Siegelman Online Advantage 1.1 PDF

Question#1 During a motor examination, the therapist asks a patient to drink from a cup. The patient has difficulty reaching for the cup and misses it several times. When moving the cup toward the mouth, the patient misses completely and bangs it into his shoulder, spilling its contents. After several trials, he is still unable to drink from the cup. The therapist documents these findings as: 1)

patient is exhibiting severe impairment in dysmetria.

2)

patient is exhibiting moderate impairment in dysdiadochokinesia.

3)

patient is exhibiting moderate impairment in dystonia.

4)

patient is exhibiting severe impairment in dyssynergia.

Rationale: The patient is exhibiting severe impairment in dysmetria (impaired ability to judge the distance or range of movement). Dysdiadochokinesia is an impaired ability to perform rapid alternating movements while dyssynergia is an impaired ability to associate muscles together for complex movement. Dystonia is a hyperkinetic movement disorder characterized by disordered tone and involuntary movements.

Question#2 A patient is transferred to a burn clinic with deep partial-thickness burns over 30% of the body. Healing of this type of burn is often characterized by: 1)

blisters and minimal edema with spontaneous healing.

2)

depressed skin area that heals with grafting and scarring.

3)

moderate edema with spontaneous healing and minimal grafting.

4)

marked edema with slow healing and extensive hypertrophic scarring.

Rationale: Deep partial thickness burns involve destruction of the epidermis with damage of the dermis down into the reticular area. Appearance is mixed red/white color with sluggish capillary refill. Superficial sensation is decreased while sense of deep pressure is retained. The burn will heal spontaneously in 3 to 5 weeks if no infection develops (infection can convert the burn to full-thickness). There is marked edema with excessive scarring (hypertrophic). Superficial burns heal with minimal edema while superficial partial-thickness burns heal spontaneously with moderate edema and minimal scarring. No grafting is required. Full-thickness burns require skin grafting; appearance is depressed with significant scarring. Question #3 A therapist works for a home health agency and is treating a patient, covered by Medicare, at home. The patient has reached ambulatory independence and is no longer homebound, but will continue to need therapy twice per week for

several weeks to reach full functional status. The patient has a good relationship with the therapist and would like to continue to be seen at home. There is a hospital physical therapy out-patient department accessible to the patient. Under Medicare guidelines, the therapist should: 1)

continue to see the patient at home because of patient preference.

2)

continue to see the patient at home and document the patient as homebound.

3)

refer the patient to the out-patient department.

4)

discharge the patient as no further benefits are available under Medicare.

Rationale: Patients must meet the definition of homebound in order to receive home care Medicare benefits under part B guidelines. Once a patient is no longer homebound, if, as a practical matter the patient can access an outpatient facility, the patient should be transferred to care in that setting. It is an ethical violation to intentionally withhold information from a record. Question #4 A patient is status post coronary artery bypass graft via sternotomy and is observing sternal precautions. Which of the following activities should be avoided while observing sternal precautions? 1)

huffing.

2)

pulling up from supine to sitting with hand rails.

3)

coughing.

4)

rolling from supine to sidelying.

Rationale: Coughing and huffing cannot be avoided due to the risk for pulmonary complications. Rolling from supine to sidelying is not contraindicated; however pulling up from the hand rails should be avoided.

Question#5 A patient is referred to physical therapy for evaluation of balance instability. The patient has a history of several falls within the last month. The therapist administers the Clinical Test for Sensory Interaction in Balance (CTSIB) using a posturography system. The patient is stable during the first 4 conditions of the test with only minimal increases of sway. During condition 5 (eyes closed and platform moving) and 6 (visual surround moving and platform moving) the patient becomes very unstable and requires the overhead harness to prevent a fall event. The therapist correctly interprets the results of this test as evidence of: 1) 2) 3) 4)

problems with sensory selection. somatosensory dependency. vestibular deficiency. visual dependency.

Correct Ans. 3

Ques. Identifiers: III / C / Inference Reasoning

Rationale: The clinical test for sensory integration in balance using dynamic posturography testing is positive for vestibular deficiency with loss of balance on conditions 5 and 6. Patients who are surface dependent (somatosensory) have difficulties with conditions 4, 5, and 6. Patients who are visually dependent have difficulties with conditions 2, 3, and 6. Sensory selection problems are evident with loss of balance on conditions 3 - 6.

Question#6 The primary reason for performing posteroanterior unilateral vertebral pressure (PACVP) in the cervical spine would be to assess: 1) 2) 3) 4)

arthrokinematic motion. osteokinematic motion. cervical PROM. muscle tone within the cervical region.

Correct Ans. 1

Ques. Identifiers: II / B / Deductive Reasoning

Rationale: PACVP tests are manual procedures that assess the glide of one vertebral segment as compared to an adjacent vertebral segment. The movement of one segment gliding with respect to another segment is considered an arthrokinematic movement so the PACVP test is assessing the arthrokinematic glide of each vertebral segment.

Question#7 A physical therapist has just begun working in a skilled nursing facility. A task that a therapist in this setting may be asked to perform that is NOT considered skilled care under the Medicare guidelines is: 1) 2) 3) 4)

taking blood pressure. using a stethoscope to determine breath sounds. providing patient education about a disease/illness. helping a patient to the toilet.

Correct Ans. 4

Ques. Identifiers: VI / F / Analysis Reasoning

Rationale: Medicare considers helping a patient to the toilet unskilled unless it is part of a treatment plan to

Question#28 An 8 year-old student has been tested and the school system is developing an individualized education plan (IEP). According to the Individuals with Disabilities Education Act (IDEA) the person that is not required to but may attend this IEP meeting is: 1)

the student's regular school teachers.

2)

the student's parent/guardian.

3)

a school administration representative.

4)

the student.

Rationale: Under the Individuals with Disabilities Education Act (IDEA) guidelines, a student may, but is not required to, attend the IEP meeting. This allows for students who might be uncomfortable in a group setting where he/she is being discussed to forgo the meeting and receive a summary of the meeting at a later time. All others are required to attend. The student's age in this case (8 years-old), might also be a factor in determining attendance at an IEP meeting. Question#29 A patient is recovering from a L2 spinal cord injury, level C on the ASIA Impairment Scale. Functional expectations for this patient include locomotion using: 1)

bilateral AFOs and canes.

2)

bilateral KAFOs and a reciprocating walker.

3)

bilateral KAFOs, Loftstrand crutches, and a four point gait.

4)

an active duty light weight wheelchair.

Rationale: A spinal cord lesion at the level of L2 is considered a lower motor neuron injury (cauda equina injury). Intact movements include hip flexion, hip adduction, and knee extension. Level C on the ASIA Scale (American Spinal Injury Association) is an incomplete lesion with motor function preserved below the level of the lesion. More than half the muscles have a muscle grade less than 3 out of 5. This patient can be expected to be a functional ambulator using bilateral ankle-foot orthoses and crutches or canes. For some community activities, the patient may elect to use a wheelchair for convenience and energy conservation but is not expected to be a full-time wheelchair user. Orthotic bracing of the knees (KAFO) is not appropriate. Question#30 A 93 year-old patient is in the intensive care unit with influenza. The patient is showing signs of dehydration and vomiting. The patient is lethargic with a respiratory rate of 8. The arterial blood gas is reported as PaO2- 86, PaCO2-

45, pH- 7.48, HCO3- 28. Physical therapy is ordered to try and increase breathing rate and improve the breathing pattern. The arterial blood gas is interpreted correctly by the physical therapist as: 1)

compensating respiratory alkalosis.

2)

significant hypoxemia.

