National Physical Therapy Examination Review & Study Guide PDF

TherapyEd www. TherapyEd.com National Physical Therapy Examination Review & Study Guide O'Sullivan & Siegelman Examinations are available online. Follow the instmctions found on your receipt or in the back of this book to access the TherapyEd Online Leaming Portal. After completing each examination, your performance will be analyzed in terms of specific domains, categories and reasoning skills. The questions that follow are the ones that constitute the online examinations. Separate TEACHING POINTS for each question contain explanations of the correct answer, incorrect choices and reasoning subtype. Domains of Knowledge Cardiovascular/ Pulmonary Systems Musculoskeletal System Neuromuscular and Nervous System Integumentary System Metabolic and Endocrine Systems Gastrointestinal System Genitourinary System Lymphatic System System Interactions Nonsystem Categories Examination Evaluatio n, Diagnosis Interventions Equipment, Devices, and Technologies r Therapeutic Modalities I 11 Safety and Protection ,. l I Professional Responsibilities ii Research and Evidence-Based Practice I Clinical Reasoning Strategies Inductive Reasoning Analysis 0 Evaluation fl Deductive Reasoning Inference Examination A Metabolic and Endocrine Syst·ems I Evaluation, Diagnosis An elderly patient with hypothyroidism is recovering from a fall and is referred to physical therapy to increase exercise tolerance and safety. The patient complains to the therapist of significant muscle pain in both lower extremities. What additional musculoskeletal effects should the therapist examine for? Choices: 1. Distal muscle weakness. 2. Proximal muscle weakness. 3. Joint laxity. 4. Decreased deep tendon reflexes. Teaching Points Correct Answer: 2 Hypothyroidism can have numerous musculoskeletal effects, including myalgia (muscle pain) and proximal muscle weakness. Incorrect Choices: Additional musculoskeletal effects include stiffness (not joint laxity) and prolonged deep tendon reflexes (DTRs) (not decreased DTRs). 'fype of Reasoning: Inferential For this question, the test taker must determine what is most likely to be true based on knowledge of hypo- thyroidism. Questions of this nature, where one must infer information, require inferential reasoning skill. In this case, one should infer that proximal muscle weakness is most likely to be present. If answered incor- rectly, review information on hypothyroidism. Genitourinary System I Examination A patient is refened to a woman's health clinic with moderate to severe uterine prolapse. What symptoms should the therapist examine for? Choices: 1. Absent perinea! sensation. 2. Bowel leakage. 3. Low back pain and perinea! discomfort aggravated by prolonged standing. 4. Low back pain and perinea! discomfort aggravated by lying down. 538... : ·. ·-. Examination A 539 Teaching Points Correct Answer: 3 Low back pain and perinea! discomfort aggravated by prolonged standing are common with uterine prolapse. Incorrect Choices: Perinea! sensation is not decreased; patients typically experience a sensation of heaviness or pulling in the pelvis. Pain is often relieved by lying down (not aggravated). Constipation and painful bowel movement are common. Type of Reasoning: Inferential This question requires one to determine what is most likely to be true based on knowledge of uterine prolapse. Questions of this nature often require inferential reasoning skill. In this case, one should infer that back and perinea! pain aggravated by prolonged standing are often associated with uterine prolapse. If answered incorrectly, review signs and symptoms of uterine prolapse. lntegumentary System I Evaluation, Diagnosis A child experienced a superficial partial-thickness burn from a scalding pot of water affecting 26% of the tho- rax and neck. On what should the therapist's INITIAL plan of care focus? Choices: 1. Return to preburn function and activities of daily living. 2. Pain management. 3. Infection management. 4. Chest wall mobility and prevention of scar contracture. Teaching Points Correct Answer: 4 Prevention of scar contracture and preservation of chest wall mobility and normal neck range of motion (ROM) are the initial major goals to focus on with this patient. Incorrect Choices: I Return to preburn function and ADLs is an important treatment goal but is not the initial focus. Pain and I. infection management are important goals of the medical team and are typically managed by the medical team. Type of Reasoning: Inductive For this question, the test taker must use clinical judgment to determine a best course of action, which neces- sitates inductive reasoning skill. Knowledge of effective treatment approaches for burns is paramount to arriving at a correct conclusion. In this case, chest wall mobility and prevention of scar contracture should be the initial focus of the therapist. Review treatment approaches for burns, especially in children, if answered incorrectly. 540 Examination A Cardiovascular/Pulmonary Systems I Evaluation, Diagnosis A patient with corona1y artery disease has been doing regular aerobic exercise on a treadmill. If the patient fails to comply in taking prescribed beta-blocker medication and continues to exercise, what potential rebound effect could result? Choices: 1. Increase in blood pressure and decrease in heart rate during exercise. 2. Decrease in blood pressure and heart rate during exercise. 3. Increase in blood pressure and heart rate during exercise. 4. Decrease in blood pressure and increase in heart rate during exercise. Teaching Points Correct Answer: 3 Beta-blockers affect the beta-1 adrenergic receptors. Blocking these inhibits the sympathetic response. However, when abruptly terminated, they cause a reflexive opposite response. This patient will demonstrate increased contractility, blood pressure (BP), and heart rate (HR) as a result. Incorrect Choices: This patient's BP will increase, but the patient's HR will not decrease with exercise. The HR and BP will increase, not decrease with exercise on a beta-blocker or when it is quickly removed. The BP will increase, not decrease with activity due to the abrupt stopping of the medication. Type of Reasoning: Inferential This question requires one to determine the likely effects of exercise and not taking beta-blocker medication. Questions of this nature, where one must infer what is most likely to be true of a situation, require infer- ential reasoning skill. For this scenario, one should infer that the patient would have an increase in blood pressure and heart rate with exercise. If answered inconectly, review information on effects of beta-blockers and exercise. ,---.._.,. Musculoskeletal I Examination A patient has persistent midfoot pain with weight bearing. The injury occurred during a soccer match when an opposing player stepped on the patient's right foot when it was planted and cutting to the left. Patient locates the pain where laces are tied. Upon examination there is splaying of the first metatarsal and increased pain when passively stressing the foot with plantarflexion and rotation. What injury should the therapist suspect the patient has sustained? Choices: 1. Lisfranc injury. 2. Turf toe. 3. Calcaneocuboid joint subluxation. 4. Hallux rigidus. Examination A 541 Teaching Points Correct Answer: I The Lisfranc injury (also known as the Lisfranc fracture, tarsometatarsal injury, or simply midfoot injury) is an injury of the foot in which one or all of the metatarsal bones are displaced from the tarsus. Direct Lisfranc injuries are usually caused by a crnsh injury, such as when a heavy object falls onto the midfoot, or when landing on the foot after a fall from a significant height. The injury often occurs when an athlete has his or her foot plantar flexed and another player lands on his or her heel. Incorrect Choices: Tu1f toe is a sprain of the MTP joint of the first toe due to hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground. Calcaneocuboid joint subluxation (also known as cuboid syndrome) is defined as a minor disruption or subluxation of the strnctural congruity of the calcane- ocuboid portion of the midtarsal joint. The disruption of the cuboid's position irritates the surrounding joint capsule, ligaments, and fibularis longus tendon. Hallux. rigid us (stiff big toe) is a degenerative arthritis and stiffness due to bone spurs that affects the MTP joint at the base of the hallux. Symptoms include pain and stiffness in the joint at the base of the big toe during use (walking, standing, bending, etc.). Type of Reasoning: Analytical This question requires one to determine a type of injury sustained based on a description of mechanism of injury and symptoms. Questions that necessitate analyzing information to determine a reasonable conclu- sion often utilize analytical reasoning skill. For this situation, the symptoms are consistent with Lisfranc injury. Review signs and symptoms of Lisfranc injury if answered incorrectly... System Interactions I Evaluation, Diagnosis A patient is referred to physical therapy with a 10-year history of rheumatoid arthritis (RA). What are possible extra-articular complications? Choices: 1. Disc degeneration. 2. Psoriatic skin and nail changes. 3. Vasculitis. 4. Conjunctivitis and iritis. Teaching Points Correct Answer: 3 Rheumatoid arthritis is a progressive autoimmune disease affecting primarily joints and synovial tissue. Extra-articular complications of the disease can include vasculitis. Incorrect Choices: The other choices are not expected extra-articular complications in patients with RA. Disc degeneration is ;1 seen in degenerative disc disease. Psoriatic skin and nail changes and conjunctivitis and iritis can be seen in psoriatic arthritis. I I I Type of Reasoning: Inferential For this question, the test taker must infer or determine what is most likely to be true for a patient with rheu- matoid a1thritis. This requires inferential reasoning skill. In tl1is case, possible extra-articular complications include vasculitis. Review information on rheumatoid arthritis if answered incorrectly. 542 Exa mination A lntegumentary System I Evaluation, Diagnosis A physical therapist is instructing an elderly patient how to perform bed mobility following a total hip replace- ment. The therapist should carefully consider the effects of aging that relate to skin. What is one such effect? Choices: 1. Increased perception of pain. 2. Impaired sensmy integrity. 3. Increased skin elasticity. 4. Increased inflammatory responsiveness. Teaching Points Correct Answer: 2 Changes in skin composition associated with aging include decreased se nsitivity to touch, decreased percep- tion of pain and temperature, and increased risk of injury. Incorrect Choices: Perception of pain is decreased (not increased). The dermis thins, and elasticity is decreased (not increased). Inflammatory responses are attenuated (not increased). Type of Reasoning: Inferential For this question, the test taker must recall the effects of aging and then determine the most likely effect that relates to the skin. This requires inferential reasoning skill. For this situation, the most likely skin effect is impaired sensory integrity. Review effects of the aging process, especially those that affect the skin, if answered incorrectly. I I. : Cardiova scular/Pulmonary System s I Examination What would a therapist who is examining the breathing pattern of a patient with a complete (ASIA A) CS spi- nal cord inju1y expect to observe? Choices: 1. Asymmetric lateral costal expansion due to ASIA A injmy. 