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Psychotherapy with multiple modalities final exam

1.

If a magnetic resonance image (MRI) correctly identifies 95% of patients as positive for anterior cruciate ligament tears, then the MRI is:

  1. Sensitive
  2. Specific
  3. Significant
  4. Stable

The correct answer is:

  1. This is the correct answer.  A test that is sensitive will correctly identify the true positives.  With high sensitivity, a test that is negative will likely mean that you can rule OUT the condition because positives are so reliable.
  2. Specificity is the % of true negatives identified.  With high specificity, a test that is positive will rule IN the condition because the negatives are so reliable.
  3. Statistically significant would mean the result is likely NOT due to chance.
  4. Stable would mean the result does not fluctuate.

2.

A 20 year old male soccer player presents with a Grade II right lateral ankle sprain upon evaluation.  What are the characteristics of a Grade II ankle sprain?

  1. Partial tear of the lateral ligament complex with mild joint instability, moderate intra-capsular swelling and tenderness, and some loss of ROM and joint function
  2. Complete rupture of the anterior talofibular ligament, calcaneofibular ligament, and capsule with mechanical joint instability; severe intra/extra-capsular swelling, ecchymosis, tenderness and inability to weight-bear.
  3. Stretch of the lateral ligament complex with no macroscopic tear or joint instability, little swelling or tenderness
  4. Partial tear of the syndesmosis, creating generalized swelling and tenderness throughout the ankle joint complex; inability to bear weight, severe ecchymosis, and mortise widening.

The correct answer is:

  1. This is the correct answer.  This describes a Grade II lateral ankle sprain.
  2. This describes a severe or Grade III lateral ankle sprain.
  3. This describes a mild or Grade I lateral ankle sprain.
  4. This describes a “high” ankle sprain, or Syndesmosis sprain.

3.

An 11 year old male presents to the physical therapy clinic with signs of hypertonicity related to cerebral palsy.  The boy has significant shortening of the left sternocleidomastoid muscle, creating a severe torticollis to the right.  This has led to a pressure ulcer forming on his right ear from contact with the wheelchair headrest.  The MOST appropriate course of action is to:

  1. Begin a course of active-assisted range of motion exercises, focusing on the upper extremities and creating a home program to improve shoulder active range of motion.
  2. Inform the patient’s family that the child should not be in a wheelchair to prevent the formation of any more pressure ulcers and decrease pain associated with torticollis.
  3. Inform the primary care provider of the child and request him/her to order an oral prescription of Baclofen because the child has developed a tolerance for the current dosage.
  4. Begin a course of passive range of motion stretches, focusing on the neck, and instruct the patient’s family on proper positioning and wheelchair adjustments to decrease the likelihood of future ulcers.

The correct answer is:

  1. This is a distractor option that does not address torticollis or ear ulceration.  While shoulder range of motion exercises may not be harmful or cause problems, it certainly won’t solve this one.
  2. This will solve the ulceration problem, but when does a physical therapist ever put a patient on bed rest?  This is not the MOST appropriate course of action.
  3. Getting an increase dosage of Baclofen may be part of the solution, but there are several issues with this item.  If the patient is affected enough to develop ulceration from positioning, he likely won’t be able to tolerate oral Baclofen (he will have to receive it intrathecally).  Also, Baclofen use does not generally create tolerance to the drug requiring higher doses.
  4. This is the MOST correct answer.  It is straightforward in describing a course of action that focuses on treating the hypertonic neck muscles, but also addresses positioning and family/patient education.

4.

A patient with a stroke affecting the right middle cerebral artery has difficulty walking, especially over uneven surfaces.  Which of the following describes the MOST appropriate initial treatment to improve the patient’s ability to walk over uneven surfaces?

  1. Place a single point cane in the patient’s left hand and train him to use a step-to gait pattern.
  2. Place a single point cane in the patient’s right hand and train him to use a step-to gait pattern.
  3. Fit the patient with a 4-wheeled walker and instruct him to use a 4-point gait pattern.
  4. Fit the patient with axillary crutches and instruct him to use a 4-point gait pattern.

The correct answer is: ?

  1. This answer is correct except for the hand placement.  With a stroke in the right MCA, the patient’s left side will be affected, requiring the cane to be in the right hand.
  2. This is the correct answer.  The question indicates that the patient has difficulty with uneven surfaces, implying that even surfaces are not as difficult.  Thus using a SPC with a swing-to gait pattern would be the most correct initial treatment.
  3. This answer is a distractor.  You cannot use a 4-wheeled walker to create a 4-point gait pattern.
  4. Axillary crutches would be a possibility; however, the 4-point gait pattern is typically used for individuals with a very low tolerance of ambulation and would not be ideal for traversing uneven terrain.  Also, it is not specified, but stroke patients often have both the lower extremity and upper extremity affected, making it difficult to negotiate axillary crutches.

