, review venous insufficiency information. Acute venous insufficiency. Acute arterial insufficiency. Chronic arterial insufficiency.

Answer 91

The patient is unlikely to respond favorably to a lumbar stabilization program. The test depicted here is the prone instability test (PIT). It is a test for instability of the lumbar spine. A negative test results suggests that the patient does not have instability of the spine and is unlikely to respond to a regimen of lumbar stabilization exercises. It is part of a cluster of tests used to determine which patients with low back pain will respond to a stabilization exercise program (Hicks et al, 2005). Incorrect Choices: Variables that may help identify patients with LBP who will respond successfully to a stabilization program would include a positive PIT, aberrant motion present, a SLR > 91°, and age less than 40 years old. The PIT is not useful in predicting how patients will respond to spinal manipulation therapy. Type of Reasoning: Inferential The patient is likely to respond favorably to a lumbar stabilization program. The patient is unlikely to respond favorably to spinal manipulation. The patient is likely to respond favorably to spinal manipulation.

Answer 92

Continue with the outlined exercise progression for that session. The physical therapist provided an exercise program, and it is appropriate for the PTA to continue to follow it. Incorrect Choices: There is no need to terminate exercise since the patients have an established exercise program. It is within a PTA’s scope of practice to progress a program, so there is no need to maintain the same intensity of exercise. There is no need to reduce the intensity of the program, as the PTA can monitor and progress a program. Type of Reasoning: EVALUATIVE This question requires one to determine a best course of action based on knowledge of supervisory guidelines and scope of practice information. This requires evaluative reasoning skill, where one weighs the options presented and determines a best course of action. For this scenario, the PTA should continue with the outlined exercise progression for that session. Review scope of practice guidelines if answered incorrectly. Terminate the exercises and have the patients monitor their pulses until the therapist returns. Have the patients continue with the same exercise until the therapist returns. Have the patients switch to a less intense exercise until the therapist returns.

Answer 93

Multiple Sclerosis. The patient’s age and sex are risk factors for multiple sclerosis. Her diverse symptoms (visual and sensory impairments) combined with fatigue that is worse in warm weather are consistent with multiple sclerosis. Incorrect Choices: The patient’s lack of upper motor neuron findings and weakness in both the upper extremities and lower extremities is inconsistent with cervical myelopathy. Myasthenia Gravis (MG), a disease of the neuromuscular junction, causes fatigue and weakness throughout the body, but not sensory changes. The patient’s chronic and periodic symptoms are not consistent with Guillain Barre Syndrome (acute demyelination of peripheral nerves and nerve roots with diffuse and rapid upper and lower extremity weakness and distal sensory impairments). Type of Reasoning: Analytical Cervical Myelopathy. Myasthenia Gravis. Guillain Barre Syndrome.

Answer 94

Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). The mCTSIB is ideally suited to assess the influence of the patient’s diverse sensory impairments(vestibular, somatosensory, vision) on postural stability. Incorrect Choices: Options #2-4 do not directly assess the patient’s sensory impairments and are specifically intended to measure static stability, functional stability limits, and mobility, respectively. Type of Reasoning: Inferential Semi-Tandem Stance Eyes Open. Functional Reach Test (FRT). Timed Up and Go (TUG).

Answer 95

Demonstrate the exercises to the patient electronically and then view the patient’s performance. Telehealth involves two-way, visual communication between the parties involved, in this case, between the PT and the patient at home. Often, tablets are used and visual insets of the participants are seen on both devices. In this case, the exercises are to be progressed. It would be BEST and quite efficient for the PT to demonstrate to this patient what needs to be done differently and then view how the patient performs. Recall that the PT and patient have been conducting electronic rehabilitation for some time. The process is interactive. There is no implication that the plan of care is to be radically changed. Incorrect Choices: While sending an app may be a supplementary way for reinforcing the exercise progressions, it is not the best means to ensure correct compliance. Comprehension of written English, difficulty with interpreting what needs to be done or pictorial instruction, and other factors may be deterrents to correct performance.Describing the exercises on the phone to the patient is unnecessary as two-way visual communication is available and well established.Having the patient return to the clinic is unnecessary at this time. If there was a significant change to the plan of care, if a reexamination of the patient was necessary, or perhaps a discharge visit was required, then a trip to the clinic would be in order. That’s not the case here. Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the potential approaches and determine which approach is best for the patient. Evaluative reasoning skills are utilized whenever one must weigh the benefits and potential drawbacks of a potential course of action. For this scenario, the therapist should demonstrate the exercises to the patient electronically and then view the patient’s performance. Review telerehabilitation guidelines if answered incorrectly. Send the patient an app showing the exercise progressions and then watch the patient’s performance using electronic means. Have the patient make a trip back to the clinic to be taught the new exercise variations. Describe the exercise progressions over the phone to the patient, while simultaneously viewing their performance electronically.

Answer 96

Jersey finger. Jersey finger is the eponym for a rupture or avulsion fracture of the flexor digitorum profundus (FDP) tendon at its insertion on the distal phalanx. The ring finger is involved in 75% of cases of jersey finger because it is more prominent than the other digits during grip. The mechanism of injury is forceful extension of the DIP joint during maximal contraction of the FDP. The key physical examination finding is an inability to actively flex the DIP joint in isolation. Incorrect Choices: A boutonniere deformity results from rupture of the central tendinous slip of the extensor tendon mechanism. With boutonniere deformities, the PIP is in a position of flexion and between the two lateral bands of the extensor mechanism. A swan neck deformity results from injury to the volar plate or transverse retinacular ligament, producing a deformity of flexion of the MCP and DIP joints with relative hyperextension of the PIP. Boutonniere and swan neck deformities may result from trauma but are often seen in patients with rheumatoid arthritis. A mallet finger results from rupture or avulsion of the terminal tendon of the extensor mechanism at the insertion on the distal phalanx. The mechanism of injury is usually traumatic forced flexion of the DIP joint and results in a deformity of flexion of the DIP with an inability to produce active extension. Type of Reasoning: ANALYTICAL This question requires one to analyze the symptoms presented and determine the likely diagnosis. This requires analytical reasoning skill, where pieces of information are evaluated in order to conclude what they mean as a whole. In this case, the presenting symptoms are most likely associated with jersey finger. Review information on jersey finger, especially symptoms and mechanism of injury, if answered incorrectly. Boutonniere deformity. Mallet finger. Swan neck deformity.

Answer 97

Community Balance and Mobility Scale (CBMT). The patient's performance on the dizziness handicap inventory and Mini-BEST reinforce their symptoms (both at rest and exertion) have improved and fall risk is very low. The CBMT is the correct answer as it includes higher level balance and mobility items, to include running short distances. It is also a reliable and valid tool for patients who have experienced a TBI (see Table 3-16). Incorrect Choices: The FGA and FIM do not assess higher level balance and mobility items. The FSST requires dynamic mobility and balance in multiple planes but does not specifically address running or other higher level community tasks. Type of Reasoning: INDUCTIVE This question requires one to use clinical judgment to determine the best examination item to assess for safe return to work and recreation. This requires inductive reasoning skill. For this situation, the best examination item is the CBMT. If answered incorrectly, review information on brain injury assessment, especially the CBMT. Functional Gait Assessment (FGA). Four Square Step Test (FSST). Functional Independence Measure (FIM).

Answer 98

Patient fails to recognize the therapist on the third consecutive postoperative visit. Postoperative adverse effects on the cardiac, pulmonary, and neuromuscular systems and on cognitive function are the main concerns for elderly surgical patients who are at high risk. Postoperative delirium is characterized by incoherent thought and speech, disorientation, impaired memory, and attention. Elderly patients usually manifest delirium following a lucid interval of 1 postoperative day or more, a condition known as interval delirium. Symptoms are often worse at night. Alternatively, the condition can be silent and unnoticed, or misdiagnosed as depression. However, the effects of elderly postoperative delirium are evident in increased morbidity, delayed functional recovery, and prolonged hospital stay. Fortunately, the postoperative cognitive dysfunction is a reversible condition in the majority of elderly surgical patients. Preoperative risk factors of bilateral total knee arthroplasty are associated with a significantly higher incidence of acute delirium than unilateral total knee arthroplasty in patients over 80 years.Failing to recognize the therapist after three visits is an indication of a declining mental condition. This would definitely be a safety consideration as the patient may not be able to follow all the precautions and may also put himself or herself in danger by walking without an ambulatory aid, etc. Wound infection is also a consideration. Contacting the surgeon is necessary. Incorrect Choices: Soreness at the incision site would be an expected common complaint. The patient being noncompliant could potentially be a safety issue; however, the therapist should first attempt behavior modification. If that failed, they could get advice from a co-worker and possibly counseling for the patient if deemed necessary. Not being able to ambulate 50 feet could be due to many problems, including pain, weakness, and balance issues. None of these factors require consultation with the surgeon at this time. Type of Reasoning: EVALUATIVE For this question, one must determine a best course of action based on presenting signs. Questions of this nature, where information is weighed to determine its significance, often necessitate evaluative reasoning skill. For this scenario, the patient failing to recognize the therapist on the third consecutive postoperative visit would be an indication to contact the surgeon. Review adverse postoperative effects, especially in older adults, if answered incorrectly. Patient is noncompliant when learning to transfer properly. Patient cannot ambulate at least 50 feet with a standard walker. Patient complains of soreness at the incision site.

Answer 99

Create a barrier to the main entrance to the gym using available heavy equipment or weights. Blockading the entrance is the FIRST thing to do. There is no mention of an active shooter. May have a knife or other weapon, even a gun; however, up to this point it is verbal threats only. In this scenario, locking and/or blocking the gym entrance would be the most prudent thing to do first considering the patient population in the gym at the time. Disaster protocols may vary among clinical facilities and each employee must be aware of that protocol. Incorrect Choices: Using fire stairs impractical with wheelchairs and patients with serious disabilities. Evacuation would not be the first action to take based on the situation. Returning patients to their rooms may put therapists and patients in harm’s way as a confrontation with the perpetrator is more likely.Placing all patients together in one dead-end space could make them all an easy target even if trying to protect them. Barring the perpetrator from the gymnasium would be a more logical action. Type of Reasoning: EVALUATIVE For this question, one must make a value judgment of a best course of action, based on the presenting information. This requires the test-taker to weigh the merits of the potential courses of action in order to determine which option should be utilized first. In this scenario, the therapists should create a barrier to the main gym entrance using available heavy equipment or weights first. Review emergency procedures, especially disaster protocols and guidelines. Rapidly return all patients to their rooms in order to shelter-in-place. Evacuate the gym via the designated fire stairs to get outside the building. Shelter all patients in a corner of the gym and surround and protect them with all available equipment and devices

Answer 100

Call emergency medical services. The patient is exhibiting signs of a severe concussion with loss of consciousness for longer than 30 seconds. The therapist should call for emergency medical services immediately. Incorrect Choices: Once EMS is activated, the head can be checked for wounds, and resting vital signs (HR and BP) can be taken. A brief cognitive assessment is not appropriate at this time. Other signs of severe concussion the patient may exhibit include one pupil larger than the other, nausea or vomiting, seizures, headache that gets worse with time, slurred speech, decreased coordination, and changes in behavior (irritability, restlessness, agitation). Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the significance of the information presented and make a decision on a best course of action. This necessitates evaluative reasoning skill, where decisions are often made based on the relevance of the information presented. In this case, the information presented is of high importance, necessitating a call for emergency medical services. If answered incorrectly, be sure to review emergency procedures for patient injuries. Determine the patient’s heart rate and blood pressure. Check the head for signs of an external wound. Perform a brief cognitive assessment once the patient is awake.

Answer 101

Canalith repositioning treatment. The goal of treatment is to remove the otoconia that have become dislodged and are free-floating in the semicircular canal (SCC), or canalithiasis. The patient’s head is guided through a series of movements to move the debris out of the involved SCC and into the vestibule. Once moved, the symptoms should resolve. Canalith repositioning maneuver (modified Epley) is used for canalithiasis. Incorrect Choices: Gaze stability exercises and postural stability exercises (sitting on a ball) are treatments used for unilateral and bilateral vestibular hypofunction (UVH, BVH). Habituation training (motion sensitivity training) is used when a patient with UVH presents with continual complaints of dizziness. Patients with central vestibular lesions may also benefit from habituation exercises. Type of Reasoning: INDUCTIVE For this question, the test-taker must recall intervention approaches for BPPV in order to arrive at a correct conclusion. Based on knowledge of effective approaches, one will utilize inductive reasoning skill to determine the intervention approach that is most effective. In this case, canalith repositioning treatment is the best approach. Review intervention approaches for BPPV if answered incorrectly. Gaze stability exercises using horizontal head rotation (X1 viewing). Postural stability exercises in sitting using a therapy ball. Habituation exercises using provocative positions and movements.