2. An increased subcostal angle due to air trapping from muscle weakness. 3. No diaphragmatic motion since the diaphragm is below the level of the lesion. 4. Rising of the abdomen due to no abdominal muscle tone on the abdominal viscera. Teaching Points Correct Answer: 4 The abdominal musculature provides external stability to the abdominal viscera. Without this, the viscera are displaced with respiration. Incorrect Choices: With an ASIA A injury, the muscle weakness would be symmetric. The diaphragm is innervated by C3-5 nerve roots, so it will be functioning in this patient. Muscle weakness will cause a restrictive disorder (inabil- ity to generate negative pressure), not an obstructive disorder (air trapping).. ··:.· Examination A 543 Type of Reasoning: Inferential One must determine what is most likely to be true for patients with cervical spinal cord injury in order to arrive at a correct condusion. Questions that ask one to predict possible outcomes often necessitate inferential reason- ing skill. For this case, the therapist should anticipate 1ising of the abdomen due to no abdominal musde tone on the abdominal viscera. Review cervical spinal cord injury effects on respiration if answered incorrectly. Metabolic and Endocrine Systems I Evaluation, Diagnosis Men are at risk for development of metabolic syndrome if they exhibit which of the following symptoms? Choices: 1. An HDL level lower than 45 mg/dL. 2. A waist size greater than 40 inches. 3. Triglyceride levels greater than 100 mg/dL. 4. Fasting blood glucose less than 100 mg/dL. Teaching Points Correct Answer: 2 Criteria for diagnosis of metabolic syndrome include abdominal obesity (waist circumference> 40 inches in men or> 35 inches in women). Incorrect Choices: Other criteria include elevated triglycerides (1 50 mg/dL or higher); low HDL levels (< 40 mg/ dL in men o r < 50 mg/dL in women); and a fasting plasma glucose level > 110 mg/dL. Type of Reasoning: Deductive This question requires the test taker to recall the guidelines for risk of developing metabolic syndrome. This is factual information, which is a deductive reasoning skill. For this situation, a waist size greater than 40 inches would be a risk factor. Review metabolic syndrome guidelines if answered incorrectly. Musculoskeletal System I Examination During an examination, the limitations of ultrasound imaging include which of the following? Choices: l. Inability to clearly see cartilage in infants. 2. Disruption of cardiac pacemakers. 3. Difficulty penetrating bone and therefore visualizing internal structure of bones. 4. Inability to give a clear picture of tendons and therefore diagnose tendon tears. Teaching Points Correct Answer: 3 Ultrasound has difficulty penetrating bone. Ultrasound images are typically used to help diagnose tendon tears, such as tears of the rotator cuff in the shoulder or Achilles tendon in the ankle; abnormalities of the muscles, such as tears; bleeding or o ther fluid collectio ns within the muscles, bursae, and joints; benign and malignant soft tissue tumors; early changes of rheumatoid arthritis; fluid in a painful hip jo int in children; lumps in the neck muscles of infants; and soft tissue masses (lumps/ bumps) in children. 544 Examination A Incorrect Choices: The other choices are not limitations of diagnostic ultrasound. Type of Reasoning: Deductive One must recall the limitations of ultrasound in order to arrive at a correct conclusion. This necessitates factual recall of guidelines, which is a deductive reasoning skill. For this scenario, difficulty penetrating bone and visualizing internal structure of bones is a limitation of ultrasound. Review ultrasound guidelines and limitations if answered incorrectly. Metabolic and Endocrine Systems I Evaluatio n, D iagnosis A patient with a body mass index (BMI) of 3 7 is referred to physical therapy for exercise conditioning. What are additional clinical manifestations associated with the BMI that this patient might exhibit? Choices: 1. Hyperpnea and hyperpituitarism. 2. Hypertension and hyperinsulinism. 3. Hormone-related cancer. 4. Hypolipoproteinemia and hypotension. Teaching Points Correct Answer: 2 Obesity is associated with hypertension, dyslipidemia, hyperinsulinemia (type 2 diabetes), and hyperglyce- mia. The presence of these comorbidities increases risk, resulting in the need for additional medical screen- ing before exercise testing. Incorrect Choices: Hyperpituitarism, hormone-related cancer, and hypotension are not associated with obesity. Type of Reasoning: Deductive For this question, the test taker must recall the clinical manifestations associated with a high BMI (obesity). This is factual information, which necessitates deductive reasoning skill. In this case, the clinical manifesta- tions include hypertension and hypelinsulinism. Review obesity guidelines if answered incorrectly. Musculoskeletal System I Examination When visually examining active abduction of the arm to 150 degrees, what is the normal composition of the m otion a therapist would expect? Choices: 1. 150 degrees of the glenohumeral motion and O degrees of scapulothoracic motion. 2. 110 degrees of the glenohumeral motion and 40 degrees of scapulothoracic motion. 3. 75 degrees of the glenohumeral motion and 75 degrees of scapulothoracic motion. 4. 100 degrees of the glenohumeral motion and 50 degrees of scapulothoracic motion. Examination A 545 Teaching Points Correct Answer: 4 Elevation of the arm into abduction involves coordinated.motions involving the scapulothoracic and gle- nohumeral joints (along with movements at the sternodavicular and aa-omioclavicular joints). While there is some variability in the precise timing and amounts during the early, middle, and late phases, motion at the glenohumeral and scapulothoracic joints generally occurs at an overall 2 to 1 ratio. Given this ratio, 150 degrees of active abduction would be a result of 100 degrees of glenohumeral and 50 degrees of scapulotho- racic motion. Incorrect Choices: The other ratios presented are not typical during normal active shoulder abduction. Type of Reasoning: Deductive One must recall the composition of motion with abduction of the arm in order to arrive at a correct conclu- sion. This necessitates recall of factual information, which is a deductive reasoning skill. For this case, the therapist should expect 100 degrees of glenohumeral motion and 50 degrees of scapulothoracic motion when abduction is 150 degrees. Review scapulothoracic and glenohumeral motion guidelines if answered incorrectly. Neuromuscular and Nervous System I Interventions To prepare a patient with a cauda equina lesion for ambulation with crutches, what upper-quadrant muscles would be the most important to strengthen? Choices: 1. Upper trapezius, rhomboids, and levator scapulae. 2. Deltoid, coracobrachialis, and brachialis. 3. Middle trapezius, serratus anterior, and triceps. 4. Lower trapezius, latissimus dorsi, and pectoralis major. Teaching Points Correct Answer: 4 The muscles needed for crutch use include the shoulder depressors and extensors along with elbow extensors. Incorrect Choices: All other choices include muscles that enhance shoulder elevation or abduction. Type of Reasoning: Inductive For this question, one must utilize clinical judgment to determine the most important muscles to strengthen for crutch use. This requires inductive reasoning skill. For this scenario, the therapist should focus on strengthening the lower trapezius, latissimus dorsi, and pectoralis major. Review muscles needed for crutch use if answered incorrectly. 546 Exam ination A Cardiova scu lar/Pu lmonary Systems I Exam ination What will a patient with a significant right thoracic structural scoliosis demonstrate on examination? Choices: 1. Decreased breath sounds on the right. 2. Decreased thoracic rib elevation on the righ t. 3. Increased lateral costal expansion on the dght. 4. Shmtened internal and external intercostals on the right. Teaching Points Correct Answer: 3 With a right thoracic scoliosis, the convex side is on the right. This would allow fo r increased aeration and mobility on that side. Incorrect Choices: The ribs would elevate normally or more on the right side. The remaining choices would be true on the con- tralateral or shortened side of th e scoliosis. The left side would have shortened muscle length and decreased aeration. Type of Reasoning: Deductive This question requires the test taker to recall the structural changes that occur with thoracic scoliosis. This necessitates the recall of facts, which is a deductive reasoning skill. For this case, the therapist should antici- pate that the patient will demonstrate an increased lateral costal expansion on the right. Review scoliosis information, especially thoracic scoliosis and structural changes, if answered incorrectly. Musculoskeletal Syst em I Interventions A therapist has been treating a patient over a period of 4 months for decreased sho ulder elevation and a loss of external rotation. Recovery has been good; however, the patient still complains of being unable to reach the upper shelves of kitchen cabinets and closets. To help the patient achieve this goal, what should be the focus of m anual therapy? Choices: 1. Superior glide. 2. Inferior glide. 3. Anterior glide. 4. Grade IT oscillations. Teaching Points Correct Answer: 3 Anterior glide would help increase external rotation (ER), which is a component of full elevation. Perform- ing anterior glides to improve ER and late flexion will help increase overhead reach since ER of humerus occurs with flexion.... :. Examination A 547 Incorrect Choices: Superior glide is not a joint mobilization for any pathology of the shoulder. Inferio r glide would help increase shoulder abduction. Grade II mobilization would not improve motion. Type of Reasoning: Inductive One must utilize knowledge of joint mobilization techniques and benefits of specific mobilization approaches in order to arrive at a correct conclusion. This necessitates dinical judgment, which is an induc- tive reasoning skill. For this situation, the therapist should focus on anterior glides to improve ER and late flexion. Review joint mobilization techniques if answered incorrectly. Neuromuscular and Nervous System I Interventions Which activity would help break up obligatory lower extremity sy.nergy patterns in a patient with hemiplegia? Choices: 1. High kneeling position, ball throwing. 2. Standing, alternate marching in place with hip and knee flexion and hip abduction. 3. Sitting, alternate toe tapping. 