5.

A physical therapist evaluating a 66 year old female who has a history of severe head trauma following a motor vehicle accident.  The patient has difficulty with rapid alternating movements while performing neurologic testing.  The BEST term to describe this specific impairment is:

  1. Ataxia
  2. Dysmetria
  3. Dysarthria
  4. Dysdiadocokinesia

The answer is:

  1. Ataxia is a global term comprising inaccuracy and decomposition of movement.  Although this encompases many forms of movement impairments, it is too general to describe difficulty with rapid alternating movement.
  2. Dysmetria is defined as a decreased ability to judge distance and range.
  3. Dysarthria is defined as a motor impairment involving the muscles used in speech and breathing.
  4. This is the correct answer.  By definition, dysdiadochokinesia is an impairment specifically involving rapid alternating movements, such as pronating and supinating one’s hands quickly.

6.

A 79 year old female presents to outpatient rehabilitation services 6 weeks following a CVA with right hemiplegia.  She complains of right shoulder pain working on functional upper extremity movements and has severe shoulder pain when practicing bed mobility activities such as rolling and scooting.  On examination, it is observed that the humeral head is inferiorly displaced.  Which of the following would be the MOST appropriate for her condition?

  1. Transcutaneous Electrical Nerve Stimulation (TENS)
  2. Functional Electrical Stimulation (FES)
  3. Short Wave Diathermy (SWD)
  4. Interferential Current  (IFC) Stimulation

The correct answer is: ?

  1. TENS is a powerful modality that will treat pain in many individuals.  This woman does complain of pain, but the impairment of an inferiorly displaced humeral head is also mentioned.  TENS will have little effect on this displacement.
  2. FES is the correct answer.  Using FES to help elevate her shoulder will treat the displacement and ideally eliminate the source of pain.
  3. SWD is a pain relief modality that is not used often.
  4. IFC is another form of TENS, and will not help much with the displaced humeral head.

7.

A 30 year old male presents to outpatient rehabilitation with numbness and tingling on the 4th and 5th fingers of the left hand consistent with nerve entrapment symptoms.  Upon further examination, it is noted that the patient has normal sensation on the dorsum of the hand on the ulnar side.  Where is the MOST likely source of nerve entrapment?

  1. Guyon’s Canal
  2. Carpal Tunnel
  3. Cubital Tunnel
  4. 1st Rib

The correct answer is:

  1. Guyon’s Canal is the correct answer.  The ulnar nerve provides the sensory innervation for the 4th and 5th digits, narrowing the answer to either the Cubital Tunnel or Guyon’s Canal.  The ulnar nerve has a dorsal cutaneous branch that innervates the dorsum of the hand.  Because dorsal sensation is intact, the nerve must be trapped at Guyon’s Canal.
  2. The median nerve passes through the Carpal Tunnel and does not innervate the 4th and 5th digits.
  3. Entrapment at the Cubital tunnel would not typically leave any sensation on the dorsum of the hand on the ulnar side.
  4. Thoracic Outlet Syndrome would have entrapment at the 1st rib, but sensation loss would occur in a similar manner to entrapment at the Cubital tunnel.

8.

A 45 year old male presents to the burn unit with partial thickness burns over the entire right arm, left arm, front of head, and front of chest.  Approximately what percentage of his body is burned?

  1. 31.5%
  2. 36%
  3. 40.5%
  4. 45%

The answer is:

This questions requires knowledge of the rule of nines: entire right arm = 9%, entire left arm = 9%, front of head = 4.5%, front of chest = 18%.  Total = 40.5%, correct answer is 3.

9.

A patient presents to the inpatient rehabilitation unit who has suffered a vertebro-basilar CVA and has difficulty adducting and depressing his eyes.  Which cranial nerve is the MOST likely cause of this impairment?

  1. CN I
  2. CN II
  3. CN III
  4. CN IV

The answer is:

Cranial nerve testing for ocular movements is performed using the “H” pattern to assess tracking movements. Difficulty adducting and depressing the eye is indicative of Trochlear nerve involvement (CN IV).

10.

A 59 year old male patient is being evaluated for left shoulder pain.  The patient reports that his shoulder pain is closely associated with activity, including stress at work.  The patient reports that at worst, the pain radiates into his neck, and he feels shortness of breath which subsides with rest.  What would the MOST appropriate intervention be?