Answer 102

Examine the right foot, leg, and hip for injury or infection. The most common cause of unilateral inguinal lymph node swelling is injury or infection involving the distal foot, leg, thigh, or hip. Abrasions in these areas, fairly routine for many athletes, are potential sources. Insect bites are another possible cause. The therapist should perform a thorough examination and treat any injuries or wounds appropriately. Incorrect Choices: Although mononucleosis (Epstein-Barr virus) is prevalent in young males, there were no complaints of sore throat or fatigue. The only swollen lymph nodes detected were in the right inguinal area. It is unlikely that mononucleosis is the source. Asking the patient about STDs at this point in the examination is also premature. STDs can result in swollen lymph nodes (chlamydia, gonorrhea, etc.) and not necessarily present with other symptoms; but, is this the next step in the PT examination? If the swollen lymph nodes were more extensive and had remained so for 2 or 3 weeks, then referral to a physician would be in order. Type of Reasoning: ANALYTICAL For this question, the test-taker must utilize knowledge of symptoms that indicate injury or infection to the distal extremity in order to determine a best course of action. This necessitates analytical reasoning skill, where the presenting symptoms are analyzed in order to determine the likely cause and ultimately, the next course of action. For this situation, the symptoms are indicative of potential injury or infection of the distal extremity and examination of the foot, leg, and hip is the next course of action. Review signs and symptoms of injury and infection in the lower extremity, especially in athletes, if answered incorrectly. Refer the athlete to a primary care physician to rule out systemic disease. Examine lymph nodes of the neck which may be swollen if mononucleosis is suspected. Ask the patient questions relating to possible STD as many symptoms are mistaken for other conditions.

Answer 103

Palpation tenderness at the distal lateral malleolus. The Ottawa Ankle Rules (see Box 2-10) were developed to provide clinicians with guidelines for determining when to order an x-ray following an acute ankle injury. Palpation tenderness of either malleoli is one of the criteria. The Ottawa Ankle Rules are highly sensitive and accurately rule out a fracture following an acute ankle injury. Incorrect Choices: The other choices are each common and important examination findings in patients after ankle sprain, but none of them is a component of the Ottawa Ankle Rules. Type of Reasoning: DEDUCTIVE For this question, the test-taker must draw from factual recall of the Ottawa Ankle Rules to guide clinical decision making about when to order ankle radiographs. This requires deductive reasoning skill, where factual information is used to guide clinical reasoning. For this situation, weak and painful resisted inversion would indicate a need for radiographs. Refer to the Ottawa Ankle Rules if answered incorrectly. Inability to fully dorsiflex the ankle. Positive anterior drawer test. Weak and painful resisted eversion.

Answer 104

To rule out liver and muscle dysfunction from statin. A small percentage of patients (<5%) who take statins (atorvastatin such as Lipitor, or others) can experience myalgia, cramps, stiffness, spasm, or weakness affecting exercise tolerance. The patient needs to see the primary care physician to have the dose or medication changed. Incorrect Choices: Determining the appropriate exercise intensity is within the scope of a physical therapist’s practice. A physical therapist (PT) is the appropriate professional in this case, so no referral is needed. These signs and symptoms are not consistent with cirrhosis or gallbladder disorders. Exercise would not worsen this condition. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the symptoms presented and determine the likely reason for the symptoms. This necessitates analytical reasoning skill. In this case, the symptoms and current use of a statin drug should prompt the therapist to refer the patient to the physician to rule out liver and muscle dysfunction from statin use. Review side effects of statin use if answered incorrectly. For an exercise test to determine the right intensity for exercise. To rule out cirrhosis of the liver. To rule out gallstones that may be obstructing the bile duct.

Answer 105

Practice stair climbing inside the parallel bars using a 3-inch step. The most appropriate lead-up activity to promote the skill of stair climbing is practice using a 3-inch step in the parallel bars. Incorrect Choices: Passive movements do not promote active learning. Marching in place and isokinetic training may improve the strength of the hip flexors but do not promote the same synergistic patterns of muscle activity as the desired skill. Type of Reasoning: INDUCTIVE One must determine through clinical judgment the BEST approach for promoting the skill of stair climbing. This question requires inductive reasoning skill, in which the test-taker must first determine the problem and then judge which intervention approach leads up to improving stair climbing ability. If this question was answered incorrectly, review information on exercises to promote stair negotiation. Practice marching in place. Strengthen the hip flexors using an isokinetic training device before attempting stair climbing. Passively bring the foot up and place it on the 7-inch step.

Answer 106

No change in neck pain, and distal symptoms decrease. The theme of this question is the centralization phenomenon. McKenzie reported that centralization occurred when a patient’s symptoms moved from a distal or peripheral area to a location closer to the spine. Numerous studies have reported that patients with spinal pain who describe a centralization of their symptoms exhibit greater reductions in pain and disability and a better prognosis compared with those who were unable to centralize symptoms. See Box 2-13 for the Neck Pain Clinical Practice Guideline. Incorrect Choices: An increase in distal symptoms is a sign that the C6 nerve root is being irritated, which may lead to a deterioration in the patient’s neurologic status. An improvement in neck pain with no change in distal symptoms is an acceptable response, but not preferred. Type of Reasoning: INDUCTIVE For this question, the test-taker must utilize clinical judgment in order to determine which response to treatment indicates a favorable response. This requires inductive reasoning skills. For this scenario, no change in neck pain and distal symptoms decreasing would indicate a favorable response to treatment. Review treatment guidelines for the lower cervical spine, especially mobilizations, if answered incorrectly. Neck pain improves, and distal symptoms increase. Neck pain improves with no change in distal symptoms. No change in neck pain, and distal symptoms increase.

Answer 107

Normal one joint hip flexor muscle length with tightness of two joint flexors. The test depicted here is the modified Thomas test. The patient’s posterior thigh touches the treatment table, but the knee is unable to come to a resting position of about 90°, implicating an adaptively shortened rectus femoris muscle. Incorrect Choices: The other answer choices do not correctly interpret the results of the test. If the one joint hip flexors were shortened, the thigh would remain elevated and the posterior thigh would not touch the treatment table. The ability of the patient’s thigh to rest comfortably on the treatment table with the knee in a position of about 90° flexion would indicate a normal test result. Type of Reasoning: Analytical Shortness of one joint and two joint hip flexor muscles. Shortness of one joint hip flexor with normal two joint hip flexor muscle length. Normal one joint and two joint hip flexor muscle length.

Answer 108

Stretching the hip flexors and plantar flexors. Duchenne MD is a rapidly progressive disorder characterized by muscle wasting and atrophy. Contractures of the hips, knees, plantar flexors, and iliotibial band are common. Scoliosis occurs at around age 11 or 12. The main focus is preventing contractures, maintaining activities of daily living (ADL), energy conservation, family education, and positioning. Incorrect Choices: Strenuous exercise and strengthening may cause breakdown of muscle fibers. Low repetition active range of motion (AROM) is safe but not strengthening. Type of Reasoning: INDUCTIVE This question requires the test-taker to draw from knowledge of Duchenne’s MD in order to determine a best course of action. This necessitates clinical judgment, which is an inductive reasoning skill. For this scenario, the therapist should focus on stretching the hip flexors and plantar flexors. Review Duchenne’s MD if answered incorrectly. Strengthening the knee extensors and plantar flexors. Strengthening the plantar flexors and stretching the hip extensors. Strengthening the hip flexors and knee extensors.

Answer 109

Patellar stabilizing brace with a lateral buttress. An increased valgus deformity can result in a greater lateral displacement force on the patella, which can disrupt patella tracking and could even lead to subluxation. The theory behind the lateral buttress brace is that it provides support to help prevent subluxation and tries to maintain the normal patella tracking. Incorrect Choices: A medial buttress would be on the wrong side. A neoprene sleeve provides some increased warmth and could be beneficial to a painful arthritic knee but would be of no benefit in patella alignment problems. A derotation brace is designed for rotary instabilities secondary to cruciate injuries. Type of Reasoning: INFERENTIAL For this question, the test-taker must utilize knowledge of abnormal patellofemoral tracking and devices used in order to arrive at a correct conclusion. One must infer what is most often used for the problem, which necessitates inferential reasoning skill. In this case, a patellar stabilizing brace with a lateral buttress is most often used. Review devices used in abnormal patellofemoral tracking if answered incorrectly. Patellar stabilizing brace with a medial buttress. Neoprene sleeve with a patellar cutout. Derotation brace.

Answer 110

Moist hot packs. Both a moist environment and heat can accelerate bacterial growth. Hot packs would be contraindicated in this case. Incorrect Choices: None of the other options are contraindicated for the treatment of this wound. They might aid in wound healing. Type of Reasoning: DEDUCTIVE This question requires one to recall knowledge of wound treatment contraindications in order to arrive at a sound conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this situation, moist hot packs are contraindicated. Review wound treatment guidelines and contraindications if answered incorrectly. Low-voltage, constant microamperage direct current. High-voltage monophasic pulsed current. Pulsed monophasic current.

Answer 111

Slow rocking on a therapy ball. Relaxation can be achieved using slow rocking (slow vestibular stimulation). Incorrect Choices: Rhythmic stabilization is a proprioceptive neuromuscular facilitation (PNF) technique used to improve postural stability. Spinning and rolling on a scooter board are interventions used to increase mobility based on fast vestibular stimulation. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall intervention approaches that promote relaxation for spastic musculature in order to arrive at a correct conclusion. This requires the recall of factual information, which is a deductive reasoning skill. For this case, slow rocking is an intervention approach that promotes relaxation. Review intervention approaches for relaxation of spastic muscles if answered incorrectly. Rhythmic stabilization. Spinning in a hammock. Rolling and spinning on a scooter board.

Answer 112

Exercises targeting hip and knee muscles. According to the Patellofemoral Pain Clinical Practice Guidelines (CPG; see Box 2-8), there is strong evidence to support the prescription of therapeutic exercises that target both the hip and knee musculature. Hip exercises should focus on the gluteal muscles. Knee exercises may include both weightbearing and non-weightbearing exercises targeting the quadriceps and hamstring muscles. Incorrect Choices: According to the Patellofemoral Pain CPG, there is only moderate evidence for the use of the other three answer choices. Running gait retraining, patellar taping, and patellofemoral knee orthoses are all interventions that physical therapists may consider in patients with patellofemoral pain. Running gait retraining may include multiple sessions of cuing to adopt a non-rearfoot strike pattern, cuing to increase cadence, and cuing to reduce peak hip adduction. Type of Reasoning: INDUCTIVE For this question, one must draw upon knowledge of effective intervention approaches for PFPS to arrive at a correct conclusion. This requires inductive reasoning skill, where clinical judgment is paramount to making a best intervention decision. In this situation, the best intervention is exercises targeting hip and knee muscles. If answered incorrectly, review intervention approaches for PFPS and the Patellofemoral Pain Clinical Practice Guidelines. Running gait retraining. Patellar taping. Patellofemoral knee orthoses.

Answer 113

Concurrent validity. Concurrent validity is a type of criterion validity. It is used when comparing two measures at the same time to determine if the experimental measure (in this case the smartphone video) can be used as a substitute for the reference measure/gold standard (three-dimensional motion capture). Incorrect Choices: Face validity indicates that a measure appears to measure what it is intended to measure. It is the weakest form of validity. Content validity is used to determine if the items that make up an instrument represent all possible content that defines the variable of interest. Predictive validity is a type of criterion validity and is used to determine if an experimental measure can predict a future outcome. Type of Reasoning: DEDUCTIVE The test-taker must draw from knowledge of research guidelines in order to arrive at a correct conclusion for this question. This requires deductive reasoning skill, where factual information is used to determine which type of validity is being established. For this situation, the research team is establishing concurrent validity. Review research guidelines and types of validity if answered incorrectly. Face validity. Content validity. Predictive validity.

Answer 114

1 MHz and 1.5 watts/cm2. 1 MHz MHz frequency is recommended for target tissue deeper than 2 cm, and 1.5 watts/cm² would increase the rate of heating, allowing it to be treated in a reasonable time frame. Incorrect Choices: The frequency 3 MHz does not penetrate past 2 cm and would not be effective at the hip. A rate of heating of 0.5 watts/cm² intensity is very slow and would result in a prolonged treatment time. Type of Reasoning: INDUCTIVE For this question, one must utilize knowledge of ultrasound guidelines in order to determine which frequency and rate of heating would provide the greatest benefit. This requires clinical judgment, which is an inductive reasoning skill. For this scenario, 1 MHz and 1.5 watts/cm2 would provide the greatest benefit. Review ultrasound guidelines, especially for the hip, if answered incorrectly. 1 MHz and 0.5 watts/cm2. 3 MHz and 1.5 watts/cm2. 3 MHz and 0.5 watts/cm2

Answer 115

Reapply a new hydrocolloid dressing and record the findings in the chart. Hydrocolloidal dressings are typically changed every 3 to 5 days or when drainage leaks out. An odor and yellowish color is to be expected as the dressing material melts. Incorrect Choices: The decision about what type of dressing to apply to a wound is the physician’s in collaboration with the wound care team. This is not an emergency situation. Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the potential courses of action and determine which one will have the most beneficial outcome. This necessitates evaluative reasoning skill, where the value of information is weighed to make decisions on next steps. For this situation, the therapist should reapply a new hydrocolloid dressing and record the findings in the chart. Review wound care guidelines, especially the use of hydrocolloidal dressings, if answered incorrectly. Reapply a new gauze dressing instead of hydrocolloid and report the findings to the physician. Speak to the nurse about changing to a hydrogel dressing. Leave the dressing off the wound and report the findings immediately to the physician.

