Examination B 2012 R&SG

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Neuromuscular I Evaluation, Diagnosis

A physical therapy plan of care for a child with spastic cerebral palsy who is 3 years old chronologically and
cognitively, but at a 6-month-old gross developmental level would include:

Choices:
1. Reaching for a black and white object while in the supine position.
2. Reaching for a multicolored object while in an unsupported standing position.
3. Reaching for a multicolored object while in an unsupp0l1ed, guarded sitting position.
4. Visually tracking a black and white object held 9 inches from his/ her face.

Teaching Points

Correct Answer: 3
The appropriate task would include the 6-month-old gross developmental level activity of working on un-
supported sitting.

Incorrect Choices:
Standing and supine are not appropriate choices (too advanced or not advanced enough). The use of a mul-
ticolored object is more appropriate than a black and white object for a 3-year-old cognitive level.

Type of Reasoning: Analysis

In this question, the test taker must take into consideration the chronological, cognitive, and gross devel-
opmentallevels of the child in order to arrive at the correct conclusion. In this scenario, the test taker must
provide the appropriate physical challenge for a child developmentally functioning at 6 months in gross
development, while providing activities that are appropriate for the 3 year-old cognitive level. If this question
was answered incorrectly, review motor and cognitive developmental milestones .

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Musculoskeletal I Interventions

A patient is receiving mobilizations to regain normal mid thoracic extension. After three sessions, the patient
complains oflocalized pain that persists for greater than 24 hours. The therapist's treatment should:

Choices:
1. Continue with current mobilizations, followed by a cold pack to the thoracic spine.
2. Place the physical therapy on hold and resume in 1 week.
3. Change mobilizations to gentle, low-amplitude oscillations to reduce the joint and soft tissue irritation.
4. Change to self-stretching activities, because the patient does not tolerate mobilization.

612
 Examination B 613

Teaching Points

Correct Answer: 3
Changing to low-amplitude oscillations will promote a decrease in the pain and tissue irritation. If pain per-
sists for more than 24 hours, the soft tissue and joint irritation may progress.

Incorrect Choices:
Pain beyond 24 hours indicates possible tissue damage, so modification would be indicated. Placing the
patient on hold would not be indicated or appropriate based on the patient's response. Self-stretching will
improve the osteokinematic motion, but not the arthrokinematic motion, so this would not be an appropri-
ate modification.

Type of Reasoning: Inference

This question requires one to understand joint mobilization techniques, coupled with recognition of pos-
sible results that may occur when utilizing the techniques. In this scenario, the patient's symptoms indicate
that the joint mobilization techniques resulted in soft tissue and joint irritation. Therefore, the therapist
should consider less irritating mobilization for improved tolerance. If this question was answered incorrectly,
refer to joint mobilization information.

Neuromuscular I Interventions

A therapist wishes to use behavior modification techniques as part of a plan of care to help shape the behavioral
responses of a patient recovering from traumatic brain injury (TBI) . The BEST form of intervention is to:

Choices:
1. Reprimand the patient every time an undesirable behavior occurs.
2. Use frequent reinforcements for all desired behaviors.
3. Allow the patient enough time for self-correction of the behavior.
4. Encourage the staff to tell the patient which behaviors are correct and which are not.

Teaching Points

Correct Answer: 2
Behavioral modification is best achieved through use of positive reinforcements for all desired behaviors.

Incorrect Choices:
Negative behaviors should be ignored, not reprimanded. Self-correction is not a form of behavior modifica-
tion.

Type of Reasoning: Evaluation

The test taker utilizes knowledge of behavioral modification techniques to choose the correct answer in this
scenario. Using evaluative skills, one determines the value of each of the four choices, and which choice is
most aligned with behavioral modification guidelines to promote positive behaviors via positive reinforce-
ment techniques.
 •
614 Examin ation B

Neuromuscular I Interventions

A patient with multiple sclerosis (MS) presents with dysmetria in both upper extremities. Which of the fol-
lowing interventions is the BEST choice to deal with this problem?

Choices:
l. 3-lb weight cuffs to wrists during activities of daily living (ADL) training.
2. Pool exercises using water temperatures greater than 85 0 F.
3. Proprioceptive neuromuscular facilitation (PNF) patterns using dynamic reversals with carefully graded
resistance.
4. Isokinetic training using low resistance and fast movement speeds.

Teaching Points

Correct Answer: 3
Dysmetria is a coordination problem in which the patient is unable to judge the distance or range of
movement (overshoots or undershoots a target). Adding manual resistance with PNF can assist the patient
in slowing down the movement and achieving better control.

Incorrect Ch oices:
The patient lacks speed control. Low-resistance, fast-speed isokinetic training is contraindicated. The
resistance of water (pool therapy) could help control the speed of movements, but the temperature is too
warm (patients with MS demonstrate heat intolerance). Weight cuffs could also help slow the movements
down, but would unnecessarily fatigue the patient (patients with MS demonstrate problems with excessive
fatigue) .

Type of Reasoning: Inference

One must understand the deficit of dysmetria in order to arrive at the correct conclusion. Using skills of
inference, the test taker uses the knowledge of dysmetria to determine what course of action is useful to
promote improved coordination and motor control. If this question was answered incorrectly, review
information on dysmetria.

Musculoskeletal I Interventions

Knee capsular tightness has limited a patient's ability to attain full flexion . An INITIAL intervention a physi-
cal therapist can employ to restore joint motion should emphasize sustained mobilization in the loose-
packed position using:

Cho ices:
1. Posterior glide and internal rotation of the tibia.
2. Anterior glide and internal rotation of the tibia.
3. Posterior glide and external rotation ofthe tibia.
4. Anterior glide and external rotation of the tibia.
 Examination B 615

Teaching Points

Correct Answer: 1
Posterior glide and internal rotation are accessory motions necessary to increase knee flexion. Initial treat-
ment should not result in pain, soreness, or diminished range of motion.

Incorrect Choices:
Anterior glide and external rotation are motions necessary for knee extension.

Type of Reasoning: Inductive

For this question, one must utilize clinical judgment and reasoning to determine the most appropriate initial
intervention approach for capsular tightness of the knee. This requires inductive reasoning skill. For this case,
the appropriate joint motion should emphasize posterior glide and internal rotation of the tibia. Review
joint mobilization techniques for the knee if answered incorrectly.

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Cardiovascular/Pulmonary and Lymphatic I Interventions

A patient recovering from cardiac transplantation for end-stage heart failure is referred for exercise train-
ing. The patient is receiving immunosuppressive drug therapy (cyclosporine and prednisone). The therapist
recognizes that this patient will:

Choices:
1. Require longer periods of warm-up and cool-down.
2 . Be unable to perform resistance training.
3 . Require a frequency of 2-3 times/week.
4. Require short bouts of exercise.

Teaching Points

Correct Answer: 1
A patient recovering from cardiac transplantation will require longer periods of warm-up and cool-down,
because physiological responses to exercise and recovery take longer.

Incorrect Choices:
Low- to moderate-intensity resistance training can be performed. Aerobic exercise should be performed
4-6 times/week, while progressively increasing the duration of training from 15 to 60 minutes per ses-
sion. (Source: ACSM Guidelines for Exercise Testing and Prescription) .

Type of Reasoning: Inference

This question requires the test taker to infer what may be true of a patient, given the diagnosis of cardiac
transplantation. Inferential reasoning skills are utilized whenever one must predict a best course of action
or determine what may be true of a person or situation. In this case, the therapist should recognize that
the patient will require longer periods of warm-up and cool-down. If this question was answered incor-
rectly, review exercise guidelines for patients with cardiac transplantation.
 •
616 Examination B

N eu r o mu s cular I Examin a ti o n

A patient presents with weakness and atrophy of the biceps brachii resulting from an open fracture of the
humerus. The therapist's examination includes needle electromyography (EMG) of the biceps. The muscle
response anticipated after the needle is inserted and prior to asking the patient to contract the muscle is:

Choices:
1. Fibrillation potentials.
2. Electrical silence.
3. Polyphasic potentials.
4. Interference patterns.

Teaching Points

Correct Answer: 2
Inserting an EMG needle into a normal muscle causes a burst of electrical activity (insertional activity),
after which the muscle produces no sound (electrical silence).

Incorrect Choices:
Fibrillation potentials are spontaneous activity seen in relaxed denervated muscle, and polyphasic poten-
tials are produced in the contracted muscle undergoing reorganization.

Type of Reasoning: Inference

One must understand the expected responses to EMG needle insertion in order to arrive at the correct
conclusion. Inferential skills are used whenever one must determine what may occur based on facts and
evidence. In this situation, the test taker must infer what happens after needle insertion and before muscle
contraction.

Geni t ou r inary I Eva luat ion , D ia gn os is

A new staff physical therapist (PT) on the oncology unit of a large medical center receives a referral for
strengthening and ambulation for a woman with ovarian cancer. She is undergoing radiation therapy after
a surgical hysterectomy. Her current platelet count is 17,000. The treatment of GREATEST BENEFIT for this
patient at this time is:

Choices:
1. Resistance training at 40%, one repetition maximum.
2. Progressive stair climbing using a weighted waist belt.
3. Active range-of-motion (AROM) exercises.
4. Resistance training at 60%, one repetition maximum.

Teaching Points

Correct Answer: 3
AROM and ADL exercises are beneficial for this patient.
 Examination B 617

Incorrect Choices:
Resistive exercise is contraindicated in patients with significant bony metastases, osteoporosis, or low platelet
count «20,000) .

Type of Reasoning: Evaluation

One must utilize knowledge of normal platelet counts and contraindications for resistive exercise in patients
with cancer. In this situation, the patient's platelet count is low, which should alert the test taker that resistive
exercise should be deferred. Questions such as these require one to review the merits of a situation, which is
an evaluative skill. Knowledge of normal blood counts is very useful information.

M u sc u los k elet al I Inte rve nti ons

A patient complains of increased pain and tingling in both hands after sitting at a desk for longer than
1 hour. The diagnosis is thoracic outlet syndrome (TOS). Which treatment would be the MOST effective
physical therapy intervention?

Choices:
1. Strengthening program for the scalenes and sternocleidomastoids.
2. Stretching program for the pectoralis minor and scalenes.
3. Cardiovascular training using cycle ergometry to reduce symptoms ofTOS.
4. Desensitization by maintaining the shoulder in abduction, extension, and external rotation with the
head turned toward the ipsilateral shoulder.

Teaching Points

Correct Answer: 2
TOS is described as compression to the neurovascular structures in the scalene triangle, the area defined
by the anterior and middle scalenes between the clavicle and the first rib. The compression is a result of a
shortened pectoralis minor and scalene muscles. Therefore, a stretching program to these muscles to gain
space in the scalene triangle is appropriate.

Incorrect Choices:
Shortening of the scalenes and sternocleidomastoids may be the culprit that caused TOS to develop.
Strengthening these muscles would not improve the amount of space in the scalene triangle space. Car-
diovascular training, especially performed in the posture using a cycle ergometer, would not improve the
disorder. The problem in TOS is too much vascular volume in too small a space. Increasing the vascular
volume through that space with cardiovascular exercise will not resolve the symptoms ofTOS. Desensi-
tization by putting the shoulder and neck in this position is likely to diminish the space in the scalene
triangle and further compress the neurovascular structures that run through that triangle.

Type of Reasoning: Analysis

This requires analytical reasoning. Ifthis question was answered incorrectly, review the causes and inter-
ventions for TOS .
618 Examination B

Metabolic/Endocrine I Evaluation, Diagnosis

A patient with diabetes is exercising. The patient reports feeling weak, dizzy, and somewhat nauseous. The
therapist notices that the patient is sweating profusely and is unsteady when standing. The therapist's BEST
immediate course of action is to:

Choices:
1. Call for emergency services; the patient is having an insulin reaction.
2. Have a nurse administer an insulin injection for developing hyperglycemia.
3. Insist that the patient sit down until the orthostatic hypotension resolves.
4. Administer orange juice for developing hypoglycemia.

Teaching Points
Correct Answer: 4
Hypoglycemia, or abnormally low blood glucose, results from too much insulin (insulin reaction). It
requires accurate assessment of symptoms and prompt intervention. Have the patient sit down and give
an oral sugar (e.g., orange juice) .

Incorrect Choices:
Once the patient is stabilized, the physician should be notified. Emergency services are generally not
needed. Profuse sweating does not usually accompany orthostatic hypotension.

Type of Reasoning: Inductive

The test taker must first determine the cause of the patient's symptoms and then the appropriate course
of action. Questions such as these utilize one's clinical judgment and diagnostic thinking, which is an
inductive reasoning skill. One should recognize that these symptoms are indicative of hypoglycemia and
require immediate administration of sugar to relieve symptoms .

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Neuromuscular I Evaluation, Diagnosis

A patient with postpolio syndrome started attending a supervised outpatient exercise program. The patient
failed to show up for follow-up sessions. The patient reported increased muscle pain and being too weak
to get out of bed for the past 2 days. The patient is afraid to continue with the exercise class. The therapist's
BEST course of action regarding exercise is to :

Choices:
1. Decrease the intensity and duration, but maintain a frequency of 3 times/ week.
2. Discharge the patient from the program because exercise is counterproductive in postpolio syndrome.
3. Decrease the frequency to once a week for an hour session, keeping the intensity moderate.
4. Reschedule exercise workouts for early morning when there is less fatigue.
 Examination B 619

Teaching Points

Correct Answer: 1
Clinical manifestations of postpolio syndrome include myalgias, new weakness as well as atrophy, and exces-
sive fatigue with minimal activity. Nonexhaustive exercise and general body conditioning are indicated. A
change in the exercise prescription (intensity and duration) is warranted.

Incorrect Choices:
The patient should not exercise to the point of fatigue and exhaustion. A frequency of once a week is too
little to be beneficial. Rescheduling exercise to early morning does not address the needed change in exercise
prescription. Stopping exercise completely will not help this patient.

Type of Reasoning: Inference

This question requires the test taker first to understand the nature of postpolio syndrome and then determine
the appropriate exercise regimen to prevent further exacerbation of symptoms. Therefore, one must infer, or
draw conclusions, from the evidence presented to arrive at the correct decision. If this question was answered
II
incorrectly, review information on postpolio syndrome .

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Cardiovasc u la r/Pulmo n ary and Lymphatic I Interventions

A person with primary lymphedema secondary to hypoplasia that began later in adolescence is referred
for physical therapy. The person recently got married and is wondering if it is likely this condition can be
passed on to their future children. It would be best to advise this patient that:

Choices:
1. Genetic risk is less than 25% of the cases of primary lymphedema.
2. Lymphedema is not related to genetic causes.
3. Secondary lymphedema is more likely to be an inheritable trait.
4. There is a strong likelihood that it could be passed on to any future children.

Teaching Points

Correct Answer: 1
There are genetic conditions associated with lymphedema. The risk is typically less than 25% of those
with a family history of primary lymphedema.

Incorrect Choices:
It is incorrect to assume that a child may develop lymphedema just because a parent has it. However,
since there is a familial link, the patient should consult with his/ her physician to understand the true
risks. Secondary lymphedema is the result of trauma or an insult to the lymphatics and is not directly as-
sociated with a family history of lymphedema.