  1. Begin passive range of motion exercises within the pain free range of motion.
  2. Postpone treatment and refer the patient to his physician for further evaluation.
  3. Apply modalities to the shoulder and instruct the patient on activity modification.
  4. Begin the patient with rotator cuff exercises within the pain reduced range of motion and instruct patient on activity modification.

The correct answer is:

  1. PROM is an excellent treatment for sore shoulders, but the patient is presenting with signs and symptoms consistent with cardiac distress, not musculoskeletal pain.
  2. This is the most appropriate initial action.  The patient is having signs of cardiac distress that would be worsened with activity.
  3. This is not appropriate considering the above information.
  4. The pain is not originating from the rotator cuff, thus this would be a poor choice.

11.

A 35 year old patient with a complete T5 spinal cord injury is working on supine to sit transfers on the mat table when he suddenly appears flushed and complains of his heart pounding.  Upon examination, his blood pressure is 180/100 and he has a pounding headache.  The most appropriate INITIAL course of action is:

  1. Lay the patient supine and notify the patient’s physician.
  2. Sit the patient up and notify the patient’s physician.
  3. Allow the patient to rest longer between sets of activity.
  4. Initiate core strengthening exercises to maintain intraabdominal pressure.

The correct answer is:

  1. This is not correct because putting the patient in supine will exacerbate the autonomic dysreflexia.
  2. This is the correct answer.  By sitting the patient up, you decrease the blood pressure in the head and mitigate the effects of the dysreflexia.
  3. This is incorrect considering that autonomic dysreflexia is a life-threatening condition
  4. Also incorrect.

12.

A 21 year old female patient presents with neck pain and stiffness that has gradually worsened over the last two weeks.  Upon examination, the patient is noted to have left-sided pain with left side bending with left rotation and reports pain at the left C5-6 junction.  Hypomobility is also noted with right side-gliding of C6.  Which of the following techniques will be most appropriate to decrease pain?

  1. Closing technique for the mid-thoracic spine.
  2. Closing manipulation in extension for C5-C6
  3. Gapping manipulation in flexion for C5-C6.
  4. Flexion/opening manipulation for mid-thoracic spine

The answer is:

  1. The cervical spine “closes” with side-bending and ipsilateral rotation (i.e. “closed” with left SB and left rot.).  Manipulating the thoracic spine for neck pain is a common treatment strategy, however the specific issues noted in the question require more than just a nonspecific t-spine manip.
  2. This is the correct answer.  The hypomobility is noted at C6 with right side-gliding and pain with left SB and rotation.
  3. This would be the treatment if the pain were on the right with the left SB and rotation.  (Difficulty “opening” the right C5-6 facet joint.
  4. Refer to #1.  Not the MOST appropriate manipulation, however this could be used as an adjunct to #2.

13.

A 22 year old female presents to the clinic with a chief complaint of knee pain following a twisting injury while playing soccer 5 days ago.  The patient’s knee is swollen significantly and is unable to jump or run.  What special test would be the MOST appropriate to diagnose the injury?

  1. Lachman’s test
  2. Posterior drawer test
  3. Active Lachman’s test
  4. External Rotation Recurvatum Test

The correct answer is:

  1. This is the most correct answer.  The overwhelming majority of injuries to female soccer players is to the ACL, especially with a running/twisting injury and swelling.  In addition, the Lachman’s test is validated well by multiple studies.
  2. PCL’s are an issue with twisting injuries, but not to the extent that ACL’s are.
  3. Active Lachman’s test has not had near the validation that the plain-vanilla Lachman’s test has.
  4. Good test, but not the MOST appropriate.

14.

A geriatric patient with “walking” pneumonia and a history of recent falls is receiving physical therapy for general strengthening.  What part of this person’s treatment be affected MOST by his lung condition?

  1. Decreased stamina/tolerance of activity
  2. Inability to participate in endurance type activities
  3. Diminished tidal volumes
  4. Lower oxygen saturation with moderate activity

The correct answer is:

  1. This is the correct answer.  Having a “walking” pneumonia and history of falls indicates a decreased tolerance of activity/stamina will likely slow therapy the most.
  2. This is related to number 1, but the patient’s treatment will focus on easy endurance type activities.  The patient will be able to participate some.
  3. Diminished tidal volume will be a part of the issue, but can be monitored and controlled with coaching.
  4. This is related to number 3, but will not be the MOST affected portion because it will be difficult for this patient to perform much moderate intensity activity.

15.

A patient complains of weakness in the right hip while she is ambulating.  Upon examination, you notice that the patient has a significant drop of the left hip while in midstance on the right leg.  The MOST appropriate treatment for this impairment would be:

  1. Standing hip abduction of the left leg.
  2. Standing hip abduction of the right leg.
  3. Standing flexion of the left leg.
  4. Standing flexion of the right leg.