Answer 116

Reapply a new hydrocolloid dressing and record the findings in the chart. Hydrocolloidal dressings are typically changed every 3 to 5 days or when drainage leaks out. An odor and yellowish color is to be expected as the dressing material melts. Incorrect Choices: The decision about what type of dressing to apply to a wound is the physician’s in collaboration with the wound care team. This is not an emergency situation. Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the potential courses of action and determine which one will have the most beneficial outcome. This necessitates evaluative reasoning skill, where the value of information is weighed to make decisions on next steps. For this situation, the therapist should reapply a new hydrocolloid dressing and record the findings in the chart. Review wound care guidelines, especially the use of hydrocolloidal dressings, if answered incorrectly. Reapply a new gauze dressing instead of hydrocolloid and report the findings to the physician. Speak to the nurse about changing to a hydrogel dressing. Leave the dressing off the wound and report the findings immediately to the physician.

Answer 117

Shave only on the right side of the face. A patient with a right hemisphere lesion (left hemiplegia) will tend to ignore items or body parts on the left side while favoring items or body parts on the right side. Incorrect Choices: All other choices do not match the above description and favor items or body parts on the left side. Type of Reasoning: INFERENTIAL One must infer, or determine what is likely to be true of a situation, in order to reach a sound conclusion. This necessitates inferential reasoning skill, where behavior in patients is predicted. In this case, one might expect the patient to shave only on the right side of the face. Review information on unilateral neglect if answered incorrectly. Eat food only from the left side of a plate. Bump his wheelchair into things on the right side. Ignore or deny the existence of the right upper extremity.

Answer 118

Sustaining pain levels of at least 2 out of 4 on the claudication scale during exercise. It has been established that in order to generate collateral circulation in patients with ischemia (i.e., claudication), patients need to exercise with at least moderate claudication pain. This level of blood and oxygen deprivation over time initiates the generation of collateral circulation. This correlates to 2 out of 4 on the claudication scale. Incorrect Choices: The ABI is not practical to assess during exercise because the patient cannot be moving during this test. While the RPE and HRmax are at moderate levels, this may not be at an intensity that elicits claudication symptoms. Type of Reasoning: INDUCTIVE For this question, one must utilize clinical judgment in order to determine the best way to monitor the intensity of exercise for a patient with claudication. This requires knowledge of the effects of exercise on claudication, which is an inductive reasoning skill. For this case, the best way to monitor exercise is to sustain pain levels of at least 2 out of 4 on the claudication scale during exercise. Review information on claudication and exercise if answered incorrectly. Assessing ankle-brachial index (ABI) during exercise. Maintaining heart rate (HR) between 60% and 70% of age-predicted HRmax during exercise. Upholding rate of perceived exertion (RPE) levels of 11 to 13 out of 20 during exercise.

Answer 119

Thoracic outlet syndrome. Hypertrophied scalene muscles can result in thoracic outlet syndrome due to their close anatomical relationship to the neurovascular structures. The neurovascular bundle passes between the anterior and middle scalene muscles and could be under pressure from hypertrophied scalenes. The anterior and middle scalenes attach to the first rib, and tightness in these muscles could result in elevation of the first rib, thereby compressing the neurovascular bundle. Neurogenic (neurological) thoracic outlet syndrome is characterized by compression of the brachial plexus. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic. Signs and symptoms of neurological thoracic outlet syndrome often include wasting in the thenar area, numbness or tingling in the fingers, pain in the shoulder and neck, ache in the arm or hand, and weakening grip. Incorrect Choices: The clinical presentation of vertebral artery occlusion varies with the area of ischemia and cause of occlusion. Vertigo, dizziness, nausea, vomiting, and head or neck pain are the most common initial symptoms reported. Other common signs and symptoms include weakness, hemiparesis, ataxia, diplopia, pupillary abnormalities, speech difficulties, and altered mental status.Cervical radiculopathy pain travels down the arm in the area of the involved nerve. Pain is usually described as sharp. There can also be a “pins and needles” sensation or even complete numbness. In addition, there may be a feeling of weakness with certain activities. Symptoms can be worsened with certain movements, like extending or straining the neck or turning the head.Complex regional pain syndrome (CRPS) is a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the injury (if an injury has occurred), which gets worse rather than better over time. None of these are normally associated with hypertrophy of the scalene muscles. Type of Reasoning: ANALYTICAL This question provides a group of symptoms, and the test-taker must determine the most likely cause. Questions that require one to determine a diagnosis based on a description of symptoms often necessitate analytical reasoning skill. For this situation, the symptoms are indicative of thoracic outlet syndrome. Review thoracic outlet syndrome if answered incorrectly. Vertebral artery obstruction. Cervical radiculopathy. Complex regional pain syndrome type 1.

Answer 120

Increased work of breathing. Full chest immersion in a pool can result in increased work of breathing as a result of increased hydrostatic pressure. Incorrect Choices: The other choices are not consistent with the physiological effects resulting from full chest immersion in a pool. Type of Reasoning: INFERENTIAL This question requires one to determine what is most likely to be true for a patient who is immersed up to the neck in a therapeutic pool. Questions that require one to make a determination of what is true of a situation often necessitate inferential reasoning skill. For this scenario, full chest immersion would likely result in increased work of breathing. Review effects of immersion if answered incorrectly. Increased forced vital capacity. Increased expiratory reserve volume. Decreased pulmonary blood flow

Answer 121

Mouth opening. The muscles involved in opening include the lateral pterygoid, anterior head of the digastric muscle, and suprahyoid muscles. Incorrect Choices: The muscles that assist with mouth closing are the masseter, temporalis, medial pterygoid, and lateral pterygoid. The muscles that assist with protrusion are the temporalis, medial pterygoid, and lateral pterygoid. The muscles that assist with retrusion are the temporalis and suprahyoid muscles. Type of Reasoning: INDUCTIVE For this question, one must utilize knowledge of musculoskeletal anatomy and muscle strengthening in order to determine the most beneficial intervention approach. This is an inductive reasoning skill. In this case, the approach improves mouth opening. If answered incorrectly, review lateral pterygoid and suprahyoid muscles. Mouth closing. Mouth protrusion. Mouth retrusion.

Answer 122

Medial cord brachial plexopathy. The patient’s history and physical examination findings are most consistent with medial cord brachial plexopathy. This can occur secondary to a Pancoast tumor (tumor of the upper lobe of the lung). Smoking and a past history of cancer are risk factors for this type of tumor. Incorrect Choices: Isolated ulnar nerve involvement does not explain the patient’s weakness in other C8-T1 muscles that are not innervated by the ulnar nerves. It also does not explain the patient’s more proximal medial arm and forearm sensory loss. Medial and ulnar compression at the axilla are also not consistent with the patient’s symptoms, and specifically the involvement of the median nerve would result in weakness in forearm flexors and pronator teres (non C8-T1 muscles), as well as sensory loss of the right palmar hand, thumb, index, long and ring fingers. C8-T1 radiculopathy would explain the majority of the patient’s findings, but if these nerve roots were involved the patient would also have weakness of radial-C8 innervated muscles. Type of Reasoning: ANALYTICAL This question provides a group of symptoms and the test-taker must determine the most likely health condition based on those symptoms. This necessitates analytical reasoning skill, where one must draw a reasonable conclusion about a situation based on pieces of information. For this situation, the symptoms are consistent with medial cord brachial plexopathy. Review the brachial plexus and associated conditions, especially medial cord plexopathy, if answered incorrectly. Cubital tunnel syndrome. Ulnar/median neuropathy at the axilla. C8-T1 radiculopathy.

Answer 123

Systematic review and meta-analysis of randomized controlled trials. Systematic review including meta-analysis of randomized controlled trials (RCTs) provides the best research evidence of effectiveness of an intervention. Incorrect Choices: Meta-analysis is not applied to cohort studies or multiple case studies. While an RCT can provide strong evidence of the effectiveness of an intervention, evidence derived from a meta-analysis that combines multiple RCTs is stronger. Type of Reasoning: DEDUCTIVE In order to arrive at a sound conclusion, the test-taker must recall research designs, specifically which designs provide the strongest research evidence. This necessitates the recall of facts, which is a deductive reasoning skill. For this scenario, systematic reviews of randomized controlled trials provide the best evidence. Review research designs if answered incorrectly. Systematic review and meta-analysis of cohort studies. Meta-analyses of multiple case studies. Randomized double-blind controlled trials.

Answer 124

Seated closed-chain toe raises. The mobilization described in the question stem would be done to improve talocrural (ankle) joint dorsiflexion. Seated closed-chain toe raises are performed with the heel in contact with the ground while the forefoot and toes are raised into the air, thereby dorsiflexing the talocrural joint. Incorrect Choices: Single limb stance as an exercise is utilized to work on one’s balance and isometric contraction of lower extremity muscles that are used for stabilization. It would have negligible impact on enhancing motion of the talocrural joint. Seated closed-chain heel raises are performed with the forefoot in contact with the ground while the heel is raised into the air, thereby plantarflexing the talocrural joint. Seated toe towel crunches target foot intrinsic muscles and would have a negligible effect on talocrural joint range of motion. Type of Reasoning: Inductive Single limb stance. Seated closed-chain heel raises. Seated toe towel crunches.

Answer 125

Caregiver training for contact guarding during level walking and stairs. Caregiver training with safety instruction in contact guarding during level walking and stairs is the best choice to keep this patient functional in the home environment. Incorrect Choices: Manual balance perturbation training will likely result in a rigid response, decreasing use of normal synergistic movements. This patient should be kept safe and ambulatory for as long as possible and not be relegated to a wheelchair. A rolling walker is contraindicated for patients with a forward, flexed posture (typical in patients with Parkinson’s disease). Type of Reasoning: INDUCTIVE This question requires clinical judgment in order to determine a best course of action. Utilizing knowledge of Parkinson’s disease and the current level of function, inductive reasoning skills are utilized to determine the focus for the plan of care. In this case, the focus should be on caregiver training for contact guarding during level walking and stairs. Review Parkinson’s disease if answered incorrectly. Manual balance perturbation training. Transfer and wheelchair training. Locomotor training using a rolling walker

Answer 126

Slightly bluish, slate-colored discoloration. Slightly bluish, grayish, slate-colored discoloration of the skin along with clubbing of the nails is characteristic of chronic hypoxia. Incorrect Choices: Pallor (lack of skin color, paleness) is indicative of anemia, internal hemorrhage, or lack of sunlight exposure. Yellowish discoloration of the skin is indicative of jaundice (liver disease). Cherry-red discoloration of the skin is indicative of carbon monoxide poisoning. Type of Reasoning: INFERENTIAL This question requires one to infer what is likely to be true of a situation in order to reach a sound conclusion. This necessitates inferential reasoning skill. For this situation, the patient with congestive heart failure is expected to show slightly bluish, slate-colored discoloration. Review congestive heart failure information if answered incorrectly. Pale, washed-out color. Yellowish discoloration. Cherry-red discoloration.

Answer 127

Range of motion (ROM) exercises and prevention of deformity. Range of motion (ROM) exercises and prevention of deformity are important elements of the plan of care. Incorrect Choices: Lightweight splints are not an initial priority and can contribute to contracture development if worn too long. Furthermore, there are no reports of arthralgia in this case. Regular exercise is important but should not be aggressive (resistive training). Also, long-term use of corticosteroids puts this patient at risk for osteoporosis. Aerobic (treadmill) training might be indicated but is not an initial priority. Splints to provide joint protection are also not an initial priority. Type of Reasoning: INDUCTIVE This question requires one to determine a best course of action based on knowledge of discoid lupus erythematosus. This necessitates clinical judgment, which is an inductive reasoning skill. For this scenario, range of motion (ROM) exercises and prevention of deformity should be the initial focus. If answered incorrectly, review information on discoid lupus erythematosus. Lightweight splints to provide joint protection. Aerobic training using a treadmill. Resistive training using weights at 60% to 80%, one repetition maximum.

Answer 128

Breathing, coughing, and pelvic floor exercises. Initial postpartum interventions (days 1 to 3) should include breathing, coughing, and pelvic floor exercises. Incorrect Choices: All other choices can be part of the postpartum exercise program during later recovery. Type of Reasoning: INDUCTIVE This question requires one to utilize knowledge of postpartum intervention approaches in order to arrive at a correct conclusion. This necessitates clinical judgment, which is an inductive reasoning skill. For this case, the therapist should include breathing, coughing, and pelvic floor exercises. Review postpartum intervention approaches if answered incorrectly. Gentle partial sit-ups and head lifts. Low-intensity aerobic conditioning. Pelvic tilts on all fours.