4. Sitting, foot slides under the seat. Teaching Points Correct Answer: 1 Kneeling positions with the hip in extension and the knee flexed to 90 degrees, is an out-of-synergy position. Balance training activities (e.g., reaching, ball throwing) enhance postural control while engaging cognitive control on the added activity (ball throwing). Incorrect Choices: Marching with hip and knee flexion and hip abduction, toe tapping in sitting, and foot slides using knee flexors in sitting all utilize movement in synergy or a synergy-supported position. Type of Reasoning: Inferential For this question, the test taker must recall out-of-sy.nergy positions and then use that knowledge to deter- mine which described position would be most beneficial for breaking up lower limb sy.nergy. This requires inferential reasoning skill. In this case, having the patient in a high kneeling position with ball throwing will accomplish this. Review out-of-sy.nergy positions if answered incorrectly. Neuromuscular and Nervous System I Examination A patient recovering from stroke repmts lack of feeling in the more-affected hand. Light touch testing reveals lack of ability to tell when the stimulus is being applied (only 1 correct response out of 10 tests). What addi- tional sensory tests should the therapist perform? Choices: 1. Test for pain and temperature. 2. Test for two-point discrimination. 3. Test for stereognosis. 4. Test fo r barognosis. - :.. 548 Examination A Teaching Points Correct Answer: 1 Testing for pain and temperature can be performed as these sensations are carried in different pathways (anterolateral spinothalamic pathways); light touch is carried in dorsal column-lemniscal pathways. Incorrect Choices: All other choices test for discriminative sensations (two-point discrimination, stereognosis, barognosis) and require intact dorsal column-medial lemniscal pathways projecting to the somatic sensory co11ex along with projection to the sensory association areas.' Type of Reasoning: Inductive For this question, one must utilize knowledge of sensoiy testing and sensory pathways in order to determine the test that is best to perform next. This reasoning process requires inductive reasoning skill, where clinical judgment is paramount to arriving at a correct conclusion. For this case, the therapist should test for pain and temperature. Review the sensory pathways if answered incorrectly. Musculoskeletal I Intervention A patient presents to physical therapy with complaint of 7/ 10 ankle pain after an inversion injuiy earlier in the day. The patient does not want to bear weight on the involved side due to pain. There is slight ecchymosis observed over the lateral ankle and foot with significant swelling. The patient is also tender to palpation on the tip of the lateral malleolus and area of the anterior talofibular ligament. In this case, what would be the therapist's INITIAL action? Choices: 1. Ice and cross friction massage to the anterior talofibular ligament. 2. Ice and compression wrap of both the foot and ankle. 3. Refer for radiography of the ankle. 4. Perform an anterior drawer test of ankle. Teaching Points Correct Answer: 3 This patient presented with inability to bear weight and had tenderness at the lateral malleolus. These are two reasons indicating that this patient should have a radiograph to rule out fracture. Indications for radiography include bone tenderness at the posterior edge or tip of the lateral malleolus, bone tenderness at the posterior edge or tip of the medial malleolus, and inability to bear weight both immediately and in the emergency department. Incorrect Choices: Although ice and compression would be an appropriate intervention for pain and swelling, the patient presents with a high suspicion for ankle fracture and this would need to be ruled out. Cross friction massage would not be appropriate during the acute phase of an injuiy. The anterior drawer test evaluates the status of the anterior talofibular ligament; however this should not be performed with a high suspicion for ankle fracture. Type of Reasoning: Inductive For this question, one must first determine the presentation of post ankle injuiy that indicate a need for radi- ography in order to arrive at a correct conclusion. Based on knowledge of signs of ankle fracture, one should determine that a refenal for radiography of the ankle is the best initial action. If answered incorrectly, review information on ankle fracture and indications for radiography. Examination A 549 Musculoskeletal System I Interventions Three months ago a patient experienced a traumatic injury to the hand that resulted in surgical tendon repair and fracture stabilization. The therapist is planning a treatment program to address tightness of the lumbri- cals. What exercises would be BEST in order to increase range of motion of the hand? Choices: 1. Both the MCP and IP joints are moved into flexion. 2. Both the MCP and IP joints are moved into extension. 3. The MCP joints are extended and the IP joints are flexed. 4. The MCP joints are flexed and the IP joints are extended. Teaching Points Correct Answer: 3 Lumbrical action is extension of the interphalangeal (IP) joint and simultaneous flexion of the metacar- pophalangeal (MCP) joint of the second through fifth digits. Therefore, the opposite motion of MCP joint extension and IP joint flexion would stretch the lumbricals. Incorrect Choices: None of the other combined motions would stretch the lumbricals. Type of Reasoning: Inductive One must determine the best exercise approach to most effectively increase range of motion of the lumbri- cals. Knowledge of the action of the lumbricals coupled with effective ways to stretch tight muscles is para- mount to choosing a correct approach. This requires clinical judgment, which is an inductive reasoning skill. In this scenario, the therapist should extend the MCP joints and flex the IP joints during exercise. Review lumbrical action and exercise for the lumbricals if answered incorrectly. Cardiovascular/Pulmonary Systems I Evaluation, Diagnosis A patient with a long history of cigarette smoking has been admitted to the hospital and presents with tachy- cardia, signs of lung infection, abnormal breath sounds in both lower lobes, and dullness to percussion. What should the therapist's initial intervention focus on with this patient? I I Choices: 1. Getting the patient to quit smoking. 2. Breathing reeducation to increase efficiency of ventilation. 3. Airway clearance and secretion removal. 4. Graded inspiratory muscle training. Teaching Points Correct Answer: 3 The patient has signs and symptoms consistent with pneumonia. It is most important to assist with secre- tions clearance to assist with recovery from the infection and to improve gas exchange. 550 Examination A Incorrect Choices: Quitting smoking is an appropriate goal for this patient but would be best timed after the acute period has passed. It isn't stated that the patient's breathing pattern is impaired and therefore it is not imperative to address it at this time. If there is an increased work of breathing, it will be rectified by clearing the secretions. Patients with a history of chronic obstructive pulmonary disease (COPD), which is presumed in this case due to the long history of tobacco use, do benefit from inspiratory muscle training (IMT). However, this is best timed after the acute infection has resolved. Type of Reasoning: Inductive This question requires one to utilize clinical judgment to consider a best course of action for a patient with pneumonia. Knowledge of effective intervention approaches for pneumonia is paramount to aniving at a correct conclusion and requires inductive reasoning skill. For this case, the therapist should focus on airway clearance and secretion removal initially. Review intervention approaches for pneumonia if answered incor- rectly. Musculoskeletal System I Evaluation, Diagnosis A patient has adhesive capsulitis of the glenohumeral joint. What is the expected greatest limitation of motion when performing shoulder ROM? Choices: 1. Flexion. 2. Abduction. 3. Medial rotation. 4. Lateral rotation. Teaching Points Correct Answer: 4 Adjlesive capsulitis is diagnosed by n umerous physical characteristics, including a thickening of the syno- vial capsule, adhesions within the subacromial or subdeltoid bursa, adhesions to the biceps tendon, and/ or obliteration of the axillary fold secondary to adhesions. Adhesive capsulitis is commonly associated with other systemic and nonsystemic conditions. By far the most common is the comorbid condition of diabetes mellitus. The common capsular pattern of limitation has historically been desoibed as diminishing motions with external (lateral) shoulder rotation being the most limited, fo llowed closely by shoulder flexion and internal rotation. Incorrect Choices: Adhesive capsulitis of the shoulder will present with loss of motion in abduction, flexion, internal rotation, and external rotation. The loss of motion is due to capsular restrictions of which there is a classical pattern of loss of motion (capsular pattern). The most severe loss of motion with a capsular pattern of the shoulder will be external (lateral) rotation. Type of Reasoning: Deductive For this question, the test taker must recall the limitations associated with adhesive capsulitis in order to arrive at a correct conclusion. This necessitates the recall of factual information, which is a deductive rea- soning skill. For this case, the therapist should anticipate that lateral rotation will be most limited in ROM. Review adhesive capsulitis information and symptoms if answered incorrectly. Examination A 551 Nonsystem I Professional Respons ibilities During a home visit an adult patient asks the physical therapist assistant to see the physical therapy progress notes in the medical record. What should the physical therapist assistant do? Choices: 1. Refuse to let the patient see the record. 2. Allow the patient to see the notes. 3. Let the patient see the notes only with the permission of the physical therapist. 4. Contact the patient's physician and explain the situation. Teaching Points Correct Answer: 2 The law requires a health care provider, except in limited circumstances, to supply a patient, upon request, complete and current information the provider has about the patient's diagnosis, treatment, and prognosis. The provider must also notify a patient of any test results in the provider's possession or requested by the provider for purposes of diagnosis, treatment, or prognosis. Incorrect Choices: The law is pretty specific. The adult patient has access to the medical record and the physical therapist assis- tant (Pli\) need not seek permission of the physical therapist (PT) or MD in this case. Type of Reasoning: Evaluative This question requires one to determine a best course of action based on knowledge of legal guidelines. Questions of this nature, where one must weigh potential options and determine which option will result in the best outcome often require evaluative reasoning skill. For this situation, the PTA should allow the patient to see the progress notes. Review legal guidelines for access to medical records if answered incorrectly. Nonsystem I Safety & Protection A chest tube gets dislodged during physical therapy treatment. If the therapist fails to cover the defect, what could the patient develop? Choices: 1. Pulmona1y embolism. 