3)

primary metabolic alkalosis.

4)

respiratory failure.

Rationale: The arterial blood gas reveals an alkalemia as the pH of the blood is above the range of normal (7.35 to 7.45). It is imperative to determine the cause of the alkalemia so that the primary problem is corrected. The metabolic HCO3 is elevated, likely due to the patient's vomiting (losing acid becoming more alkalotic). The pulmonary system is compensating for this by creating an acidosis to compensate for the metabolic alkalosis. The treatment therefore should not include changing the respiratory pattern or rate as it is the system providing the compensation. If the patient's respiratory system was "normalized", the alkalosis would worsen, not improve. Question# 31 A patient presents with rotator cuff impingement involving primarily the supraspinatus tendon secondary to a restriction of inferior glide of the glenohumeral capsule. Which activity would be advisable prior to the restriction being eliminated? 1)

finger climbing on the wall.

2)

shoulder internal/external rotation exercises.

3)

passive elevation using overhead pulleys and the opposite upper extremity.

4)

Codman's pendulum exercises with weight in hand.

Rationale: Shoulder internal/external rotation exercises will not irritate the impinged tendon while they do assist with healing secondary to revascularization. Both wall climbing exercises and passive exercises with the pulleys may cause further irritation of the tendon. Since the restriction is still present every time the arm is elevated the tendon becomes impinged, so those two exercises are counterproductive to healing. The Codman's exercise may also take the shoulder too far into the elevated range since the patient has minimal control of the swing secondary to the use of momentum to create the motion. Question# 32 A 16 year-old fell during a rock climbing expedition. The individual is complaining of pain over the left lateral chest wall. The chest wall has no noticeable paradoxical motion of the rib cage. Palpation reveals crepitation over the right lateral lower thoracic wall. Which of the following signs or symptoms would be expected in this scenario? 1)

increased thoracic excursion.

2)

asymmetrical breathing pattern.

3)

use of accessory muscles of inspiration.

4)

increased abdominal muscle contraction during exhalation.

Rationale: Given the tactile crepitus, it is likely the rock climber has fractured one or more ribs. Since there is no observable paradoxical motion of the thorax, it is unlikely to be a flail chest. Unilateral pain will cause an asymmetrical breathing pattern and a shallow breathing pattern which could be measured as a decreased excursion of the thorax. Since there is no need to increase either volume of the breath or rapidity of exhalation, there is no need for any accessory muscle use. Question# 33 A physical therapist is treating an 83 year-old out-patient who has metastatic prostate cancer. The therapist receives a phone call from the patient's son who is trying to help determine whether his father needs help from an aide in order to cope at home. Under HIPAA guidelines, the therapist can provide information and advice to the son: 1)

without consulting the father since the son is a family member.

2)

only with the father's written permission.

3)

as long as the father does not verbally object.

4)

only with the father and son together to discuss the concerns.

Rationale: The HIPAA Privacy Rule allows physicians, hospitals, and other providers to disclose information, when needed, to a family member or other person responsible for the care of the patient about the patient's condition with the patient's consent. If a patient is incapacitated, providers can share appropriate information with the family member or involved person if it is determined that doing so is in the patient's best interest. In this case, verbal consent from the father is adequate. There was nothing in this case that indicated that the father was cognitively impaired.

Question# 34 An 83 year-old patient is hospitalized for an exacerbation of COPD. The patient is afebrile, in no distress, with oxygen saturations at 93% on 2 liters of supplemental oxygen. The patient states that coughing is currently not clearing secretions as well as usual. The therapist should: 1)

teach the patient to huff instead of cough to improve cough effectiveness.

2)

assist the patient's cough by pushing in on the abdomen in time with the patient's own cough effort.

3)

endotracheally suction the patient to clear retained secretions.

4)

use tracheal stimulation in order to improve the cough effectiveness.

Rationale: The huff is an effective alternative to coughing in a patient with diseased airways such as with COPD. The assisted cough is used only for patients who do not have intact sensation in their abdomen, such as a patient s/ p spinal cord injury. Suctioning this patient is only indicated when unable to clear secretions independently and the secretions are interfering with gas exchange. As this patient has adequate saturations and is in no distress, there is no need for suctioning at this time. Finally, tracheal stimulation is used to initiate a cough. This patient has no problems initiating a cough. It is the effectiveness of the cough that is in question.

Question# 35 The most important outcome of the patient history/interview is to: 1)

develop a rapport with the patient.

2)

determine if the patient has any "red flags".

3)

identify the patient's current medications.

4)

determine the patient's diagnosis.

Rationale: The determination of "red flags" is the most important component of the patient history/interview. Identifying "red flags" will guide the physical therapist as to whether the patient requires a referral to another healthcare provider and it will also dictate the flow of the tests and measures component of the examination. The other items are valuable and typically components of the history/interview, but they are not critical in terms of determining if it is safe to proceed with the remainder of the examination.

Question# 36 A patient is referred for physical therapy with chronic pain and postural abnormalities. The patient describes diffuse aching in the spine and legs as well as frequent disabling headaches. Examination reveals increased thoracic kyphosis and bowing of both the femora and tibiae. A radiograph of the spine shows loss of height with widening and thickening of the vertebra. A radiograph of the skull shows marked patchy sclerosis of the bone with significant thickening. The therapist recognizes these findings are consistent with: 1)

osteoporosis.

2)

Paget's disease.

3)

osteopenia.

4)

degenerative joint disease.

Rationale: Paget's disease (osteitis deformans) is a progressive metabolic bone disease that affects older adults. It is characterized by excessive bone thickening and hypertrophy. Symptoms includ pain (muscular and skeletal), deformities (kyphoscoliosis, bowing, coxa varus and waddling gait, vertebral compression or collapse), and fractures. Additional symptoms may evolve with bone thickening of the skull including headache, mental confusion, sensorineural hearing loss, tinnitus, and lightheadness/dizziness/vertigo. Osteoporosis results in bone loss and osteopenia results in bone thinning on x-ray. Osteoarthritis (DJD) is characterized by marked cartilage deterioration in synovial joints and vertebral deterioration. Question# 37 Following examination and evaluation, a therapist determines that a patient would benefit from distraction of the right temporomandibular (TM) joint. This maneuver is accomplished by moving the mandible in which direction? 1)

inferior glide.

2)

posterior glide.

3)

medial glide.

4)

anterior glide.

Rationale: By definition, joint distraction describes moving one joint surface perpendicular to the other joint surface. Since the maxillary surface of the TM joint faces caudally a perpendicular movement from this surface would entail an inferior glide of the TM joints condylar surface.

Question# 38 A patient recovering from traumatic brain injury demonstrates behaviors consistent with Level IV of the Rancho Los Amigos Levels of Cognitive Functioning Scale. Appropriate training activities during the physical therapy session include: 1)

assisted walking in a quiet hall.

2)

PNF lower extremity patterns while in sitting.

3)

assisted walking in the clinic gym.

4)

ball bouncing while walking.

Rationale: The patient is confused and agitated based on the Level IV designation. Behaviors are bizarre and nonpurposeful relative to the immediate environment. Gross attention is very brief while selective attention is often nonexistent. The patient lacks both short and long-term recall. Consistency and structure are essential as is modeling calm behavior. The patient cannot be expected to do well with new or unfamiliar tasks (PNF patterns) or working in an open and variable environment (PT gym). Dual tasking (ball bouncing while walking) also exceeds this patient's cognitive abilities.

Question# 39 Company records were examined to identify all individuals complaining of low back pain (LBP) within the past 5 years. Records were also examined to identify a second group of individuals without LBP. Both groups were matched for age, sex, weight, and job status. The researchers then compared the frequency of LBP in both groups relative to job status. This study is an example of a: 1)

case control, type 3 study design.