Answer 129

Palmar surface of the thumb and distal, radial forearm. The C6 nerve root supplies both sides of the thumb and the radial aspect of the forearm. Incorrect Choices: The C7 root supplies the middle of the hand (second, third, and fourth fingers, palmar surface). The C8 root supplies the ulnar border of the hand (fifth finger). The T1 root supplies the medial surface of the forearm. Type of Reasoning: DEDUCTIVE One must recall sensory testing guidelines in order to arrive at a correct conclusion for this question. This requires the recall of facts, which is a deductive reasoning skill. For this situation, the therapist should focus on the palmar surface of the thumb and distal, radial forearm. Review sensory testing for the upper extremity, especially the C6 distribution, if answered incorrectly. Second, third, and fourth fingers, palmar surface. Ulnar border of the hand (fifth finger). Medial (ulnar) forearm.

Answer 130

Fasciculations with potential lower motor neuron (peripheral nervous system) involvement. The patient is having pronounced fasciculations in multiple muscles in the anterior, lateral, and posterior compartment of the leg, consistent with peripheral nervous system involvement. These findings should be correlated with lower extremity reflex, strength, and sensory testing to determine the most likely cause of peripheral nervous system pathology (e.g., radiculopathy, polyneuropathy, mononeuropathy, motor neuron disease). Incorrect Choices: Muscle spasticity would be velocity dependent and occur with movement (e.g., clonus, Hoffman’s sign, hyperreflexia) and less likely to be seen at rest. Myotonia is caused by dysfunction in the muscle membrane and is often associated with inherited myopathic disorders. Individuals with myotonia have difficultly relaxing the muscle (e.g., releasing their grip on objects). Fibrillations are not visible and can only be seen on needle EMG examination. Fibrillations are pathologic and consistent with peripheral nervous system damage to motor axons and/or the anterior horn cell. Type of Reasoning: Analytical Muscle spasticity with potential upper motor neuron (central nervous system) involvement. Myotonia with potential myopathy. Benign fibrillations with no concern of neuromuscular pathology.

Answer 131

Impaired auditory comprehension. Fluent aphasia is characterized by impaired auditory comprehension and fluent speech that is of normal rate and melody (e.g., Wernicke’s aphasia). Incorrect Choices: Nonfluent aphasia is characterized by speech that is slow, hesitant, awkward, interrupted, and produced with effort (e.g., Broca’s aphasia). Patients tend to have good awareness of their deficit and comprehension. Impaired articulation characterizes the patient with dysarthria (a motor speech disorder). Type of Reasoning: DEDUCTIVE One must recall the characteristics of fluent aphasia in order to arrive at a correct conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, fluent aphasia is characterized by impaired auditory comprehension. Review types of aphasia, especially fluent aphasia, if answered incorrectly. Slow, hesitant speech. Good comprehension. Impaired articulation.

Answer 132

Consistency of performance in variable environments. This patient demonstrates good functional recovery. Motor learning for the autonomous stage of motor learning should utilize variable practice in variable environments. Incorrect Choices: Mental practice and breaking down tasks into components can be helpful in the early cognitive stage of motor learning. Serial practice order is indicated for the middle, associative stage of motor learning. Type of Reasoning: INDUCTIVE One must utilize clinical judgment in order to determine a best intervention approach for a patient with CVA. Having knowledge of the stages of recovery, coupled with sound inductive reasoning skills, one should conclude that consistency of performance in variable environments is the best focus for intervention. Review motor learning strategies for CVA if answered incorrectly. Use of mental practice to improve performance. Breaking down complex tasks into component parts. Use of serial practice order of related skills.

Answer 133

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

Answer 134

Age The risk of a rotator cuff injury increases with age. Rotator cuff tears are most common in individuals over the age of 60. There tends to be a significant decrease in blood flow in the elderly compared with younger individuals. In this patient, other risk factors include occupation and playing tennis (overhead activities). Combined with the history of trauma, the index of suspicion for a rotator cuff tear should be high in this patient. Incorrect Choices: Gender, hypertension, and a history of prostate cancer are not risk factors associated with rotator cuff tears. Type of Reasoning: Deductive Gender Hypertension Prostate cancer

Answer 135

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

Answer 136

Urinary tract infection. These are signs and symptoms of urinary tract infection. Evidence of fever is especially significant. The physician should be informed. Incorrect Choices: The other choices do present with these same signs and symptoms. Fever is uncommon. Type of Reasoning: ANALYTICAL For this question, one must analyze the symptoms presented in order to determine the most likely diagnosis. Questions of this nature often necessitate analytical reasoning skill. For this situation, the symptoms are consistent with a urinary tract infection. Review signs and symptoms of urinary tract infection if answered incorrectly. Bladder cancer. Benign prostatic hyperplasia. Renal calculi (kidney stones).

Answer 137

Few localized trigger points with referred patterns of pain during palpation. MFP is a chronic pain disorder characterized by localized trigger points and referred patterns of pain. Pressure on sensitive points in muscle (trigger points) causes referred pain in seemingly unrelated parts of the body. Incorrect Choices: Chronic fatigue, sleep disturbances, generalized tender points, and irritable bowel syndrome are symptoms of fibromyalgia and not necessarily of myofascial pain syndrome. Type of Reasoning: INFERENTIAL One must infer or determine what is likely to be the findings of a patient with myofascial pain syndrome in order to arrive at a correct conclusion. Questions that provide a diagnosis and require the test-taker to identify likely symptoms or findings often necessitate inferential reasoning skill. For this case, one should expect to see few localized trigger points with referred pattern of pain during palpation. If answered incorrectly, review information on myofascial pain syndrome. Multiple generalized local tender points in muscle without referred patterns of pain. Chronic fatigue, decreased exercise tolerance, and headaches. Irritable bowel syndrome and sleep disturbance.

Answer 138

Patellar tilt test. The patellar tilt test is a nonprovocative test used to identify reduced patellar mobility (positive test), which prompts a moderate change in the likelihood of patellofemoral pain being present. Specifically, the test is used to determine the structural tightness of the lateral patellar retinaculum. The test also assists in classifying patients into the category of patellofemoral pain with mobility impairments. See Box 2-8 for the Patellofemoral Pain Clinical Practice Guidelines. Incorrect Choices: The Thessaly test is a pain provocation test for meniscal injuries. The patellar apprehension test is utilized to determine if patellar instability is present. The Noble compression test is a provocative test for iliotibial band friction syndrome. Type of Reasoning: INFERENTIAL This question requires the test-taker to infer which special test will be best in assisting in the classification of PFPS. This requires inferential reasoning skill where one uses judgement to determine what is likely to be a best course of action in a situation. For this case, the patellar tilt test may assist in the classification of PFPS. Review the Patellofemoral Pain Clinical Practice Guidelines if answered incorrectly. Patellar apprehension test. Thessaly test. Noble compression test.

Answer 139

Myositis ossificans. Soft tissues that were injured in a traumatic event initially develop a hematoma and subsequently can develop into myositis ossificans. Myositis ossificans is a benign, ossifying soft-tissue lesion typically occurring within skeletal muscle, usually in adolescents and young adults. The most frequent symptoms and signs are pain and tenderness with a soft tissue mass. Approximately 80% of cases arise in the large muscles of the proximal extremities. Incorrect Choices: A stress fracture is an overuse injury. Bone is constantly attempting to remodel and repair itself, especially when extraordinary stress is applied. When enough stress is placed on the bone, it causes an imbalance between osteoclastic and osteoblastic activity, and a stress fracture may appear. Insidious onset of pain and swelling over the affected region is the most important complaint, initially during the activity. Neoplasms, or cancer of bone, change the appearance of bone on an x-ray. Bone may look ragged or may appear to have a hole in it. Hematomas look very different from tumors or bones on an x-ray because they are mostly fluid, and tumors and bones are solid. Type of Reasoning: ANALYTICAL For this question one must analyze the symptoms and information presented in the picture in order to determine the most likely diagnosis. This requires analytical reasoning skill, where assessing information from pictures is often used to reach sound conclusions. In this case, the symptoms presented and the picture depict myositis ossificans. Review signs and symptoms of myositis ossificans if answered incorrectly. Femoral stress fracture. Neoplasm. Quadriceps hematoma.

Answer 140

Dysmetria. Dysmetria is an inability to judge the distance or range of movement. It includes both overestimation (hypermetria) and underestimation (hypometria) of the required range needed to reach the goal. Incorrect Choices: Dysdiadochokinesia is an impaired ability to perform rapid alternating movements (RAM). Dyssynergia is an impairment in movement composition. Movements are typically performed in component parts rather than as a single, smooth activity. Intention (kinetic) tremor is an involuntary oscillatory movement that occurs during voluntary movement. Type of Reasoning: ANALYTICAL For this question, one must analyze the symptoms presented in order to determine the most likely cause. This requires analytical reasoning skill. For this situation, the symptoms are consistent with dysmetria. Review signs of dysmetria if answered incorrectly. Dysdiadochokinesia. Dyssynergia. Intention tremor.

Answer 141

Gallstones. Classic symptoms of gallstones include nausea and RUQ pain, which can radiate to the right scapula. Gallstones are found more commonly in patients who are overweight or obese, female, and around the fourth decade of life. Gallstones occur more commonly in patients eating meals high in fat/cholesterol. Incorrect Choices: Cirrhosis does not typically cause any pain as the primary complaint. Ascites, which is not seen in all cases of cirrhosis, can cause abdominal distension, which is described as “discomfort” more than pain. Patients with acute pancreatitis will present very ill and not often ambulatory. The pain is severe and usually in the epigastrium radiating to the mid back. Patients often experience nausea and vomiting. Although alcohol consumption can lead to pancreatitis, this patient did not mention heavy alcohol use. Renal stones will often present with flank pain, and in some cases the pain can radiate to the groin depending on the location of the stone. This pain is also very severe and can cause vomiting. Type of Reasoning: ANALYTICAL This question requires one to analyze the symptoms presented in order to draw a logical conclusion about the most likely cause for them. When pieces of information are analyzed in order to draw a conclusion, analytical reasoning skills are utilized. For this situation, the most likely source of the symptoms is gallstones. Review signs and symptoms of gallstones if answered incorrectly. Cirrhosis. Acute pancreatitis. Renal stones.

Answer 142

Potassium depletion. Diuretics inhibit potassium, sodium, and water resorption by the kidneys. For patients taking diuretics, the therapist must monitor for possible symptoms consistent with potassium depletion and dehydration. Clinical signs and symptoms of potassium depletion include muscle weakness, fatigue, cardiac arrhythmia, abdominal distention, and nausea. Incorrect Choices: Water intoxication results from intake of large amounts of water without balanced solute ingestion. This may occur in individuals who drink only water after having the flu or in athletes who have lost a large amount of body fluid during strenuous exercise that has been replaced by water only. Symptoms include sleepiness, confusion, decreased alertness, poor motor coordination, and hyperventilation. Common causes of metabolic acidosis include drug or chemical toxicity, renal failure, severe diarrhea, and diabetic ketoacidosis. Symptoms of metabolic acidosis are headache, fatigue, drowsiness, nausea, hyperventilation, and convulsions. Hypoglycemia is often seen in patients with diabetes mellitus and is usually the result of a decrease in food intake or an increase in physical activity soon after insulin administration. Symptoms of hypoglycemia include shakiness, perspiration, irritability, pallor, weakness, blurred vision, headache, slurred speech, and hunger. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the adverse side effects of a diuretic in order to arrive at a correct conclusion. This requires deductive reasoning skill, where factual information is recalled in order to determine a correct answer. For this situation, a potential adverse side effect is potassium depletion. Review information on diuretics, especially adverse side effects, if answered incorrectly. Water intoxication. Metabolic acidosis. Hypoglycemia.

Answer 143

Hypotension and dizziness. All of these medications lower blood pressure. If the dosage is too great for patients, they will be hypotensive and likely feel dizzy. Incorrect Choices: Beta-blockers and calcium antagonists control arrhythmias. All medications stabilize blood pressure. If the dose of all these medications is too great, then the patient might experience extreme fatigue. Type of Reasoning: DEDUCTIVE One must recall the adverse effects of various medications in order to arrive at a correct conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, all of the medications may cause hypotension and dizziness. Review adverse effects of cardiac medications if answered incorrectly. Arrhythmia and unstable blood pressure. Extreme fatigue and arrhythmias. Hypotension and decreased electrolytes.

Answer 144

Call for emergency medical services. These are all signs of shunt blockage. Emergency medical services are indicated. Incorrect Choices: All other choices are inappropriate given the emergency nature of this problem and they may also be harmful, exacerbating the developing pressure in the brain (especially the head-down position). Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the options presented and determine which option will most effectively address the problem at hand. This requires evaluative reasoning skill in order to reach a sound conclusion. For this situation, the therapist should call for emergency medical services. Review emergency procedures for shunt blockage if answered incorrectly. Immediately place firm pressure over the fontanel. Administer emergency oxygen. Place the child in a head-down position.