2. Pulmonary edema. 3. Pneumothorax. 4. Aspiration pneumonia. Teaching Points Correct Answer: 3 With the removal of the chest tube, there is an increased positive pressure on the lung tissue. The lung is not able to inflate, and it succumbs to the pressure and therefore collapses. 552 Examination A Incorrect Choices: Chest tube placement or removal has no effect on clotting and circulation. Pulmonary edema is caused by increased hydrostatic pressure within the pulmonary vascular system or by changes in the vascular mem- brane. A chest tube would have no effect on this. Aspiration pneumonia requires that a person inhales or has something travel into the trachea that was unintended. The removal of a chest tube would have no bearing on this. Type of Reasoning: Inferential For this question, one must determine what is likely to be true of a situation, which requires inferential reasoning skill. ln order to arrive at a correct conclusion, one must draw from knowledge of chest tubes and risks associated with removal. In this case, if a chest tube becomes dislodged, the likely result is development of a pneumothorax. Review chest tube guidelines if answered incorrectly. Cardiovascular/Pulmonary Systems I Interventions Following a motor vehicle accident, a patient with chest trauma developed atelectasis. What is the LEAST appropriate intervention to help with the immediate management of atelectasis? Choices: 1. Pain reduction techniques. 2. Segmental breathing. 3. Incentive spirometry. 4. Paced breathing. Teaching Points Correct Answer: 4 In order to reverse atelectasis, the patient needs a technique to facilitate deep breathing. Paced breathing controls the rate of breathing, not the depth of breathing, and will therefore be ineffective. Incorrect Choices: Reducing the patient's pain associated with the trauma will allow the patient to take deeper breaths, whicl1 will decrease atelectasis. Segmental breathing will allow for prolonged inspiration with a breath hold. The long inspiration will facilitate deeper breathing, which can reverse the atelectasis. A breath hold will allow collateral ventilation via the pores of Kohn, which will result in increased pressures to inflate alveoli and therefore reverse atelectasis. Incentive spirometry will cause increased deep breathing with visual feedback, which can reverse atelectasis. Type of Reasoning: Inductive This question requires clinical judgment and knowledge of atelectasis in order to determine a best course of action. This necessitates inductive reasoning skill where clinical judgment is used to reach a sound conclu- sion. In this case, the least effective treatment would be paced breathing. Review atelectasis and treatment approaches if answered incorrectly. Examination A 553 Musculoskeletal System I Evaluation, Diagnosis Following a reattachment of the flexor tendons of the fingers, the patient is in a splint. One physical therapy goal is to minimize adhesion formation. What should the physical therapist teach the patient to perform after 72 hours post-surgery? Choices: 1. Passive extension and active flex.ion of the interphalangeaJ joints. 2. Active extension and flex.ion of the interphalangeal joints. 3. Active extension and passive flexion of the interphalangeal joints. 4. Gentle passive extension and flexion of the interphalangeal joints. Teaching Points Correct Answer: 3 Severe edema increases tendon drag and likelihood of rupture. Therefore, wait until 48 to 72 hours postop prior to initiating range of motion (ROM) therapy. This patient is a few days postop and can begin passive finger flex.ion with caution so as not to disrupt the repair. Begin by blocking the metacarpophalangeal (MCP) in full flex.ion and actively extend interphalangeal (IP) joints, followed by passive proximal interphalangeal (PIP) flex.ion and active extension. Incorrect Choices: Generally for weeks 1 through 3 there should be no active flex.ion of the involved digits, as this could damage and/or tear the repair. Passive extension of the fingers should not be done until there is adequate strength of the repair. Type of Reasoning: Inductive One must utilize clinical judgment coupled with knowledge of flex.or tendon repairs in order to arrive at a correct conclusion. This requires inductive reasoning skill. For this scenario, the therapist should teach the patient to perform active extension and passive flex.ion of the interphalangeal joints. If answered incorrectly, review treatment approaches for flex.or tendon repairs. Muscu loske letal System I Evaluation, D iagnosis A patient with a transtibial amputation of 2 months' duration complains of an intense burning pain that seems to emanate from the heel. This phantom pain mirrors the patient's preoperative pain. What is the most likely previous source of this pain? Choices: 1. Dorsalis pedis artery obstruction. 2. Popliteal artery obstruction. 3. Damage to the superficial peroneal (fibular) nerve. 4. Damage to the tibial nerve. 554 Examination A Teaching Points Correct Answer: 4 Although the limb is no longer there, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. Sometimes, the brain memory of pain is retained and is interpreted as pain regardless of signals from injured nerves. In addition to pain in the phantom limb, some people experience other sensations such as tingling, cramping, heat, and cold in the p01tion of the limb that was removed. The question describes pain in the heel. Nerve supply to the heel is by the calcaneal branch of the tibial nerve. Incorrect Choices: Dorsal is pedis artery and popliteal a1tery are incorrect because phantom limb pain is the result of nerves being cut. The superficial peroneal (fibular) nerve ends above the ankle by dividing into the medial and lateral cutaneous branches. These nerves provide sensory innervations to the lateral and anterolateral skin of the distal leg and to the dorsum of the foot. Type of Reasoning: Inferential For this question, one must make a determination what is most likely to be true of a situation, while using knowledge of phantom limb pain. This requires inferential reasoning skill. For this case, because of the description of pain experienced, the source is most likely damage to the tibial nerve. Review phantom limb pain and tibial nerve innervation if answered incorrectly. Nonsystem I Therapeutic Modalities A patient's plan of care includes use of iontophoresis for the management of calcific bursitis of the shoulder. To administer this treatment using the acetate ion, what current characteristics and polarity should be used? Choices: 1. Monophasic twin-peaked pulses using the positive pole. 2. Monophasic twin-peaked pulses using the negative pole. 3. Direct current using the positive pole. 4. Direct current using the negative pole. Teaching Points Correct Answer: 4 The acetate ion has a negative charge, and thus a negative pole will be needed to repel the drug into the tis- sue. Direct current will continuously drive the acetate into the tissue during the treatment time. Incorrect Choices: While monophasic, twin-peaked current has polarity, it is a pulsed current and will not be able to continu- ously drive the acetate into the tissue resulting in less medication being delivered to the site. The positive pole will not repel the acetate ion. Type of Reasoning: Deductive For this question, one must recall the guidelines for application of iontophoresis and treatment using the acetate ion. This necessitates factual recall of information, which is a deductive reasoning skill. In this case, the therapist should use direct current using the negative pole. Review iontophoresis guidelines if answered incorrectly..... =::. , :.....·... Examination A 555 Musculoskeletal System I Evaluation , D iagnosis A snowmobile left the trail and strnck a tree. The d1iver's left knee was flexed approximately 90 degrees and the tibia impacted with the inside front of the snowmobile. What would this mechanism of injury MOST LIKELY result in? Choices: 1. Dislocated patella. 2. Sprained or ruptured posterior cruciate ligament (PCL). 3. Sprained or ruptured anterior cruciate ligament (ACL). 4. Rupture of the popliteal artery. Teaching Points Correct Answer: 2 The above scenario describes one of the most common mechanisms of injury of the PCL, the "dashboard injury." This occurs when the knee is flexed, and an object forcefully strikes the proximal anterior tibia and displaces it posteriorly. It is called a "dashboard injury" because it can occur in automobile collisions when the tibia forcefully hits the dashboard. The PCL attaches from the lateral aspect of the medial femoral condyle to just posterior to the posterior horn of the medial meniscus. It is the primary restraint to posterior displacement of the tibia on the femur. Incorrect Choices: The usual mechanism of the ACL injury is in a noncontact deceleration that produces a valgus twisting injury (e.g., athlete quickly pivoting in the opposite direction). Other mechanisms of injury of the ACL can occur with hyperextension of the knee and severe medial tibial rotation. The most common mechanism for patella dislocation is a powerful contraction of the quadriceps in combi- nation with sudden flexion and external rotation of the tibia on the femur. This question describes trauma to the tibia, not the patella. Rupture of the popliteal artery can occur from severe trauma resulting in a dislocation of the tibia on the femur. The most common mechanism of injmy for a posterior knee dislocation is a direct force on the tibia while the knee is flexed, forcing the tibia posteriorly on the femur (e.g., dashboard injury). A tibial disloca- tion certainly could have occurred with the snowmobile injury, but it would not be the most likely. Type of Reasoning: Inferential For this question, the test taker must determine what is most likely to be true, based on a description of an injury. Questions of this nature, where one determines what is most likely to be true, require inferential reasoning skill. In this scenario, the mechanism of injury would most likely result in a sprained or ruptured posterior cruciate ligament (PCL). Review PCL injuries and dashboard injuries if answered incon:ectly. Muscu loske letal System I Evaluation, Diagnosis The interview with an 18-year-old female cross-country runner elicits a history of stiffness and d iffuse ache in her right knee that is aggravated by prolonged sitting. Going down stairs is also painful. Based on this infor- mation, what is the LIKELY diagnosis that should serve as a focus for the physical examination? Choices: 1. Iliotibial band friction syndrome. 2. Osgood-Schlatter disease. 3. Meniscal tear. 4. Patellofemoral syndrome. 