Type of Reasoning: Inference

This question requires the test taker to determine what is likely to be true based on clinical knowledge.
This is an inferential reasoning skill. For this situation, it would be best to advise the patient that genetic
risk is less than 25% of the cases of primary lymphedema. Refer to primary lymphedema guidelines and
risk factors if answered incorrectly.
620 Examination B

Cardiovascular/Pulmonary and Lymphatic I Interventions

A patient is recovering from open heart surgery (coronary artery bypass graft [CABC]). The PT supervising
the patient's outpatient exercise program at 8 weeks' postsurgery recognizes that resistance training with
moderate to heavy weights:

Choices:
1. Is absolutely contraindicated.
2. Should include upper body exercises only.
3. Should be based on 60%-80%, one repetition maximum initially.
4. Should be avoided during the first 3 months.

Teaching Points
Correct Answer: 4
Moderate to heavy resistance exercises should be avoided until the sternum has healed, generally by 3
months. Patients with sternal movement or wound infection should perform lower extremity resistance
exercises only.

Incorrect Choices:
Once cleared, initial loads for the upper body should be 30%-40%, one repetition max, and 50%-60%
for hips and legs. (Source: ACSM Guidelines for Exercise Testing and Prescription.)

Type of Reasoning: Deductive

One must recall the guidelines for cardiac exercise post-CABC in order to arrive at a correct conclusion.
This requires recall of factual guidelines, which is a deductive reasoning skill. For this question, the key
words are " 8 weeks' postsurgery, " which should draw one to conclude that resistance training with moder-
ate to heavy weights should be avoided during the first 3 months. If this question was answered incor-
rectly, review cardiac exercise guidelines, especially post-CABC .

•
Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

A patient with asthma is taking a drug from the sympathomimetic group, albuterol (Ventolin) . What is the
MOST important effect of this medication?

Choices:
1. Increases airway resistance and decreases secretion production.
2 . Reduces airway resistance by reducing bronchospasm.
3. Reduces bronchial constriction and high blood pressure (BP) that accompanies exercise.
4. Increases heart rate (HR) and BP to enhance a training effect during aerobic activity.

Teaching Points
Correct Answer: 2
Sympathomimetics are a class of drugs that mimics the effects of stimulation of body organs and struc-
tures by the sympathetic nervous system. Albuterol (Ventolin) has the primary action of reducing airway
resistance by a decrease in bronchospasm.
 Examination B

Incorrect Choices:
Albuterol decreases airway resistance and has no effect on the volume or consistency of airway secretions.
The primary effects of albuterol are on /32 receptors in the bronchiole smooth muscle. It may also have an
effect on /31 receptors, producing cardiovascular adverse reactions of increased BP and tachycardia. These
adverse effects can result in a patient monitoring exercise parameters at lower exercise workloads and reduc-
ing aerobic training effects.

Type of Reasoning: Inference

This question, while requiring knowledge of the effects and side effects of medication (a deductive skill), also
requires one to determine the MOST important effects (not adverse effects) . Therefore, this question utilizes
inferential reasoning, in which the test taker must draw conclusions based on the information presented and
determine what is most important, which encourages inferential deductive reasoning. If this question was
answered incorrectly, refer to information on sympathomimetic medications.

Cardiovascular/Pulmonary and Lymphatic I Interventions

A PT decides to exercise a patient with lower extremity lymphedema using aquatic therapy. Hydrostatic
pressure exerted by the water can be expected to:

Choices:
1. Provide joint unloading and enhance ease of active movement.
2. Reduce effusion and assist venous return.
3. Increase resistance as speed of movement increases.
4. Increase cardiovascular demands at rest and with exercise.

Teaching Points

Correct Answer: 2
The pressure exerted by water on an immersed object is equal on all surfaces (Pascal's law). As the depth
of immersion increases, so does hydrostatic pressure. Increased pressure limits effusion, assists venous
return, and can induce bradycardia.

Incorrect Choices:
The other choices do not relate directly to hydrostatic pressure. Buoyancy of water provides an environ-
ment of relative weightlessness and assists in joint unloading and active movement. Hydromechanics,
movement of water molecules, increases the resistance of water as speed of movement increases. Hot
water immersion (>3 5 0 C) can increase cardiovascular demands at rest and with exercise.

Type of Reasoning: Deductive

This question primarily requires recall of physics, including hydrostatic pressure and buoyancy. In order
to arrive at the correct conclusion, one must apply knowledge of hydrostatic pressure to the patient in this
case. This patient has a history of myocardial infarction (MI) and is deconditioned. If this question was
answered incorrectly, refer to information on effects of hydrostatic pressure on cardiovascular function.
 •
622 Examination B

Musculoskeletal I Interventions

A therapist determines that a patient is walking with a backward trunk lean with full weight on the right
leg. The patient also demonstrates great difficulty going up ramps. The BEST intervention to remediate this
problem is to:

Choices:
1. Stretch hip abductors through side-lying positioning.
2. Stretch hip flexors through prone-lying positioning.
3. Strengthen hip extensors through bridging.
4 . Strengthen knee extensors with weights, using 80%, one repetition maximum.

Teaching Points

Correct Answer: 3
Backward trunk lean (gluteus maximus gait) is the result of a weak gluteus maximus. It causes increased
difficulty going up stairs or ramps. Functional training exercises such as bridging are indicated.

Incorrect Choices:
The patient is able to perform a backward trunk lean in standing, indicating adequate range in hip flexors.
Ability to take full weight on the limb without knee buckling indicates adequate strength of knee exten-
sors. Tightness in hip abductors is rare and would result in the posture (lateral lean) being maintained
during all phases of gait.

Type of Reasoning: Inference

In this question, the test taker must determine the cause of a backward trunk lean and difficulty ascending
ramps, and which muscle groups require strengthening. This type of question requires one to make infer-
ences or draw conclusions from the evidence presented in order to make a clinical decision. If this ques-
tion was answered incorrectly, review knowledge of gait deviations and their causes.

Integumentary I Examination

If a patient has developed a thick eschar secondary to a full-thickness bum, the antibacterial agent MOST
effective for infection control is:

Choices:
1. Silver nitrate.
2. Sulfamylon.
3. Panafil.
4. Nitrofurazone.

Teaching Points
Correct Answer: 2
Sulfamylon penetrates through eschar and provides antibacterial control.
 Examination B 623

Incorrect Choices:
Silver nitrate and nitrofurazone are superficial agents that attack surface organisms. Panafil is a keratolytic
enzyme used for selective debridement.

Type of Reasoning: Analysis

This question requires recall of the properties of each agent in antibacterial control and then determination
of which one would MOST effectively promote infection control. Therefore, the test taker must analyze each
agent and rely on knowledge of these agents to arrive at the correct conclusion. If this question was answered
incorrectly, review information on agents used after burns.

"
Neuromuscular I Evaluation, Diagnosis

An elderly person has lost significant functional vision over the past 4 years, and complains of blurred
vision and difficulty reading. The patient frequently mistakes images directly in front of her, especially in
bright light. When walking across a room, the patient is able to locate items in the environment using pe-
ripheral vision when items are located to both sides. Based on these findings, the therapist suspects:

Choices:
1. Glaucoma.
2. Homonymous hemianopsia.
3. Cataracts.
4. Bitemporal hemianopsia.

Teaching Points
Correct Answer: 3
Cataracts, which cause a clouding of the lens, result in a gradual loss of vision; central vision is lost first,
then peripheral.

Incorrect Choices:
Glaucoma produces the reverse symptoms: loss of peripheral vision occurs first, then central vision, pro-
gressing to total blindness. Hemianopsia is a field defect in both eyes that often occurs fo llowing stroke.
There was no mention of cerebrovascular accident (CVA) in the question.

Type of Reasoning: Analysis

In this question, symptoms are presented and one must make a determination of the most likely diag-
nosis. These types of questions require analysis of the meaning of information presented that utilizes
analytical reasoning skill. If this question was answered incorrectly, refer to information on visual deficits
associated with aging.
624 Examination B

Musculoskeletal I Examination

A patient presents with complaints of pain and difficulty with ADL that is consistent with carpal tunnel syn-
drome. The BEST test that would help identify the cause of the symptoms would be the:

Choices:
1. Allen's test.
2. Pronator teres syndrome test.
3. Phalen's test.
4. Ulnar nerve tension test.

Teaching Points

Correct Answer: 3
Phalen's test places stress on the compartment where the median nerve passes into the hand, so this test is
typically positive for patients with carpal tunnel syndrome.

Incorrect Choices:
Allen's test is utilized to identify appropriate blood flow of the radial and ulnar arteries into the hand. The
pronator teres syndrome test also involves the median nerve, but patients with median nerve involvement
caused by an entrapment at the pronator teres will have signs and symptoms proximal to the hand as well.
The ulnar nerve tension test (UL1T3) is utilized to determine an abnormal motion/glide for the ulnar nerve.
None of these tests would duplicate the signs and symptoms of carpal tunnel syndrome.

Type of Reasoning: Deductive

For this question, the test taker must recall provocative testing guidelines in order to arrive at a correct con-
clusion. Specifically, one must recall the provocative test that is used to determine the cause for the patient's
symptoms. This is factual recall of information, which is a deductive reasoning skill. For this scenario,
Phalen's test is the best test to use. Review provocative tests of the hand and wrist, especially median nerve
testing, if answered incorrectly.

Neuromuscular I Interventions

A patient incurred a right CVA 1 month ago and demonstrates moderate spasticity in the left upper extremity
(predominantly increased flexor tone) . The major problem at this time is a lack of voluntary movement con-
trol. There is minimal active movement, with 1/4 inch subluxation of the shoulder. The initial treatment activity
of GREATEST BENEFIT is:

Choices:
1. Sitting, weight bearing on extended left upper extremity, weight shifting.
2. PNF D2 flexion pattern, left upper extremity.
3. Quadruped, rocking from side to side.
4. Sitting, left active shoulder protraction with extended elbow, and shoulder flexed to 90°.
 Examination B 625

Teaching Points

Correct Answer: 1
Sitting, weight bearing, and rocking on an extended left upper extremity will help to decrease the flexor tone.
It also provides joint compression (approximation) at the shoulder, which will help maintain shoulder posi-
tion and stimulate stabilizing muscles.

Incorrect Choices:
Quadruped is too strenuous for this patient at this time (maximum weight bearing on a weak, unstable up-
per extremity) . The other two activities demand more voluntary control than this patient currently
demonstrates.

Type of Reasoning: Inductive

The test taker must make a determination of where the patient is currently functioning and match this
knowledge to what the patient could most likely tolerate and achieve success in during interventions. In this
situation, the patient would benefit the most from weight-bearing activities through the affected extremity
with weight shifting. Questions such as these require clinical judgment, which is an inductive reasoning skill.

Musc u loske letal I Ex aminati on

An older adult presents with complaint of pain in the right hip region. The subjective symptoms appear to be
consistent with hip osteoarthrosis. The clinical test that the physical therapist would perform to assist in mak-
ing this diagnosis would be the:

Choices:
1. Craig's test.
2. Scouring test.
3. Posterior impingement test.
4. Thomas test.

Teaching Points

Correct Answer: 2
A positive scouring test would be a consistent finding for a patient who has osteoarthrosis of the hip joint. It
compresses the joint.

Incorrect Choices:
Craig's test is utilized to examine for increased or decreased anterior antetorsion angle. The Thomas test
examines the flexibility of the hip flexor muscles. The posterior impingement test is utilized to examine for
impingement of the posterior hip joint capsule and/or labrum. Therefore, none of these tests would produce
positive findings consistent with hip osteoarthrosis.

Type of Reasoning: Deductive

This question requires one to recall the appropriate test for hip osteoarthrosis in order to arrive at a correct
conclusion. This is factual recall of guidelines, which is a deductive reasoning skill. For this case, the scour-
ing test is best. Review provocative testing of the hip, especially the scouring test if answered incorrectly.
626 Examination B

"
Musculoskeletal I Examination

The therapist in the photograph is testing which muscle?

Choices:
1. Supraspinatus.
2. Anterior deltoid.
3. Middle deltoid.
4. Upper trapezius.

Teaching Points

Correct Answer: 1
The muscle being tested is the supraspinatus. The empty-can position puts the supraspinatus muscle in its
most effective position for contraction. Weakness may be a result of inflammation, neuropathy of the supras-
capular nerve, or a tendon tear.

Incorrect Choices:
The muscle test for the anterior deltoid would have the humerus and forearm in neutral, rather than internal
rotation of the humerus and pronation of the forearm shown in the picture. The muscle test for the middle
deltoid would have the shoulder in abduction to 90°. The muscle test for the upper trapezius is the shoulder
shrug.

Type of Reasoning: Analysis

In this situation, the test taker must recall knowledge of muscle testing of the supraspinatus to arrive at the
correct conclusion. Whereas recall of muscle testing positions and procedures can be simple recall, the pic-
ture utilizes analysis of information coupled with recall, which becomes an analytical skill. If this question
was answered incorrectly, refer to information on special tests of the shoulder complex.

"
Neuromuscular I Examination

During an examination, a patient demonstrates large-amplitude, sudden flailing motions of the arm and leg
on one side of the body with primary involvement of axial and proximal joint muscles. The therapist deter-
mines the patient is exhibiting:

Choices:
1. Athetosis.
2. Hemiballismus.
3. Chorea.
4. Intention tremor.
 Examination B 627

Teaching Points

Correct Answer: 2
Hemiballismus refers to sudden, jerky, forceful, and flailing involuntary movements on one side of the body.
["Hemi" was a clue] .

Incorrect Choices:
Athetosis refers to slow, writhing, and twisting involuntary movements. Chorea refers to rapid, irregular, and
jerky involuntary movements. Intention tremor refers to involuntary oscillatory movements that occur dur-
ing voluntary movement. None of these are localized just to one side of the body.

Type of Reasoning: Analysis

In order to arrive at a correct conclusion, one must analyze the presenting symptoms and determine
the most likely cause for those symptoms. This requires analytical reasoning skill. In this situation,
the symptoms indicate hemiballismus. If answered incorrectly, review signs and symptoms of
hemiballismus .

•
M u sculoske letal I Examination

A patient is referred to physical therapy after an antero-inferior dislocation of the right shoulder. A possible
positive examination finding as the result of this trauma would be:

Choices:
1. Weak rhomboids.
2. Positive drop arm test.
3. Weak deltoids.
4. Positive Neer's test.

Teaching Points

Correct Answer: 3
Because of the anatomical position of the axillary nerve, it can be damaged by an antero-inferior dislocation
at the glenohumeral joint. This results in weak deltoids.

Incorrect Choices:
A drop arm test evaluates the integrity of the rotator cuff. A Neer's test evaluates impingement of the shoul-
der. The rhomboids are innervated by the dorsal scapular nerve. Anatomically, the dorsal scapular nerve is
medial and posterior to the shoulder joint.

Type of Reasoning: Analysis

This question requires one to recall musculoskeletal anatomy of the shoulder and the various tests that can
be administered to determine dysfunction in the shoulder. For this case, the drop arm test and Neer's test are
not administered to determine anterior shoulder dislocation, and rhomboids do not playa role in anterior
shoulder stability. Through analysis of the information presented, the test taker should conclude that weak
deltoids are the most likely cause.
628 Exa mination B

Nonsystem I Safety, Professional Responsibilities, Research

A team of researchers investigates the use of constraint-induced movement therapy on patients with chronic
stroke (>1 year poststroke) using a multicenter randomized controlled trial (ReT) . This type of design pro-
vides the highest level of evidence because it uses:

Choices:
1. Alternating experimental and control conditions for a subject.
2. Random assignment to matched cohort groups.
3. A sample of convenience for the intervention group.
4. Random assignment to an experimental or control group.