2)

before-after, type 3 study design.

3)

descriptive, type 4 study design.

4)

randomized control, type 1 study design.

Rationale: This is an example of a type 3, case control design. A group of interest (LBP) was compared to a matched group without LBP. A determination of the influence of job status based on the frequency of LBP was made. This is a retrospective (backward-in-time) study. It has a low level of confidence in that co-intervention and contamination may have occurred in the 5 year study period. Before-after, type 3 study design is a prospective (forward-in-time) study of a single group of patients assessing an outcome. There is no control group as in a randomized control, type 1 design. Descriptive, type 4 study design involves describing a group of individuals with similar characteristics (LBP). There is no control group or scientific rigor.

Question# 40 A patient recovering from a lower extremity chronic quadriceps strain is practicing squat jumps. The patient is instructed to drop into a partial squat position and then jump vertically into a fully extended position. The patient absorbs the shock of landing by returning to the squat position and then repeats the activity. This exercise is an example of: 1)

plyometric drills.

2)

open-kinetic chain exercise.

3)

core stabilization training.

4)

isokinetic exercise.

Rationale: Plyometric training involves activating muscles eccentrically (partial squat) followed by concentric action (jump). They are used in advanced rehabilitation and sports specific training to promote quick, powerful movements. The initial eccentric activity provides stretch to the muscle while the concentric phase uses the elastic recoil of muscle and neuromuscular (muscle spindle) support of contraction. Open-kinetic chain resistance exercise (isotonic, isokinetic, isometric) uses resistance applied to the distal segment of the limb. Core stabilization training refers to strengthening of proximal limb segments and the trunk. Isokinetic exercise uses dynamometers to provide maximum resistance throughout the entire range.

Question# 41 A patient is receiving treatment in an out-patient physical therapy facility. During the treatment session, the patient walks across the room to the treatment table and slips, but catches himself from falling by reaching out and grabbing onto a nearby table. The patient apologizes for his clumsiness and says he has not hurt himself. The therapist knows that an incident report should be completed whenever: 1)

there is an injury to a patient.

2)

something unusual occurs.

3)

the facility may be at fault.

4)

the patient may be at fault.

Rationale: Staff should complete an incident report for any unusual occurrence to minimize and manage the facility's risk. Completing the report does not assign blame. It allows the facility to monitor all unusual occurrences and identify potential problem areas. An accident report is required if a patient is injured or harmed in any way.

Question# 42 With aging, the peak force generated during a single maximal contraction against a constant force can be expected to: 1)

increase with greater muscle fatigue.

2)

decrease with slower onset of muscle fatigue.

3)

increase with decreased muscle fatigue.

4)

decrease with quicker onset of muscle fatigue.

Rationale: Changes with aging in response to open-chain resistance training include: (1) decreased peak force generated during a single maximal contraction against a constant force (isometric work), and (2) decreased peak force generated as the muscle is shortened (concentric work). For both types of exercise, the muscle fatigues more quickly. Speed of response (both reaction time and movement time) is slower.

Question# 43 A patient presents with complaint of shooting pain in the left lateral thigh and leg as well as muscle weakness in the left gluteus medius and peroneal (fibular) muscles. These findings are most consistent with a neurologic radiculopathy at the dermatomal level of: 1)

L3.

2)

L5.

3)

L4.

4)

S1.

Rationale: The L5 dermatome travels down the lateral thigh and leg so any pain related to a neurologic condition involving the L5 spinal nerve will follow that path. Both the gluteus medius and peroneal muscles receive significant contributions from the L5 spinal nerve, so if there was abnormal function of L5, both of those muscles would demonstrate weakness.

Question# 44 The primary outcome of continuous passive motion (CPM) in the early treatment phase following a total knee replacement is increased: 1)

passive knee extension.

2)

active knee flexion.

3)

passive hip flexion.

4)

active hip flexion.

Rationale: Studies have indicated that active knee flexion is the most significant finding during early rehabilitation. The other motions are affected by CPM, but not to the same degree as active knee flexion.

Question# 45 An acute care hospital is developing primary prevention health promotion programs. An example of a primary health prevention program would be one that focuses on:

1)

a support group for people with Parkinson's disease.

2)

exercises for people with multiple sclerosis.

3)

screening elders at risk for falls.

4)

reducing cigarette use in chronic smokers.

Rationale: The goal of primary prevention is to prevent a first occurrence, or episode of a health problem. Screening elders at risk for falls will identify elders at risk before those falls occur. The other three choices focus on people that already have a health problem and those efforts would be secondary, not primary prevention.

Question# 46 A patient with a T10 incomplete s 1)

10% BWS, treadmill speed at 3.0 mph.

2)

30% BWS, treadmill speed at 0.25 mph.

3)

30% BWS, treadmill speed at 3.5 mph.

4)

50% BWS, treadmill speed at 1.0 mph.

Rationale: Spinal cord injury, ASIA C, signifies an incomplete lesion with motor function preserved below the level of the lesion;. At least half of key muscles below the neurological level have a muscle grade less than 3. This patient will require manual assistance to move the limbs initially, necessitating a slow treadmill speed and partial BWS to start. Partial BWS is typically 30%;. A 10% BWS is a goal to progress toward during training while 50% doesn't allow enough active participation by the patient. Speeds are very slow to start (e.g. 0.25 mph) and gradually increased.

Question# 47 pinal cord lesion (C on the ASIA Impairment Scale) is receiving locomotor training using partial body weight support (BWS) on a motorized treadmill. The BEST initial prescription for this patient to begin training is: The design of the quadrilateral socket for the transfemoral prosthesis incorporates: 1)

high anterior and medial walls.

2)

high anterior and lateral walls.

3)

wide medial brim and posterior shelf.

4)

convex lateral wall to provide pressure on the femoral triangle.

Rationale: The quadrilateral socket is designed with a horizontal shelf for the ischial tuberosity and gluteal musculature, a medial brim at the same level as the posterior shelf, and anterior wall 2.5 to 3 in. higher to apply a posteriorly directed force to retain the ischial tuberosity on the shelf. The high lateral wall aides in medial-lateral stabilization. The anterior wall has a convexity, Scarpa's bulge, to maximize pressure distribution in the area of the femoral triangle.

Question# 48 A frail, elderly patient has been admitted to a nursing home. The patient has multiple flexion contractures and has not been ambulatory for the last year. The MOST important aspect of the initial physical examination is: 1)

manual muscle testing.

2)

functional testing using the Functional Independence Measure (FIM).

3)

pressure sore risk using the Norton Risk Assessment scale.

4)

sitting balance assessment using Multidirectional Reach.

Rationale: Patient safety is the primary concern for a therapist. This person was admitted to a nursing home, they are in a frail, and non-ambulatory state. The patient is at risk for pressure ulcers. The Norton Risk Assessment scale or Braden Scale for Predicting Pressure Sore Risk are important measures to assess the client's pressure ulcer risk. They incorporate a variety of measurements including sensation, mobility, nutrition, mental alertness, and incontinence/moisture. Once risk is assessed, appropriate prevention and treatment can be implemented. Manual muscle testing, sitting balance, and functional abilities are important, but the Norton Risk Assessment scale incorporates multiple measures to determine the client's risk for pressure ulcers. It includes five subscales: physical condition, mental state, activity, mobility, and incontinence. Question# 49 Physical therapy intervention is being provided to an individual with a lateral epicondylosis of the left elbow. The patient is compliant with attendance and activities during the clinic visits, but there is concern that the patient is not performing their home exercise program. The most likely mechanism to identify if the patient is performing their home exercise program is to: 1)

ask the patient if they are performing the home exercise program.