556 Examination A Teaching Points Correct Answer: 4 Patellofemoral syndrome ("runner's knee") is the most common overuse injury among runners. It occurs due to mistracking of the patella within the intercondylar groove. It generally occurs in younger, recreational runners and is more common in women. The main symptom of patellofemoral pain syndrome is knee pain, especially when sitting with knee flexion. This is known as the theater sign or movie-goer's knee. Squatting, jumping, or using the stairs (especially going down stairs) will also be painful. There may also be occasional buckling of the knee. Incorrect Choices: Iliotibial (IT) band friction syndrome also occurs in runners, but pain will be located over the lateral knee. It is the result of irritation of the distal pmtion of the IT band as it rubs against the lateral femoral condyle. This overuse injury occurs with repetitive flexion and extension of the knee. It is most common in athletes who participate in long-distance running. Osgood-Schlatter disease occurs most often in children who participate in sports that involve running, jump- ing, and swift changes of direction such as soccer and basketball. The main symptom is painful swelling over the tibial tubercle. They may have leg or knee pain, which gets worse with running, jumping, and climbing stairs. The tibial tubercle is tender to palpation. Pain from meniscal tears is usually deep within the knee, accompanied by swelling and symptoms of pop- ping, catching, or locking. Type of Reasoning: Analytical This question provides a group of symptoms, and the test taker must determine the most likely diagnosis. This requires analytical reasoning skill, where pieces of information are analyzed in order to draw conclu- sions. For this case, the most likely diagnosis is patellofemoral syndrome. Review signs and symptoms of patellofemoral syndrome if answered incorrectly. Lymphatic System I Interventions Following mastectomy with axillary lymph node dissection, a patient developed 4+ edema in the ipsilateral arm. A compression garment was ordered. What is the primary reason this garment decreases edema? Choices: 1. It decreases the osmotic pressure of the capillaries. 2. It increases the capillary permeability. 3. It exceeds the internal tissue hydrostatic pressure. 4. It equals the fluid outflow from the capillaries. Teaching Points Correct Answer: 3 The external pressure caused by the compression garment essentially increases the amount of pressure on the tissue. This causes a relative increase in the hydrostatic pressure in the extravascular space compared with the intravascular space. Incorrect Choices: Osmotic pressure is most directly related to the protein content. Increases in external pressure will not modify this pressure gradient. An external pressure will have no effect on the vascular permeability. If the fluid outflow is equaled from the capillaries, then there is not a pressure gradient between two areas. There- fore, there will be no transfer of fluid from one area to the other. Examination A 557 Type of Reasoning: Deductive This question requires the test taker to recall the therapeutic properties of pressure garments in order to arrive at a correct conclusion. This necessitates recall of factual guidelines, which is a deductive reasoning skill. For this situation, the garment decreases edema because it exceeds the internal tissue hydrostatic pressure. Review properties of pressure garments for edema if answered incorrectly. Muscu loskeleta l System I Interventions A patient presents with a chronic restriction of the temporomandibular joint (TMJ). The physical therapist observes the situation seen in the picture during mouth-opening range of motion (ROM) assessment. What is the BEST intervention if the patient has a classic TMJ unilateral capsular restriction? Choices: 1. Left TMJ, superior glide manipulation. 2. Left TMJ, inferior glide m anipulation. 3. Right TMJ, superior glide manipulation. 4. Right TMJ, inferior glide manipulation. Teaching Points Correct Answer: 4 Right TMJ, inferior glide. In the photo, the chin has deviated to the right at terminal opening. The active range of motion (AROM) will be limited with ipsilateral opening and a lateral deviation to the side ofrestric- tion for patients with a TMJ capsular pattern of restriction. Incorrect Choices: The left TMJ incouectly states the capsular pattern. Additionally, superior glide manipulation on the right would compress the joint, not affording a stretch to the capsule tightness. It I Type of Reasoning: Inductive This question requires clinical judgment in order to determine a best intervention approach for a patient with TMJ dysfunction. Knowledge of effective intervention approaches for the TMJ is paramount to arriving at a correct conclusion, necessitating inductive reasoning skill. For this case, the BEST intervention approach is right TMJ, inferior glide manipulation. Review intervention approaches for the TMJ if answered incorrectly. 558 Examinat ion A N e uro muscula r a n d Nervou s Syst e m I Exam inatio n A patient in the late stages of Parkinson's disease exhibits episodes of akinesia while walking. What should the therapist examine? Choices: 1. Primary involvem ent of the head and trunk. 2. Associated dyskinesias. 3. Primary involvement of the hips and knees. 4. Triggers that precipitate the freezing episodes. Teaching Points Correct Answer: 4 Freezing of gait (episodes of akinesia) is typically associated with a trigger (e.g., turning, changing direction or speed, doorways). Identification of triggers is helpful in developing the plan of care. Incorrect Cho ices: Freezing is most often evident during gait and typically involves th e entire body, not individual segments of the body. Associated dyskinesias m ay be present but do not typically influence freezing episodes. Type of Reasoning: Inductive For this question, one must utilize clinical judgm ent and knowledge of Parkinson's disease in order to arrive at a correct conclusion. This requires inductive reasoning skill. For this situation, the therapist should examine triggers that precipitate the freezing episodes. Review Parkinson's disease, especially examination of akinesia, if answered incorrectly. M etab o lic a n d Endo c r ine Systems I Ev a luatio n , D iagn osis A p atient is referred to physical therapy for balance and gait training following two falls in the hom e in the past month. The therapist no tes in the medical record that the patient has adrenal insufficiency. What are the metabolic abnormalities associated with adrenal insufficiency? Choices: 1. Hypokalemia. 2. Hyponatremia. 3. Hyperglycemia. 4. Alkalosis. Teaching Points Correct Answer: 2 Metabolic abnorm alities seen in adrenal insufficiency include hyponatremia (decreased sodium concentra- tion in the blood) secondary to renal loss of sodium ions. A decrease in cortisol results in an inability to regulate potassium and sodium. Incorrect Choices: Patients with adrenal insufficiency will be hyperkalemic, hypoglycemic, and may have acidosis. Type of Reasoning: Deductive For this questio n, the test taker must recall the m etabolic abnormalities that are often associated with adre- nal insufficiency in order to arrive at a correct conclusion. This necessitates the recall of factual info rmation, which is a deductive reasoning skill. For this case, hypo natremia is often associated with adrenal insuffi- ciency. Review signs and symptoms of adrenal insufficiency if answered incorrectly. Examinat ion A 559 N o n sys tem I Saf ety A physical therapist is treating a patient with active infectious hepatitis B. In addition to wearing a protective gown when in the patient's room, what precautions should be taken to avoid transmission of the disease? Choices: 1. Avoid d irect contact with the patient's blood or blood-contaminated equipment by wearing gloves. 2. Avoid direct contact with any pa11 of the.patient. 3. Have the patient wear a mask to minimize droplet spread of the organisms from coughing. 4. Provide tissues and no-touch receptacles for disposal of tissues. Teaching Points Correct Answer: I Hepatitis B is transmitted in blood, body fluids, or body tissues. Precautions should include avoiding direct contact with bl ood o r blood-contaminated equipment. Incorrect Choices: This is not an airborne infectious disease. The patient does no t need to wear a m ask or have specific no-touch tissue receptacles. Contact with body surfaces with no blood droplets or open wounds sho uld also not be an issue. Type of Reasoning: Deductive For this question, one must recall the guidelines fo r standard precautions. This is factual information, which is a deductive reaso ning skill. For this case, in addition to wearing a protective gown, the therapist sh ould avoid direct contact with the patient's blood or blood-con tam inated equipm ent by wearing gloves. Review standard precautions, especially for hepatitis B, if answered incorrectly. Musculosk e le t a l S y s t e m I Exam ina t ion Idiopathic scoliosis is suspected in a 12-year-o ld girl. During the physical examination, what is the standard screening test fo r this condition ? Choices: 1. Longsitting, fmward bend test. 2. Standing, Adam's forward bend test. 3. Sitting, rotation test to the right and left. 4. Standing, backward extension test. Teaching Points Correct Answer: 2 Screening is most commonly done on adolescents. Fem ales achieve adolescence about two years before males and are afflicted with scoliosis requiring treatment three to four times more frequently than males. The Adam's forward bend test is the standard screening test for scoliosis. During the test, the child will bend forward with feet together, knees straight, and arms hanging free. The therapist observes child fro m the back, looking for a difference in the shape of the ribs on each side. A spinal deformity is most noticeable in this position. 560 Examination A Incorrect Choices: All other choices are not appropriate for examining for scoliosis (e.g., backward extension, trunk rotation, forward bending in longsitting). Type of Reasoning: Deductive For this question, the test taker must recall the guidelines for conducting a scoliosis screening test in order to arrive at a correct conclusion. This necessitates factual recall of testing guidelines, which is a deductive reasoning skill. For this situation, the standard screening test is standing, Adam's forward bend test. Review scoliosis screening guidelines if answered i_ncorrectly. System Interactions I Evaluation, Diagnosis A patient had anterior cruciate ligament (ACL) reconstructive surge1y 2 weeks ago. During the initial examina- tion, the physical therapist noticed marked edema around the knee and calf. Knee passive range of motion (PROM) was limited from - 5 degrees extension to 90 degrees offlexion. Hip PROM was within normal limits. Ankle dorsiflexion was limited to O degrees because of pulling pain in the calf. Marked tenderness to super- ficial palpation to anterior knee and posterior calf and increased temperature were also noted. The patient is experiencing calf pain and discomfort when standing during partial weight-bearing ambulation. Upon com- pletion of the examination, what is the BEST intervention at this time? Choices: 1. Isometrics and PROM for the knee. 2. Massage to knee and calf to help alleviate the expected postsurgical edema. 