Answer 145

Sitting, bilateral symmetrical UE PNF D2 flexion patterns using rhythmic initiation. Sitting bilateral symmetrical UE PNF D2 flexion patterns using rhythmic initiation are the best choices to open up the chest and enhance lung function (restrictive lung function is common in patients with PD). The sitting posture is a good starting position for a patient with postural instability since the base of support (BOS) is wide and the center of mass (COM) is lowered compared to standing. Incorrect Choices: Progression can occur from sitting to standing postures, but beginning in standing is not a good choice. Supine, UE PNF lift, and reverse lift patterns using rhythmic initiation can be used to improve rolling in patients with PD. Quadruped, arm and leg raises do not address the problem of restrictive lung disease. Type of Reasoning: INDUCTIVE This question requires one to utilize clinical judgment coupled with knowledge of PNF approaches to determine a best course of action for a patient with PD. This necessitates inductive reasoning skill. For this situation, sitting, bilateral symmetrical UE PNF D2 flexion patterns using rhythmic initiation is best. Review PNF approaches and intervention approaches for PD if answered incorrectly. Supine, UE PNF lift and reverse lift patterns using rhythmic initiation. Quadruped, alternate arm and leg raises. Standing, bilateral symmetrical UE PNF D2 flexion patterns using dynamic reversals.

Answer 146

Resistance = 26 ccH2O, 15 minutes continuously. This represents 40% of the patient’s MIP, which is within the optimal training range for increasing ventilatory muscle strength (30%–75% of MIP). Incorrect Choices: 65 and 59 ccH2O are at 100% and 90% of the patient’s maximum, which is too hard of a training protocol. 13 ccH2O is only 20% of the patient’s maximum, which is too easy to cause changes in strength or endurance. Type of Reasoning: INDUCTIVE For this question, one must utilize knowledge of inspiratory muscle training guidelines and MIP values to determine a correct course of action. This requires clinical judgment, which is an inductive reasoning skill. For this case, the therapist should choose resistance = 26 ccH2O, 15 minutes continuously to increase the patient’s functional capacity. If answered incorrectly, review inspiratory muscle training guidelines and MIP values. Resistance = 65 ccH2O, 15 minutes continuously. Resistance = 59 ccH2O, 30 minutes continuously. Resistance = 13 ccH2O, 30 minutes continuously

Answer 147

Steady increase in systolic pressure and either a slight increase or decrease in diastolic pressure. A steady increase in systolic pressure and either a slight increase or decrease in diastolic pressure is a normal response to ramp exercise protocol. With a continual, steady increase in exercise, the systolic blood pressure will continue to rise because the patient is not permitted to reach steady state. Incorrect Choices: In a healthy individual, there should not be a blunted systolic blood pressure response. This occurs most frequently in patients on a beta-blocker. In a normal patient who is not on medications, it is not a normal response to have a drop in blood pressure. A drop in blood pressure would indicate an inability to maintain cardiac output at that intensity of exercise. Diastolic blood pressure does not increase steadily with activity. The normal increase or decrease of diastolic blood pressure is 10 mmHg. Type of Reasoning: DEDUCTIVE One must recall the expected changes in blood pressure during treadmill exercise in order to reach a sound conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, the therapist should expect a steady increase in systolic pressure and either a slight increase or decrease in diastolic pressure. Review responses to treadmill exercise if answered incorrectly. Blunted rise in systolic pressure and a slight decrease in diastolic pressure. Slight drop in systolic pressure and either a slight increase or decrease in diastolic pressure. Steady increase in systolic pressure accompanied by a steady increase in diastolic pressure

Answer 148

Erythrocyte sedimentation rate. Polymyalgia rheumatica is a systemic inflammatory disorder that primarily affects proximal muscles in the shoulder and pelvic girdles, and muscular arteries such as the temporal artery. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood tests are general markers of inflammation and are markedly elevated in patients with the disorder. In addition to those described in the question stem, common clinical findings include weakness, malaise, low grade fever, sweats, weight loss, and depression. Incorrect Choices: Myelin basic protein levels are determined following a lumbar puncture with aspiration of cerebrospinal fluid. Elevated myelin basic protein levels are suggestive of demyelinating diseases such as multiple sclerosis. Elevated serum acid levels are seen in patients with gout and may be seen in patients with other conditions such as diabetes, hypothyroidism, and obesity. Creatine kinase levels are used to help diagnose conditions associated with muscle damage such as rhabdomyolysis and myocardial infarction. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall laboratory testing guidelines related to polymyalgia rheumatica in order to reach a correct conclusion. This is factual information, which is a deductive reasoning skill. For this case, an erythrocyte sedimentation rate test would best establish the diagnosis of this disease. Review laboratory testing guidelines for polymyalgia rheumatica and other forms of arthritis if answered incorrectly. Myelin basic protein. Serum uric acid. Creatine kinase.

Answer 149

Prone positioning on a large gymnastic ball with the child looking up. The child with Down syndrome typically demonstrates hypotonia, developmental delay in postural stability, and poor use of proprioception for postural control. Prone positioning on a large gymnastic ball and having the child look up (neck extension) and/or reach up is a good early intervention to activate the postural extensors. Incorrect Choices: Slow, repetitive rocking on a large ball is relaxing and not indicated for patients with hypotonia. Quadruped opposite arm and leg lifts and standing, weight shifts in modified plantigrade are dynamic stability (controlled mobility) activities and are too advanced for this child, who lacks basic stability. Type of Reasoning: INDUCTIVE One must utilize knowledge of effective intervention approaches to activate postural extensor muscles in order to arrive at a correct conclusion. This necessitates clinical judgment, which is an inductive reasoning skill. For this scenario, the therapist should place the child in prone on a large ball with the child looking up. Review intervention approaches for promoting extensor muscle activation if answered incorrectly. Slow, repetitive rocking movements with the child seated on a large gymnastic ball. Quadruped, opposite arm and leg lifts. Standing, weight shifts in modified plantigrade.

Answer 150

Task-specific practice of familiar activities progressing from parts to whole. Dyspraxia is an impairment of skilled learned movement (a disconnect between the idea for movement and its motor execution). Task-specific practice using familiar activities and progression from parts to whole is the best choice to enhance learning. Incorrect Choices: Reeducation of weak muscles in isolated movements will not carry over to improved functional task performance. Compensatory techniques may be necessary if the dyspraxia is severe and the patient fails to benefit from a remedial intervention program (not evident in this case). Manual facilitation may benefit the patient during task practice, but both maximum use and practice of new tasks are not likely to benefit the patient. Type of Reasoning: INDUCTIVE For this question, the test-taker must draw from knowledge of dyspraxia and effective intervention approaches for it in order to arrive at a correct conclusion. This necessitates clinical judgment, which is an inductive reasoning skill. In this case, the focus of intervention should be task-specific practice of familiar activities progressing from parts to whole. If answered incorrectly, review intervention approaches for dyspraxia. Reeducation of weak muscles using isokinetics before activity practice. Compensatory training strategies with maximum use of environmental cues. Maximum use of manual facilitation of movements and new tasks.

Answer 151

Anterior to posterior glide of the proximal carpal row on distal radius and ulna. A Grade IV anterior to posterior glide of proximal carpal row on distal radius and ulna is the correct choice because during wrist flexion, the proximal row moves dorsally on the distal radius and ulna. Incorrect Choices: Posterior to anterior glide of the proximal carpal row on distal radius and ulna is a component motion for wrist extension. Posterior to anterior glide of the lunate on capitates would likely improve wrist extension. Anterior to posterior glide of lunate on capitates may assist with flexion but does not address the primary area of motion during wrist flexion. Type of Reasoning: INFERENTIAL This question requires one to determine which intervention approach will have the optimal outcome in improving a wrist flexion limitation. This requires one to determine what is most likely to be true, which is an inferential reasoning skill. For this case, the best technique would be a Grade IV anterior to posterior glide of the proximal carpal row on distal radius and ulna. Review joint manipulation techniques, especially for the wrist, if answered incorrectly. Posterior to anterior glide of the proximal carpal row on distal radius and ulna. Posterior to anterior glide of the lunate on capitates. Anterior to posterior glide of lunate on capitates

Answer 152

Acromioclavicular (AC) sprain. Typically AC sprains will have pain at extremes of active range of motion (AROM), especially horizontal adduction and full elevation and pain on passive horizontal adduction and elevation. There are special tests for AC joint disorders:,* Acromioclavicular shear test: positive if abnormal movement of AC joint or pain at joint Incorrect Choices: Calcific tendinitis may be asymptomatic and an incidental finding on an imaging study. If it is symptomatic, it can behave similarly to impingement syndrome. Supraspinatus tendinitis and subacromial bursitis will typically have a painful arc of motion from 60° to 120° of elevation and not at end range. TOS will usually manifest itself with proximal (supraclavicular and shoulder) pain and distal neurovascular symptoms of the upper extremity. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the symptoms presented in order to draw a sound conclusion about the likely diagnosis. This necessitates analytical reasoning skill, where pieces of information are analyzed to determine their relevance. In this case, the symptoms are consistent with acromioclavicular (AC) sprain. Review symptoms of AC sprain if answered incorrectly. Calcific supraspinatus tendinitis. Subacromial bursitis. Thoracic outlet syndrome.

Answer 153

Instruct the patient to protrude the tongue, observe for unilateral deviation. The hypoglossal nerve innervates the tongue. It is best tested by having the patient protrude the tongue. The therapist observes for deviation to the affected side. The tongue should also be inspected for muscle wasting and fasciculations. Articulation problems (dysarthria) occur with lesions of CN XII. Incorrect Choices: The gag reflex is impaired with lesions of CN IX Glossopharyngeal and CN X Vagus. Clenching the teeth and holding against resistance are tests for CN V Trigeminal. Showing the teeth and puffing out the cheeks are tests for CN VII Facial. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the guidelines for testing hypoglossal nerve (CN XII) function. This is factual information, which requires deductive reasoning skill. In this case, the therapist should instruct the patient to protrude the tongue and observe for unilateral deviation. If answered incorrectly, review testing guidelines for the hypoglossal nerve. Stimulate the back of the throat on each side and observe for gag reflex. Instruct the patient to clench the teeth and hold against resistance. Instruct the patient to show the teeth and puff out the cheeks

Answer 154

Posterior tibialis tendon. The posterior tibial tendon helps hold up the arch up and provides support when stepping off on the toes when walking. If this tendon becomes inflamed, overstretched, or torn, one may experience pain on the inner ankle and gradually lose the inner arch on the bottom of the foot, leading to flatfoot (posterior tibial tendon dysfunction [PTTD]). Incorrect Choices: The other choices are not associated with acquired flatfoot. Type of Reasoning: DEDUCTIVE For this question, one must recall the tendon that is associated with flatfoot deformity. This necessitates the recall of factual information, which is a deductive reasoning skill. For this scenario, the tendon to be examined is the posterior tibialis tendon. Review flatfoot deformity if answered incorrectly. Anterior tibialis tendon. Fibularis longus tendon. Achilles tendon.

Answer 155

Positive Hoffman’s test. Due to compression of the spinal cord, patients with a cervical myelopathy typically exhibit upper motor neuron signs, such as the presence of pathological signs (Hoffman’s, Babinski, clonus), hyperreflexia, and ataxia. Additional clinical findings include loss of strength in the upper extremities, clumsiness, and bilateral upper extremity paresthesias. Incorrect Choices: Each of the incorrect choices is characteristic of the presentation of a patient who might have a lumbo-sacral radiculopathy. These findings include signs of lower motor neuron disease in a myotomal pattern or sensory deficits in a dermatomal distribution. Type of Reasoning: INFERENTIAL This question requires the test-taker to infer what is likely to be true of a situation after weighing the information provided. Inferential reasoning skill is often used to draw conclusions about likely findings or symptoms based on a provided diagnosis. In this case, a positive Hoffman’s test would corroborate the diagnosis of cervical myelopathy. If answered incorrectly, review information on cervical myelopathy and Hoffman’s sign. Diminished patellar tendon and Achilles tendon reflexes. Loss of sensation in the L5 dermatome. Muscle weakness in the S1 distribution.