2)

have the patient complete an outcome measure survey to determine their progression.

3)

perform a reassessment to determine if there are significant changes in the patient's functional status.

4)

ask the patient to demonstrate the components of the home exercise program.

Rationale: If the patient is performing the exercises at home they should be able to easily perform them in the clinic with no cueing. Patients may not always be reliable so asking them about performance may not help answer the concerns. Measured improvements via the outcome measure or by functional assessment may be related to many factors such as normal healing, the benefits of the clinical intervention, etc. Changes in those measures will not provide specific information regarding performance of home exercise programs. Question# 50 The father accidentally spilled a cup of tea on his child resulting in a 10 percent total body surface area (TBSA) burn. The father is quite upset and is concerned that his child is in pain from the burn. Based on this information and the accompanying figure, the child's burn is most likely: 


! 1)

superficial partial thickness.

2)

deep partial thickness.

3)

full thickness.

4)

superficial.

Rationale: Superficial partial thickness burns usually present as pink or red, and wet. Sensation is intact, but the integument is not. These injuries involve the dermis and usually heal within a couple weeks primarily through epithelialization which helps to minimize scarring. A superficial burn presents as pink or red, the surface is dry, sensation intact, and the integument is intact. These injuries involve primarily the epidermis, although a small portion of the dermis may be damaged. These burns heal without scarring in a few days to two weeks. Deep partial thickness burns are waxy white with red patches, wet, sensation to pressure is intact while sensation to light touch or pin prick is usually absent. Healing is slow, scarring is excessive, and grafting may be needed. A full thickness burn appears like a charred structure that is white, leathery, dry, and anesthetic. This requires grafting for healing. The burn pictured in this question is very typical of a spill burn (most common for toddlers). Less than a cup of coffee (or in this case a tea) can easily cause a burn of 10% TBSA (total body surface area). Fortunately in this case, the therapist can tell the father that his child's injuries will heal rapidly with little chance of scarring although some minor discoloration may be present.

Question# 51 A patient is referred to physical therapy for cervical pain following a whiplash injury from a motor vehicle accident. The therapist positions the patient to administer a hot pack and notices a dark, irregular black-blue nevus with irregular borders on the upper back. The patient relates that the mole had always been there and it has been somewhat itchy lately. The therapist's BEST course of action is: 1)

refer the patient to or call her primary physician immediately.

2)

suggest the patient follow it weekly and document any changes.

3)

continue with her scheduled treatments and monitor it closely.

4)

talk to the patient and spouse about the seriousness of the findings.

Rationale: The nevus or mole findings are suggestive of malignant melanoma. The therapist should examine the lesion looking for warning signs (ABCDE): Asymmetrical shape; Border is irregular or jagged; Color is mixed; Diameter is equal to or greater than 7mm; and lesion is Evolving. Itching and bleeding occurs in advanced stages. Immediate referral to the primary physician is indicated; surgical excision is indicated with no evidence of metastatic spread.

Question# 52 A high school cross-country runner is seen in physical therapy for shin splints. The patient presents with localized pain and tenderness over the anterior tibialis as well as generalized muscle aches and joint pains. During the initial examination the therapist notices a solid red central spot with rings on the posterior calf. The patient tells the therapist he doesn't know how he injured his calf and almost didn't keep his appointment today because he thinks he is coming down with the flu. He has a slight fever and headache. The therapist's BEST course of action is to: 1)

refer him to his primary physician immediately.

2)

skip therapy that day and send him home to recover from the flu.

3)

treat his anterior tibialis pain and tenderness and instruct him to go home to rest.

4)

tell his mother to enforce bed rest and ice to his lower leg until he feels better.

Rationale: Along with the symptoms of shin splints (a localized problem), he is exhibiting the classic signs and symptoms of Lyme disease: the bull's-eye rash with expanding rings, fever, malaise, headache and muscle aches and joint pains. He should be referred to his primary physician immediately for a Lyme disease workup (blood work confirms the presence of the tick spirochete disease). Early diagnosis and treatment is the key to successful management.

Question# 53 A patient presents with lymphedema of the left upper extremity following a radical mastectomy. The patient weighs 160 pounds, is 5'5'', and has a resting BP of 115/80, a resting HR of 90 and a respiratory rate of 12/minute. Initial pressure setting for compression therapy that would be appropriate in this case is: 1)

45 psi.

2)

60 psi.

3)

80 psi.

4)

115 psi.

Rationale: Typically, the external pressure is set at or slightly below the diastolic pressure when using compression therapy. The pressure should be high enough to move the blood through the venous system. External pressures significantly less are ineffective in moving fluids and external pressures significantly greater will retard or stop the flow of blood. Some suggest that compression can be slightly greater than diastolic pressure applied due to the relatively short intermittent nature of the technique.

Question# 54 A patient recovering from stroke is able to generate a contraction in the elbow flexors of the affected right upper extremity but the contraction fades out quickly. He is unable to generate significant active tension from mid range to the maximally shortened position. The therapist documents this finding as: 1)

passive insufficiency.

2)

muscle inhibition.

3)

active insufficiency.

4)

overload.

Rationale: Active insufficiency refers to the inability of a muscle to generate significant active tension when it is maximally shortened. Muscles that that cross more than one joint are more likely to exhibit active insufficiency. Passive insufficiency refers to the inability of the muscle-tendon unit to allow the joints to move through the full available range of motion due to restrictions in length (e.g., contracture). Muscle inhibition results from spinal reflex circuits (autogenic inhibition results from activation of the Golgi tendon organ in the agonist muscle; reciprocal inhibition results from activation of the muscle spindle afferents, IA, of the antagonist muscle). Overload refers to the minimum threshold for the intensity and duration of stress for a muscle to become stronger. Question# 55 The therapist is examining the skin of a patient of color who has a diagnosis of anemia. In this situation, it would be BEST if the therapist first examines the: 1)

lips and mucous membranes of the mouth.

2)

palms and soles of the feet.

3)

backs of the hands.

4)

dorsum of the feet and lower legs.

Rationale: Pallor (decreased redness) is seen in anemia and in arterial insufficiency (decreased blood flow). In dark-skinned persons, inspecting the palms and soles will reveal pallor. The lips are unreliable as melanin in the lips can simulate cyanosis.

Question# 56 A patient is referred for vestibular rehabilitation following a motor vehicle accident two weeks ago. The patient reports mild neck pain from whiplash injury and mild vertigo and nausea with change in head position. She also reports loss of balance with mild gait instability and the need for use of a cane. The physician indicates on the referral suspected benign paroxysmal positional vertigo [BPPV] in the posterior semicircular canal. The MOST appropriate intervention is: 1)

canalith repositioning treatment.

2)

balance exercises.

3)

habituation training.

4)

Brandt-Daroff repositioning movements.

Rationale: Benign paroxysmal positional vertigo (BPPV) is characterized by acute onset of vertigo and is positional, related to the provoking stimulus of head movement. It can be effectively treated by canalith repositioning treatment (CRT) which involves a series of head rotations by the therapist. CRT is contraindicated in this case however due to the acute whiplash injury. Brandt-Daroff treatment involves active repositioning movements by the patient (e.g., sit to sidelying to sit) with the head rotated 45. It is the better choice as it produces less stress on the neck while still working to return the dislodged otoconia into the vestibule (the primary goal of BPPV intervention). Balance exercises are indicated for safety but will not serve to move the otoconia. Habituation training is indicated for patients with unilateral vestibular hypofunction who demonstrate continued complaints of dizziness.