3. Ice and interferential current to alleviate edema and facilitate movement. 4. Immediate referral to the surgeon. Teaching Points Correct Answer: 4 The patient may have a deep vein thrombosis (DVf) based on increased swelling, temperature, tenderness, and pain in the calf with weight bearing 2 weeks after surgery, so referral to the surgeon is the best interven- tion at this time. Incorrect Choices: All other answer choices are appropriate once DVf is ruled out. Type of Reasoning: Inductive This question requires one to determine a best course of action based on analysis of symptoms after an ACL reconstruction. Questions of this nature often require clinical judgment, which is an inductive reasoning skill. Based on the symptoms, the therapist should make an immediate referral to the surgeon, as the symp- toms are indicative of a DVf. Review signs and symptoms of DVf if answered incorrectly. Examination A 561 Geniturinary System I Intervention A woman is referred to physical therapy with a diagnosis of pelvic floor weakness after delivering a baby. Proper instructions for pelvic floor exercises would NOT include which of the following? Choices: 1. Stop and start the flow of urine every time you go to the toilet. 2. Squeeze the muscles around the vagina, imagining you are stopping the flow of urine, hold for 5-10 seconds, then relax. 3. Repeat the exercises ten times, three times a day. 4. Start in supine position and progress to sitting and standing practice. Teaching Points Correct Answer: I Kegel exercises (pelvic floor exercises) should not include stopping and starting the flow of urine every time one goes to the toilet. This can be used once as a test to find if the correct muscles are contracting. Continued use can result in bladder complications (e.g., infection, overuse). Incorrect Choices: Proper instructions for Kegel exercises include: lie down, sit, or stand with your legs slightly apart and relax your thighs, buttocks, and abdomen m uscles. Tighten the ring of m uscle around your front and bad 1.0 mm of horizontal or downsloping depression) is a significant finding, representative of myocardial ischemia. Incorrect Choices: Both HR and BP are expected to rise (the levels of 140 and 140/80 are not significant for most patients). The appearance of a single PVC is also not significant because single PVCs can occur in individuals w ithout a cardiac history. 710 Examination B Type of Reasoning: Inference When questions provide a diagnosis and the test taker m ust determine the symptoms to watch for, infer- ential reasoning is used. To answer this question correctly, the test taker must have knowledge of cardiac rehabilitation guidelines and indications for terminating exercise programs. If this question was answered incorrectly, refer to post-MI rehabilitation guidelines. Neuromuscular I Interventions An infant who was 39 weeks gestational age at birth and is now 3 weeks chronological age demonstrates colic. In this case, what is the BEST intervention the PT should teach the mother? Choices: 1. Stroking and tapping. 2. Neutral warmth. 3. Visual stimulation with a colored object. 4. Fast vestibular stimulation. Teaching Points Correct Answer: 2 Neutral warmth achieved through wrapping or bundling the infant is a calming stimulus. Incorrect Choices: All of the other choices would likely increase arousal of the infant. The infant is still too developmentally im- mature for any of the stimuli oth er than neutral warmth. Type of Reasoning: Inductive One utilizes clinical judgment, with combined knowledge of inhibitmy and facilitatory stimuli in infants, in order to choose the best solution. In this scenario, the newborn is too developmentally immature to manage facilitatory stimuli and requires stimuli that are calm ing or inhibitory, especially if colic is demonstrated. If this question was answered incorrectly, refer to appropriate stimuli for newborns. N e uromuscu lar I Examination A therapist is treating a patient with Brown-Sequard syndrome that resulted from a gunshot wo und. Which of the following would the therapist expect to find during the examinatio n? Choices: 1. Sparing of tracts to sacral segments with preservation of perianal sensation and active toe fl exion. 2. Loss of motor function and pain and temperature sensation with prese1vation of light toud1 and proprio- ception below the level of the lesion. 3. Loss of motor function below the level of the lesion primarily in the upper extremities. 4. Ipsilateral loss of motor function, ipsilateral loss of light touch and proprioception, and contralateral loss of pain and temperature. Examination B 711 Teaching Points Correct Answer: 4 Brown-Sequard syndrome is a hemisection of the spinal cord characterized by ipsilateral loss of dorsal col- umns with loss of touch, pressure, vibration and proprioception; ipsilateral loss of corticospinal tracts with loss of motor function below level of lesion; contralateral loss of spinothalamic tract with loss of pain and temperature below level of lesion; at lesion level bilateral loss of pain and temperature. Incorrect Choices: Anterior cord syndrome: loss of lateral corticospinal tracts with bilateral loss of motor function; loss of spi- nothalamic tracts with bilateral loss of pain and temperature; preservation of dorsal columns (priopriocep- tion, vi bratory sense). Central cord syndrome: Loss of spinothalamic tracts with bilateral loss of pain and temperature; loss of ven- tral horn with bilateral loss of motor function (primarily the upper extremities); preservation of propriocep- tion and discriminatory sensation. Sacral sparing: sparing of tracts to sacral segments with preservation of perianal sensation, rectal sphincter tone, active toe flex.ion. Type of Reasoning: Analysis This question requires factual recall of neuroanatomy in order to arrive at the correct conclusion. O ne should recall the nature of Brown-Sequard syndrome as a hemisection of the spinal cord, which results in both ipsi- lateral and contralateral losses below the level of lesion. One also must separate out the symptoms of other spinal cord syndromes, which are different from this scenario. If this question was answered incorrectly, refer to spi nal cord injuries and syndromes. Neuromuscular I Interventio n s A patien t is recovering from stroke and presents with moderate impairments of the left upper and lower extremities. The PT's goal today is to instruct the patient in a stand-pivot transfer to the more affected side so the patient can go home on a weekend pass. The spouse is attending today's session and will be assisting the patient on the weekend. What is the BEST choice for teaching this task? Choices: 1. Practice the task first with the patient then with the caregiver. 2. Demonstrate the task, then have the caregiver practice with the patient. 3. Practice the task first with the caregiver, then with the patient. 4. Demonstrate the task, and then practice with the patient. Teaching Points Correct Answer: 4 To ensure optimal motor learning, first demonstrate the task at ideal performance speeds. This provides the patient with an appropriate reference of correction (cognitive map) of the task. Then use guided practice with the patient to ensure safety and successful performance. Incorrect Choices: Caregivers should become involved only after initial practice of the task with the patient and after the safety of the patient can be assured. Type of Reasoning: Inference One must rely upon beliefs and assumptions about the clinical situation above in order to choose the best solution. This is a skill of inferential reasoning, in which the test taker must determine the best course of action to ensure optimal motor learning in educating a caregiver and a patient in transfer skills. Inferential reasoning combines clinical judgment with the need to draw conclusions from evidence presented. 712 Examination B Musculoskeletal I Examination A patient presents with low back pain of insidious onset. Based on the history and subjective complaints, the patient appears to have a dysfunction of a lumbar facet joint. What clinical test should be utilized to confirm this diagnosis? Choices: 1. McKenzie's side glide test. 2. Stork standing test. 3. Slump test. 4. Lumbar quadrant test. Teaching Points Correct Answer: 4 The motion of the lumbar quadrant test places the lumbar facet joint in its maximally closed and therefore most provocative position, so if positive it is typically indicative of a lumbar facet dysfunction. Incorrect Choices: The slump test is utilized to assess the neurodynamics of the spinal and peripheral nerves. The stork stand- ing test is utilized to identify a spondylolisthesis. McKenzie's side glide test is utilized to determine if a disc dysfunction with nerve root involvement is present versus a postural disorder. Type of Reasoning: Deductive This question requires the test taker to recall testing guidelines for lumbar facet dysfunction. This necessitates the recall of facts and guidelines, whicl1 is a deductive reasoning skill. For this situation, the lumbar quadrant test is best to confirm lumbar facet dysfunction. Review lumbar testing guidelines if answered incorrectly, especial ly the lumbar quadrant test. Nonsystem I Equipment, Devices When using a patellar tendon-bearing (P'J'B) prosthesis, a patient experiences excessive knee flexion in early stance. What is the MOST likely cause of this problem? Choices: 1. Socket is aligned too far back or tilted posteriorly. 2. foot position is inset too much. 3. Socket is aligned too far fmward or tilted anteriorly. 4. Foot position is outset too much. Teaching Points Correct Answer: 3 In a P'I'B prosthesis, the socket is normally aligned in slight flexion to enhance loading on the patellar ten- don, prevent genu recurvatum and resist the tendency of the amputated limb to slide too deeply into the socket. If it is aligned incorrectly (too far anterior or excessively flexed), it will result in excessive knee flexion in early stance. Examination B 713 Incorrect Choices: A socket aligned too posterior results in insufficient knee flex.ion. Excessive foot inset results in lateral thrust at midstance. Excessive foot outset results in medial thrust'at midstance. Type of Reasoning: Analysis One must understand and analyze the properties and potential issues in using a PTB prosthesis in order to choose the best response. In this situation, excessive knee flex.ion in early stance is indicative of the socket aligned too far fo1ward or anteriorly tilted. If this question was answered incorrectly, refer to information on P'TB prosthetic alignment. lntegumentary I Evaluation, Diagnosis A patient presents with bluish discoloration of the skin and nail beds of the fingers and toes. Palms are also cold and moist. What is the MOST likely cause of these changes? Choices: 1. Carotenemia. 2. Hypothyroidism. 3. Cyanosis. 