Teaching Points

Correct Answer: 4
An ReT uses a randomization process to assign subjects to either an experimental group(s) or a control
(comparison) group. Subjects in the experimental group receive the intervention and are then compared
with subjects in the control group, who do not receive the intervention.

Incorrect Choices:
Alternating experimental and control conditions for a subject is an A-B-A-B design, typically used in single-subject
design studies. A cohort design investigates a group of subjects without a control group (sample of convenience).

Type of Reasoning: Deductive

One must recall the guidelines for an ReT in order to arrive at a correct conclusion. Questions that require
one to recall facts or guidelines often necessitate deductive reasoning skill. For this case, this type of research
design provides the highest level of evidence due to the random assignment to an experimental or control
group. If this question was answered incorrectly, review research guidelines, especially ReT study designs.

Neuromuscular I Interventions

A therapist has been asked to give an in-service presentation to staff aides on safe guarding techniques in a
nursing home. The patients are at risk for falls. In order to best prepare for this talk. the therapist should:

Choices:
1. Survey the audience a day before the scheduled session.
2. Provide a questionnaire to all participants 2 weeks before the scheduled session.
3. Survey the audience at the scheduled session.
4. Provide a questionnaire to a random sampling of participants 1 week before the scheduled presentation.

Teaching Points

Correct Answer: 2
A questionnaire to all participants represents the best method of needs assessment in this situation.

Incorrect Choices:
Leaving the survey to the day of or day before the presentation does not allow for adequ ate advanced plan-
ning to meet the group's needs. Using a random sample of participants will not adequately represent the
needs of the whole group.
 Examination B 629

Type of Reasoning: Evaluation

This question requires one to evaluate the merits of the statements presented, and the test taker must de-
termine which course of action best meets the needs of the group . In a situation in which a therapist is
preparing for an in-service, it is ideal to perform a needs assessment of the group as a basis for planning the
manner in which to deliver information to the group. Evaluation questions can be challenging, because they
require one to make a judgment call based on knowledge and experience .

•
Neuromuscular I Interventions

The patient with left hemiplegia would be LEAST likely to respond in therapy if the motor learning strategies
emphasized:

Choices:
1. Maximum use of verbal cues.
2. Encouraging the patient to slow down.
3. Simplification/restructuring of the environment, including removal of all clutter.
4. Maximum use of demonstration and gesture.

Teaching Points
Correct Answer: 4
The patient with left hemiplegia typically demonstrates visuospatial perceptual deficits. Maximum use of
demonstration and gesture would be inappropriate to assist this patient in the relearning of motor tasks.

Incorrect Choices:
The other choices are all valid motor learning strategies that can be used to assist the patient with left hemi-
plegia.

Type of Reasoning: Inference

One must utilize knowledge of deficits related to right eVA (and, therefore, left hemiplegia) in order to
arrive at the correct conclusion. Because of expected visuospatial deficits, it would be least beneficial to maxi-
mize use of demonstration and gestures. The test taker must account for the key information in this ques-
tion (patient with left hemiplegia) in order to infer the least effective intervention approach.

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

A 2-week-old infant born at 27 weeks' gestation with hyaline membrane disease is referred for a physical
therapy consult. Nursing reports that the child "desaturates to 84% with handling" and has minimal secre-
tions at present. The PT should:

Choices:
1. Provide suggestions to nursing for positioning for optimal motor development.
2. Perform manual techniques for secretion clearance, 2-4 hours daily, to maintain airway patency.
3. Put the PT consult on hold, because the child is too ill to tolerate exercise.
4. Delegate to a physical therapy assistant (PTA) a maintenance program of manual techniques for secretion
clearance.
630 Examination B

Teaching Points

Correct Answer: 1
Excessive handling of a premature infant can cause oxygen desaturation. It is in the best interests of the
infant to limit the number of handlers. The PTs role should be to assist nursing in developing positioning
schedules, positions for feeding, infant stimulation activities, etc.

Incorrect Choices:
At present, there is little information provided that would necessitate the PT or PTA to be a direct caregiver to
this child.

Type of Reasoning: Inductive

The test taker must utilize clinical judgment coupled with knowledge of neonatology physical therapy practice
to arrive at the correct conclusion. One uses inductive reasoning skills whenever diagnostic thinking or clinical
judgment is utilized. If this question was answered incorrectly, refer to information on neonatology practice .

•
Musculoskeletal I Evaluation, Diagnosis

A patient sustained a valgus stress to the left knee while skiing. The orthopedist found a positive McMurray's
test and a positive Lachman's stress test. The patient has been referred to physical therapy for conservative
management of this problem. The BEST intervention for the subacute phase of physical therapy is:

Choices:
1. Open-chain strengthening of the quadriceps femoris and hip adductors to inhibit anterior translation of the
tibia on the femur.
2. Closed-chain functional strengthening of the quadriceps femoris and hip abductors to promote regaining
terminal knee extension.
3. Closed-chain functional strengthening of the quadriceps femoris and hamstrings, emphasizing regaining
terminal knee extension.
4. Open-chain exercises of the hip extensors and hamstrings to inhibit anterior translation of the femur on the
tibia.

Teaching Points

Correct Answer: 3
The evaluation is suggestive of an unhappy triad injury. Closed-chain exercises are emphasized during the
subacute phase to enhance functional control of the muscles surrounding the knee. Terminal extension
must be achieved during this stage if normal function is to occur.

Incorrect Choices:
Open-chain exercise does not promote regaining functional control for the muscle surrounding the knee.
Focus on the hip abductors (rather than the hamstrings) will not promote regaining functional control of the
knee joint.

Type of Reasoning: Analysis

The test taker must have knowledge of the patient's exact deficits and appropriate interventions in order to
make the correct decision in this case. This requires knowledge of McMurray's test, Lachman's test, and reha-
bilitation strategies after an unhappy triad injury. In this type of question, the meaning of the information
presented is analyzed to make the appropriate decision.
 •
Examination B 631

M u sc ul os k e leta l I Evaluation , Diagnosis

A patient with pain in the left lateral face and head is found to have limited active and passive mouth opening
range of motion. However, passive lateral deviation is full to both sides. The likely reason for the limitation in
mouth opening range of motion is:

Choices:
1. Capsular restriction of the left temporomandibular joint.
2. Decreased flexibility in the muscles of mastication on the left.
3. An anteriorly displaced disc without reduction in the left temporomandibular joint.
4. An anteriorly displaced disc with reduction in the left temporomandibular joint.

Teaching Points

Correct Answer: 2
Mouth opening requires lengthening of the muscles of mastication as the body of the mandible moves away
from the upper palate. Lateral deviation does not require a significant lengthening in the muscles of mas-
tication, as the primary motion of the mandible is a slight anterior translation of the mandibular condyle
without increasing the distance between the body of the mandible and the upper palate.

Incorrect Choices:
Unilateral capsular and interarticular restrictions of the temporomandibular joint would result in a deflec-
tion of the mandible toward the side of restriction with opening and would limit lateral deviation away
from the side of restriction due to a decreased anterior translation of the mandibular condyle. An anterior
disc displacement with reduction would not limit mouth opening.

Type of Reasoning: Analysis

This question requires an understanding of the basic biomechanics of the temporomandibular joint and the
ability to analyze examination findings in order to arrive at a correct conclusion. The question tests the abil-
ity to relate various examination findings to normal and abnormal anatomy and biomechanics and make
an appropriate clinical diagnosis, which is an analytical reasoning skill. For this case, the symptoms indicate
decreased flexibility in the muscles of mastication on the left. Review temporomandibular joint function
and dysfunction if answered incorrectly.

No nsyste m I S afe ty, P ro fess io na l Re spo ns ibiliti e s, Research

A patient with TBI has a convulsive seizure during a therapy session. The patient has lost consciousness and
presents with tonic-clonic convulsions of all extremities. The therapist's BEST response is to:

Choices:
1. Initiate rescue breathing immediately and call for help to restrain the patient.
2. Position in side-lying, check for an open airway, and immediately call for emergency assistance.
3. Position in supine-lying with head supported with a pillow, and wait out the seizure.
4. Wrap the limbs with a sheet to prevent self-harm, position in supine-lying, and call for emergency assis-
tance.
632 Exam ination B

Teaching Points
Correct Answer: 2
This is an emergency situation. In order to prevent aspiration, turn the head to the side or position in side-
lying. Check to see whether the airway is open, and wait for tonic-clonic activity to subside before initiating
artificial ventilation, if needed.

Incorrect Choices:
Supine positioning can be life-threatening if the tongue falls backward to restrict the airway. Rescue breathing
and restraining the patient are not indicated.

Type of Reasoning: Evaluation

This question requires one to make a value judgment of the most appropriate course of action in a treat-
ment situation. In this case, the symptoms of the patient constitute an emergency, and the therapist should
undertake first-aid actions and call for emergency assistance. If this question was answered incorrectly, refer
to first-aid guidelines for patients with seizure disorders.

Nonsystem I Safety, Professional Responsibilities, Research

A therapist wants to know whether neurodevelopmental treatment (NDT) handling techniques produce an
improvement in independent rolling that lasts longer than 30 minutes. In this study, rolling is the:

Choices:
1. Independent variable.
2. Dependent variable.
3. Intervening variable.
4. Control variable.

Teaching Points

Correct Answer: 2
The dependent variable is the change or difference in behavior (in this example, rolling) that results from the
intervention.

Incorrect Choices:
NDT handling is the independent variable. The terms "intervening" and "control" are not used to correctly
define the study.

Type of Reasoning: Deductive

Information related to research protocols and guidelines are often deductive reasoning- type questions. Here,
the test taker must recall factual knowledge to make the correct decision. If this question was answered incor-
rectly, refer to terminology related to quantitative research, especially for types of variables.
 •
Examination B 633

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

An adult with no significant past medical history presents to the emergency room with complaints of fever,
shaking chills, and a worsening productive cough. The patient has chest pains over the posterior base of the left
thorax, which are made worse on inspiration. What would be an expected physical finding for this patient?

Choices:
1. Crackles over the left thorax.
2. Slowed respiratory rate.
3. Symmetrical breathing.
4. Increased chest excursion.

Teaching Points

Correct Answer: 1
Crackles are a typical finding over the area correlating with an infiltrate.

Incorrect Choices:
With a lower than normal tidal volume, a respiratory rate would have to be elevated, not slowed, to main-
tain an adequate minute ventilation (respiratory rate times tidal volume = minute ventilation) . Because the
patient is having pain, thoracic expansion would likely be limited and asymmetrical.

Type of Reasoning: Inference

In this question, one must draw conclusions from the evidence presented about the patient. In this situa-
tion, the patient's symptoms would NOT indicate the possibility of a slowed respiratory rate or symmetrical
breathing. Therefore, to arrive at the correct conclusion, one must infer or make conclusions based on the
evidence presented.

Neuromuscular I Examination

A patient is referred to physical therapy for functional gait difficulties. The patient is unable to take a normal
step and drags the left foot. Examination reveals muscle weakness with fasciculations in the left lower leg. The
therapist should also examine for:

Choices:
1. Increased tone and hyperreflexia.
2. Decreased tone and hyporeflexia.
3. Muscle spasms and positive Babinski.
4. Dyssynergia and timing deficits.

Teaching Points

Correct Answer: 2
Muscle weakness with fasciculations is symptomatic of a lower motor neuron (LMN) lesion. Other signs and
symptoms of a LMN lesion include hypotonia or flaccidity, hyporeflexia or absent reflexes, and neurogenic
atrophy.

Incorrect Choices:
The other choices are all signs and symptoms of upper motor neuron (UMN) lesions.
634 Examination B

Type of Reasoning: Inductive

This question requires the test taker to determine a best course of action based on signs and symptoms
presented. This necessitates clinical judgment, which is an inductive reasoning skill. In this situation, the
therapist should also examine for decreased tone and hyporeflexia. If answered incorrectly, review informa-
tion on lower motor neuron lesions

•
Metabol ic/Endocrine I Evaluation, Diagnosis

An elderly patient with hyperthyroidism is referred to physical therapy following a period of prolonged
bedrest. During exercise, the therapist recognizes that this patient will demonstrate increased risk for:

Choices:
1. Decreased heart rate and blood pressure.
2. Muscle weakness and joint pain .
3. Arrhythmias and bradycardia.
4. Atrial fibrillation and myocardial infarction.

Teaching Points

Correct Answer: 4
Hyperthyroidism is a hypermetabolic state and is associated with exercise intolerance and impaired car-
diopulmonary function . Symptoms include dyspnea, fatigue, tachycardia, and arrhythmia. In older people
there is increased risk of aggravating preexisting heart disease (e.g., atrial fibrillation, angina, and myocardial
infarction) .

Incorrect Choices:
Heart rate is increased during exercise in hyperthyroidism. Muscle weakness (typically proximal) and fatigue
are present while increased joint pain is not characteristic. Tachycardia, not bradycardia, is seen.

Type of Reasoning: Inference

This question provides a diagnosis and the test taker must determine the likely risk factors for it. This re-
quires inferential reasoning skill, in which one determines what is most likely to be true of a diagnosis. For
this case, the risk factors include atrial fibrillation and myocardial infarction. Review risk factors for hyperthy-
roidism if answered incorrectly.

Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient strained the lower back muscles 3 weeks ago, and now complains of pain (6/ 1O). Upon examination,
the therapist identifies bilateral muscle spasm from TlO-L4. The therapist elects to apply interferential current
to help reduce pain and spasm . The BEST electrode configuration to choose in this case would be:

Choices:
1. Two electrodes, with current flow parallel to the spinal column.
2. Two electrodes, with current flow perpendicular to the spinal column.
3. Four electrodes, with current flow diagonal to the spinal column.
4 . Four electrodes, with current flow perpendicular to the spinal column.
 Examination B 635

Teaching Points

Correct Answer: 3
The crisscrossed electrode configuration allows: (1) a greater area to be treated and (2) current interference to
occur between the frequencies of the two circuits because of the diagonal pattern.

Incorrect Choices:
A crisscrossed electrode configuration is needed to create interferential current. None of the other electrode
configurations facilitates the flow of current diagonal to the spinal column, which would cause the frequen-
cies to intersect.

Type of Reasoning: Deductive

This question requires recall of factual information related to the protocol for electrode placement
when using interferential current. The test taker must refer to this knowledge to understand that four
electrodes with current flowing diagonal to the spinal column are best for treating the patient's
symptoms.

Neuromuscular I Examination

An infant is independent in sitting, including all protective extension reactions and can pull-to-stand through
kneeling, cruise sideways, and stand alone. The infant still demonstrates plantar grasp in standing. This in-
fant's chronological age is approximately:

Choices:
1. 5 months.
2.6 months.
3. 8- 9 months.
4. 10-15 months.

Teaching Points

Correct Answer: 3
The 8- to 9-month-old will be able to pull-to-stand, stand alone, and cruise sideways, but because he/she is
not yet walking, may still exhibit plantar grasp in the standing position.

Incorrect Choices:
At 5 months, the infant can roll prone to supine and demonstrates head control in supported sitting. At 6
months, the infant can sit independently and pull-to-stand. At 10-15 months, the infant typically begins to
walk unassisted.