Question# 57 A patient presents with pain of the cervical region. During the history it is noted that the patient is taking the medication Fosamax. Which intervention would be contraindicated based on the use of this medication? 1)

joint mobilization.

2)

aerobic exercise.

3)

soft tissue techniques.

4)

aquatic exercise.

Rationale:Fosamax is a medication for patients with osteoporosis. Therefore joint mobilization would be contraindicated for a patient with osteoporosis. The other interventions would not be considered contraindications for a patient with osteoporosis.

Question# 58 The Gross Motor Function Measure is used to evaluate change in gross motor function and not quality of movement. This test is used primarily with children who have a diagnosis of: 1)

spina bifida.

2)

developmental delay.

3)

sensory processing disorder.

4)

cerebral palsy.

Rationale: The Gross Motor Function Measure (GMFM) is an assessment to determine quantity of movement in children with cerebral palsy. The assessment was developed and validated for measuring change over time in gross motor function for children with cerebral palsy. Assessments must be used for the purpose for which they were developed. The Sensory Integration and Praxis Test assesses sensory integration. WeeFim, School Function Assessment and the Pediatric Evaluation of Disability Inventory (PEDI) are functional tests and measures considered indicators for health-related outcomes. Question# 59 A therapist is examining a Spanish-speaking patient. The patient speaks no English and the therapist speaks no Spanish; no one else is available for translation. The therapist uses the referral information and gestures in order to best communicate with the patient. After having the patient sign a consent form, written in English, the therapist initiates the examination. In doing so, the therapist does not meet the ethical principle of: 1)

beneficence.

2)

non-maleficence.

3)

veracity.

4)

autonomy.

Rationale: Ethical standards require that a patient understand the procedure that is recommended and agrees to it. The patient either must have a translator or have the consent form translated into Spanish to fulfill this standard. The principle of patient autonomy, i.e., involvement and agreement with the procedures has not been met in this situation. The therapist has met the principle of beneficence, i.e., the obligation to help people in need. There is no indication that the therapist has harmed the patient, thus non-maleficence is not a concern. Lastly, the situation does not raise of question of veracity or truth telling. Question# 60 A patient is 2 days post left CVA and has just been moved from the intensive care unit to a stroke unit. During the initial interview and history, the therapist finds the patient's speech is of normal rate and melody. Auditory comprehension appears impaired and use of word substitutions make no sense. These difficulties are consistent with: 1)

global aphasia.

2)

dysarthria.

3)

Wernicke's aphasia.

4)

Broca's aphasia.

Rationale: This patient is demonstrating classic signs of Wernicke's aphasia (a type of fluent, aphasia). It is the result of a lesion involving the posterior portion of the first temporal gyrus of the left hemisphere. Wernicke's aphasia is characterized by impaired auditory comprehension with fluently articulated speech marked by word substitutions. Frequent neologisms (nonsense words) are present. Broca's aphasia is characterized by slow and hesitant speech with limited vocabulary and labored articulation. There is relative preservation of auditory comprehension. Global aphasia is a severe aphasia with marked dysfunction across all language modalities. Dysarthria is an impairment in the motor production of speech. Question# 61 In order to conceptualize outcomes, the World Health Organization adopted a classification for understanding functioning and disability, the International Classification of Functioning (ICF) model (or ICIDH-2) in 2001. Target outcomes at the activity level for an 8 year-old boy referred to therapy with a diagnosis of developmental coordination disorder would include: 1)

improved walking skills and ability to ride a bike.

2)

increased range of motion and muscle strength.

3)

improved patterns of normal movement.

4)

inclusion in playground game activities with peers.

Rationale: The activity level defines performance of a task or action by an individual (e.g. walking, riding a bike). The body function and structure ICF level defines functioning at the physiological and anatomical levels. Thus impairments that specify problems in body function or structure are defined (e.g. range of motion, balance, memory, sensory abilities, praxis, and so forth). The final dimension of the ICF model is at the participation level, defined as an individual's involvement in life situations (e.g. playground activities with peers). Question# 62 A patient has a 4 year history of multiple sclerosis and is referred for physical therapy. The physical therapist suspects trigeminal nerve impairment. Appropriate motor tests for the trigeminal nerve include asking the patient to: 1)

look up and away while touching the cornea with a piece of cotton.

2)

put out the tongue and check for deviation to one side.

3)

clench the teeth followed by pushing the mouth open against resistance.

4)

follow the therapist's finger movements with both eyes and observe for oscillations of the eyes.

Rationale: The trigeminal nerve (CN V) innervates the muscles of mastication (masseter and temporalis muscles). Motor function can be examined by asking the patient to clench the teeth while palpating the masseter and temporalis muscles. The patient can also be asked to open the mouth against resistance. The jaw jerk is also an appropriate motor test for this cranial nerve. The corneal reflex test investigates the afferent (ophthalmic branch) of CN V This is NOT a motor test for CN V. The tongue (tongue protrusion) is supplied by the hypoglossal nerve (CN XII). Oscillations of the eyes, termed nystagmus, is a function of CN VIII.

Question# 63 A therapist has been managing a patient for 3 previous visits with a diagnosis of patellofemoral pain of the right knee. Upon presentation today the patient states that his physician had prescribed some DMARDS for him to take to control his pain better. What would be the primary concern regarding this medication as to the physical therapy intervention? 1)

potential exists that the patient will become addicted to the medication.

2)

the patient may become lightheaded and predisposed to falling while performing exercise.

3)

the patient may choose to discontinue physical therapy as the pain diminishes.

4)

pain may be masked during the physical therapy intervention as the patient is progressed.

Rationale: Patient progression through interventions is challenging and is typically based on the patient's ability to report accurate changes in symptoms. If a patient's ability to judge pain is altered by taking DMARDS (diseasemodifying, anti-rheumatic drugs), then the ability to provide accurate feedback during physical therapy interventions may become impaired. Patients who are taking pain medications very seldom become addicted. It is important to monitor patients on medications. Patients on pain medications should recognize that the pain is gone as a result of the medication; however, physical therapy intervention still remains a priority. Question# 64 During an electromyography examination, a therapist observes fibrillation potentials. These are indicative of: 1)

myotonic dystrophy.

2)

myopathy.

3)

lower motor neuron injury.

4)

artifacts.

Rationale: Fibrillation potentials (biphasic spikes) result from spontaneous depolarization of a single muscle fiber. They are indicative of lower motor neuron disorders, such as peripheral nerve injury, anterior horn cell disease, radiculopathies, and polyneuropathies with axonal degeneration. Myotonic dystrophy results in complex repetitive discharges that increase and decrease in amplitude, creating a "dive-bomber" sound. Myopathy produces polyphasic potentials that occur with voluntary contraction, not at rest. An artifact is any unwanted electrical signal recorded by the EMG (e.g., 60 cycle interference in the room). Question# 65 A four year-old boy is observed to move from the floor to standing during the physical therapist's examination. The child manually assists knee extension by "walking" his hands up his lower extremities. What pathology is likely to reveal this sign? 1)

hip dysplasia.

2)

Legg-Calve'-Perthes disease.

3)

arthogryposis.

4)

Duchenne's muscular dystrophy.