4. Liver disease. Teaching Points Co rrect Answer: 3 Bluish discoloration of the skin and nailbeds of fingers and toes, along with palms that are cold and moist, is indicative of cyanosis. It is caused by an excess of deoxygenated hemoglobin in the blood. It may be cen- tral (due to advanced lung disease, congenital hea11 disease, abnormal hemoglobin) or peripheral (decreased blood flow, venous obstruction). I Incorrect Choices: I Liver disease produces jaundice (diffusely yellow skin and sderae). Carotenemia produces a yellow color, espe- cially in the palms, soles, and face (does not affect the sclerae). Hypothyroidism produces dry and cool skin. Type of Reasoning: Analysis Questions that provide a group of symptoms and the test taker must determine the diagnosis often require analytical reasoning skill. In this situation, the symptoms described indicate the condition of cyanosis. Key words that help one to arrive at a correct conclusion are "bluish discoloration." If this question was an- swered incorrectly, review signs and symptoms of cyanosis. 714 Examination B Card iovascu la r/Pulmonary I Interve ntion An outpatient physical therapist is examining a patient who unde1went a total knee arthroplasty 2 weeks ago. The patient rep011s that the entire leg has started swelling in the past 2 days. On examination there is pitting edema throughout the lower leg and foot with tenderness throughout the mid calf. Girth measurements reveal a 3.5 cm increase in the size of the mid calf in the symptomatic leg. What recommendation should the physi- cal therapist make to the patient? Choices: 1. Rest, ice, and elevate the affected lower extremity. 2. Go home and monitor symptoms. Phone the physician if there is no improvement in 24 hours. 3. Go immediately to the em ergency department. 4. Go to the physician's office after the therapy session for further assessment. Teaching Points Correct Answer: 3 The patient scores a 3 on Well's criteria for deep vein thrombosis, placing him/ her in the high probability category. The most appropriate response for the physical therapist would be to send the patient to the emer- gency department for further assessment. Incorrect Choices: Any choice except sending the patient to the emergency department would place the patient at an unneces- saiy risk for developing a pulmonaiy embolism. Type of Reasoning: Evaluation This question requires one to be familiar with the signs and symptoms associated with deep vein throm- bosis. To answer this question correctly one must evaluate the clinical presentation of the patient and weigh the merits of each approach, considering safety of the patient. This is an evaluative reasoning skill. For this situation, the therapist should recommend that the patient go immediately to the emergency depa11ment. Review signs and symptoms of deep vein thrombosis if answered incorrectly. Musculoskeletal I Examination A patient complains of persistent wrist pain after painting a house 3 weeks ago. The patient demonstrates signs and symptoms consistent with de Quervain's tenosynovitis. What special test can be used to confirm the diagnosis? Choices: 1. Finkelstein's test. 2. Phalen's test. 3. Froment's sign. 4. Craig's test. Exam ination B 715 Teaching Points Correct Answer: 1 Pinkelstein's test is specific for reproducing the pain associated with de Quervain's tenosynovitis of the ab- ductor pollicis longus and extensor pollicis brevis. Inco rrect Choices: Froment's sign is used to identify ulnar nerve dysfunction. Phalen's test identifies median nerve compression in the carpal tunnel. Craig's test identifies an abnormal femoral antetorsion angle, which you hopefully eliminated first. Type of Reasoning: Deductive This question requires factual recall of lmowledge of provocative tests for de Q uervain's tenosynovitis. In this case, the appropriate test is Finkelstein's test, which reproduces the pain of the abductor po llicics longus and extensor pollicis brevis tendons associated with de Que1vain's. If this question was answered incorrectly, refer to provocative testing of the hand or wrist and de Quervain's tenosynovitis. Car d iova s cula r/Pulmo n a ry I Examina tion As part of the chai1 review, the physical therapist views the patient's most current chest fi lm. i I· II I Based on this film, what is the MOST likely examination finding? Choices: 1. Increased lateral costal expansion. 2. Increased subcostal angle. 3. Decreased inspiratio n:expiration (I:E) ratio. 4. Decreased mediate percussion. Teaching Points Correct Answer: 2 This film demonstrates a patient with hyperinflated lungs as evidenced by the flattened diaphragm, blunted costophrenic angle, and increased amount of air. This will cause the subcostal angle to increase significantly. Incorrect Choices: Hyperinflated lungs are indicative of obstructive disease. The I:E ratio will increase in this case as the patient has difficulty getting air out. There is no evidence of secretions in this film, which would alter t he resonance of mediate percussion, so it can be assumed that this finding would be normal. Lateral costal expansio n would be decreased in this patient due to the hyperinflated lungs. Type of Reasoning: Analysis This questio n requires the test taker to determine the MOST likely examination finding b ased o n the x-ray. Questions that require analysis of pictures and graphs often necessitate analytical reasoning skill. If this q uestion was answered incorrectly, review signs and symptoms of hyperi nflated lungs. 716 Examination B Neuromuscular I Examination An elderly patient with persistent balance difficulty and a history of recent falls (two in the past 3 months) is referred for physical therapy examination and evaluation. During the initial examination, what should the therapist examine first? Choices: 1. Level of dyspnea during functional transfers. 2. Cardiovascular endurance during a 6-minute walking test. 3. Sensory losses and sensory organization of balance. 4. Spinal musculoskeletal changes seconda1y to degenerative joint disease (DJD). Teaching Points Correct Answer: 3 A critical component of balance control is sensory input from som atosensory, visual and vestibular receptors, and overall sensory organization of inputs. Initial examination should address these elements before moving on to assess the motor components of balance (e.g., postural synergies). The Clinical Test for Sensory integra- tion in Balance (CTSIB) or m odified CTSTB (Shumway-Cook, Horak) are appropriate instruments. Incorrect Choices: Cardiovascular endurance and level of dyspnea during functional transfers are appropriate elements to examine but should occur after key elem ents of balance are examined (senso1y components and integration; motor and synergistic elements). In this case, DJD changes would not be crucial to examine initially. Type of Reasoning: Inductive This case scenario requires the test taker to combine lmowledge of the somatosensory system and possible reasons for falls in order to arrive at the correct conclusion. A key facet of this question is in the terms "ini- tial session" and "oucial." These words should cause the test taker to focus on what should come first in a sequence of intervention events and what is most important for the patient. This requires the use of clinical judgment, which is an inductive reasoning skill. Musculoskeletal I Interventions To reduce an elderly individual's chronic forward head posturing in standing and sitting, what muscles are likely shortened and should be stretched? Choices: 1. Middle trapezius and rhomboid muscles. 2. Rectus capitis anterior muscles. 3. Longus capitis and longus colli muscles. 4. Rectus capitis posterior major and minor. , :. -.. Examination B 717 Teaching Points Correct Answer: 4 Forward head posturing or forward translation of the occiput in relation to the neck and trunk is associated with extension of the occipital axial joint and flexion of the lower and mid cervical spines. Chronic exten- sion of the occipital axial joint will lead to sho11ening of the suboccipital extensor muscles (rectus capitis posterior major and minor), and localized stretching of these muscles would be indicated as part of a thera- peutic intervention to reduce forward head posturing. Incorrect Choices: Muscles anterior to the axis for mid and lower cervical flexion and extension will be chronically overlength- ened, and therefore further stretching of these would not be indicated. Forward head posturing is also associated with forward scapular posturing, and therefore further stretching of scapular adductors (middle trapezius and rhomboid muscles) would not be indicated. Type of Reasoning: Inductive One must determine the best clinical course of action in order to arrive at a correct conclusion. Questions of this nature often require clinical judgment, which is an inductive reasoning skill. For this specific deficit, the therapist should consider exercises for the rectus capitis posterior minor and rectus capitis posterior major muscles. Review muscle actions of the cervical spine and upper trunk as well as exercises for forward head posturing if answered incorrectly. Cardiovascu lar/Pu lmonary I Examination What are the major benefits of using the 6-Minute Walk Test as an outcome measure? Choices: 1. Accurately documen ts maximal exercise capacity. 2. Provides good correlation with functio nal abilities. 3. Allows determination of severity of lung disease. 4. Provides determination of peak oxygen uptake. Teaching Points Correct Answer: 2 The 6-Minute Walk Test (GMWT) shows a good correlation with function, as the GMWT is a submax test, and function is performed at a submax work level. Incorrect Choices: The GMWr does not correlate to lung disease severity. The GMWT has only about a 73% correlation with VO 2max · The 10-Meter Shuttle Walk Test would be a better test to use if correlation with VO2 is desired. As the GMWT doesn't correlate with VO2max' it cannot document maximal exercise capacity. Type of Reasoning: Deductive This question requires the test taker to recall the benefits of the GMWT. This necessitates the recall of factual information, which is a deductive reasoning skill. For this situation, the GMWT is a helpful measure, as it is correlated with functional abi lities. Review benefits of the GMWT if answered incorrectly. 718 Examination B Musculoskeletal I Exam ination During a postural screen for a patient complaining of low back pain, the therapist notices that the knees are in genu recurvatum. What are the common contributory problems for which the therapist should examine? Choices: 1. Ankle dorsiflexion and hip abduction. 