Type of Reasoning: Deductive

In this question, one must recall the developmental milestones of an infant in order to arrive at the correct
conclusion. This type of recall is factual and based on guidelines, which is a deductive reasoning skill. If this
question was answered incorrectly, refer to the developmental milestones and reflexes of infants.
 •
Examination B

Musculoskeletal I Interventions

A retired bus driver has experienced increasing frequency of low back pain over the past 10 years. The patient
states that nonsteroidal anti-inflammatory drugs (NSAlDs) help to relieve the symptoms, but there is always a
nagging-type pain. The patient reports significant stiffness in the morning that dissipates by noon after exercis-
ing and walking. Pain is exacerbated with frequent lifting and bending activities, as well as sitting for long
periods. Physical therapy intervention should emphasize:

Choices:
1. Modalities to reduce pain, joint mobilization, and lumbar extension exercises.
2. Toint mobilization, soft tissue mobilization, and flexion exercises.
3. Postural reeducation, soft tissue mobilization, and dynamic stabilization.
4. Modalities to reduce pain, postural reeducation, and dynamic stabilization exercises.

Teaching Points

Correct Answer: 3
This is a long-term degenerative and postural dysfunction that is manageable with medication and proper
physical activity. Therefore, the most effective use of treatment time should emphasize regaining normal
postural alignment and functional ADLs.

Incorrect Choices:
Whereas modalities and mobilization can relieve acute pain, this is a chronic problem that demands
choices appropriate for long-term management of the problem.

Type of Reasoning: Inference

One must consider all of the patient's symptoms and determine what the likely cause( s) of the symptoms is
(are) in order to make an appropriate decision for intervention. This requires the use of inferential reason-
ing, in which decisions are made after drawing conclusions from the evidence presented.

Musculoskeletal I Evaluation, Diagnosis

A patient presents to physical therapy with a primary complaint of low back pain and right lower extremity
radicular symptoms extending distally to the calf of 2 weeks' duration. Current pain intensity is rated as 2/ 10
with rest and 5/ 10 during lumbar extension movements. What is the strongest prognostic indicator that would
affect the clinical outcome?

Choices:
1. 2/ 10 pain intensity with rest.
2. 5/ 10 pain intensity during lumbar extension.
3. Lower extremity radicular symptoms.
4. Current symptom duration (2 weeks).

Teaching Points

Correct Answer: 3
The presence of lower extremity radicular symptoms in patients experiencing low back pain is a strong nega-
tive prognostic indicator for achieving good clinical outcomes.
 Exa mi nation B 637

Incorrect Choices:
Pain intensity with rest in this case was fairly low (i.e., 2/10) and this pain intensity assessment alone may be
limited because it does not consider pain intensity during activity. An increase in pain intensity with lumbar
extension movements (i.e., 5/ 10) does provide important information relevant to activity; however, it does
not necessarily indicate a poor prognosis alone and is not as strong a negative prognostic indicator when
compared to lower extremity radicular symptoms. Symptom duration of 2 weeks is not considered a chronic
state; therefore, it may not be viewed as a negative prognostic indicator for clinical outcomes.

Type of Reasoning: Evaluation

This question requires one to understand the concept of positive and negative prognostic indicators for good
clinical outcomes. A positive prognostic indicator is one that is associated with achieving a good clinical
outcome. A negative prognostic indicator (which was the focus of this question) is one that is associated
with not achieving a good clinical outcome. In order to answer this question correctly, one must determine
what provided information is associated with NOT achieving a good clinical outcome based on this clinical
scenario.

Syst em Int e ract ion s I Evalua ti o n, Diagnosis

An elderly patient with diabetes and bilateral lower extremity amputation is to be discharged from an acute
care hospital 2 weeks' postsurgery. The incisions on the residual limbs are not healed and continue to drain.
The patient is unable to transfer because the venous graft sites in the upper extremities are painful and not
fully healed. Endurance out-of-bed is limited. The BEST choice of discharge destination for this patient is
a/the:

Choices:
1. Skilled nursing facility.
2 . Home.
3. Custodial care facility.
4. Rehabilitation hospital.

Teaching Points

Correct Answer: 1
A skilled nursing facility is the best facility, because the patient continues to require nursing care for the
open wounds. Initiation of physical therapy when this patient is able is also available.

Incorrect Choices:
Discharge to home would be premature, because the patient is unable to transfer. Custodial care involves
medical or nonmedical care that does not seek a cure. A rehabilitation hospital is not appropriate at this
time, because the patient cannot actively participate in rehabilitation 3 hours/ day.

Type of Reasoning: Inductive

One must utilize clinical judgment in this situation to make an appropriate determination for the best dis-
charge situation for this patient. The key is that the patient's current medical status requires continued nurs-
ing care, which can be managed at a skilled nursing facility. In addition, the patient can continue to receive
rehabilitation at a duration that is most appropriate for the patient's current tolerance for functional activity.
Questions that require clinical judgment often utilize inductive reasoning skill.
 Examination

•
638 B

Neuromuscular I Examination

A patient currently being seen for low back pain awoke one morning with drooping left facial muscles and ex-
cessive drooling. The patient was recovering from a cold and had experienced an earache in the left ear during
the previous 2 days. The therapist suspects Bell's palsy, which can be confirmed by examining:

Choices:
1. Trigger points for pain, especially over the temporomandibular joint (TMJ) .
2. Taste over the anterior tongue, and having the patient raise the eyebrows and puff the cheeks.
3. Taste over the posterior tongue, and having the patient protrude the tongue.
4. Corneal reflex and stretch reflexes of facial muscles.

Teaching Points

Correct Answer: 2
Bell's palsy is a lower motor neuron lesion affecting the branches of the facial nerve, CN VII. Examination
of the motor function of the muscles of facial expression (i.e., raise eyebrows, show teeth, smile, close eyes
tightly, puff cheeks) and taste over the anterior tongue will reveal deficits of CN VII function.

Incorrect Choices:
Taste over the posterior tongue is a function of CN IX (glossopharyngeal). Strength of tongue protrusion is a
function of CN XII (hypoglossal) . Pupillary reflexes are a function of CN II (optic).

Type of Reasoning: Inference

In this question, the suspected diagnosis and symptoms are provided, but the test taker must determine how
to best confirm this diagnosis through testing of the cranial nerves. This question requires inferential critical
reasoning, which uses clinical decision-making based on facts and evidence. If this question was answered
incorrectly, refer to information on Bell's palsy.

Neuromuscular I Examination

A PTA is assigned to ambulate a patient with a lO-year history of Parkinson's disease (PD) . The PT instructs the
PTA to watch for:

Choices:
1. Decreased trunk rotation with shorter steps.
2. Wider steps and increased double support time.
3. Unsteady, uneven gait with veering to one side.
4. An abnormally wide base of support.

Teaching Points

Correct Answer: 1
Gait changes characteristic of PD include loss of arm swing and reciprocal trunk movements, shuffling gait,
and festinating gait (an abnormal and involuntary increase in the speed of walking).

Incorrect Choices:
Patients with PD take shorter steps (not longer). Veering to one side only is indicative of a unilateral
peripheral vestibular deficiency (the patient veers to the side with the dysfunction). An abnormally wide base
of support is indicative of gait unsteadiness, but is not typical in the patient with PD.
 Examination B 639

Type of Reasoning: Deductive

This question essentially requires one to recall the typical gait pattern of patients with PD. This type of recall
is factual and based on guidelines, thus utilizing deductive reasoning skills. If this question was answered
incorrectly, refer to information of gait patterns in PD .

•
C ard io v asc ula r/Pu lm o n a ry a n d Lym p h atic I Ev a lu ati o n , D iagn o sis

A patient with congestive heart failure (CHF) is on a regimen of diuretics (chlorothiazide). The potential ad-
verse side effects of this medication that the PT should be alert for include:

Choices:
1. Orthostatic hypotension and dizziness.
2. Reflex tachycardia and unstable BP.
3. Myalgia and joint pains.
4. Hyperkalemia and premature ventricular contractions (PVCs) .

Teaching Points

Correct Answer: 1
Thiazide diuretics are used to manage mild to moderate hypertension. Adverse side effects include orthos-
tatic hypotension and dizziness, along with drowsiness, lethargy, and weakness. These represent a safety risk
during functional training and gait.

Incorrect Choices:
BP is lowered and is more stable, not less. Hypokalemia (not hyperkalemia) can occur, resulting in
increased PVCs. Muscle cramps and weakness can occur. Joint pains are likely caused by a comorbid
condition.

Type of Reasoning: Inference

The test taker utilizes factual knowledge of side effects of medications, coupled with knowledge of CHF to
make the correct decision in this case, using inferential reasoning skills.

Musculoskeleta l I Evaluat ion, D iagnosis

A patient with a traumatic injury to the right hand had a flexor tendon repair to the fingers. Physical therapy
intervention after this type of repair would begin:

Choices:
l. After the splint is removed in 2-3 weeks, to allow full AROM of all affected joints.
2. After the splint is removed in 4- 6 weeks, to allow ample healing time for the repaired tendon.
3. Within a few days after surgery, to preserve tendon gliding.
4. Within a few days after surgery, to allow for early initiation of strengthening exercises.
640 Examination B

Teaching Points

Correct Answer: 3
Early passive and active assistive exercises promote collagen remodeling to allow free tendon gliding.

Incorrect Choices:
When rehabilitation is delayed by several weeks, adhesions form, which restrict free tendon gliding. Early
initiation of strengthening exercises is contraindicated.

Type of Reasoning: Inductive

This question requires one to use clinical judgment to make a determination of the best intervention for a
patient who has had a recent flexor tendon repair of the hand. One utilizes knowledge of hand therapy and
early tendon repair protocols to arrive at the correct conclusion. If this question was answered incorrectly,
review flexor tendon repair information and therapy protocols .

•
Musculoskeletal I Examination, Diagnosis

A female patient complains of intermittent pain in the right sacroiliac region. There was an insidious onset
approximately 4 months ago. Pain has gradually worsened and is now fairly constant and does not vary much
with activity or movement. Active motion assessment of the lumbar spine reveals no change in symptoms
with movement. Sacroiliac provocation tests are negative. The patient is mildly tender over the right sacroiliac
region. The MOST likely diagnosis for the above patient would be:

Choices:
1. Sacroiliac joint sprain.
2. Multifidus muscle strain.
3. Right L5/S1 facet joint arthrosis.
4. Ovarian cyst.

Teaching Points

Correct Answer: 4
An ovarian cyst can refer pain to the sacroiliac region and is more likely to cause constant pain that does not
vary much with activity. Symptoms are not likely to be reproduced with a musculoskeletal examination.

Incorrect Choices:
A sacroiliac joint strain, L5/S 1 facet arthrosis, and multifidus muscle strain should cause reproduction of the
patient's symptoms with active movements. The symptoms should be activity related. They will therefore
vary in intensity depending on the particular activity in which the patient engages. In addition, a sacroiliac
sprain would likely be symptomatic with SI provocation tests.

Type of Reasoning: Analysis

This question provides a group of symptoms and the test taker must determine the most likely cause for
them. This is an analytical reasoning skill. For this situation, the symptoms are consistent with an ovarian
cyst. Review signs and symptoms of an ovarian cyst if answered incorrectly.
 Exa min ation B

•
641

Neuromuscular I Examinat ion

The therapist suspects that a patient recovering from a middle cerebral artery stroke is exhibiting a pure hemi-
anopsia. This can be examined using a:

Choices:
1. Distance acuity chart placed on a well-lighted wall at patient's eye level 20 feet away.
2. Penlight held approximately 12 inches from the eyes and moved to the extremes of gaze right and left.
3. Penlight held G inches from the eyes and moved inward toward the face.
4. Visual confrontation test with a moving finger.

Teaching Points

Correct Answer: 4
Visual field is examined using the confrontation test. The patient sits opposite the therapist and is instructed
to maintain his/her gaze on the therapist's nose. The therapist slowly brings a target (moving finger or pen)
in the patient's field of view alternately from the right or left sides. The patient indicates when and where he/
she first sees the target.

Incorrect Choices:
Distance acuity vision is tested using a Snellen eye chart at a distance of 20 feet. Ocular pursuit is tested
using a penlight moved in an H pattern to the extremes of gaze. Convergence is tested using a penlight and
ruler; the patient keeps the penlight in focus as it moves inward from a distance of 4 or G inches.

Type of Reasoning: Inference

This question basically asks the test taker to recall the appropriate examination approach for hemianopsia.
Questions such as these do require recall of factual knowledge (knowledge of the different tests), but then
that knowledge must be applied to the specific patient presented in the question, which moves beyond fac-
tual recall to drawing a conclusion, which is an inferential reasoning skill .

•
Musculoskeletal I Evaluation, Diagnosis

An overweight adult patient complains of right anterior hip and knee pain while walking, especially when
weight bearing on the right. Lumbar AROM is normal and pain free. Right hip AROM and PROM are limited
compared to the left. Right knee AROM and PROM are full and pain free. There is no pain with resisted testing
at the right hip or right knee. The scouring test reproduces the patient's hip and knee symptoms. Hip joint
distraction relieves these symptoms. Based on the above findings, the MOST LIKELY diagnosis would be:

Choices:
1. Piriformis strain.
2. Hip degenerative joint disease.
3. Patellofemoral syndrome.
4. Trochanteric bursitis.
642 Examination B

Teaching Points

Correct Answer: 2
Scouring test or compression at the hip joint reproduces the patient's symptoms, suggesting a joint problem
at the hip . The scouring test can also result in referred pain to the knee. Weight bearing that compressed the
hip joint also reproduces the patient's symptoms. Distraction of the hip joint surfaces relieves symptoms,
suggesting hip DJD. The anterior knee region is a common pain referral site for the hip joint. In addition, the
overweight condition supports the diagnosis of hip DJD due to excessive compressive forces over an extend-
ed period of time.

Incorrect Choices:
There is no pain with resisted testing, which rules out a contractile problem. Knee AROM, PROM, and re-
sisted testing are negative, ruling out patellofemoral syndrome. Pain from trochanteric bursitis is specifically
localized to the greater trochanter on the lateral aspect of the hip.

Type of Reasoning: Analysis

For this question, a group of symptoms is presented and the test taker must analyze each in order to de-
termine the most likely diagnosis. Questions of this type often require analytical reasoning skill, in which
pieces of information are weighed to draw reaso nable conclusions. For this case, the symptoms most likely
indicate the presence of hip degenerative joint disease (DID) . If answered incorrectly, review hip DJD signs
and symptoms.

Nonsystem I Safety, Professional Responsibilities, Research

A therapist investigated the accuracy of pulse oximeter estimates during exercise. Correlational analysis meas-
ured the strength of the relationship between two types of ear probe-equipped pulse oximeters during heavy
cycle exercise under hypoxic conditions. The investigator found measured arterial oxyhemoglobin saturation
(%Hb0 2 ) levels to have a correlation of 0.89 at high saturation, but only 0.68 at low saturation levels. The
results of this study suggest:

Choices:
1. Both devices are highly accurate at all saturation levels.
2. Accuracy of the measurements increases at higher saturation levels.
3. During heavy exercise, oxygen saturation levels should be interpreted cautiously.
4. Both devices are only moderately accurate.

Teaching Points

Correct Answer: 2
The result of the study indicates that the correlation between the two types of oximeters was high when oxy-
gen saturation levels were high (0.89), but only moderate (0.68) at low oxygen saturation levels.

Incorrect Choices:
Accuracy was not the same at all saturation levels, and the high correlation during high saturation suggests
that the devices are accurate during heavy exercise.