Rationale: Standing up with the aid of hands pushing on knees is considered a positive Gower's sign. It is common in boys with Duchenne's muscular dystrophy. It is indicative of children who are compensating for proximal weakness in the knees, hips and pelvic girdle. Hip abduction, limitation or asymmetry is the most consistent sign of hip dysplasia in neontates. Ortolani and Barlow signs are the two primary clinical tests used to assess hip stability in neonates less than 1 month of age. Legg-Calve' Perthes disease is a bone abnormality that affects a child's hips. Interruption of the blood flow from the medial femoral circumflex artery is suspected to lead to aseptic avascular necrosis and to Legg-Calve' Perthes disease. The onset of Legg-Calve' Perthes disease is between the ages of 4 and 8 with boys affected 4 times more often than girls. Children with the syndrome present with a limp of insidious onset and frequently a positive Trendelenburg sign. Arthrogryposis is distinguished at birth by the presence of multiple congenital contractures.

Question# 66 A patient with incomplete spinal cord injury has been practicing transfers from wheelchair-to-floor. The patient is able to describe the component steps accurately and to sequence them in the right order. The patient is still struggling with overall timing, efficiency, and economy of effort. The BEST motor learning strategy for the therapist to use is to: 1)

focus the patient on watching body movements during practice using a large floor mirror.

2)

provide constant tactile guidance during practice attempts.

3)

provide constant verbal cueing during practice attempts.

4)

allow repetitive practice focusing the patient on the "feel" of the movements.

Rationale: This patient is in the middle or associative stage of motor learning. The patient understands the idea of the task, i.e. cognitive mapping, achieved during the initial cognitive stage of learning. During the middle stage of learning, errors are becoming less apparent and some trial and error practice (active learning) is appropriate. The use of constant tactile guidance and constant verbal cueing are contraindicated as is an emphasis on visual feedback (all are more appropriate for early cognitive learning). Emphasis on use of proprioceptive (intrinsic) feedback and active learning is the correct choice. Question# 67 To examine a patient recovering from stroke with a suspected deficit in astereognosis, the therapist would ask the patient, with eyes shut, to identify: 1)

different weighted, identically shaped cylinders placed in the hand.

2)

a series of familiar objects placed in the hand and manipulated.

3)

the vibrations of a tuning fork when placed on a bony prominence.

4)

a series of letters traced on the palm of the hand.

Rationale: Stereognosis is the ability to recognize different objects placed in the hand and manipulated. A variety of small and culturally familiar objects of differing size and shape are used (e.g. key, coin, safety pin). Astereognosis represents complete absence of this ability and parietal lobe impairment (sensory association areas). Barognosis is the ability to recognize different weights placed in the hand using identically shaped objects. Pallesthesia is the ability to recognize vibratory stimuli, i.e., a vibrating tuning fork placed on a bony prominence. Graphesthesia is the ability to recognize letters, or symbols traced on the skin.

Question# 68 A morbidly obese individual who weighs 365 pounds is referred for nutritional counseling and exercise intervention. MOST APPROPRIATE initial physical therapy intervention for this individual would be: 1)

treadmill training at 65% maximal voluntary capacity 3 times per week and a home walking program.

2)

standing, lower extremity leg lifts using light weights and a daily home walking program.

3)

seated cycle ergometry at 50% maximal oxygen consumption and on alternate days pool calisthenics.

4)

stationary cycle training at 60% maximal voluntary capacity 3 times a week and light weights for upper extremity resistance training.

Rationale: Excess body weight will influence overall endurance, level of exertion, and incidence of exercise induced trauma including back injury, foot/ankle trauma. According to the American College of Sports Medicine, a safe initial exercise prescription for the obese individual should include: (1) non-weight-bearing exercise, walking, and resistance training daily or at least 5 days per week, (2) 40-60 minutes per day or 20-30 min twice daily, and (3) 50-60% of maximal oxygen consumption. Non-weight-bearing exercise reduces strain on the weight-bearing joints and risk of injury. Examples include seated cycle ergometry, seated resistance exercises, and pool exercises. Low resistance exercises using distributed practice and circuit training also reduce the likelihood of injury. This patient will not be able to use a regular stationary ergometer due to size.

Question# 69 A patient arrives for a regularly scheduled cardiac rehab class but does not begin exercising with the rest of the class. The patient says she doesn't feel very well and has a temperature with chills, nausea, and sweats. When asked if in any pain, the patient reports an aching pain in the shoulder and back. Palpation reveals tenderness in the posterior subcostal and costovertebral regions. The therapist's BEST course of action is to: 1)

apply a hot pack and allow the patient to rest until feeling better.

2)

initiate a referral for medical workup for suspected urinary tract infection.

3)

initiate a referral for medical workup for suspected pelvic inflammatory disease.

4)

send the patient home and instruct to contact her M.D. if not feeling better in a few days.

Rationale: A medical referral is indicated with signs and symptoms of acute infection. Common signs and symptoms of urinary tract infection (UTI) include: urinary frequency and urgency; pain in the shoulder, back, lower abdomen or groin; fever and chills; costovertebral tenderness; hematuria (blood cells in urine); nocturia (urination at night); dysuria (painful urination); and pyuria (pus in urine). Pelvic inflammatory disease (PID) is an inflammation of the fallopian tubes and produces signs and symptoms of lower abdominal pain.

Question# 70 A patient recovering from traumatic brain injury is sitting on a platform mat and demonstrates sacral sitting with a kyphotic upper spine and a forward poking head posture. The MOST appropriate initial intervention in sitting to ensure optimal function is: 1)

resisted holding using the PNF technique of rhythmic stabilization.

2)

forward-backward weight shifts using resisted movement to the upper trunk.

3)

active assisted mobilization of the pelvis to neutral using manual contacts.

4)

side to side weight shifts using active reaching movements of the upper extremities.

Rationale: Modification of the pelvic position to a neutral position (reversing the sacral sitting position of a posterior pelvic tilt) promotes good lumbar and trunk alignment. Many additional postural problems (kyphosis and forward head) are correctable by aligning the pelvis first and achieving a stable base. Only then can the therapist focus on stability control in sitting (e.g., using the PNF technique of rhythmic stabilization). Weight shifts in any direction are contraindicated as the basic requirement for dynamic stability has not been achieved, i.e., stability control.

Question# 71 A patient recovering from a stroke demonstrates poor appetite and weight loss, difficulty sleeping, impaired concentration, and lack of interest in activities outside the home. The primary physician has prescribed Amitriptyline Hydrochloride, a tricyclic anti-depressant. During a home physical therapy session, the patient demonstrates increased balance difficulties. The therapist should examine for: 1)

blurred vision, ataxia, and hypertension.

2)

tachycardia, palpitations, and hypertension.

3)

hypotension, bradycardia, and nausea.

4)

drowsiness, dizziness, and postural hypotension.

Rationale: This patient is exhibiting clinical depression. Pharmacological management with tricyclic antidepressants can cause a number of adverse changes affecting balance. Early changes include drowsiness and dizziness. Continued use can result in orthostatic hypotension, restlessness, fatigue and abnormal movements. Tachycardia, palpitations, and blurred vision can also occur as adverse effects of this medication but not hypertension or bradycardia. Fall prevention strategies are an important part of the plan of care.

Question# 72 A patient with a T5 complete spinal cord lesion is a recent admission to a SCI rehabilitation unit. On the second day of therapy the patient complains of a sudden onset of a throbbing headache. The therapist notices profuse sweating of the face, neck, and shoulders. The patient becomes very apprehensive and reports not being able to see clearly. The therapist's BEST course of action is to: 1)

take the patient's heart rate and lower to supine with head supported.

2)

allow the patient to rest and monitor BP and HR closely.

3)

return the patient to the unit, report to the charge nurse and document findings in the medical record.

4)

take the patient's BP and activate the emergency response system.