The correct answer is:

  1. This is the most correct answer.  The patient is demonstrating a Trendeleburg gait with the weakness on the right hip abductors.  The trick (and this is very true in the clincal world) is that while standing on the involved hip and abducting the opposite, you are loading the right hip (closed-chain) more than the left hip (open chain).  Thus you are MORE effective at strengthening the right hip abductors by using the closed chain exercise.
  2. Good, but this open chain activity for the right hip abductors is not as appropriate as a closed-chain activity.
  3. Not directly related to the impairment.
  4. Same as (3).

16.

A patient presents to the clinic with signs of lethargy and mild dizziness.  The patient’s resting blood pressure is 100/70.  Which of the following is MOST likely to cause this decrease in blood pressure?

  1. Lisinopril
  2. Prednisone
  3. Sertraline
  4. Metformin

The correct answer is:

  1. This is the correct answer.  Lisinopril is an ACE inhibitor and is used primarily for the treatment of hypertension. 
  2. This is used to treat inflammatory diseases and is typically not associated with decreases in blood pressure.
  3. Sertraline treats depression and is typically not associated with decreases in blood pressure.
  4. Metformin controls blood sugar in Type II Diabetes and is not typically associated with decreases in blood pressure.

17.

A patient presents to the clinic with right shoulder pain and complains of difficulty reaching overhead, with pain especially from 60-120 degrees of shoulder flexion.  Which special test would be MOST informative for this set of symptoms?

  1. Neer Test
  2. Empty Can Test
  3. Crossover Test
  4. Push Off Test

The correct answer is:

  1. This is the correct answer.    The Neer Test is a test for subacromial impingement and is typically associated with the painful arc.
  2. The Empty Can Test assesses supraspinatus pathology.
  3. The Crossover Test checks for AC Joint pathology
  4. The Push Off Test assesses strength and integrity of the subscapularis, one of the rotator cuff muscles.

18.

A patient is in the inpatient rehabilitation unit for a total knee replacement.  While reviewing the case, you note that the patient has been diagnosed with an infection of Methicillin-resistant Staphylococcus aureus (MRSA) and is in an isolation room.  What is the MOST appropriate action to take to prevent contamination?

  1. Don gown, mask, gloves, and respirator before entering the room, wash hands after.
  2. Limit therapy sessions to less than 15 minutes and limit contact during treatment.
  3. Don gloves when in contact with the patient and wash hands after.
  4. Wash hands before and after contact with the patient, but do not touch the patient.

The correct answer is:

  1. This is the most conservative of precautions that is used for droplet precautions, especially the mask.  MRSA requires contact precautions.
  2. This is not appropriate.
  3. Handwashing and gloves are the MOST appropriate.  If you anticipate extensive contact, donning a gown would also be appropriate for Contact Precautions.
  4. This is not appropriate.

19.

A 32 year old female presents to the clinic complaining of left shoulder pain.  The patient’s symptoms include pain with reaching and limited motion in all planes.  The patient’s symptoms have been progressively worsening over the last month.  What would be the MOST effective initial treatment?

  1. Refer the patient to their primary care provider for intracapsular corticosteroid injections.
  2. Begin gentle progressive stretching exercises with the focus on increased active range of motion.
  3. Initiate rotator cuff strengthening exercises, focusing on external rotation.
  4. Instruct the patient on Codman pendulum exercises and apply a moist heat pack.

The correct answer is:

  1. While corticosteroid injections can be a helpful to achieve short term results, there is little evidence they have long term effects.
  2. This is the most correct answer.  An effective treatment program for adhesive capsulitis should use gentle progressive stretching as the primary treatment.
  3. This is not appropriate considering the symptoms of adhesive capsulitis.
  4. This is not appropriate.

20.

While treating a patient for cardiac rehab, a physical therapist relies on the Borg RPE scale.  The Borg rating of perceived exertion scale (RPE) is MOST representative of which type of data scale?

  1. Nominal
  2. Ordinal
  3. Cardinal
  4. Marginal

The correct answer is:

  1. Nominal scales are used to indicate categories that are not higher or lower (example: race, gender, etc.)
  2. Ordinal scales are used to represent data that is comparatively higher or lower that other data.  This is the most correct answer.
  3. Cardinal scales are used when there is an absolute zero and are quantitative.  Age and weight are good examples of these.
  4. Not related.

21.

A physical therapist is trying to determine which special test to use for an examination and is researching the statistical values of each.  What is the MOST important statistical attribute a special test must have to effectively limit Type I errors?