Type of Reasoning: Deductive

This type of question requires knowledge of guidelines in correlational research and parameters for high
versus moderate correlation. This type of knowledge is factual recalL using deductive reasoning skills. If this
question was answered incorrectly, refer to correlational research guidelines.
 •
Examination B 643

Musculoskeletal I Examinat ion

A college soccer player sustained a hyperextension knee injury when kicking the ball. The patient was taken to
the emergency room of a local hospital and was diagnosed with "knee sprain." The player was sent to physi-
cal therapy the next day for rehabilitation. As part of the examination to determine the type of treatment plan
to implement, the therapist conducted the test shown in the figure. Based on the test picture, the therapist is
examining the integrity of the:

Choices:
1. Anterior cruciate ligament.
2. Posterior cruciate ligament.
3. Medial meniscus.
4. Iliotibial band.

Teachin g Points

Correct Answer: 1
The test shown in the figure is Lachman's stress test to determine the integrity of the anterior cruciate ligament.

Incorrect Choices:
The posterior cruciate is examined using the posterior drawer and the reverse Lachman's stress test. The
medial meniscus is examined using McMurray's and Apley tests. The iliotibial band is tested using the Noble
compression test.

Type of Reasoning: Inference

The question requires the test taker to recall the visual information depicted as a test of integrity of the ante-
rior cruciate ligament. This is factual recall of visual information, but also requires one to sort out other tests
that may appear similar in order to arrive at the correct conclusion. This skill is therefore inferential, requir-
ing one to draw conclusions based on visual information.

Musculoskeletal I Evaluation, Diagnosis

A patient is seen in physical therapy 2 days after a motor vehicle accident. The chief complaints are headaches,
dizziness, neck pain with guarding, and a "sensation of a lump in the throat." Plain film x-rays were read as
negative. The therapist should refer this patient for a:

Ch oices:
1. Second series of plain fi lm x-rays.
2. Myelogram.
3. T2 magnetic resonance imaging (MRI) .
4. Computed tomography (0') scan.
644 Examination B

Teaching Points

Correct Answer: 4
The primary concern of the therapist is to rule out strong suspicions of an upper cervical spine fracture. cr
scan is still preferred for assessing cortical bone, especially spinal fractures.

Incorrect Choices:
Plain films, already taken, did not show any fracture, which is not uncommon. A second series would not be
expected to reveal any new information. The T2 MRl and myelogram are not as specific for assessing bony
anatomy as the cr scan.

Type of Reasoning: Inductive

One must consider the symptoms of the patient and a possible cause to arrive at the conclusion that a cr
would be the most appropriate next step in determining the cause for the symptoms. Inductive reasoning
skills are utilized when one must use knowledge of symptoms plus diagnostic skills to make an appropriate
decision. If this question was answered incorrectly, refer to information on indications for cr scans.

Neuromuscular I Examination

During a test of upper extremity rapid alternating movement (RAM), the movements of the hands and elbows
become irregular with wider excursions than expected. As speed is increased, the movements become more
disorganized. These findings are indicative of

Choices:
l. Upper motor neuron weakness.
2. Lower motor neuron weakness.
3. Brainstem dysfunction.
4. Cerebellar dysfunction.

Teaching Points

Correct Answer: 4
Cerebellar dysfunction is characterized by classic cerebellar movement disturbances of dyssynergia (in this
case), dysmetria, and dysdiadochokinesia. Movement decomposition is velocity dependent, with greater
disturbances in movement control at higher speeds.

Incorrect Choices:
UMN lesions can produce weakness and dyssynergia accompanied by spasticity. Spasticity is velocity depend-
ent, with slowing of movements at faster speeds. LMN lesions produce weakness or paralysis, with hypotonia
or flaccidity. Brainstem dysfunction produces a variety of deficits, with mixed sensory/motor symptoms. All
of these findings are not reported in this case.

Type of Reasoning: Analysis

For this question, the test taker must analyze the symptoms presented and determine the likely cause for
such symptoms. Questions of this nature require analytical reasoning skill. For this scenario, the symptoms
indicate cerebellar dysfunction. Review symptoms of cerebellar dysfunction if answered incorrectly.
 Exam ination B 645

Musculoskeletal I Interventions

A patient presents with a persistently downwardly rotated and adducted scapula during humeral elevation.
This is BEST treated with stretching of the:

Choices:
1. Pectoralis major and strengthening of the rhomboid muscles.
2 . Pectoralis minor and strengthening of the trapezius muscles.
3. Serratus anterior and strengthening of both the levator scapula and lower fibers of the trapezius muscles.
4. Rhomboid muscles and strengthening of the serratus anterior muscle.

Teaching Points

Correct Answer: 4
The rhomboids are scapular downward rotators, scapular adductors, and scapular elevators. Insufficient
length of the rh omboids would limit upward scapular rotation and stretching to restore proper length of
these muscles would help to promote upward scapular rotation.

Incorrect Choices:
The serratus anterior muscle acts as an upward scapular rotator and scapular abductor. Weakness of the
serratus anterior would impair active scapular upward rotation and strengthening exercises would p romote
upward scapular rotation.

Type of Reasoning: Inductive

This question requires the test taker to determine a best course of action to improve a deficit. Questions of
this nature require clinical judgment, which is an indu ctive reasoning skill. For this case, the deficit is best
treated with stretching of the rhomboid muscles and strengthening of the serratus anterior muscle. If an-
swered incorrectly, review muscle actions of the shoulder girdle, especially scapular movers and stabilizers.

Neuromuscular I Evaluation, Diagnosis

A patient is recovering from stroke and, at 4 months, is ambulating with a straight cane for household distanc-
es. During outpatient physical therapy, the therapist has the patient practice walking with no assistive device.
Recurvatum is observed that worsens with continued walking. The therapist's BEST strategy is to:

Choices:
1. Practice isolated small-range quadriceps eccentric control work in standing, and continue with the straight
cane.
2. Give the patient a small-based quad cane (SBQC) to improve stability, and have him/her practice AROM in
supine.
3. Put the patient on a Cybex and work on increasing quadriceps torque output at higher loads and increasing
speeds.
4. Give the patient a KAFO to control the hyperextension and a hemi walker.
646 Examination B

Teaching Points

Correct Answer: 1
Eccentric quadriceps control work (closed-chain exercises) is indicated in order to reduce recurvatum. The
patient should continue with the straight cane until ab le to walk without the device and recurvatum.

Incorrect Choices:
Open-chain exercises (Cybex, AROM) do not adequately address the functional demands of gait. The use of
SBQC or hemi walker will not correct the problem. A KAFO is inappropriate to stabilize the knee, which can
be effectively stabilized using either an AFO or a Swedish knee cage. The use of an orthosis should be consid-
ered only as a last resort.

Type of Reasoning: Inductive

One must use clinical judgment and knowledge of recurvatum in ambulation to arrive at the correct conclu-
sion. Inductive reasoning questions require use of knowledge combined with clinical judgment to determine
the best course of action in clinical situations. In this situation, the test taker must recognize that the recurva-
tum indicates eccentric quadriceps control work.

•
Neuromuscular I Evaluation, Diagnosis

A patient recovering from an incomplete spinal cord injury at the L3 level (ASIA scale D) ambulates with bilat-
eral Lofstrand crutches. The patient reports great difficulty going down ramps with unsteady, wobbly knees. An
appropriate intervention for this problem would be:

Choices:
1. Prolonged icing to reduce hamstring pain.
2. Biofeedback training to reduce knee extensor spasticity.
3. Progressive resistance training for the quadriceps.
4. Stretching using a posterior resting splint for tight plantar flexors .

Teaching Points

Correct Answer: 3
A spinal cord injury at the level of L3 affects knee extensors. ASIA scale D means the injury is incomplete,
with at least half of the key muscles below the neurological level having a muscle grade of 3 or more. A weak
knee will wobble or buckle going down stairs or ramps. It is the result of weak quadriceps or knee flexor con-
tracture. Strengthening exercises using progressive resistance training for the quadriceps are
indicated.

Incorrect Choices:
Biofeedback training may reduce knee extensor spasticity, but this may only increase knee instability, and is
not indicated in this case. There is no indication that hamstring pain or tight plantar flexors are present or
precipitating causes of the patient's problem.

Type of Reasoning: Inference

In this question, the test taker must understand what impairments result from L3 spinal injury and what
clinical interventions can be implemented to improve the patient's deficits. In this situation, the patient's
deficits indicate weak knee extensors, which can be strengthened through a progressive resistive exercise pro-
gram. If this question was answered incorrectly, refer to information on lumbar level spinal cord injury.
 Examination B 647

Nonsystem I Safety, Professional Responsibilities, Research

Under HIPPA rules, it is illegal to release protected health information (PHI) without a competent patient's
consent to:

Choices:
l. The insurance company that is paying for the patient's treatment.
2. The patient's spouse.
3. Another health care provider involved in the care of the patient.
4. Report suspected abuse.

Teaching Points

Correct Answer: 2
A spouse does not have the legal right to the patient's information without the patient's consent.

Incorrect Choices:
Those individuals involved in the care of the patient, a legal guardian with power of attorney in situations
in which the patient is judged mentally incompetent, or the patient's payer have a legal right to information
regarding a patient's care without obtaining the patient's consent for releasing information. The therapist
has a positive legal obligation to report suspected abuse whether or not consent is granted.

Type of Reasoning: Evaluation

In this question, one must determine the strength of the statements presented as well as which statement
adheres to legal guidelines related to HIPPA. Evaluation questions often require test takers to make value
judgments and recall certain guidelines in order to make those judgments .

•
Musculoskeletal I Interventions

With respect to a worker's sitting posture, the greatest reduction in lumbar spine compression forces would be
achieved by:

Choices:
l. Using a 2-inch gel seat cushion.
2. Increasing the chair backrest-seat angle to between 90 and llOo.
3. Eliminating armrests on the chair.
4. Decreasing the chair backrest-seat angle to 85 °.

Teaching Points

Correct Answer: 2
Maximal reduction of lumbar disc pressures can be achieved by increasing the angle between the seat pan
and the chair backrest to between 90 and llO°, using armrests for support, or adding a lumbar support.
Combining the effects of all three provides the best solution.
648 Examination B

Incorrect Choices:
A gel seat cushion reduces pressures on the ischial seat. Eliminating armrests or decreasing the chair back-
rest-seat angle would only worsen the problem.

Type of Reasoning: Inference

This question requires one to make a clinical determination of the best course of action. Inferential ques-
tions require one to make sense of information presented and to draw conclusions from it. Therefore, one
must draw conclusions about the sitting posture in order to determine which solution would most effec-
tively reduce compression forces in the lumbar spine .

•
Musculoskeletal I Evaluation, Diagnosis

A baseball pitcher is referred to physical therapy with progressive posterior shoulder pain and weakness of
the shoulder abductors and lateral rotators. The therapist notices muscle wasting superior and inferior to the
scapular spine. The patient's problem is MOST LIKELY attributable to damage involving the:

Choices:
1. Spinal accessory nerve.
2. Long head of the biceps brachii.
3. Scalene muscles.
4. Suprascapular nerve.

Teaching Points
Correct Answer: 4
Microtrauma to the suprascapular nerve can occur with repetitive activities involving shoulder "cocking" and
follow-through resulting in inflammation and muscle weakness of the muscles supplied by the suprascapular
nerve (the supraspinatus and infraspinatus muscles).

Incorrect Choices:
Damage to the spinal accessory nerve will promote weakness and atrophy of the upper trapezius muscle.
Damage to the long head of the biceps brachii or scalene muscles will not present with posterior shoulder
pain, weakness with shoulder abduction/external rotation, and/or atrophy of the supraspinatus and infraspi-
natus muscles.

Type of Reasoning: Analysis

This question requires one to rely on knowledge of shoulder neuroanatomy in order to choose the correct
solution. This type of recall is factual in nature, with basic analysis or interpretation of the information pre-
sented. In this case, the patient's weakness of the shoulder abductors and lateral rotators is indicative of dam-
age to the suprascapular nerve. If this question was answered incorrectly, refer to shoulder neuroanatomy
and functional anatomy.
 Examination B 649

Cardiovascular/Pulmonary and Lymphatic I Examination

A patient with severe COPD, GOLD stage 4, shows which of the following physical examination findings?

Choices:
1. Pectus excavatum with an increased thoracic excursion.
2. Pectus carinatum with decreased thoracic excursion.
3. Kyphosis with an increased thoracic excursion.
4. Barreled chest with a decreased thoracic excursion.

Teaching Points

Correct Answer: 4
A patient with severe COPD (GOLD 4) will have lost much of the elastic recoil properties of the lung. The
usual elastic properties of the lung tissue help to pull the thorax into the normal chest wall configuration of
health. Without these elastic recoil properties the patient's thorax will "barrel" in appearance, meaning it is
larger and rounder than what you would normally expect. As the thorax has moved into an inspiratory posi-
tion at rest, there is less movement available, so a decreased thoracic excursion would be expected.

Incorrect Choices:
Pectus excavatum (funnel chest) is not an acquired chest wall deformity that results in decreased thoracic ex-
cursion . Pectus carinatum (pigeon breast) is not an acquired chest wall deformity that results in a decreased
thoracic excursion. While the barreling of the chest of COPD often has a kyphosis associated with it, the
second hallmark to the chest wall deformity of COPD is a decrease in excursion.

Type of Reasoning: Deductive

This question provides a diagnosis and the test taker must recall the likely presentation of that diagnosis.
This is a deductive reasoning skill, as one must recollect the signs and symptoms of COPD in order to arrive
at a correct conclusion. For this case, one should expect a barreled chest with a decreased thoracic excursion.
Review signs and symptoms of COPD if answered incorrectly.

•
Neuromuscular I Evaluation, Diagnosis

A patient is recovering from surgical resection of an acoustic neuroma and presents with symptoms of dizzi-
ness, vertigo, horizontal nystagmus, and postural instability. To address these problems, physical therapy plan
of care should incorporate:

Choices:
1. Prolonged bedrest to allow vestibular recovery to occur.
2 . Strengthening exercises focusing on spinal extensors.
3. Repetition of movements and positions that provoke dizziness and vertigo.
4. Hallpike's exercises to improve speed in movement transitions.
650 Examination B

Teaching Points

Correct Answer: 3
In patients with unilateral vestibular pathology, habituation training (use of positions and movements that
evoke symptoms) will encourage the vestibular system to recalibrate. Good recovery can generally be expect-
ed with gradual progression of exercises.

Incorrect Choices:
Prolonged bedrest will delay recovery and may result in incomplete recovery. Strengthening exercises for
spinal extensors are not indicated in the case information. Hallpike-Dix maneuver is used for assessment and
diagnosis of benign paroxysmal positional vertigo and is not a set of exercises.

Type of Reasoning: Inference

One must have knowledge of acoustic neuroma and expected symptomatology in order to choose the correct
intervention approach. Inferential reasoning often requires the test taker to draw conclusions
based on the evidence presented. Questions that ask what to expect from a diagnosis or a set of symptoms
often require use of inferential reasoning. If this question was answered incorrectly, review intervention
approaches for vestibular pathology.

Cardiovasc u lar/Pulmonary and Lymphatic I Evaluation , Diagnosis

A physical therapist is treating a patient with diabetic peripheral neuropathy. The patient recently began taking
Lyrica (pregabalin) . During a monofilament exam of the feet the therapist notices circumferential marks bilat-
erally at the level of the malleoli after the socks are removed. The patient is complaining of increased difficulty
ambulating long distances. In this situation, it is MOST important to:

Choices:
1. Begin manual lymphatic drainage for secondalY lymphedema.
2. Complete the examination and instruct in proper skin care precautions.
3. Contact the physician about possible development of congestive heart failure.
4. Educate the patient about the risks of foot ulceration.