Answer 156

Temporary pallor and cyanosis of the digits. Raynaud disease is a vasospastic disorder characterized by intermittent episodes of small artery constriction of the digits of the fingers (rarely the toes), causing temporary pallor and cyanosis. Incorrect Choices: The condition is most likely caused by hypersensitivity of the digital arteries to cold (not tactile stimulation). The condition is temporary and not associated with loss of proprioception or tactile discrimination. Type of Reasoning: DEDUCTIVE This question provides a diagnosis, and the test-taker must infer the most likely examination findings. Questions of this nature often require inferential reasoning skill. For this situation, one would expect to see temporary pallor and cyanosis of the digits. Review signs and symptoms of Raynaud’s disease if answered incorrectly. Hypersensitivity to tactile stimuli. Loss of proprioception of the affected fingers. Loss of two-point discrimination in the affected hands

Answer 157

Stabilize the left shoulder and stretch the neck into right side-bending and left rotation. A left-sided torticollis is present with contracture of the left sternocleidomastoid. The muscle action of the left sternocleidomastoid is left side-bending and right rotation. To most effectively stretch the left sternocleidomastoid, stabilize the left shoulder and place the cervical spine into a combination of right side-bending and left rotation. Incorrect Choices: While right side-bending would still stretch the left sternocleidomastoid, the muscle is most effectively stretched with a combination of side-bending and rotation. Placing the cervical spine in left side-bending and right rotation would be an effective stretch for the right sternocleidomastoid. Type of Reasoning: INDUCTIVE This question requires the test-taker to recall the best treatment approaches for torticollis, specifically, stretching techniques to normalize the muscle length of the sternocleidomastoid. This requires clinical judgment, which is an inductive reasoning skill. For this case, the therapist should stabilize the left shoulder and stretch the neck into right side-bending and left rotation to stretch the sternocleidomastoid. Review stretching guidelines for torticollis if answered incorrectly. Stabilize the left shoulder and stretch the neck into right side-bending. Stabilize the left shoulder and stretch the neck into left side-bending. Stabilize the left shoulder and stretch the neck into left side-bending and right rotation.

Answer 158

Pressure-tolerant weight bearing is occurring. Pressure areas of the typical transtibial residual limb include the patellar tendon, the medial tibial plateau, the tibial and fibular shafts, and the distal end. Incorrect Choices: These are expected areas of redness. All other choices would not result in that pattern of redness. Type of Reasoning: INFERENTIAL For this question, one must infer what is likely to be true for a patient who is gait training with a transtibial prosthesis. This requires inferential reasoning skill. Using knowledge of prosthetics, one should conclude that pressure-tolerant weightbearing is occurring during stance. Review gait training guidelines with transtibial prosthetics if answered incorrectly. The socket is too small and the residual limb is not seated properly. The socket is too large and pistoning is occurring. There is improper weight distribution during stance

Answer 159

Percussion and shaking can be done in the area surrounding the chest tube. It is possible to complete manual techniques in the area of the chest tube. It is often the area in most need of airway clearance. It is important to consider pain management when doing this intervention. Incorrect Choices: Percussion and shaking are not contraindicated, but it is important to consider that this may be agitating to patients with a severe brain injury. Also, placing the patient in Trendelenburg should be avoided in the acute period to eliminate increases in intracranial pressure. Percussion and shaking can be completed bilaterally and with the chest tube in place. It is important to attend to patient comfort and chest tube positioning when in right side-lying. Type of Reasoning: INDUCTIVE This question requires one to determine a best course of action based on knowledge of airway clearance guidelines. This requires clinical judgment, which is an inductive reasoning skill. For this scenario, it is possible to perform percussion and shaking in the area surrounding the chest tube. Review airway clearance techniques, especially around chest tube sites, if answered incorrectly. Percussion and shaking are contraindicated due to the traumatic brain injury. Percussion and shaking can be done only in the right side-lying position. Percussion and shaking can be done only when the chest tube is removed.

Answer 160

Deep venous thrombosis. The calf is a common location for the development of deep venous thrombosis (DVT). When symptomatic, the patient typically describes the pain associated with a DVT as throbbing or burning. Incorrect Choices: There is no information in the patient profile to suggest that this patient sustained a gastrocnemius strain. Pain is not a primary complaint for the patient who develops lymphedema. While lumbosacral radiculopathy may cause calf pain and burning, it does not lead to swelling of the calf. Additionally, “throbbing” is a pain descriptor that is most often associated with vascular conditions. Type of Reasoning: Analytical Gastrocnemius strain. Lymphedema. Lumbosacral radiculopathy.

Answer 161

Wells Criteria. Wells Criteria are highly sensitive and specific for the diagnosis of DVT. Several clinical examination findings are assigned a point value and the total score of the findings determines the clinical probability of the patient having a DVT. See Table 4-13 for the complete list of Wells Criteria and scoring. Incorrect Choices: Homan’s sign is an unreliable test to diagnose DVT and is no longer recommended. Only about half of patients with DVT experience pain with Homan’s sign. Stemmer’s sign is a special test used to identify the presence of lower extremity lymphedema. The Thompson test is used to determine if a patient has a tear of the Achilles tendon. Type of Reasoning: Deductive Homan’s sign. Stemmer’s sign. Thompson test.

Answer 162

Recent prolonged bed rest. A DVT occurs when a blood clot forms in a deep vein, usually in the leg or thigh. Prolonged bed rest or immobilization of the lower limb, such as after a major surgery or illness, are often associated with development of a DVT. Being sedentary for long periods such as during air travel can also lead to the development of a DVT. Other risk factors in this patient include male gender, age > 60 years, and a previously documented DVT. Incorrect Choices: None of the other answer choices are risk factors for DVTs delineated in Wells Criteria. Type of Reasoning: Deductive Hypertension. Hyperlipidemia. Chronic low back pain.

Answer 163

Mobility combined with mechanical compression. According to the Venous Thromboembolism Clinical Practice Guideline published by Hillegass et al. (see Box 4-3), there is strong evidence for physical therapists to promote a culture of mobility coupled with mechanical compression (graded compression stockings) for patients with a DVT that have been initiated on an anticoagulant. Incorrect Choices: Bed rest places a patient at further risk for a DVT or pulmonary embolism. It may be helpful to have a patient use an assistive device if they are experiencing pain associated with the newly diagnosed DVT, but evidence suggests that movement is beneﬁcial and there is no indication to prevent weight-bearing on the affected limb. Type of Reasoning: Inductive Continue bed rest. Bed rest of 72 hours after starting the anticoagulant. Mobility with an assistive device to prevent weight-bearing on the right lower limb

Answer 164

Open chain resisted knee flexion. The attachments of the medial meniscus include the semimembranosus tendon, MCL and fibrous capsule, and medial meniscopatellar ligament. During open chain resisted knee flexion, the semimembranosus tendon will pull on the posterior aspect of the medial meniscus and in doing so may tear the surgical repair. Resisted knee flexion should be avoided for several weeks postoperatively until the repair site is stable. Incorrect Choices: Ankle pumps do not produce any adverse forces on the healing meniscus and are beneficial development postsurgically and during periods of immobilization for prevention of DVT. Isometric quad sets produce little tibiofemoral joint motion. Resisted knee extension produces some anterior meniscal motion via the medial meniscopatellar ligament, but the amount of translation is minimal and not harmful to the repair. Type of Reasoning: INDUCTIVE One must determine the type of exercise to avoid interruption of a medial meniscus repair in order to arrive at a correct conclusion. Drawing from knowledge of kinesiology, the test-taker must utilize clinical judgment to draw a correct conclusion, which is an inductive reasoning skill. For this case, open chain resisted knee flexion should be avoided. If answered incorrectly, review exercise guidelines for medial meniscus repair. Ankle pumps. Isometric quadriceps contractions. Open chain resisted knee extension.

Answer 165

A posterior rolling walker. A posterior rolling walker is used to promote an upright posture (eliminates the forward lean seen in use of the standard anterior walker). The addition of wheels improves walking speed and reduces energy expenditure. Incorrect Choices: All other choices do not achieve these same goals. Type of Reasoning: INDUCTIVE One must utilize knowledge of mobility devices in order to arrive at a sound conclusion for this question. This necessitates clinical knowledge and judgment, which is an inductive reasoning skill. For this scenario, the therapist should choose a posterior rollator walker to promote an upright posture and higher walking speeds. Review mobility devices, especially rolling walkers, if answered incorrectly. A reciprocating gait orthosis. An anterior rolling walker. Loftstrand (forearm) crutches.

Answer 166

Prone with a pillow placed under the patient’s hips and lumbar spine. Patients with central spinal stenosis have a position preference of flexion of the lumbar spine. Flexion of the low back opens the vertebral canal and lumbar foramina, thereby relieving pressure on lumbosacral nerve roots. The “shopping cart sign” is an illustration of how leaning forward in flexion can help alleviate symptoms in patients with spinal stenosis. Placing a pillow under the hips and low back of the prone patient puts the lumbar spine into some flexion and is more comfortable than prone lying in neutral. Incorrect Choices: Each of the other options places the patient into lumbar spine extension and will exacerbate the patient’s symptoms. Type of Reasoning: INDUCTIVE For this question, the test-taker must determine a best course of action, based on knowledge of the diagnosis and positions that alleviate symptoms of the condition. This requires clinical judgment, which is an inductive reasoning skill. For this case, the therapist should place the patient in prone with a pillow placed under the patient’s hips and lumbar spine. Review positioning techniques for central spinal stenosis if answered incorrectly. Prone with the patient propped up on elbows. Prone with the foot of the bed slightly elevated. Prone with the head of the bed slightly elevated

Answer 167

Acute anterior compartment syndrome. Acute compartment syndromes are usually the result of direct trauma or a tibial fracture, resulting in swelling and increased compartmental pressure that results in local muscle ischemia. The six Ps of a compartment syndrome are pain, palpable tenderness, paresthesia, paresis, pallor, and pulselessness. Four of the Ps were described in the question stem: severe pain, paresthesias, paresis (weak ankle dorsiflexors), and pulselessness. Incorrect Choices: While a syndesmosis injury is possible, that type of injury does not typically present with any type of neurovascular deficit. Chronic exertional compartment syndrome and medial tibial stress syndrome are both overuse disorders, whereas an acute traumatic injury was described in this question. Type of Reasoning: ANALYTICAL For this question, the test-taker must analyze the symptoms presented in order to make an accurate determination of the diagnosis. This requires analytical reasoning skill, where pieces are information are weighed to draw correct conclusions. For this scenario, the symptoms most likely indicate acute anterior compartment syndrome. If answered incorrectly, review information on acute anterior compartment syndrome. Syndesmosis injury. Chronic exertional compartment syndrome. Medial tibial stress syndrome.

Answer 168

Encourage expression of feelings and memories. When treating the patient with a terminal illness, the therapist should provide support and understanding of the grief process, encourage expression of feelings and memories, and respect privacy, cultural, or religious customs. Incorrect Choices: The therapist needs to maintain the boundaries of treatment and not discharge the patient. Keeping friends and relatives updated would violate the patient’s privacy unless specific permission is given by the patient. The patient should be kept involved in the decision planning in order to reduce anxiety. Type of Reasoning: EVALUATIVE One must weigh the options presented in order to determine the best course of action for a patient with AIDS. This necessitates evaluative reasoning skill, where one weighs the benefits of potential courses of action. For this scenario, the therapist should encourage expression of feelings and memories. Review the grief process for patients with terminal illness if answered incorrectly. Discontinue treatment if the patient/therapist relationship becomes overly dependent. Keep the patient’s friends and relatives up to date on the patient’s treatment and state of mind. Discontinue any activities that may cause the patient discomfort in order to keep anxiety levels low.

Answer 169

L1. Hip flexors are innervated and functional at the L2 spinal cord level (key muscle). Therefore, an L1 lesion would produce complete loss of this muscle function. Incorrect Choices: Key muscles innervated and therefore functional at the remaining lumbar segments include knee extensors at L3, ankle dorsiflexors at L4, and long toe extensors at L5. Type of Reasoning: DEDUCTIVE For this question, the test-taker must recall the innervation levels of the lumbar spine in order to arrive at a correct conclusion. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, the lack of hip flexion, abduction, and knee extension are consistent with an L1 spinal cord lesion. Review innervation of the lumbar spine, especially L1, if answered incorrectly. L3. L4. L5.

Answer 170

Briefly examine the patient and intervene appropriately. If a PT accepts an individual for physical therapy services, the PT will be responsible for the examination, evaluation, and intervention of a patient. At the least, a systems review and brief plan of care should be formulated before intervening. Electronic medical records help to minimize difficulties in handwriting interpretation; however, systems aren’t perfect. Incorrect Choices: Asking the patient for information can be unreliable. Trying to reach the ill therapist by phone is inappropriate and may also be unreliable since the ill therapist may not have access to the medical record at home. It is not the co-worker’s responsibility to interpret others’ notes; no one should have access to patient information if not involved in the care of that patient. Type of Reasoning: EVALUATIVE This question requires one to weigh the potential courses of action and determine which action will resolve the problem at hand. This necessitates evaluative reasoning skill, where potential courses of action are weighed to draw sound conclusions. For this situation, the therapist should briefly examine the patient and intervene appropriately. Review professional roles and responsibilities if answered incorrectly. Ask the patient what treatment had been administered in the last session. Attempt to reach the ill therapist by phone before commencing the session. See if other coworkers can figure out how to access the information in the medical record.