  1. Sensitivity
  2. Specificity
  3. Positive likelihood ratio
  4. Negative likelihood ratio

The correct answer is:

  1. High sensitivity effectively limits type II errors (False negatives).  In essence, high sensitivity indicates that if the test is negative, you can effectively rule out the condition, with very few false negatives.
  2. High specificity effectively limits type I errors (False Positives).  High specificity indicates that if the test is positive, you can effectively rule IN the condition with very few false positives.
  3. Positive likelihood ratios indicate a likelihood that a positive test is accurate.  This does relate to Type I errors, however the calculation to create the LR+ uses the raw sensitivity and specificity and is used to compare one test to another in the likelihood of accurate positives.
  4. Negative likelihood ratios indicate a likelihood that a negative test is accurate.  This relates to Type II errors, and is calculated in a similar way to positive likelihood ratios.

22.

A physical therapist is evaluating a 50 year old patient with a generally swollen right leg.  The patient does not report any trauma to the leg and describes the swelling as increasing gradually over the last 12 months.  The swelling is non-pitting, primarily below the knee.  The leg is not red or hot, and the patient indicates that his leg just feels “heavy.”  What is the MOST likely origin of the swelling?

  1. Systemic infection
  2. Chronic inflammation
  3. Congestive heart failure
  4. Lymphedema

The correct answer is:

  1. Swelling from an systemic infection would not be insidious over 12 months (thus acute) and would be associated with redness and hotness.
  2. Swelling from chronic inflammation would likely be associated with some type of trauma or pain, and is not the MOST appropriate response.
  3. Congestive heart failure can cause swelling, but is more likely to be pitting and more generalized.
  4. Lymphedema is the correct answer.  This condition is typically associated with a “heaviness” that appears gradually and usually involves non-pitting edema.

23.

A physical therapist is evaluating a patient with pain that radiates throughout his lower extremities.  The patient has significant foot drop while ambulating and complains of numbness and tingling extending from the great toe up to the knee along the anterior leg.  What is the MOST likely pathology underlying these symptoms?

  1. Sciatic nerve entrapment
  2. Deep peroneal nerve inflammation
  3. Tibial nerve entrapment
  4. L5 nerve root entrapment

The answer is:

  1. Sciatic nerve entrapment can occur and cause symptoms radiating down the posterior leg.  Foot drop is not common with this condition.
  2. Deep peroneal nerve inflammation can lead to drop foot, however the deep peroneal nerve only innervates a small portion of the dorsum of the foot, thus eliminating this choice.
  3. Tibial nerve entrapment would affect the posterior leg, extending to the heel.  Motor loss would be present in the plantarflexors.
  4. This is the correct answer.  Tibialis anterior weakness and sensory loss along the anterior leg below the knee are the most common signs of L5 nerve root entrapment.

24.

A patient has right leg pain and displays redness and swelling throughout the foot and ankle distal to the knee that has developed over the last 3 days.  The patient reports no trauma and complains of a deep ache in the calf musculature.  What is the MOST appropriate initial treatment?

  1. Refer to physician to further examination..
  2. Elevate the lower extremity and apply an ice modality.
  3. Instruct the patient on range of motion exercises and begin a home exercise program.
  4. Perform instrument assisted manual soft tissue mobilization to decrease the swelling.

The correct answer is:

  1. This is the correct answer.  Symptoms of a DVT include redness and swelling combined with a deep ache.  Suspected DVT’s should be ruled out before beginning treatment.
  2. While this may help alleviate some of the symptoms, applying an ice pack in elevation is not the MOST appropriate initial treatment.
  3. Again, this may help with swelling, but is not the MOST appropriate treatment.
  4. This could dislodge the DVT which could travel and create a pulmonary embolism.  This is contraindicated until diagnostic ultrasound can rule out any DVT’s.

25.

A patient with cystic fibrosis is receiving postural drainage and percussion for the right lung’s middle lobe.  What is the MOST appropriate patient position?

  1. Supine on a wedge with the left shoulder elevated on pillows with the head lower than the pelvis.
  2. Supine on a wedge with the right shoulder elevated on pillows with the head lower than the pelvis.
  3. Prone with the right shoulder elevated on pillows and the head on the same plane as the pelvis.
  4. Prone with the left shoulder elevated on pillows and the head on the same plane as the pelvis.

The correct answer is:

  1. This is the drainage position for the left lingular lobe.
  2. This is the correct position and is most appropriate for the right middle lobe.
  3. This is the drainage position for the right posterior lower lobe.
  4. This is the drainage position for the left posterior lower lobe.