Teaching Points

Correct Answer: 3
It is important to recognize serious side effects of commonly used medications and to institute contact with
the physician as appropriate.
Lyrica is used to help treat diabetic neuropathy. Serious side effects include heart failure, greater
difficulty walking long-distances, and lymphedema (marks from the sock).

Incorrect Choices:
Although patient education and manual lymphatic drainage can be important parts of treatment, they are
not as important as recognizing the potential for heart failure.

Type of Reasoning: Inductive

This question requires clinical judgment in order to determine a best course of action for a patient with
diabetic neuropathy. This necessitates inductive reasoning skill. For this case, the symptoms should alert the
therapist to contact the physician about possible development of congestive heart failure. If answered incor-
rectly, review diabetic neuropathy guidelines and common medications for diabetes.
 Exa mination B 651

Musculoskeletal I Examination

A patient presents to the clinic with pain and decreased function of the right shoulder. A full tear of the right
rotator cuff musculature is suspected. The special test that would provide the most valid and reliable informa-
tion confirming this suspicion would be the:

Choices:
1. Neer's impingement test.
2. Empty-can test.
3. Yergason's test.
4. Clunk test.

Teaching Points

Correct Answer: 2
The primary intent of the empty-can test is to assess if the rotator cuff is intact. If the rotator cuff is fully torn, the
empty-can test will be positive, meaning that the arm will fall from a fully elevated position if it is unsupported.

Incorrect Choices:
Yergason's test assesses if the transverse ligament is intact. Neer's impingement test assesses for impingement of
the rotator cuff, so once the tendon is torn this will no longer be positive. The clunk test is described as a test to
assess for a glenoid labrum tear. None of these tests would be positive with a full tear of the rotator cuff.

Type of Reasoning: Deductive

This question requires the test taker to recall provocative testing guidelines for rotator cuff tears in order to
arrive at a correct conclusion. This necessitates recall of facts, which is a deductive reasoning skill. For this
case, the empty-can test should be performed to confirm the tear. Review provocative testing of the shoulder,
especially rotator cuff injuries, if answered incorrectly.

•
Cardiovascular/Pulmonary and Lymphatic I Interventions

A patient who is 5 weeks' post-myocardial infarction (MI) is participating in a cardiac rehabilitation program.
The therapist is monitoring responses to increasing exercise intensity. The indicator that exercise should be
immediately terminated is:

Choices:
1. Systolic BP > 140 mm Hg or diastolic BP > 80 mm Hg.
2. Peak exercise HR > 140.
3. 1.5 mm of downsloping ST segment depression.
4. Appearance of a PVC on the electrocardiogram (ECG) .

Teaching Points

Correct Answer: 3
The upper limit for exercise intensity prescribed for patients post-MI is based on signs and symptoms. Of
the choices, only ST segment depression (> 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 without a
cardiac history.
652 Examination B

Type of Reasoning: Inference

When questions provide a diagnosis and the test taker must 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, the BEST intervention the PT could teach the mother is:

Choices:
1. Stroking and tapping.
2. Fast vestibular stimulation.
3. Neutral warmth.
4. Visual stimulation with a colored object.

Teaching Points

Correct Answer: 3
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 other than neutral warmth.

Type of Reasoning: Inductive

One utilizes clinical judgment, with combined knowledge of inhibitory 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 calming or inhibitory, especially if colic is demonstrated. If
this question was answered incorrectly, refer to appropriate stimuli for newborns.

Neuromuscular I Examination

A therapist is treating a patient with Brown-Sequard syndrome that resulted from a gunshot wound. The thera-
pist's examination should reveal:

Choices:
1. Loss of motor function and pain and temperature sensation, with preservation of light touch and position
sense below the level of the lesion.
2. Loss of upper extremity function (cervical tract involvement), with preservation of lower extremity function
(lumbosacral tract involvement).
3. Sparing of tracts to sacral segments, with preservation of perianal sensation and active toe flexion .
4. Ipsilateral weakness and loss of position sense and vibration below the lesion level, with contralateral loss
of pain and temperature sensation.
 Examination B 653

Teaching Points

Correct Answer: 4
Brown-Sequard syndrome is a hemisection of the spinal cord characterized by ipsilateral weakness and loss
of position and vibration sensation below the level of the lesion; there is also contralateral loss of pain and
temperature sensation a few segments below the level of the lesion.

Incorrect Choices:
Other choices describe anterior cord syndrome (choice 1), central cord syndrome (choice 2), or sacral spar-
ing (choice 3) .

Type of Reasoning: Analysis

This question requires factual recall of neuroanatomy in order to arrive at the correct conclusion. One 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 spinal cord injuries and syndromes .

•
Neuromuscular I Interventions

A patient 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. The BEST choice for teaching this task is to:
Choices:
1. Practice the task first with the caregiver, then with the patient.
2. Demonstrate the task and then practice with the patient.
3. Practice the task first with the patient, then with the caregiver.
4. Demonstrate the task then have the caregiver practice with the patient.

Teaching Points

Correct Answer: 2
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.
654 Exa mination 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. Slump test.
2. Stork standing test.
3 . McKenzie's side glide 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, which 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,
especially the lumbar quadrant test.

Nonsystem I Equipment, Devices, Therapeutic Modalities

When using a patellar tendon-bearing (PTB) prosthesis, a patient will experience excessive knee flexion in
early stance if the:

Choices:
1. Socket is aligned too far forward or tilted anteriorly.
2. Socket is aligned too far back or tilted posteriorly.
3. Foot position is outset too much.
4. Foot position is inset too much.

Teaching Points

Correct Answer: 1
In a PTB 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 655

Incorrect Choices:
A socket aligned too posterior results in insufficient knee flexion . 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 flexion in early stance is indicative of the socket
aligned too far forward or anteriorly tilted . If this question was answered incorrectly, refer to information on
PTB prosthetic alignment.

"
Integumentary I Evaluation, Diagnosis

Bluish discoloration of the skin and nailbeds of fingers and toes along with palms that are cold and moist is
indicative of:

Choices:
1. Liver disease.
2 . Carotenemia.
3. Cyanosis.
4. Hypothyroidism.

Teaching Points
Correct Answer: 3
Bluish discoloration of the skin and nail beds of fingers and toes, along with palms that are cold and moist
are 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 heart disease, abnormal hemoglobin) or peripheral
(decreased blood flow, venous obstruction).

Incorrect Choices:
Liver disease produces jaundice (diffusely yellow skin and sclerae) . 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.
656 Exa mination B

Musculoskeletal I Evaluation, Diagnosis

An outpatient physical therapist is examining a patient who underwent a total knee arthroplasty 2 weeks ago.
The patient reports 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 to the physician's office after the therapy session for further assessment.
4. Go immediately to the emergency department.

Teaching Points

Correct Answer: 4
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-
sary risk for developing a pulmonary 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
department. 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. An appropriate special test to confirm the
diagnosis is:

Choices:
l. Phalen's test.
2. Finkelstein's test.
3. Froment's sign.
4. Craig's test.
 Examination B 657

Teaching Points

Correct Answer: 2
Finkelstein's test is specific for reproducing the pain associated with de Quervain's tenosynovitis of the ab-
ductor pollicis longus and extensor pollicis brevis.

Incorrect 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 knowledge of provocative tests for de Quervain's tenosynovitis. In this
case, the appropriate test is Finkelstein's test, which reproduces the pain of the abductor pollicics longus and
extensor pollicis brevis tendons associated with de Quervain's. If this question was answered incorrectly, refer
to provocative testing of the hand or wrist and de Quervain's tenosynovitis.

Cardiovascular/Pulmonary and Lymphatic I Examination

As part of the chart review, the physical therapist views the patient's most current chest film.

Based on this film, what is the MOST likely examination finding?

Choices:
1. Decreased inspiration:expiration (I:E) ratio.
2. Decreased mediate percussion.
3. Increased lateral costal expansion.
4. Increased subcostal angle.

Teaching Points

Correct Answer: 4
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 the resonance
of mediate percussion, so it can be assumed that this finding would be normal. Lateral costal expansion
would be decreased in this patient due to the hyperinflated lungs.

Type of Reasoning: Analysis

This question requires the test taker to determine the MOST likely examination finding based on the x-ray.
Questions that require analysis of pictures and graphs often necessitate analytical reasoning skill. If this
question was answered incorrectly, review signs and symptoms of hyperinflated lungs.
658 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 session, it is crucial to examine:

Choices:
1. Spinal musculoskeletal changes secondary to degenerative joint disease (DJD).
2. Cardiovascular endurance during a 6-minute walking test.
3. Sensory losses and sensory organization of balance.
4. Level of dyspnea during functional transfers.

Teaching Points

Correct Answer: 3
A critical component of balance control is sensory input from somatosensory, 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 modified CTSIB (Shumway-Cook, Horak) are appropriate instruments.

Incorrect Choices:
Cardiovascular endurance and level of dyspnea during functional transfers are appropriate elements to ex-
amine, but should occur after key elements of balance are examined (sensory 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 knowledge 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 "crucial." 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 the therapist should
consider stretching exercises to:

Choices:
1. Middle trapezius and rhomboid muscles.
2. Longus capitis and longus colli muscles.
3. Rectus capitis posterior minor and rectus capitis posterior major muscles.
4. Rectus capitis anterior muscles.
 Examination B 659

Teaching Points

Correct Answer: 3
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 shortening 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 associ-
ated with forward scapular posturing and therefore further stretching of scapular adductors (middle trape-
zius 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.

Cardiovascular/Pulmonary and Lymphatic I Examination

The 6-minute walk test is a helpful outcome measure as it has:

Choices:
1. The ability to determine the severity of lung disease.
2. The ability to determine peak oxygen uptake.
3. Good correlation with functiona l abilities, such as ADLs.
4. The ability to document maximal exercise capacity.

Teaching Points

Correct Answer: 3
The 6-minute walk test (6MWT) shows a good correlation with function, as the 6MWT is a submax test and
function is performed at a submax work level.

Incorrect Choices:
The 6MWT does not correlate to lung disease severity.
The 6MWT has only about a 73% correlation with V0 2max ' The lO-Meter Shuttle Walk Test would be a better
test to use if correlation with V0 2 is desired
As the 6MWT doesn't correlate with V0 2max' it cannot document maximal exercise capacity.

Type of Reasoning: Deductive

This question requires the test taker to recall the benefits of the 6MWT. This necessitates the recall of factual
information, which is a deductive reasoning skill. For this situation, the 6MWT is a helpful measure, as it is
correlated with functional abilities. Review benefits of the 6MWT if answered incorrectly.
 Examination

•
660 B

Musculoskeletal I Examination

During a postural screen for a patient complaining of low back pain, the therapist notices that the knees are in
genu recurvatum. Possible contributory postures include:

Choices:
1. Ankle plantarflexion and anterior pelvic tilt.
2. Ankle dorsiflexion and hip abduction.
3. Forefoot varus and posterior pelvic tilt.
4. Lateral tibial torsion and anterior pelvic tilt.

Teaching Points

Correct Answer: 1
A common contributory problem or correlated motion for 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 varus may lead to tibial internal rotation, but
not genu recurvatum. Tibial external rotation will lead to abnormal stresses at the knee joint, but not genu
recurvatum.

Type of Reasoning: Inference

The test taker must understand the nature of genu recurvatum and contributory postures in order to choose
the correct answer. This requires recall of lower extremity 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 incorrectly, refer to information on postural screen-
ing, kinetic chain, and genu recurvatum.

Musculoskeletal 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. This is MOST likely due to:

Choices:
l. Degenerative joint disease (DJD) of the hip.
2. Sacroiliac (SI) dysfunction.
3. L4 nerve root compression.
4. L5 nerve root compression.
 Examination B 661

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.

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 reasoning skill, using knowledge of neuroanatomy to
determine that the most likely cause is L4 nerve 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. The patient is also hypertensive and requires careful monitoring. The therapist's BEST
approach is to take BP:

Choices:
1. Pre- and postactivities, using the nons hunt arm.
2. In sitting when activity has ceased, using the shunt arm.
3. In the supine position, using the shunt arm.
4. Every minute during walking, using the nonshunt arm.

Teaching Points

Correct Answer: 1
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 atrioventricular 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.
662 Examination B

"
Integumentary 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. The therapist suspects:

Choices:
1. Herpes simplex infection.
2. Psoriasis.
3. Herpes zoster infection.
4. Dermatitis.

Teaching Points
Correct Answer: 3
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 nerve).

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 I Examination

While providing sports coverage at a local high school, a physical therapist is asked to examine an athlete with
a knee injury. Based on the mechanism of injury, the therapist suspects rupture of the ACL. What test should
be performed immediately to identify a torn ACL?

Choices:
1. Posterior sag test.
2. McMurray's test.
3. Lachman's stress test.
4. Reverse Lachman's stress test.
 Examination B 663

Teaching Points

Correct Answer: 3
Lachman's stress test is the primary clinical test utilized to identify if the anterior cruciate ligament is intact
or ruptured.

Incorrect Choices:
McMurray's test is utilized to identify the integrity for the meniscus. The reverse Lachman's stress and poste-
rior sag tests are both tests utilized to test the integrity of the posterior cruciate ligament.

Type of Reasoning: Deductive

For this question, the test taker must recall the testing guidelines to confirm the presence of an ACL tear.
This requires factual recall of guidelines, which is a deductive reasoning skill. For this situation, Lachman's
stress test is best to use. Review testing guidelines for knee injuries, especially Lachman's stress test if
answered incorrectly.

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

After a myocardial infarction (MI) , a patient is a new admission to a phase 3 hospital-based cardiac rehabilita-
tion program. During the initial exercise session, the patient's ECC responses are continuously monitored via
radio telemetry. The therapist notices three PVCs occurring in a run with no P wave. The therapist should:

Choices:
1. Continue the exercise session, but monitor closely.
2. Stop the exercise and notify the physician immediately.
3. Have the patient sit down and rest for a few minutes before resuming exercise.
4. Modify the exercise prescription by decreasing the intensity.

Teaching Points

Correct Answer: 2
A run of three or more PVCs occurring sequentially is ventricular tachycardia. The rate is very rapid, result-
ing in seriously compromised cardiac output. This is potentially an emergency situation that can deteriorate
rapidly into ventricular fibrillation (no cardiac output) 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 whether
or not the PVCs and absence of P wave are significant enough to warrant physician notification. This type of
reasoning is inductive, and the test taker is called to make a decision for the safety of the patient. In this 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 ECCs.
664 Examination B

Neuromuscular I Evaluation, Diagnosis

A patient 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. The BEST explanation for his problem is:
Choices:
1. Ideational apraxia.
2. Anosognosia.
3. Somatognosia.
4. Visual agnosia.

Teaching Points

Correct Answer: 4
All of the choices are indicative of perceptual dysfunction. 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:
Ideational 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 information on
the various perceptual problems after CVA .

•
Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

A home care PI 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-
tory of fall injury except for minor bruising. The patient is currently taking a number of medications. The drug
MOST likely to contribute to dizziness and increased fall risk is:

Choices:
1. Colace.
2. Coumadin sodium.
3. Nitroglycerin.
4. Albuterol.
 Examination B 665

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 anticlotting medication. Adverse effects can include increased risk of
hemorrhage, which 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 and determines that nitroglycerin is most likely to cause increased risk of falls,
because this is one of the common side effects.

Musculoskeletal I Interventions

A patient complains of foot pain when first arising that 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 the distal aspect of the calcaneus. Early management would include:

Choices:
1. Modalities to reduce pain.
2. Use of a resting splint at night.
3. Strengthening of ankle dorsiflexors.
4. Prescription for a customized orthosis.