Answer 171

Painful upper extremity motion as a result of skin irritation and soft tissue fibrosis. Patients undergoing radiation therapy often experience skin irritation, swelling, and fibrosis of connective tissue at the treatment site. Ipsilateral trunk and upper extremity mobility may be painful and limited if the target of radiation therapy is the breast or in the axilla. Incorrect Choices: Hemorrhage following heavy resistance exercise is a possibility if the patient’s platelet count drops too low, but this is a side effect of chemotherapy, not radiation therapy. Chemotherapy attacks the rapidly dividing cancer cells, but it also affects all rapidly dividing cells in the body, including all blood cell types. Chemotherapy can also be toxic to the cells that line the gastrointestinal tract and can result in nausea and vomiting, which may lead to poor nutritional intake and dehydration. Lymphedema is a complication that can occur after treatment of breast cancer as a result of the removal of lymph nodes, typically in the axillary and pectoral regions. Radiation to the axillary lymph nodes may cause lymphedema, but the treatment site in this case was the breast. Type of Reasoning: INDUCTIVE For this question, the test-taker must determine a best course of action in developing a treatment plan based on possible side effects associated with radiation therapy. This requires clinical judgment, which is an inductive reasoning skill. For this case, it is MOST IMPORTANT to consider the presence of painful upper extremity motion as a result of skin irritation and soft tissue fibrosis. If answered incorrectly, review side effects of radiation therapy. Increased possibility of hemorrhage resulting from heavy resistance exercise. Gastrointestinal dysfunction. Development of lymphedema in the ipsilateral upper extremity.

Answer 172

Tilted toward the involved side, with the chin rotated toward the opposite side. Congenital muscular torticollis involves a shortened sternocleidomastoid (SCM) muscle with a weakened contralateral SCM muscle, with a resulting posture of lateral flexion of the head to the involved (right) side, tight SCM muscle side and rotation of the head to the noninvolved (left) side. Incorrect Choices: The other choices do not correctly identify the impairments in head position and ROM seen with muscular torticollis. Type of Reasoning: INFERENTIAL For this question, the test-taker must determine what is likely to be the clinical presentation for a child with torticollis. This requires one to recall the symptoms of congenital muscular torticollis in order to determine the likely clinical presentation, necessitating inferential reasoning skill. For this case, one would expect the head to be tilted toward the involved side with the chin rotated toward the opposite side. Review symptoms of congenital muscular torticollis if answered incorrectly. Tilted toward the noninvolved side, with the chin rotated toward the same side. Limited in ROM in lateral flexion toward the involved side. Limited in ROM in neck flexion and extension

Answer 173

Osteoporosis. This patient is exhibiting several risk factors for osteoporosis: postmenopausal age, low body weight, loss of height, sedentary lifestyle, tobacco use, and hyperthyroidism (Graves’ disease). Signs and symptoms include severe and localized thoracic-lumbar pain, increased pain with prolonged upright posture, decreased pain in hook-lying, loss of height, and kyphosis (dowager’s hump). Her pain is most likely due to compression fractures, which can be confirmed on x-ray. Osteoporosis can be confirmed with a bone density scan. Incorrect Choices: Osteoarthritis produces asymmetrical pain with typical involvement of large weightbearing joints. Gout pain is limited to only a few joints, typically affecting the first metatarsal, the knee, or the wrist. Spinal stenosis typically occurs in the lumbar spine and is accompanied by pain when standing and walking, extending into the buttocks and proximal thigh, nocturnal pain, and lower motor neuron (LMN) signs. Type of Reasoning: ANALYTICAL This question provides a group of symptoms, and the test-taker must determine the most likely diagnosis based on a risk factor assessment. This requires analytical reasoning skill where symptoms are analyzed to reach sound conclusions. For this scenario, one would suspect the problem to be osteoporosis. Review risk factors for the development of osteoporosis if answered incorrectly. Osteoarthritis. Gout. Spinal stenosis

Answer 174

Valgus position of the heel. Excessive foot pronation is known as pes planus or pes valgus—a “flat foot deformity.” The foot remains in pronation at the subtalar joint during weightbearing. The slight pronation of both the subtalar and transverse tarsal joints seen in normal stance is exaggerated. Incorrect Choices: The question asks what this observation during gait would reveal. Many patients have pronated feet without plantar fasciitis. Overpronation can cause stress or chronic inflammation on the plantar fascia ligament (plantar fasciitis) and lead to numerous related foot and ankle injury conditions. Over time, the force of the impact is absorbed into the tissues, which can lead to conditions such as Achilles tendinitis, bunions, heel spurs, metatarsalgia, Morton’s neuroma, plantar fasciitis (heel and arch pain), posttibial tendinitis, shin splints, and tarsal tunnel syndrome, as well as knee pain (chondromalacia, iliotibial band syndrome), hip pain, and lower back discomfort. Related conditions include corns, calluses, and hammertoes. Forefoot valgus and varus position of the heel are not congruent with foot pronation. Type of Reasoning: INFERENTIAL For this question, one must determine the likely clinical presentation based on the provided clinical observation. This necessitates inferential reasoning skill, where one determines what is likely to be true of a situation. In this case, one would expect valgus position of the heel to be present. If answered incorrectly, review flat foot deformity and clinical findings. Varus position of the heel. Forefoot valgus. Plantar fasciitis.

Answer 175

Intermittent compression pump. An intermittent compression pump provides external pressure, increasing the external hydrostatic pressure, which encourages reabsorption of the edema and minimizes fluid outflow from vessels. Pressures greater than 45 mmHg are contraindicated. Incorrect Choices: The other physical agents are not effective for this type of edema. In addition, the target area is too large for ultrasound (US) to cover reasonably, and a contrast bath would require the patient to be treated in a dependent position, which would further contribute to edema formation. Type of Reasoning: INDUCTIVE For this question, one must utilize clinical judgment in order to determine the best intervention approach for a patient with phase II lymphedema venous insufficiency. This requires inductive reasoning skill. Having knowledge of effective edema reduction techniques for this diagnosis, the therapist should choose the intermittent compression pump to reduce edema. Review edema reduction techniques for venous insufficiency if answered incorrectly. Crushed ice pack. Pulsed ultrasound. Contrast bath

Answer 176

Walking 30 minutes three times weekly. Walking 30 minutes three times weekly. Weightbearing, non-jarring exercises have been proven to reduce or slow bone loss without causing vertebral compression. Incorrect Choices: Individuals with osteoporosis should initially avoid high-impact exercises to limit excessive vertebral loading, which is the case with aerobics and jogging.Initially, exercise intensity should be lower at first (50% of the one rep max and more frequently than one time per week). Type of Reasoning: INDUCTIVE For the question, the test-taker must utilize clinical judgment in order to determine the best recommendation for exercise for a patient with osteoporosis. This requires inductive reasoning skill, where application of clinical knowledge is paramount to arriving at a correct conclusion. For this scenario, the therapist should first recommend walking 30 minutes three times weekly. If answered incorrectly, review exercise programs for individuals with osteoporosis. High-impact aerobics for 45 minutes two to three times per week. Jogging 30 minutes four times weekly. Strengthening exercises to the upper and lower extremity muscles beginning at 75% of one rep maximum one time per week.

Answer 177

Do you have difficulty breathing? Symmetrical bilateral edema can signify congestive heart failure (CHF). Moderate to severe CHF can lead to pulmonary edema and subsequent shortness of breath. Intermittent compression may shift a significant amount of fluid from the periphery to the core circulation, thus increasing the load on the heart and immediate risk for a cardiac event. It is important to screen patients for shortness of breath as heart failure with pulmonary edema are contraindications to intermittent pneumatic compression. Incorrect Choices: A bull’s-eye rash is associated with Lyme’s disease and may cause joint pain and myalgia but would not result in bilateral lower extremity edema. Asking a patient if they experienced a fall and ankle sprain would explain unilateral localized pain and swelling but not bilateral edema. A gradual weight change over 1 year is less concerning than a rapid fluctuation in weight over days to weeks. Specifically, rapid weight changes are associated with high-risk health conditions (e.g., CHF, cancer, liver, or renal disease) that are recognized as contraindications to intermittent compression. Type of Reasoning: EVALUATIVE For this question, the test-taker must weigh the questions presented and determine which question is most important to ask prior to use of intermittent compression. Evaluative reasoning skill is often used when weighing the merits of potential courses of action. For this scenario, it is most important to ask if the patient has difficulty breathing, as this can signify CHF. Review contraindications for intermittent compression, if answered incorrectly. Did you recently have a “bull’s-eye” rash anywhere on your body? Did you recently fall and sprain your ankle? Has your weight gradually changed in the past the 12 months?

Answer 178

Prone, with no pillow under the hips or abdomen. Neutral or extended position of the spine allows for separation of the vertebral bodies while preventing excessive stress on the posterior structures. Incorrect Choices: All of the other choices place the person in a flexed position, which places greater stress on the posterior structures of the disc. In the early stages of treatment, a flexed position is inadvisable with a posterior herniation. Type of Reasoning: INDUCTIVE For this question, one must utilize clinical judgment to determine the best positioning for lumbar traction. This requires inductive reasoning skill. For this case, the therapist should position the patient in prone, with no pillow under the hips or abdomen. Review lumbar traction techniques, especially for a posterior herniation, if answered incorrectly. Prone, with a pillow under the hips and abdomen. Supine, with the hips and knees flexed to 45 degrees. Supine, with hips and knees flexed to 90 degrees.

Answer 179

Rectus capitis posterior major, upper trapezius. Muscles that will adaptively shorten in an individual with this posture also include the cervical paraspinal muscles, scalenes, levator scapulae, and suboccipital muscle group. Incorrect Choices: Due to the excessive kyphosis, the muscle fibers of the lower trapezius will be in a lengthened position and should be the target of strengthening exercises, not a stretching program. Type of Reasoning: INDUCTIVE For this question, the test-taker must draw from knowledge of treatment techniques for forward head posture, thoracic kyphosis, and rounded shoulders in order to arrive at a correct conclusion. This necessitates clinical judgment, which is an inductive reasoning skill. For this case, the therapist should focus on strengthening the pectoralis minor, rectus capitis posterior major, and upper trapezius. Review treatment techniques for postural dysfunction if answered incorrectly. Rectus capitis posterior major, lower trapezius. Upper trapezius, lower trapezius. Rectus capitis posterior minor, lower trapezius.

Answer 180

Diaphragm. Contraction of the diaphragm causes the ribs to move outward, which is the desired motion in this case. Incorrect Choices: Facilitating the rectus abdominis will cause trunk flexion, which will not increase lower rib expansion. Anterior scalenes facilitation will assist with increasing the negative pressure on inspiration; however, it will not assist with expanding the lower rib cage. Facilitation of the internal intercostals will cause the opposite motion than the desired lower rib expansion. Type of Reasoning: INDUCTIVE One must determine, based on the deficits presented, which muscle to facilitate in order to improve function. This requires inductive reasoning skill, where clinical judgment is paramount to arriving at a correct conclusion. For this situation, the therapist should focus on facilitating the diaphragm. If answered incorrectly, review facilitation techniques of the rib cage. Rectus abdominis. Anterior scalenes. Internal intercostals.

Answer 181

Femoroacetabular impingement. Femoroacetabular impingement (see Box 2-4) results from a deformity of the femoral head or neck and the acetabular rim. Patients typically complain of anterior groin or hip pain reproduced by FADDIR and/or FABER tests, hip internal rotation less than 20° (with the hip at 90° of flexion), mechanical symptoms such as snapping or clicking, and radiographic findings of a cam (femoral neck/head) or pincer (acetabular rim) deformity. Incorrect Choices: Trochanteric bursitis is an inflammation of the deep trochanteric bursa, and the associated pain is palpable at the lateral aspect of the hip. Piriformis syndrome occurs when tightness or spasm of the piriformis muscle causes compression of the sciatic nerve. Symptoms are typically located in the buttock region, not the groin. Iliotibial band friction syndrome results from tightness of the IT band and results in pain at the distal lateral knee. Type of Reasoning: ANALYTICAL This question provides a group of signs and symptoms, and the test-taker must determine the most likely diagnosis. This necessitates analytical reasoning skill, where information is weighed or analyzed to draw a correct conclusion. In this case, the diagnosis is most likely femoroacetabular impingement. Review symptoms of femoroacetabular impingement if answered incorrectly. Trochanteric bursitis. Piriformis syndrome. Iliotibial band friction syndrome.

Answer 182

Therapeutic aquatics, 3 days/week for 20 minutes. A good choice for an initial intervention is therapeutic aquatics. The warmth of the water can ease muscle and joint pain, and the buoyancy can assist fatigued limbs. An initial exercise duration of up to 20 minutes per session in 2- to 4-minute intervals is recommended. Incorrect Choices: All other choices are too vigorous for this patient at this time. If weakness or symptoms are recent, exercise duration should be no more than 15 minutes per session. Type of Reasoning: INDUCTIVE For this question, the test-taker must determine the best initial intervention approach for a patient with PPS. This necessitates clinical judgment, which is an inductive reasoning skill. For this case, the therapist should initiate intervention with therapeutic aquatics, 3 days/week for 20 minutes. Review intervention approaches for PPS if answered incorrectly. Treadmill training at 2 mph and a 10 degree slope, 3 days/week for 30 minutes. Cycle ergometry at peak heart rate, 3 days/week for 40 minutes. Strength training at 70% 1 RM, 2 days/week.