26.

A patient is being evaluated by a physical therapist for a diabetic ulcer that penetrates the subcutaneous tissue, extending into the subcutaneous fat and fascia but without any gangrene or osteomyelitis present.  The physical therapist wishes to document the severity of the ulcer.  What is the MOST appropriate objective measure of the wound?

  1. Measure the depth and shape of the ulcer and classify it as a Grade 2 ulcer on the Wagner Ulcer Grade Classification System.
  2. Measure the depth and shape of the ulcer and classify it as a Grade 3 ulcer on the Wagner Ulcer Grade Classification System.
  3. Measure the depth and shape of the ulcer and classify it as a Grade 4 ulcer on the Wagner Ulcer Grade Classification System.
  4. Measure the depth and shape of the ulcer and classify it as a Grade 5 ulcer on the Wagner Ulcer Grade Classification System.

The correct answer is:

  1. This is the correct answer.  As a physical therapist, you should always document depth and shape of the ulcer.  Grade 2 on the Wagner Scale is defined as a deep ulcer penetrating into the subcutaneous tissue, but without gangrene.  The Wagner scale is commonly used to classify diabetic ulceration.
  2. Grade 3 is defined as a wound extending into the bone and tendon with osteomyelitis present.
  3. Grade 4 is defined as a wound with a small (size of 1 digit) amount of gangrene.
  4. Grade 5 is defined as a wound with a large amount of gangrene, indicating the need for amputation of the involved limb.

27.

A physical therapist is evaluating a patient with ulceration on the lower extremity.  The leg is apparently swollen and red upon examination.  Which of the following grouping of symptoms is MOST consistent with this type of ulceration?

  1. Ulceration is on the lateral leg, pulseless, cool, and painful.
  2. Ulceration is medial leg, shows permanent blanching, and is painless.
  3. Ulceration is upon bony prominences, shows non-blanchable redness at the perimeter of the wound, and has a pink appearance.
  4. Ulceration is upon the bony prominence, began as a small scrape or blister several months ago, with a concomitant diagnosis of diabetic neuropathy.

The correct answer is:

  1. These are the most common symptoms of arterial insufficiency ulcers.
  2. This is the correct answer.  Venous insufficiency ulcers are typically less painful than arterial ulcers.
  3. These are symptoms common to pressure ulcers.
  4. These are symptoms consistent with diabetic ulceration.

28.

A physical therapist is performing a treadmill exercise stress test using the Bruce protocol.  During stage 3 of the test, the P wave increases in height and the S-T segment begins to become significantly upsloping.  What is the MOST appropriate course of action?

  1. Stop the test and refer patient to a physician.
  2. Lower the stage back to stage 2 and monitor for improved electrocardiographic indicators.
  3. Continue with the test without any modification, monitoring for symptoms of cardiac distress.
  4. Discontinue the test, and monitor the patient’s vital signs for 10 minutes.

The correct answer is:

  1. The Bruce Protocol for an exercise stress test involves using a 12-lead ECG monitor to evaluate the amount of stress placed on the heart.  You would stop the test if there was S-T elevation or depression, or the signs of a number of other ECG signs (see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123032/)  P wave increases and S-T upsloping are normal responses to a stress test.
  2. This is not appropriate for the Bruce Protocol.
  3. This is the correct answer.  Both of these signs are normal responses to the stress test.
  4. If the patient requested to stop, this would be the appropriate action.  Because it is not mentioned in the question, this is NOT the most appropriate course of action.

29.

A patient is receiving cardiac rehab and has a heart rate of 110 during moderate intensity exercise.  The patient reports a 16 on the Borg RPE scale.  Which class of heart medications is MOST likely present?

  1. Beta Blockers
  2. Angiotensin-Converting Enzyme (ACE) Inhibitors
  3. Calcium Channel Blockers
  4. Angiotensin II Receptor Blockers

The correct answer is:

  1. This is the correct answer.  Beta blockers work on the beta-adrenergic receptors to decrease sympathetic responses to stress, primarily the heart rate.  The Borg Scale should represent Heart Rate divided by 10.  Thus there is a disparity in heart rate and exertion, indicating a blunted heart rate.
  2. ACE inhibitors block the angiotensin-converting enzyme to prevent vessel constriction during sympathetic responses to stress, primarily blood pressure.
  3. Calcium channel blockers work on the heart musculature to decrease the force of contraction, as well as decreasing the vasoconstrictive smooth muscle in the arteries.  The primary response is decreased blood pressure.
  4. Angiotensin II Receptor Blockers do not prevent the angiotensin I to angiotensin II conversion; rather, they block the receptors of angiotensin II and have an effect similar to the ACE inhibitors.