Teaching Points

Correct Answer: 2
The symptoms are suggestive of plantar fasciitis. The focus of patient management should be on decreasing
the irritation to the plantar fascia. This is most effectively done with a resting night splint.

Incorrect Choices:
Modalities to reduce pain offer some symptomatic relief; however, the pain is not constant. Strengthening
the dorsiflexors will not change irritation to the plantar fascia. A customized orthosis may be necessary at a
later time if primary symptoms do not resolve after early management.

Type of Reasoning: Inductive

This question requires one to recognize the patient's symptoms as plantar fasciitis and then recall the
common treatment strategies for this condition. This requires one to utilize clinical judgment, which is an
inductive reasoning skill. If this question was answered incorrectly, refer to guidelines of treatment of plantar
fasciitis.
666 Examination B

Neuromuscular I Interventions

A patient with a no paraplegia (ASIA A) resulting from a spinal cord injury is ready to begin community
wheelchair training. The therapist's goal is to teach the patient how to do a wheelie in order to manage curbs.
The BEST training strategy is to instruct the patient to:

Choices:
1. Throw the head and trunk backward to rise up on the large wheels.
2. Place a hand on the top of the handrims to steady the chair, while throwing the head and trunk forward .
3. Lean backward while moving the hands slowly backward on the rims.
4. Grasp the handrims posteriorly, and pull them forward abruptly and forcefully.

Teaching Points

Correct Answer: 4
A wheelie can be assumed by having the patient place his/ her hands posterior on the handrims and pulling
them abruptly and sharply forward. If the patient is unable to lift the casters in this manner, throwing the
head back forcefully when pulling the handrims may work. An alternate technique is to grasp the handrims
anteriorly, pull backward, then abruptly and forcefully reverse the direction of pull. The therapist can assist
by steadying the chair at the patient's balance point until the patient learns to adjust the position through
the use of handrim movements forward and backward.

Incorrect Choices:
Throwing the head and trunk backward alone or with moving the hands backward on the handrims will not
result in a wheelie.

Type of Reasoning: Evaluation

This question requires one to evaluate the merits of each of the four possible solutions and to determine
which solution seems most reasonable, which is an evaluative reasoning skill. One must recall knowledge of
the strategies and techniques involved in performing a wheelie in order to arrive at the correct conclusion. If
this question was answered incorrectly, refer to information on community wheelchair training, especially
wheelie techniques.

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

A PT should be alert to recognize the signs and symptoms associated with the onset of aspiration pneumonia.
Of the following, the patient MOST susceptible to develop this form of pneumonia is one with:

Choices:
l. Amyotrophic lateral sclerosis (ALS) with dysphagia and diminished gag reflex.
2. A complete spinal cord lesion at T2, with diminished coughing ability and forced vital capacity (FVC) .
3. A circumferential burn of the thorax associated with significant pain.
4. Severe scoliosis with compression of internal organs, including the lungs.
 Examination B 667

Teaching Points

Correct Answer: 1
Aspiration pneumonia results from an abnormal entry of fluids or matter (including food) into the airways.
A patient with ALS with an inability to swallow (dysphagia) and diminished gag reflex is most susceptible to
aspiration pneumonia.

Incorrect Choices:
Others listed may be susceptible to other forms of pneumonia or even, though less likely, aspiration pneu-
monia.

Type of Reasoning: Evaluation

In this question, the test taker must evaluate the four patient circumstances presented and determine which
patient is most at risk for aspiration pneumonia. This requires one to determine the value of the informa-
tion presented in each patient circumstance, which requires skills in evaluation. To arrive at the correct
conclusion, one must understand each diagnosis and risks associated with those diagnoses, which should be
reviewed if this question was answered incorrectly.

Musculoskeletal I Interventions

A patient demonstrates quadriceps weakness (4/5) and difficulty descending stairs. The BEST intervention to
regain functional strength in the quadriceps is:

Choices:
1. Isokinetic exercise, at 36°/sec.
2. Progressive resistance exercises, 70% 1 repetition maximum, three sets of 10.
3. Partial squats, progressing to lunges.
4. Maximum isometric exercise, at 45 and 90° of knee extension.

Teaching Points

Correct Answer: 3
Closed-chain exercises are the most appropriate in this example because of the patient's difficulty descend-
ing stairs. Moving the body over a fixed distal segment provides loading to muscles, joints, and noncontrac-
tile soft tissues while stimulating the sensory receptors needed for stability and balance.

Incorrect Choices:
Open-chain exercise (all other choices), while improving strength, does not adequately prepare an individu-
al for functional weight bearing.

Type of Reasoning: Analysis

One must analyze the four choices presented in order to determine which activity is best to regain func-
tional quadriceps strength. In this situation, a closed-chain activity is optimal because it is aligned most
closely with the patient's functional challenge, which is descending stairs. This requires analytical reasoning
skill to determine the precise meaning of the information presented in the four choices. If this question was
answered incorrectly, review information on indications for closed-chain exercises.
 •
668 Examination 8

Neuromuscular I Evaluation, Diagnosis

Independent community ambulation as the primary means of functional mobility is a realistic functional
expectation for a patient with the highest level of complete spinal cord injury (ASIA A) at:
Choices:
1. Midthoracic (T6-9).
2. High lumbar (Tl2-Ll).
3. Low lumbar (L4-S).
4. Low thoracic (T9 -10).

Teaching Points

Correct Answer: 3
Patients with low lumbar lesions (L4-S) can be independent and functional with bilateral AFOs and canes.

Incorrect Choices:
Patients with complete higher lesions (all other choices) can learn to ambulate with KAFOs and crutches, but
exhibit a high rate of orthotic rejection in favor of primary wheelchair mobility. Rejection is due to the high
levels of energy expenditure during ambulation.

Type of Reasoning: Inference

One must infer the abilities and limitations of each of the spinal injury levels presented in order to make an
appropriate determination for the patient who can most realistically perform community ambulation as a
primary means of mobility. This requires one to use knowledge of neuroanatomy and spinal innervation lev-
els to determine how the intact musculature can realistically allow for community ambulation. If answered
incorrectly, refer to spinal innervation levels and intact musculature for ambulation.

Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient presents with multiple fractures of both hands and wrists as a result of a mountain bike accident.
Now, S weeks later, the patient has vertigo, limited wrist and finger motion, and dry, scaly skin over the in-
volved areas. The physical agent of GREATEST BENEFIT to select in this case would be:

Choices:
1. Paraffin.
2. Hot packs.
3. Functional electrical stimulation.
4. Contact ultrasound (US).

Teaching Points
Correct Answer: 1
Paraffin bath will provide circumferential heating of the hands and fingers and aid in softening the skin.

Incorrect Choices:
Active exercise, including functional electrical stimulation, would be more effective after the application of
paraffin because tissue extensibility and pliability would be increased. Hot packs or US using direct contact
would not completely cover the area to be treated.
 Examination B 669

Type of Reasoning: Inductive

This question requires one to use his/ her clinical judgment to make the best determination for a modality to
remedy the symptoms of the patient, which is an inductive reasoning skill. In this circumstance, paraffin is
ideal for circumferential heating and skin softening. If this question was answered incorrectly, refer to indica-
tions for paraffin treatment.

•
Nonsystem I Equipment, Devices, Therapeutic Modalities

An elderly patient demonstrates a history of recent falls (two in the past 2 months) and mild balance instabil-
ity. The therapist's referral is to examine the patient and recommend an assistive device as needed. Based on
the patient's history, it would be BEST to select a:

Choices:
1. Folding reciprocal walker.
2. Front wheel rolling walker that folds.
3. Standard, fixed-frame walker.
4. Hemi walker.

Teaching Points
Correct Answer: 2
A rolling walker will provide added stability, while maintaining gait as a continuous movement sequence.
The additional benefit of a folding walker facilitates easy transport and mobility in the community.

Incorrect Choices:
A standard fixed-frame walker requires the patient to lift the walker and increases the energy expenditure. A
hemi walker decreases the stability offered. A reciprocal walker requires increased motor control to use and
also provides less stability.

Type of Reasoning: Inference

One must determine how each of the assistive devices will best aid stability for a patient with a history of
falls and mild balance instability. Questions that require one to infer information and draw conclusions
from that information encourage inferential reasoning skill.

•
Musculoskeletal I Interventions

After surgery, a patient develops a stiff pelvis and limited pelvic/ lower trunk mobility. The therapist elects to
use sitting exercises on a therapy ball to correct these impairments. In order to improve lower abdominal con-
trol, the ball would have to move:

Choices:
1. Forward, producing posterior tilting of the pelvis.
2. Backward, producing posterior tilting of the pelvis.
3. Forward, producing anterior tilting of the pelvis.
4. Backward, producing anterior tilting of the pelvis.
670 Examination B

Teaching Points

Correct Answer: 1
Contraction of the lower abdominals results in posterior tilting of the pelvis and can be achieved with for-
ward or anterior movement of the therapy ball.

Incorrect Choices:
The other choices incorrectly state the effects of this sitting ball exercise. Backward or posterior motion of the
ball produces anterior tilting of the pelvis.

Type of Reasoning: Analysis

One must link the motion of the therapy ball to the motion achieved at the pelvis in order to make a correct
determination in this scenario. Using analytical reasoning skills, the test taker must determine the meaning
of the information presented, and then link this information to improvement in lower abdominal control.
In this case, forward motion of the ball will promote posterior pelvic tilt and contraction of the lower ab-
dominals. If this question was answered incorrectly, review principles of therapy ball activities.

Neuromuscular I Evaluation, Diagnosis

A patient presents with weakness in the right lower leg 3 weeks after a motor vehicle accident. The patient
complains of spontaneous twitching in the muscles of the lower leg. The therapist visually inspects both limbs
and determines that muscle bulk is reduced on the involved right limb. Girth measurements confirm a I-inch
difference in the circumference of the right leg measured 4 inches below the patella. Deep tendon reflexes and
tone are diminished. Based on these signs and symptoms, the therapist concludes the patient is exhibiting:

Choices:
1. Pyramidal tract dysfunction in the medulla.
2. Guillain-Barre syndrome.
3. Brainstem dysfunction affecting extrapyramidal pathways.
4. Peripheral nerve injury.

Teaching Points

Correct Answer: 4
This patient is exhibiting signs and symptoms of lower motor neuron injury (hypotonia, hyporeflexia, pa-
resis, neurogenic atrophy). The presence of muscle fasciculations is a hallmark sign oflower motor neuron
injury.

Incorrect Choices:
Upper motor neuron lesions (cortical or pyramidal tracts) would result in hypertonicity (hypotonicity ini-
tially during shock), hyperreflexia, generalized paresis, and variable disuse atrophy. Guillain-Barre syndrome
is a lower motor neuron condition that produces symmetrical and ascending signs. Extrapyramidal signs
(involuntary movements) are not evident in this case.

Type of Reasoning: Inductive

This question requires one to use diagnostic thinking and clinical judgment, which is an inductive reasoning
skill. One should recognize that the hypotonia, hyporeflexia, paresis, and muscle fasciculations are indicative
of a lower motor neuron injury and, therefore, a peripheral nerve injury. If this question was answered incor-
rectly, refer to information regarding lower motor neuron injuries and symptomatology.
 Examination B 671

Musculoskeletal I Examination

An elderly adult patient presents with a history of and subjective complaints consistent with lumbar central
spinal stenosis. The most appropriate clinical test used to differentiate spinal stenosis from intermittent
vascular claudication would be:

Choices:
l. Bicycle (van Gelderen's) test.
2. Lumbar quadrant test.
3. Femoral nerve traction test.
4. Valsalva's maneuver.

Teaching Points

Correct Answer: 1
The bicycle (van Gelderen's) test is designed to differentiate between spinal stenosis and intermittent
vascular claudication. Van Gelderen's bicycle test is designed to stress the LE vascular system without
causing any central canal or foraminal stenosis that could be misinterpreted as intermittent neurogenic
claudication.

Incorrect Choices:
The lumbar quadrant test is utilized to identify a lumbar facet dysfunction. The femoral nerve traction test
is utilized to identify if there is an entrapment of the femoral nerve and thus it is not related to either of
these two conditions directly. Valsalva's maneuver is utilized to identify a space-occupying lesion such as a
disc herniation, a tumor, etc. This would not be sensitive in identifying a spinal stenosis.

Type of Reasoning: Deductive

One must recall the testing guidelines of the lumbar spine in order reach a correct conclusion. This
necessitates the recall of factual information, which is a deductive reasoning skill. Through the deductive
process, one should recall that the bicycle (van Gelderen's) test is most appropriate to differentiate spinal
stenosis from intermittent vascular claudication. Review lumbar testing guidelines if answered incorrectly,
especially the bicycle test.

Cardiovascular/Pulmonary and Lymphatic I Interventions

A patient with bacterial pneumonia has crackles and wheezes at the left lateral basal segment and decreased
breath sounds throughout. The patient is on 4 L of oxygen by nasal cannula with a resulting arterial oxygen
saturation (SaOJ of 90%. Respiratory rate is 28. What is the MOST BENEFICIAL intervention for this case?

Choices:
1. Postural drainage, percussion, and shaking to the right basilar segments in order to keep the right lung
healthy.
2. Postural drainage, percussion, and shaking over the appropriate area on the left lateral thorax for secretion
removal.
3. Breathing exercises encouraging expansion of the right lateral basilar thorax, because the left side is not cur-
rently participating in gas exchange.
4. Positioning in left side-lying to improve ventilation/perfusion ratios.
672 Examination B

Teaching Points

Correct Answer: 2
A treatment of postural drainage, percussion, and shaking to the appropriate lung segments is advisable. The
standard postural drainage position for the lateral basilar segment of the left lower lobe is in side-lying posi-
tion with the head of bed tipped in full Trendelenburg position. Given the borderline Sa0 2 values on 4 L of
oxygen, modification of the position may be necessary for patient tolerance.

Incorrect Choices:
There is nothing that will ensure that the right lung stays healthy or makes it more functional. Therefore,
choices 1 and 3 are incorrect answers. Placing the patient in the left side-lying position would increase blood
flow to the left lateral base, an area that is getting little ventilation . This position would worsen ventilation/
perfusion matching.

Type of Reasoning: Inductive

One must utilize clinical judgment to determine which intervention approach is most beneficial, given
the patient's diagnosis and symptoms. This is an inductive reasoning skill, in which clinical judgment and
diagnostic thinking are used to arrive at the correct conclusion. If this topic is not well understood, refer to
indications for modified postural drainage procedures.

System Interactions I Evaluation, Diagnosis

A therapist receives a referral to see an elderly patient in the intensive care unit (leU) recovering from a severe
case of pneumonia. The therapist recognizes that the disorientation is due to delirium rather than dementia
because the:

Choices:
1. Symptoms are intermittent.
2. Patient demonstrates persistent personality changes.
3. Level of arousal is significantly depressed.
4. Patient has hallucinations throughout the day.

Teaching Points

Correct Answer: 1
Acutely ill, hospitalized elderly patients frequently exhibit delirium, a fluctuating attention state. Patients
demonstrate a fluctuating course with symptoms of confusion that alternate with lucid intervals. Sleep/wake
cycles are disrupted and confusion is typically worse at night.

Incorrect Choices:
All other choices are signs of chronic dementia.