2. Forefoot varus and posterior pelvic tilt. 3. Ankle plantarflexion and anterior pelvic tilt. 4. Lateral tibial torsion and anterior pelvic tilt. Teaching Points Correct Answer: 3 A common contributory problem or correlated motion fo r genu recurvatum is ankle plantarflexion due to shortened gastrocnemius muscles. Alterations occurring up the kinetic chain include anterior pelvic tilt to maintain the center of gravity over the feet. Incorrect Choices: Ankle dorsiflexion will lead to increased knee flexion. Forefoot vams may lead to tibial internal rotation, but not genu recmvatum. Tibial external rotation will lead to abnormal stresses at the knee jo int, but not genu recu1vatum. Type of Reasoning: Inference The test taker must understand the nature of genu recmvatum and contributory postures in order to choose the correct answer. This requires recall of lower extrem ity musculoskeletal pathology and biomechanics. Questions that require one to draw conclusions based on presented evidence often necessitate the use of inferential reasoning skills. If this question was answered inconectly, refer to information on postural screen- ing, kinetic chain, and genu recurvatum. Musculoskele tal I Evaluation, Diagnosis After treating a patient for trochanteric bursitis for 1 week, the patient has no resolution of pain and is com- plaining of problems with gait. After reexamination, the therapist finds weakness of the quadriceps femoris and altered sensation at the greater trochanter. What is the MOST likely cause of the problems? Choices: 1. LS nerve root compression. 2. Sacroiliac (ST) dysfunction. 3. L4 nerve root compression. 4. Degenerative joint disease (DJD) of the hip. Teaching Points Correct Answer: 3 The positive findings are consistent with an L4 nerve root compression. Incorrect Choices: Weakness of only one muscle group is not a common finding for DJD or SI dysfunction. LS nerve root com- pression would result in hamstring weakness. :... Examination B 719 Type of Reasoning: Analysis In this question, the symptoms are provided and the test taker must make a determination of the possible diagnosis. Questions such as these require analytical reasohing skill, using knowledge of neuroanatomy to determine that the most likely cause is L4 ne1ve root compression. If this question was answered incorrectly, review information on nerve compressions of the lumbar spine. Genitourinary I Examination A patient in chronic renal failure is being seen in physical therapy for deconditioning and decreased gait en- durance. The therapist needs to schedule the patient's sessions around dialysis, which is received three morn- ings a week. What guidelines should the therapist follow when taking the patient's blood pressure? Choices: 1. Every minute during walking, using the nonshunt arm. 2. Pre- and postactivities, using the nonshunt arm. 3. In sitting when activity has ceased, using the shunt arm. 4. In the supine position, using the shunt arm. Teaching Points Correct Answer: 2 A dialysis shunt would interfere with taking BP. Use the nonshunt arm. Pre- and postexercise measurements are appropriate. Incorrect Choices: The shunt arm cannot be used to take BP. Taking BP in the shunt arm or during walking would result in inaccurate measurements. Type of Reasoning: Inference One must reason the best way to monitor a patient's BP using the appropriate guidelines when the patient has an at1ioventricular shunt in the arm for dialysis. Guidelines dictate that you should not take BP on the arm where the shunt is located. Also, monitoring BP is best carried out pre- and postactivity to determine tolerance for activity. This type of reasoning is inferential because one must infer the best approach to pa- tient care, considering the diagnosis and limitations of the patient. lntegumentary I Evaluation, Diagnosis A patient who is currently being treated for low back pain arrives for therapy complaining of pain across the middle of the right chest and back. When the therapist inspects the skin, clustered vesicles are apparent in a linear arc. The surrounding skin is hypersensitive. What is the MOST likely diagnosis? Choices: 1. Herpes simplex infection. 2. Psoriasis. 3. Dermatitis. 4. Herpes zoster infection. 720 Examination B Teaching Points Correct Answer: 4 Herpes zoster is an acute infection caused by reactivation of the latent varicella-zoster virus (shingles). It is characterized by painful vesicular skin eruptions that follow the underlying route of a spinal (in this case) or cranial nerve. Additional symptoms include fever, gastrointestinal disturbances, malaise, and headache. Incorrect Choices: Herpes simplex is an infection caused by the herpes simplex virus. These infections tend to occur on the face (around the mouth and nose). They are sometimes referred to as "cold sores." Psoriasis is a chronic skin condition characterized by red patches covered by dry, silvery scales. Dermatitis is an inflammatory condition of the skin characterized by eruptions ( not associated with an underlying route of a ne1ve). Type of Reasoning: Analysis One must recall the signs and symptoms of herpes zoster infection in order to arrive at a correct conclusion. This requires analytical reasoning skill because one must weigh the symptoms provided in order to deter- mine the most likely diagnosis. For this question, the key words of "vesicles" and "linear arc" help guide one toward the correct conclusion. If this question was answered incorrectly, review signs and symptoms of herpes zoster infection. Musculoskeletal / Examination The physical therapist is examining the muscle length of the patient's left hip and knee. What muscle length test is being shown in the picture below? I i I I I I I Choices: 1. FABER test. 2. Thomas test. 3. Noble tesl. 4. Ober test. Examination B 721 Teaching Points Correct Answer: 2 The Thomas test is utilized to test for hip flexor length and to distinguish between one joint and two joint hip flexor tightness. With low back and sacrum flat on the table, a normal one joint hip flexor length would be with thigh flat on the table. Normal two joint hip flexor length would be 80° of knee flexio n. Incorrect Choices: The Ober test is pe1formed for tightness of the tensor fascia latae and iliotibial band. The Noble test is per- formed for iliotibial band friction syndrome. The FABER test is hip flexion, abduction, and external rotation and is to screen hip and SI pathology. Type of Reasoning: Analysis One must understand the tests described in the question in order to choose the correct one. Through analyti- cal reasoning, the test taker must determine how each test is performed and for what purpose. If this ques- tion was answered incorrectly, review information on special tests. Cardiovascular/Pulmonary I Evaluation, Diagnos is After a myocardial infarction (Ml), a patient is a new admission to a phase 3 hospital-based cardiac rehabilita- tion program. During the initial exercise session, the patient's ECG responses are continuously monitored via radio telemetry. The therapist notices three PVCs occurring in a run with no P wave. What action should the therapist take? Choices: 1. Modify the exercise prescription by decreasing the intensity. 2. Stop the exercise and notify the physician immediately. 3. Continue the exercise session, but monitor closely. 4. Have the patient sit down and rest for a few minutes before resuming exercise. Teaching Points Correct Answer: 2 A run of three or more PVCs occurring sequentially is ventricular tachycardia. The rate is ve1y rapid, result- ing in seriously compromised cardiac output. This is potentially an em ergency situatio n that can deteriorate rapidly into ventricular fibrillation ( no cardiac o utput) and cardiac arrest. Incorrect Choices: The other choices, which involve continuation of exercise, put the patient at serious risk for cardiac arrest. Type of Reasoning: Inductive This question requires the test taker to use diagnostic reasoning and clinical judgment to determine whetl1er or not the PVCs and absence of P wave are significant enough to warrant physician notificatio n. This type of reasoning is inductive, and the test taker is called to make a decision for the safety of the patient. In iliis case, physician notification is warranted, and exercise should be halted immediately. If this question was answered incorrectly, refer to cardiac rehabilitation guidelines and interpretation of ECGs. 722 Examination B Neuromuscular I Evaluatio n, Diagnosis A palient with left hemiplegia is able to recognize his wife after she is with him for a while and talks to him but is unable to recognize the faces of his children when they come to visit. The children are naturally very upset by their father's behavior. What is the BEST explanation for his problem? Choices: 1. Somatognosia. 2. Anosognosia. 3. Visual agnosia. 4. Ideational apraxia. Teaching Points Correct Answer: 3 All of the choices are indicative of perceptual dysfu nction. This patient is most likely suffering from visual ag- nosia, which is an inability to recognize familiar objects despite normal function of the eyes and optic tracts. Once the wife talks with him, he is able to recognize her by her voice. Incorrect Choices: Ideatio nal apraxia is the inability to perform a purposeful motor act, either automatically or upon com- mand. Anosognosia is the frank denial, neglect, or lack of awareness of the presence or severity of one's paralysis. Somatognosia is an impairment in body scheme. Type of Reasoning: Analysis In this question, one must recall the meaning of the four choices provided and apply them to the patient's symptoms as described. This requires analytical reasoning, which often requires one to determine the mean- ing of statements or medical terminology. If this question was answered incorrectly, refer to info rmatio n on the various perceptual problems after CVA. Card io v ascular/Pulmonary I Evaluation, Di agnosis A home care PT receives a referral to evaluate the fall risk potential of an elderly community-dweller with chronic coronary artery disease (CAD). The patient has fallen three times in the past 4 months, with no his- to1y of fall injury except for minor bruising. The patient is currently taking a number of medications. What is the drug that is MOST likely to contrib ute to dizziness and increased fall risk? Choices: 1. Colace. 2. Albuterol. 3. Nitroglycerin. 4. Coumadin sodium......... ,, Examination B 723 Teaching Points Correct Answer: 3 Of the medications listed, nitroglycerin has the greatest risk of causing dizziness or weakness due to postural hypotension. Fall risk is increased even with small doses of nitroglycerin. Incorrect Choices: Colace (docusate sodium), an anticonstipation agent, can result in mild abdominal cramps and nausea. Coumadin (warfarin sodium) is an antidotting medication. Adverse effects can include increased risk of hemorrhage, w hich indirectly can result in lightheadedness. Dosages are carefully monitored. Albuterol, a bronchodilator, can cause tremor, anxiety, nervousness, and weakness. Type of Reasoning: Inference One must infer information from the four medications provided in order to determine the one that is most likely to contribute to increased fall risk. In this circumstance, using inferential reasoning, one recalls the side effects of each medicine an d determines that nitroglycerin is most likely to cause increased risk of fa lls because this is one of the common side effects. Musculoskeletal I Interventions A patient complains of foot pain when first arising tha t eases with ambulation. The therapist finds that symp- toms can be reproduced in weight bearing and running on a treadmill. Examination reveals pes planus and pain with palpation at th e distal aspect of the ca

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