30.

A 12 year old male athlete is being evaluated by a physical therapist.  The patient reports pain with running and has a sharp pain over the patellar tendon, particularly on the tibial tubercle.  Which of the following disorders is MOST likely present?

  1. Legg-Calvé-Perthes’ disease
  2. Chondromalacia patellae
  3. Osgood-Schlatter disease
  4. Pes anserine bursitis

The correct answer is:

  1. Legg-Calvé-Perthes’ disease is characterized by loss of blood supply to the head of the femur and subsequent bone death.  The cause is often unknown and typically occurs in boys from 4-10 years old.
  2. Chondromalacia patellae is characterized by cartilage loss or disturbance underneath the patella.  This is evinced by pain with knee motion, but not a painful tibial tubercle.
  3. This is the correct answer.  Osgood-Schlatter disease is characterized by a painful bump over the tibial tubercle and pain with sporting activities.  This is most common in young children who are very active in sports, particularly males.
  4. Pes anserine bursitis is characterized by pain at the insertion of the sartorius, gracilis, and semitendinosus, which is medial to the tibial tubercle by 3-4 cm.

31.

A patient is recovering from a broken tibia and has just been instructed to discontinue use of a walking boot.  The patient demonstrates excessive pronation and complains of pain and instability in the ankle while ambulating.  Which of the following is the MOST appropriate treatment?

  1. Begin a single leg standing program and advance to eccentric calf strengthening as tolerated.
  2. Begin with open-chain exercises and progress to closed-chain strengthening of the ankle as tolerated.
  3. Begin with closed-chain exercises and progress to open-chain strengthening of the ankle as tolerated.
  4. Begin a strengthening program involving primarily ankle evertors, progressing as tolerated.

The correct answer is:

  1. This is a good answer, but not the MOST correct.
  2. This is the correct answer.  Progressive strengthening of the ankle will be the MOST appropriate treatment.
  3. This answer is backwards and not the most appropriate.
  4. This may be a part of the program, but is not the most appropriate treatment for ankle weakness after discontinuing a walking program.

32.

A patient reports pain around the anterior aspect of the calcaneus extending toward the 2nd metatarsal head.  The patient has the most pain when first standing up after waking which gradually lessens throughout the day.  The patient has recently begun a walking program.  Which of the following disorders is MOST likely present?

  1. Medial deviation of the 1st metatarsal
  2. Metatarsalgia
  3. Tarsal tunnel syndrome
  4. Plantar fasciitis

The correct answer is:

  1. A bunion or medical deviation of the 1st metatarsal presents with pain over the medial side of the head of the 1st metatarsal.
  2. Metatarsalgia is pain localized under the ball of the foot, typically under the head of the first metatarsal.
  3. Tarsal tunnel syndrome presents with numbness and pain throughout the first 3 toes secondary to the tibial nerve being compressed.
  4. Plantar fasciitis is typically associated with pain at the anterior portion of the calcaneus and increased symptoms with the first steps of the day that gradually decreases.  This is the correct answer.

33.

A physical therapist is evaluating a patient with back pain.  The patient reports having pain that has increased steadily over the last 2 months and is constant and unremitting.  The pain radiates into both lower extremities.  The patient also feels marked weakness throughout the right lower extremity.  What is the MOST appropriate initial treatment?

  1. Discontinue treatment and refer patient to primary care physician for further testing.
  2. Begin a program of core strengthening, focusing on transversus abdominis training and progressing toward a long term stabilization program.
  3. Instruct the patient in appropriate lower extremity exercises to improve leg strength, focusing on the right leg.
  4. Initiate piriformis stretching as tolerated and instruct the patient in self mobilization techniques to improve mobility throughout the lumbar spine.

The correct answer is:

  1. This is the correct answer.  Constant pain without any relation to position is a key indicator of spinal cancer.
  2. This would be appropriate for individuals with poor core strength and signs of hypermobility in the lumbar spine.
  3. This would be appropriate for signs of weakness.
  4. This would be appropriate for signs of piriformis syndrome.

34.

After working for several hours as a mechanic, a patient describes sharp elbow pain over the origin point of the common extensor tendon of the wrist extensors.  The pain is alleviated with rest.  Which of the following disorders is MOST likely present?

  1. Medial epicondylitis
  2. Lateral epicondylitis
  3. Anconeus tendonitis
  4. Olecranon bursitis

The correct answer is:

  1. Medial epicondylitis presents with pain on the medial elbow over the flexor tendons.
  2. This is the correct answer.  Pain is typically over the extensor tendons, especially on the insertion point of the lateral epicondyle.  Repetitive motions involving mechanic work are also among common causes of lateral epicondylitis (tennis elbow).
  3. The anconeus assists in extension of the elbow and would present with pain over the olecranon process.
  4. Olecranon bursitis would present with pain and swelling over the olecranon process.