Rationale: This patient is presenting with signs of autonomic dysreflexia (AD). Signs and symptoms include sudden and significant elevation in BP (>20mmHg), visual field changes, and changes in heart rate (arrhythmias, fibrillation, PVCs). In SCI, AD is common with lesions above T6 and results from the disruption of autonomic pathways from the hypothalamus (loss of sympathetic inhibitory output below the level of the lesion). It is always an emergency situation as AD can quickly result in stroke, renal or retinal hemorrhage, seizure, or myocardial infarction. Suspected triggers (e.g. full bladder, tight or restrictive clothing) should be checked immediately and the patient's head should be elevated.

Question# 73 A patient with a 10-year history of osteoarthritis is referred to physical therapy following a right knee joint replacement. The patient is currently using a wheeled walker and walks slowly with a stiff knee and an antalgic gait. Gait is frequently interrupted by dizziness which the patient describes as disabling. The patient takes daily ibuprofen and Darvocet for pain. During the history, the therapist's questions should focus on the presence of drug adverse effects. The one side effect that is NOT expected is: 1)

headaches.

2)

photosensitivity.

3)

ringing in the ears.

4)

epigastric pain.

Rationale: Any patient with a prolonged history of NSAIDs use (longer than 3 months) is at risk for gastropathy (erosive gastritis, ulcers, bleeding). Signs and symptoms include epigastric pain, nausea, loss of appetite. Occasionally, painless GI hemorrhage can be present. GI bleeding can result in bloody stools, and dizziness/falls secondary to decreased blood flow to the brain. Additional side effects (among many) include: fatigue, itching, headache, anxiety, confusion, blurred vision, dry mouth, tinnitus, and impaired hearing. Photosensitivity is not associated with prolonged NSAID use.

Question# 74 A 3 year-old with bronchopulmonary dysplasia had been doing well at home for the last 6 months. The child has just been diagnosed with pneumonia. The CXR shows an infiltrate at the right base on the AP film and the infiltrate is anterior on the lateral view. You are teaching the parents how to perform postural drainage on the child. The proper position would be lying on the: 1)

left side, rotated 1/4 turn forward with the feet elevated higher than the head.

2)

right side, rotated 1/4 turn backwards with the feet elevated higher than the head.

3)

right side, rotated 1/4 turn forward with the feet elevated higher than the head.

4)

left side, rotated 1/4 turn backwards with the feet elevated higher than the head.

Rationale: The infiltrate of right anterior base is most likely the right middle lobe. The standard postural drainage position for the right middle lobe is lying on the left side, rotated 1/4 turn backwards with the feet elevated higher than the head.

Question# 75 A patient is referred to physical therapy following recent resection of a cerebellar tumor. The patient presents with symptoms of dysdiadochokinesia, dysmetria, and action tremor. These symptoms indicate a primary deficit in the functions of the: 1)

neocerebellum.

2)

spinocerebellum.

3)

vermis.

4)

vestibulocerebellum.

Rationale: The neocerebellum (cerebrocerebellum) controls ipsilateral limb movements, ensuring coordination (adequate force, direction, extent of movement, ordering and timing). The spinocerebellum and vermis control synergistic action of axial and girdle muscles (postural stability) while the vestibulocerebellum controls equilibrium responses and head and eye muscles.

Question# 76 A community dwelling elder who has been living alone is referred for fall risk assessment. Upon arrival to the patient's home, the therapist observes the patient is demonstrating mental confusion. He has a productive cough with rust-colored sputum with sharp chest pain and SOB. Respirations are rapid. The therapist's BEST course of action is to: 1)

ask the agency to send the nurse practitioner tomorrow to evaluate the patient.

2)

document the findings and provide scheduled physical therapy examination.

3)

document the findings and cancel the scheduled physical therapy examination.

4)

consult with his primary physician immediately.

Rationale: This patient is exhibiting signs and symptoms of pneumonia (productive cough, pleuritic chest pain, shortness of breath). Mental confusion is a common additional symptom in the elderly along with changes in sleep habits and loss of appetite. His physician should be contacted immediately with symptoms of inadequate ventilation.

Question# 77 A 92 year-old individual who lives alone is referred for home physical therapy to improve functional mobility. During the initial history, the patient reveals he weighs about 100 lbs and has not been eating well lately. Skin turgor is poor and he complains of a dry mouth and decreased urination. He demonstrates postural hypotension when moving from sitting to standing position and dizziness when standing. The therapist suspects: 1)

dehydration.

2)

diabetes.

3)

peripheral edema.

4)

potassium depletion.

Rationale: This patient is exhibiting classic signs and symptoms of dehydration (fluid loss): weight loss, excessive thirst, poor skin turgor, dryness of mouth, low urine output, postural hypotension and dizziness. Additional signs and symptoms include absence of sweat, increased body temperature, increased hematocrit, and confusion. If the state persists, the patient can progress to unconsciousness. While diabetes can produce increased thirst and weight loss, increased urination is seen. Peripheral edema produces weight gain and dependent edema. Potassium depletion produces muscle weakness, fatigue, nausea and vomiting, and cardiac arrhythmias.

Question# 78 Which of the following neuromuscular effects are common in both heat and cold modality applications? 1)

increased pain threshold.

2)

decreased muscle tone.

3)

decreased nerve conduction velocity.

4)

increased pain threshold and decreased muscle tone.

Rationale: Both physical agents can decrease pain (increased pain threshold). Cold will decrease nerve conduction velocity, one of the mechanisms that decrease pain and reduced muscle tone (spasticity), whereas heat will increase nerve conduction velocity which has no effect on pain or spasticity.

Question# 79 A 72 year-old patient with osteoporosis is referred to physical therapy for management of postural abnormalities and core strengthening. Examination reveals an increase in dorsal kyphosis with forward rounded shoulders, forward head position, and posterior pelvic position. Which of the following is NOT an appropriate choice for intervention with this patient? 1)

supine lying, shoulder press toward the floor with mid-back lift.

1)

supine lying, shoulder press toward the floor with mid-back lift.

2)

supine lying, abdominal crunches with head and shoulder lifts.

3)

bridging lifts with arms extended overhead.

4)

standing, wall push-ups.

Rationale: The postural changes described (dorsal kyphosis with forward rounded shoulders, forward head position, and posterior pelvic position) are typical abnormal changes associated with osteoporosis. All of the exercise choices are appropriate to improve postural alignment and strength for this patient except abdominal crunches which are absolutely contraindicated. All forward-bending (flexion) exercises of the trunk should be avoided as they can cause increased compression on the vertebral column and could result in compression fractures. These include abdominal crunches, sit-ups, straight leg raises, toe touches (from a seated or standing position) and any exercise in which the trunk bends and twists.

Question# 80 A patient recovering from stroke is ambulatory in the parallel bars with moderate assistance of one. The patient demonstrates a consistent problem, on the affected side, of knee hyperextension during forward progression. The best intervention strategy is: 1)

supine, bridging, progressing to holding in the bridge position.

2)

sitting, knee slides underneath the patient's seat.

3)

standing, weight shifts onto the affected lower extremity in step position.

4)

small range squats/wall slides using a small stability ball.

Rationale: Knee hyperextension on the affected limb during forward progression is a common gait deviation following stroke and can be the result of (1) a plantarflexion contracture, (2) impaired proprioception, (3) severe spasticity in the quadriceps, or (4) weak knee extensors with compensatory locking of the knee in hyperextension. Small-range squats strengthen hip and knee extensors (closed chain exercises) while improving range in ankle dorsiflexion. The small stability ball assists in maintaining the lumbar curve while enhancing ease of motion. Spasticity can be counteracted by not allowing the knee to go fully back into hyperextension. The other functional training tasks do not enhance the required knee control, e.g. bridging promotes hip extension with knee flexion, knee slides promote knee flexion control. Standing weight shifts do not counteract knee hyperextension. Question# 81 A hospital human resource manager is interviewing a prospective physical therapist for employment. The physical therapy department has had a high turnover rate as a result of staff members taking maternity leave and job-related disability leave. It is illegal for the manager to ask whether this female applicant: 1)

can fulfill the hours and days per week that the job requires.