Answer 183

Circumduction. Circumduction is the most likely compensatory gait deviation when tibial advancement is limited (e.g., spasticity of plantar flexors). Incorrect Choices: Trendelenburg gait is a lateral trunk lean that results from a weak or paralyzed gluteus medius on the stance side. An exaggerated flexion synergy results in flexion, abduction, and external rotation at the hip when the leg is lifted. An exaggerated extension synergy results in extension, adduction, and internal rotation (a scissoring pattern). Type of Reasoning: INFERENTIAL This question requires one to determine what is most likely to be true for a patient with a gait deviation. This requires inferential reasoning skill. Based on the description of symptoms, one should infer that circumduction would be the most likely gait deviation. Review gait deviations associated with limited tibial advancement. Trendelenburg. Exaggerated flexion synergy. Exaggerated extension synergy.

Answer 184

Locomotor training using a personal listening device with 80 to 100 beats/min music. Locomotor training using a personal listening device and 80 to 100 beats/min music has been shown to improve rhythmicity and decrease FOG episodes in patients with PD. Incorrect Choices: Part-to-whole training is not effective for motor skills with highly integrated elements (gait). Light resistance will likely increase the patient’s stiffness during gait (already a problem with PD). BWSTT might be helpful to improve the rhythmicity of gait, but 40% unweighting is too high and 2.7 mph is too fast for this patient. Type of Reasoning: INDUCTIVE For this question, one must utilize knowledge of Parkinson’s disease and effective gait training approaches in order to arrive at a correct conclusion. This necessitates inductive reasoning skill, where clinical judgment is paramount to choosing sound conclusions. For this situation, the best intervention approach is locomotor training using a personal listening device with 80 to 100 beats/min music. Review gait training approaches for PD if answered incorrectly. Part-to-whole training in sequencing of required gait elements. Walking using lightly resisted progression with elastic bands to facilitate forward progression. Body weight support and treadmill training (BWSTT), 40% unweighting, 3% incline, at 2.7 mph.

Answer 185

Dorsal (anterior) glide of the proximal phalanx on the metatarsal. An anterior or dorsal glide of the phalanx on the metatarsal would be used to increase first metatarsophalangeal extension. In this plane, a concave surface is moving on a convex surface, so the anterior glide will occur in the same direction as the osteokinematic or physiologic motion of extension. Incorrect Choices: Medial and lateral glides may be used to improve abduction/adduction or overall mobility of the joint. A plantar or posterior glide of the first phalanx would be used to improve metatarsophalangeal joint flexion. In this plane, a concave surface is moving on a convex surface, so the plantar glide will occur in the same direction as the physiologic motion of plantarflexion. See Table 2-1 for a review of the concave-convex rule application to peripheral joints. Type of Reasoning: INDUCTIVE For this question, one must recall joint mobilization guidelines and then apply them to a patient who has limited metatarsophalangeal extension with pain and stiffness. This requires inductive reasoning skill, where clinical knowledge is applied to therapeutic situations. For this case, the therapist should choose dorsal (anterior) glide of the proximal phalanx on the metatarsal. If answered incorrectly, review joint mobilization information, especially for the foot. Medial glide of the proximal phalanx on the metatarsal. Lateral glide of the proximal phalanx on the metatarsal. Plantar (posterior) glide of the proximal phalanx on the metatarsal.

Answer 186

Hyperalgesia, allodynia, and hyperpathia. CRPS includes symptoms of pain, vascular changes, and atrophy. Early signs (stage 1) include hyperalgesia (increased sensitivity to pain), allodynia (all stimuli are perceived as painful), and hyperpathia (increased intensity) with edema, increased sweating, and thin, shiny skin. Incorrect Choices: Later signs and symptoms (stage 2) include increased pain with edema and atrophic skin and nail changes. Late stage changes (stage 3) include spreading pain, hardening of edema, cool, dry, and cyanotic skin, developing osteoporosis, and ankylosis. Type of Reasoning: INFERENTIAL One must infer what is likely to be true of a patient with early stage CRPS in order to arrive at a sound conclusion. This necessitates inferential reasoning skill, where one determines what is likely to be true of therapeutic situations. In this case, the early stage presentation is likely to be hyperalgesia, allodynia, and hyperpathia with edema, increased sweating, and thin, shiny skin. Review signs and symptoms of CRPS if answered incorrectly. Worsening pain with edema and atrophic skin and nail changes. Cool, dry, and cyanotic skin with thickened fascia and developing contracture. Muscle atrophy, osteoporosis, and developing ankylosis.

Answer 187

Nerve conduction velocity (NCV) testing. NCV provides the most useful measurement of demyelinization in polyneuropathy. Conduction time is measured by recording the evoked potential from either a motor or sensory nerve. Speed of nerve transmission is directly related to level of myelination. Incorrect Choices: EMG is used to document (1) the different types of peripheral axonal injury (axonotmesis, neurotmesis) and (2) impairment of muscle recruitment. TENS is an electrical modality designed to provide afferent stimulation for pain management. Motor point stimulation is the area on the skin of greatest excitability to stimulate a muscle. Type of Reasoning: DEDUCTIVE This question requires one to recall the benefits of each of the potential tests provided in order to choose the one that will be most useful in determining whether demyelination has taken place. This necessitates the recall of factual information, which is a deductive reasoning skill. For this situation, nerve conduction velocity (NCV) testing would be most useful. Review testing for demyelinization if answered incorrectly. Electromyography (EMG). Transcutaneous electrical nerve stimulation (TENS). Motor point stimulation.

Answer 188

HLA-B27 genetic marker test. The HLA-B27 test is primarily ordered to help strengthen or confirm a suspected diagnosis of ankylosing spondylitis (AS), reactive arthritis (formerly Reiter’s syndrome), and juvenile rheumatoid arthritis. The test alone is not diagnostic of AS. It is ordered as part of a group of tests to help diagnose inflammatory arthritic conditions. This group of tests typically includes a rheumatoid factor, erythrocyte sedimentation rate, and a C-reactive protein. Incorrect Choices: Myelin basic protein levels are determined following a lumbar puncture with aspiration of cerebrospinal fluid. Elevated myelin basic protein levels are suggestive of demyelinating diseases such as multiple sclerosis. A1c, also called hemoglobin A1c or glycated hemoglobin, is hemoglobin with glucose attached. The A1c test evaluates the average amount of glucose in the blood over the last 2 to 3 months and is ordered to measure blood sugar levels in patients with diabetes or suspected diabetes/prediabetes. Creatine kinase levels are used to help diagnose conditions associated with muscle damage such as rhabdomyolysis and myocardial infarction. Type of Reasoning: DEDUCTIVE This question requires the test-taker to recall laboratory testing guidelines for AS. This necessitates the recall of factual information, which is a deductive reasoning skill. For this case, an HLA-B27 test would help establish the diagnosis. Review information on AS and laboratory testing if answered incorrectly. Myelin basic protein. A1c. Creatine kinase.

Answer 189

Pulmonary embolism due to use of birth control. Patients taking hormonal birth control are at increased risk for pulmonary embolism or deep venous thrombosis. If a patient taking hormonal contraceptives experiences a marked increase in their respiratory and heart rates, they should be referred for emergency medical treatment. Normal adult respiratory rates are 12–20 breaths per minute and the normal adult heart rate is 60–100 beats per minute. Incorrect Choices: It is highly unlikely that anxiety would cause a drop in SpO2. Pleural effusion due to lung cancer is very unlikely in a premenopausal woman with no history of smoking. A tension pneumothorax typically occurs as a result of trauma and does not usually result from exercise. Type of Reasoning: INFERENTIAL This question requires the test-taker to analyze the presenting patient symptoms and then determine what is mostly likely to be the cause for such symptoms. This requires inferential reasoning skill, where one infers or determines what is likely to be true of a clinical situation. In this case, the symptoms are consistent with a pulmonary embolism. If answered incorrectly, review symptoms of pulmonary embolism. Anxiety due to stress at work and home. Pleural effusion due to lung cancer. Tension pneumothorax due to increased exercise

Answer 190

Perform a canalith repositioning maneuver. The patient’s presentation is consistent with right posterior canal benign paroxysmal positional vertigo (BPPV) which is treated with the canalith repositioning maneuver. Incorrect Choices: The log roll maneuver is used to treat horizontal canal BPPV. Gaze stabilization exercises and Cawthorne-Cooksey exercises are used to address impairments associated with vestibular hypofunction. BPPV results in overactivity of vestibular receptors due to the presence of otoconia in the semicircular canal, rather than diminished vestibular function. Type of Reasoning: INDUCTIVE For this question, one must recall effective treatment approaches for BPPV in order to arrive at a correct conclusion. This requires inductive reasoning skill, where clinical judgment and knowledge of treatment guidelines guide clinical reasoning. For this scenario, the most appropriate treatment is performing a canalith repositioning maneuver. Review treatment guidelines for BPPV if answered incorrectly. Perform a log roll maneuver. Perform gaze stabilization VOR x 1 exercises in sitting. Perform Cawthorne-Cooksey exercises.

Answer 191

Benign paroxysmal positional vertigo. BPPV involves brief attacks of vertigo and nystagmus that occur with a change in head position. The test depicted here is the supine head roll test (or simply, roll test). A positive test will lead to nystagmus and reproduction of the patient’s symptoms (vertigo). The Dix-Hallpike test is also diagnostic of BPPV. Incorrect Choices: Rotation of the head to one side should not trigger vertigo or nystagmus in any of the other answer choices listed here. Meniere’s disease is an episodic vertigo syndrome that is associated with the accumulation of endolymph and often leads to bilateral symptoms. An acoustic neuroma can compress CN VIII and lead to vestibular symptoms, but it is not dependent on the position of the head. Meningitis is typically caused by a viral infection and leads to inflammation of the meninges surrounding the brain and spinal cord. Typical symptoms include headache, fever and neck stiffness. Type of Reasoning: Analytical Meniere’s disease. Acoustic neuroma. Meningitis

Answer 192

Unequal pupils. Unequal pupils potentially signify a serious eye or central nervous system condition and warrant the activation of the Emergency Response System and emergency transport. Incorrect Choices: Sensitivity to light or noise, confusion, and memory problems are concerning, but not emergent findings. These should be followed by a TBI or concussion assessment. A single episode of vomiting does not require EMS activation or urgent transport but does require ongoing monitoring of vital signs and evaluation by a physician. However, repeated bouts of vomiting should result in EMS activation and transportation to emergency care. Type of Reasoning: Evaluative Sensitivity to light or noise. Confusion and memory problems. Vomiting

Answer 193

A null hypothesis states that there is no difference or no relationship between variables or groups. Incorrect Choices: A research question is inquisitive in nature and is typically stated in the form of an actual question. It states what issue or problem the research is trying to answer. As its name implies, the purpose statement explicitly describes the purpose of a study. The research hypothesis is essentially the same as the research question. It states that a relationship between variables exists and that manipulating the independent variable will bring about a change in the dependent variable. Type of Reasoning: Deductive Research question. Purpose statement. Research hypothesis

Answer 194

The clinic will be reimbursed according to previously agreed upon rates per intervention. Preferred provider organizations (PPO’s) reimburse healthcare providers based on an established set rate for services rendered. The provider will not get paid more or less than the agreed upon rater per intervention. Incorrect Choices: The United States government does not decide pay rates for preferred providers organizations, but it does for government networks, like Medicare and Medicaid. Reimbursement based on the typical cost of care for a diagnosis (diagnosis-related group) reflects the way acute care hospitals get paid. Finally, in contrast to PPO’s, health maintenance organizations (HMO) are reimbursed a set amount a month. Type of Reasoning: Inferential The clinic will be reimbursed according to rates decided by the United States legislature. The clinic will be reimbursed based upon the typical charges needed to care for a patient, based on diagnosis. The clinic will be reimbursed a set amount per month from the insurer, regardless of billings.

Answer 195

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

Answer 196

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

Answer 197

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

Answer 198

A strong positive relationship. Correlational analysis is used to measure a relationship or correlation between two quantifiable variables or groups. The closer the value of the coefficient is to 1.0, the more linear the relationship between the two variables. A coefficient of 0.96 is a strong, nearly perfect, positive, linear relationship. Incorrect Choices: A weak positive relationship would be indicated by a smaller number such as 0.35, for example. A correlation coefficient with a negative value, such as r = -0.96, would indicate a strong, negative (or inverse) relationship between the variables. Type of Reasoning: Deductive A weak positive relationship. A strong negative relationship. A weak negative relationship.

Answer 199

Place firm pressure proximal to the site of the arterial line insertion. The first response should be to apply direct pressure above the site of catheter placement. The radial artery is relatively superficial and firm, direct pressure should be effective in controlling bleeding. Incorrect Choices: The physical therapist should never attempt to replace a line that has become dislodged or removed. The appropriate response is to minimize bleeding and call for support from qualified staff. Calling for support should not delay applying firm, direct pressure to control bleeding. If applying direct pressure is unsuccessful, a tourniquet may be appropriate. However, it should not be the first choice when responding to this problem. Type of Reasoning: Evaluative Attempt to replace the line immediately. Call the nursing station for support. Place a tourniquet over the forearm proximal to the arterial line insertion.