35.

A patient presents with rheumatoid arthritis and finger pain.  The 2nd digit has a flexed metacarpophalangeal joint, hyperextended proximal interphalangeal joint, and a flexed distal interphalangeal joint.  Which of the following is the MOST accurate description of the position?

  1. Swan neck deformity
  2. Boutonniere deformity
  3. Mallet finger deformity
  4. De Quervain syndrome

The correct answer is:

  1. This is the correct answer.
  2. Boutonniere deformity is just opposite of the Swan Neck
  3. Mallet finger involves just flexion of the DIP joint.
  4. De Quervain syndrome is tenosynovitis of the extensor pollicis brevis and abductor pollicis longus as they pass under the fascial sheath that covers the two tendons.

36.

A physical therapist examines a patient and determines that the patient has a positive Active Compression test (O’Brien’s Test).  Which of the following pathologies is MOST implicated?

  1. Rotator cuff tear
  2. Biceps tendonitis
  3. Superior labral tear
  4. Acromioclavicular joint sprain

The correct answer is:

  1. RTC tears are indicated by tests such as the drop arm test, external rotation lag sign, belly press test.
  2. This is indicated by tests such as Yergason’s Test.
  3. This is the correct answer.  The O’Brien’s test is indicative of SLAP tears.
  4. AC joint sprains are indicated by tests similar to the Cross-over test.

37.

While examining a patient’s lumbar x-ray films, a physical therapist notices that the L5 vertebra is displaced anteriorly on sacrum by approximately 50% of the vertebral body.  How will this MOST affect physical therapy if the patient is being treated for low back pain?

  1. Emphasize core strengthening, especially in spine neutral
  2. Begin progressive gluteal and quad strengthening to assist the lumbopelvic fascia
  3. Avoid extension activities, especially in standing
  4. Add progressive external oblique training as tolerated to assist proper spinal alignment

The correct answer is:

  1. This is a great consideration, but not the MOST important of the choices.
  2. Good consideration, but not the MOST important of the choices.
  3. This is the correct answer.  Extension activities will exacerbate any pain from this spondylolisthesis. 
  4. Good consideration, but not the MOST important of the choices, very similar to #1.

38.

A physical therapist is treating a patient with cervical pain.  The patient reports that the pain occurs with most movements and feels “stiff” with active range of motion.  What is the MOST appropriate course of action?

  1. Refer to primary care physician for further testing.
  2. Initiate thoracic spine thrust manipulation.
  3. Instruct the patient on cervical spine stabilization exercises and issue a home exercise program.
  4. Initiate an upper extremity exercise routine to improve scapular and cervical range of motion and progress as tolerated.

The correct answer is:

  1. This is not appropriate as there are no red flags mentioned in the question
  2. This is the most appropriate action.  Increasing amounts of literature suggest that for hypomobility of the neck, thrust manipulation of the thoracic spine can provide short-term improvements in patients with mechanical neck pain.
  3. The cervical spine is stiff and needs more mobility, not necessarily more stabilization, although postural activities could also benefit the patient.  Of the choices presented, this is not the MOST appropriate.
  4. This is not the most appropriate initial action.

39.

A patient has just undergone a total hip replacement via a posterior surgical approach.  Which of the following combinations of movements of the hip are MOST important to avoid?

  1. Extension, medial rotation, and abduction.
  2. Extension, external rotation, and adduction.
  3. Flexion, medial rotation, and adduction.
  4. Flexion, external rotation, and abduction

The correct answer is:

The most correct answer is 3-flexion, medial rotation, and adduction.  These are the standard precautions to avoid dislocation with a THA that used a posterior surgical approach.

40.

A patient who has suffered a cutting injury to the entire left half of the spinal cord at the T8 level is being examined by a physical therapist.  Which of the following impairments would be MOST apparent on the ipsilateral lower extremity?

  1. Loss of pain and temperature sensation
  2. Loss of movement and light touch sensation
  3. Loss of peripheral smooth muscle control
  4. Loss of coordination and accuracy.

The correct answer is:

  1. This would be lost on the contralateral lower extremity due to the decussation of these sensory afferent fibers.
  2. This is the correct answer.  These pathways decussate in the brain stem.
  3. This is not correct at all since arterial smooth muscle relies wholly on adrenergic receptors.
  4. This would be caused by an injury at the cerebellar level.
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