2)

is planning to start a family.

3)

has the qualifications that the job requires.

4)

has a disability that would prevent her from satisfactorily performing the job.

Rationale: The Pregnancy Discrimination Act, an amendment to Title VII of the 1964 Civil Rights Act, prohibits an employer from using pregnancy-related information as a means of determining suitability for employment. It is not illegal to ask about information that was mentioned in the other choices.

Question# 82 A review of the medical record reveals a newly arrived patient suffers from a potassium imbalance (potassium level is 2.5mEq/L). During the initial examination, the therapist should examine for: 1)

muscle wasting with hyperexcitability.

2)

leg cramps and myalgia with fasciculations.

3)

muscle weakness with fatigue and leg cramps.

4)

muscle weakness with hyperreflexia and fasciculations.

Rationale: Normal serum potassium levels are from 3.5 to 5.5 mEq/L. This patient is suffering from hypokalemia (low potassium). Possible changes include: muscle weakness and fatigue, leg cramps, and hyporeflexia. Cardiac symptoms (postural hypotension, dizziness, ECG abnormalities), respiratory distress, cognitive symptoms (irritability, confusion, depression) and GI symptoms (nausea, diarrhea, abdominal cramps) can also result from hypokalemia. Myalgia and fasciculations are not characteristic. Question# 83 A therapist is providing an electrical stimulation treatment. When the therapist turns on the machine, the patient jumps and cries out that he has received a shock. The ethical principle that has NOT been met in this situation is: 1)

autonomy.

2)

fidelity.

3)

non-maleficence.

4)

veracity.

Rationale: A health provider is obligated not to harm the patient. In this situation, the therapist has caused harm. Autonomy is the patient's right to make decisions about his care; fidelity is one's faithfulness to his/her duties; and veracity is telling the truth.

Question# 84 A patient with a right middle cerebral artery stroke demonstrates early recovery movements in the left upper extremity (stage 2), left homonymous hemianopsia and a left unilateral neglect. The exercise intervention that represents the BEST choice to promote functional recovery is: 1)

sitting, left upper extremity extended and weightbearing.

2)

PNF chop/reverse chop with right arm leading.

3)

sitting, arms cradled position, active holding.

4)

PNF lift/reverse lift pattern with right arm leading.

Rationale: The PNF pattern of lift/reverse lift moves the affected arm in an out-of-synergy pattern. Obligatory synergies can be expected in early (stage 2) and middle (stage 3) following stroke and should be discouraged. Allowing the sound arm to move in the chop/reverse chop pattern would move the affected arm in-synergy and is therefore contraindicated. Sitting, left upper extremity weightbearing is a good out-of-synergy activity but does little for left unilateral neglect. The arms cradled position places the left upper extremity in an in-synergy position and is contraindicated for patients who demonstrate obligatory synergies.

Question# 85 Two patients are being seen in an out-patient physical therapy department for strengthening exercises following an internal fixation to repair a hip fracture. Patient A has a managed care health insurance policy that allows 15 visits per episode of illness. Patient B has a managed care policy that allows unlimited physical therapy visits as long as progress is being made. Both patients will require at least 25 visits to reach maximum functional improvement. To best help Patient A reach maximum improvement, the therapist should: 1)

write an appeal to Patient A's insurer justifying more visits.

2)

do nothing and advise Patient A that coverage cannot be changed.

3)

provide care to Patient A but do not bill for it.

4)

work with the APTA to lobby for improved physical therapy benefits for Patient A's policy.

Rationale: Physical therapists should serve as patient advocates and be involved in appealing to insurers for exceptions that will result in the patient reaching a goal. The insurer will evaluate the appeal based on the determination that the additional costs associated with the appeal are justified by the anticipated outcome. Providing care without billing for it could financially harm the facility unless pro bono care is granted in this case. Working with the APTA to improve physical therapy benefits is a noble cause; however, Patient A will not benefit as it usually takes a long time to make policy and regulatory changes.

Question# 86 A 30 year-old patient is brought into the emergency room by ambulance following a motor vehicle accident while being an unrestrained passenger. The patient complains of right-sided chest pain and has a consistent tracheal deviation to the left. What pathology would be the most likely cause of tracheal shift to the left? 1)

right lung collapse.

2)

right pneumothorax.

3)

rib fractures.

4)

flail chest.

Rationale: Given this patient was the passenger and was unrestrained, and complaining of right sided chest pain, the likely scenario is that the patient was forced into contact with the passenger side door. This could cause rib fractures on the right, causing the pain in the R chest but this alone wouldn't cause a tracheal shift. Tracheal shifts are caused by either a pneumothorax (with a tracheal shift away from the cause) or a lung collapse (with a tracheal shift toward the cause). In this case, the tracheal shift is away from the trauma, making the best answer a R pneumothorax. If a flail chest was enough to cause a tracheal shift, it would not be consistently toward one side, but it would alternate with the respiratory cycle.

Question# 87 A 72 year-old individual wants to begin an exercise training program that includes weights. The expected musculoskeletal changes that occur with aging that might influence the patient's response to training include: 1)

decreased muscle mass with greater decrease in Type I fibers.

2)

decreased motor unit recruitment.

3)

decreased muscle mass with greater decrease in Type II fibers.

4)

increased speed of movement.

Rationale: Musculoskeletal changes associated with aging include decreased muscle mass with greater decreases in Type II (fast twitch) fibers responsible for rapid powerful contractions (power and mobility). Overall strength and speed of movement are decreased. Type I (slow twitch) fibers responsible for slow speed contraction and continuous activity (postural control) are less affected. Decreased motor unit recruitment is a neuromuscular change associated with aging. Question# 88 A developmental examination of a 20 month-old reveals the following: inability to move forward in prone, inability to move in or out of sitting without support, a "bunny hopping" pattern instead of reciprocal creeping, and impairments of fine motor control when manipulating a cube. All of these developmental milestones should have been reached by the age of: 1)

6 months.

2)

9 months.

3)

12 months.

4)

15 months.

Rationale: The behaviors are all typically developed by 9 months of age. Children at six months-old are typically able to roll segmentally, go from sitting to quadruped or prone, able to reach on one arm in prone and able to hold a small object in each hand. Children at 12 months are able to creep well, over, around, and on objects and walk with one arm held. Children at 15 months are able to take independent steps with a wide base of support, creep backwards down stairs. They have a precise, controlled release grasp of a small container with wrist extended.

Question# 89 A researcher investigated the effect of constraint induced movement (CIM) therapy on motor function of the upper extremity in chronic stroke. Fifty patients were randomly divided into groups: the CIM intervention and the conventional physical therapy intervention. The Wolf Motor Action Test was used to measure function before and after the interventions. After evaluating the results, the researcher accepted the null hypothesis. This can be interpreted as: 1)

there was a statistical difference; conventional PT was more effective than CIM.

2)

CIM was superior to conventional PT but did not rise to the level of statistical significance.

3)

there was no statistical difference in the two interventions in terms of motor outcomes.

4)

there was a statistical difference; CIM was more effective than conventional PT.

Rationale: The null hypothesis is a hypothesis of no difference or effect. Inferential statistics are used for hypothesis testing. A statistically significant statistic (P