Type of Reasoning: Evalu ation

One must evaluate the merits of each of the four statements in order to determine which statement most
likely seems true for the patient's symptoms and diagnosis. In this case, the disorientation is due to delirium,
because the symptoms are intermittent, whereas patients with dementia experience constant, disorientation.
Questions that require one to determine the value and merits of statements presented utilize evaluative rea-
soning skill, which can be challenging because of the need to make a judgment call.
 Exa mination B 673

Nonsystem I Safety, Professional Responsibilities, Research

A comparison of the effects of exercise in water, on land, or combined on the rehabilitation outcome of pa-
tients with intra-articular anterior cruciate ligament reconstructions revealed that less joint effusion was noted
after 8 weeks in the water group. An appropriate statistical test to compare the girth measurements of the
three groups is:

Choices:
1. Spearman's rho .
2. Analysis of covariance.
3 . AN OVA.
4. Chi square.

Teaching Points

Correct Answer: 3
ANOVA is a parametric statistical test used to compare three or more treatment groups (in this example, in
water, on land, or combined exercise groups) on a measure of the dependent variable (joint effusion girth
measurements) at a selected probability level.

Incorrect Choices:
Analysis of covariance compares two or more groups, but also controls for the effects of an intervening vari-
able. Chi square is a nonparametric statistical test used to compare data in the form of frequency counts.
Spearman's rho (rank correlation coefficient) is a nonparametric test used to correlate ordinal data.

Type of Reasoning: Deductive

Questions that require one to recall factual information, especially information related to research protocols,
require deductive reasoning skill. One must utilize knowledge of the indications for each statistical test in
order to arrive at the correct conclusion. If this question was answered incorrectly,
review information on guidelines for the use of AN OVA as well as parametric and nonparametric
statistical tests.

Neuromuscular I Interventions

A patient has a recent history of strokes (two in the past 4 months) and demonstrates good return in the right
lower extremity. The therapist is concentrating on improving balance and independence in gait. Unfortunately,
speech recovery is lagging behind motor recovery. The patient demonstrates a severe fluent aphasia. The BEST
strategy to use during physical therapy is:

Choices:
1. Demonstrate and gesture to get the idea of the task across.
2. Utilize verbal cues, emphasizing consistency and repetition.
3. Consult with the speech pathologist to establish a communication board.
4. Have the family present to help interpret during physical therapy sessions.
674 Examination B

Teaching Points

Correct Answer: 1
Fluent aphasia (Wernicke's aphasia) is a central language disorder in which spontaneous speech is preserved
and flows smoothly while auditory comprehension is impaired. Demonstration and gesture (visual modali-
ties) offer the best means of communicating with this patient.

Incorrect Choices:
Verbal cues are best for patients with nonfluent aphasia (Broca's aphasia) in which understanding of verbal
cues is intact but motor production of speech is not. A communication board is not needed. The fami ly will
also have difficulties communicating with the patient.

Type of Reasoning: Inductive

In this question, the patient requires gait training, but has limitations in communication from Wernicke's
aphasia. The test taker must determine the best way to communicate with a patient who has this deficit,
which is to provide demonstrations and gestures, rather than verbal cues. Questions that elicit clinical judg-
ment to determine a best course of action utilize inductive reasoning skills. If this question was answered
incorrectly, refer to information on communication with patients who have Wernicke's aphasia .

•
Musculoskeletal/Examination

During a gait examination, a patient with a transfemoral prosthesis demonstrates terminal swing impact. Ad-
ditional examination is needed as the therapist suspects the:

Choices:
1. Prosthesis is externally rotated.
2. Hip flexors are weak.
3. Prosthesis has insufficient knee friction.
4. Prosthesis has too little tension in the extension aid.

Teaching Points

Correct Answer: 3
Terminal swing impact refers to the sudden stopping of the prosthesis as the knee extends during late swing.
Possible causes can include insufficient knee friction or too much tension in the extension aid. In addition,
if the patient with an amputation fears the knee will buckle at heel strike, the patient can use forceful hip
flexion to extend the knee.

Incorrect Choices:
Faulty socket contour results in an externally rotated prosthesis. The extension aid has too mu ch tension (not
too little) . Weak hip flexors would result in decreased force to extend the knee.

Type of Reasoning: Inference

One must infer the reason for the terminal swing impact when walking with an above-knee prosthesis, which
is an inferential reasoning skill (requiring one to draw conclusions based on presented evidence) . Using
knowledge of above-knee prostheses and proper tension of the extension aid, one can infer that the tension
on the extension aid is too high. If this question was answered incorrectly, review information on above-knee
prosthesis fit and functions .
 Examination B 675

Integumentary I Interventions

A patient was burned over 40% of the body in an industrial accident, and has full-thickness burns over the
anterior trunk and neck and superficial partial-thickness burns over the shoulders. The procedures of GREAT-
EST BENEFIT to stabilize this patient out of positions of common deformity include:

Choices:
1. Splints utilizing a flexed position for the shoulders and body jacket for the trunk.
2. Plastic cervical orthosis and axillary splints utilizing an airplane position.
3. Soft cervical collar with an intrinsic plus hand splint.
4. A cervical thoracic lumbosacral orthosis CCfLSO) used during all upright activities.

Teaching Points

Correct Answer: 2
The common deformity for the anterior neck is flexion; the appropriate positioning device is a firm rigid
plastic cervical collar that stresses extension. The common deformity of the shoulders is adduction and inter-
nal rotation; the appropriate position device is an axillary or airplane splint that stresses abduction, flexion,
and external rotation.

Incorrect Choices:
Choices that involve hand splints should be ruled out immediately, because there is no mention of burns to
the hands. A CfLSO would prevent neck flexion, but does not deal with the potential shoulder deformities.
The CfLSO could also restrict breathing and enhance the risk of pneumonia.

Type of Reasoning: Inductive

This question requires one to recall common positioning techniques after burns to the anterior trunk and
neck. Using knowledge of the typical deformity and contracture patterns with burns to this area, one can
reason that the solution is to utilize axillary splints and cervical orthosis to bring about abduction, flexion,
and external rotation of the shoulders and cervical extension. Questions that require one to make interpreta-
tions of clinical guidelines and make judgments from this utilize inductive reasoning skills.

Metabolic/Endocrine I Evaluation, Diagnosis

A patient with type 2 diabetes is referred to physical therapy for exercise conditioning. The therapist recog-
nizes that this patient's diabetes is the result of:

Choices:
1. Impaired ability of the tissues to use insulin and insulin deficiency.
2. Pancreatic tumor.
3. Loss of beta-cell function and insulin deficiency.
4. Metabolic syndrome.

Teaching Points

Correct Answer: 1
Type 2 diabetes results from impaired ability of the tissues to use insulin (insulin resistance), accompanied
by a relative lack of insulin or impaired release of insulin.
676 Examination B

Incorrect Choices:
Type 1 diabetes results from loss of pancreatic beta-cell function and an absolute insulin deficiency. Meta-
bolic syndrome is a precursor to type 2 diabetes and is evidenced by abdominal obesity, high triglycerides,
low high-density lipoprotein (HDL), hypertension, and high fasting plasma glucose (> no mg/dL). Pancre-
atic tumor is not a causative factor in type 2 diabetes.

Type of Reasoning: Deductive

One must recall the factual guidelines of type 2 diabetes in order to arrive at a correct conclusion. This re-
quires deductive reasoning skill. For this situation, type 2 diabetes is the result of an impaired ability of the
tissues to use insulin and insulin deficiency. If this question was answered incorrectly, review type 2 diabetes
information, especially causes of the condition .

8100
•
Neuromuscular I Interventions

Which intervention is BEST to improve left-sided neglect in a patient with left hemiplegia?

Choices:
1. Hook-lying, holding, light resistance to both hip abductors.
2. Rolling, supine to side-lying on right, using a PNF lift pattern.
3. Bridging with both arms positioned in extension at the sides.
4. Sitting, with both arms extended, hands resting on support surface, active holding.

Teaching Points

Correct Answer: 2
Incorporating the involved left side into a crossing the midline activity (rolling, using PNF lift) is best.

Incorrect Choices:
All other choices involve symmetrical activity and do little to bring attention to the involved hemiplegic side.

Type of Reasoning: Inference

One must link the deficit of the patient (left-sided neglect) to the best treatment approach in order to
arrive at the correct conclusion. This requires inferential reasoning skill, as one must infer the course of ac-
tion that will have the best clinical outcome. In this circumstance, rolling supine to side-lying on the right
using a PNF lift pattern is best because it incorporates use of the left side and promotes crossing the mid-
line. If this question was answered incorrectly, review treatment strategies for hemiplegia, especially PNF.

•
Cardiovascular/Pulmonary and Lymphatic I Examination

A patient with no significant past medical history who now presents with a bacterial pneumonia in the right
anterior base would present with which of the following exam findings?

Choices:
l. Crackles on inspiration only at right anterior base, decreased Sa0 2 and productive cough x 3 days.
2. Wheezes on inspiration only throughout the right lung fields, decreased Sa0 2 , dry cough x 1 day.
3. Decreased breath sounds throughout all lung fields, increased Sa0 2 , febrile.
4. Bronchial breath sounds at the right anterior base, increased Sa0 2 , febrile.
 Examination B 677

Teaching Points

Correct Answer: 1
Bacterial pneumonia has a gradual onset of days with a productive cough. As pneumonia interferes with
the transport of oxygen from the alveoli to the pulmonary capillaries, the Pa0 2 and therefore the Sa0 2
would be expected to be lower than expected and crackles in the area of the pneumonia is a usual finding.

Incorrect Choices:
Wheezing may occur with a bacterial pneumonia and resound within that thorax, and a decrease in Sa0 2,
making this portion of the answer plausible. But a more abrupt onset with a dry cough is consistent with a
viral infection, not bacterial infection.
An increased Sa0 2 would not be seen, negating this answer as possibilities. Febrile (with fever) cer-
tainly would be plausible, but the overall decreased breath sounds don't fit with a pneumonia in a specific
region of the lung.
An increased Sa0 2 would not be seen, negating these answers as possibilities. Febrile (with fever) cer-
tainly would be plausible, as is a bronchial breath sound in the specific involved region of the lung.

Type of Reasoning: Inference

One must infer or draw a reasonable conclusion about what is likely to be true of a diagnosis in order
to arrive at a correct conclusion. This necessitates inferential reasoning skill. For this case, a patient with
bacterial pneumonia of the right anterior base would have crackles on inspiration at right anterior base,
decreased Sa0 2 , and a productive cough for 3 days. Review signs and symptoms of bacterial pneumonia if
answered incorrectly.

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

A patient with chronic obstructive pulmonary disease (COPD) reports to the fourth outpatient pulmonary
rehabilitation session complaining of nausea, gastric upset, and feeling jittery. The patient reports no change
in pulmonary symptoms. The PT records the fo llowing set of vital signs: temperature 98 .6°P, HR no beats/
min and irregular, BP 150/ 86, respiratory rate 20. Breath sounds show no change from baseline. The therapist
checks the medical record and finds that the patient has no history of gastric disease. The patient is presently
taking theophylline, albuterol sulfate (Ventolin), and triamcinolone diacetate (Amcort). The PT should:

Choices:
1. Send the patient home and notify the physician of current symptoms.
2 . Have the patient increase use of Vento lin to improve respiratory status.
3. Call the patient's physician and report signs of theophylline toxicity.
4 . Have the patient stop use of Amcort until he/she schedules an appointment with the physician.

Teaching Points

Correct Answer: 3
Theophylline is a bronchodilator used to reverse airway obstruction. The combination of symptoms of ir-
regular HR, feeling jittery, and gastric upset is consistent with theophylline toxicity. Because theophylline
toxicity can cause arrhythmias and seizures, the patient's physician should be notified by the PT rather than
wait for the patient to return home to call the physician. It is also likely that a blood test will be needed to
check the theophylline toxicity level and this could be done at the facility.
678 Examination B

Incorrect Choices:
Ventolin is a bronchodilator used in the treatment of asthma or COPD. Amcort is an anti-inflammatory
agent used to manage bronchial asthma. Neither drug produces the same combination of symptoms de-
scribed in the case. The therapist should not recommend increasing or stopping a prescribed medication.
This is usually the physician's responsibility.

Type of Reasoning: Evaluation

This question requires one to make a judgment for the well-being of the patient as well as to make a determi-
nation of the reason for the patient's symptoms. Value judgments require the use of evaluative reasoning skill
in order to determine the best course of action. If this question was answered incorrectly, review information
on theophylline toxicity and adverse reactions/side effects of Vento lin and Amcort.

"
Neuromuscular I Evaluation, Diagnosis

The therapist is treating a I -year-old child with Down syndrome at home, and notices decreasing strength
in the extremities, with neck pain and limited neck motion. Upper extremity deep tendon reflexes (DTRs)
are 3+. The therapist suspects:

Choices:
1. Upper motor neuron signs consistent with Down syndrome.
2. Atlanto-axial subluxation with spinal cord impingement.
3. Lower motor neuron signs consistent with Down syndrome.
4. Atlanto-axial subluxation with lemniscal impingement.

Teaching Points

Correct Answer: 2
Ligamentous laxity is a hallmark of Down syndrome, and can lead to atlanto-axial instability (AAI), with
spinal cord impingement. This is a medical emergency situation. Decreased muscle strength and increased
DTRs are the signs of dislocation from loss of cord function. In this case, the increasing symptomatology
(changes in strength, neck pain, limited neck motion, hyperreflexia) is significant for a developing sub-
luxation. Other UMN signs (clonus, positive Babinski response) may also occur.

Incorrect Choices:
Children with Down syndrome often have low tone, not upper motor neuron or lower motor neuron
signs. Lemniscal impingement would result primarily in sensory changes.

Type of Reasoning: Analysis

In this question, symptoms are provided and the test taker must determine the cause. This type of ques-
tion requires analytical reasoning, in which the test taker must determine the meaning of the symptoms
presented. In this situation, one should determine that the symptoms indicate atlanto-axial subluxation
with spinal cord impingement, a medical emergency, which should be reviewed if this question was an-
swered incorrectly.
 •
Examination B 679

Neuromuscular I Evaluation, Diagnosis

Which of the following factors is likely to contribute to subluxation and shoulder pain in hemiplegia?

Choices:
1. Spastic paralysis of the biceps.
2. PROM with normal scapulohumeral rhythm.
3. Traction acting on a depressed, downwardly rotated scapula.
4. Spastic retraction with elevation of scapula.

Teaching Points

Correct Answer: 3
Shoulder pain and subluxation in hemiplegia may be caused by a number of different factors. One major
cause is traction and gravitational forces acting on a depressed, downwardly rotated scapula.

Incorrect Choices:
An appropriate treatment intervention involves PROM with careful attention to maintaining scapulo-
humeral rhythm. This intervention if performed correctly is NOT likely to cause pain. Spastic biceps is
likely, but is not a contributing factor to subluxation and pain. Spastic retraction of the scapula is likely
but with depression and downward rotation (not elevation) .

Type of Reasoning: Inference

This question requires the test taker to determine which causative factor is unlikely to result in shoul-
der pain in hemiplegia. This requires one to draw conclusions from the information presented and to
make assumptions about that information, which draws upon inferential reasoning skill. One must have
knowledge of the factors that affect subluxation as well as those that do not in order to arrive at the cor-
rect conclusion.

8105
Neuromuscular I Examination

While gait training a patient recovering from a OIA, the therapist observes the knee on the affected side going
into recurvatum during stance phase. The MOST LIKELY cause of this deviation can be attributed to:

Choices:
1. Weakness or severe spasticity of the quadriceps.
2. Weakness of the gastrocnemius-soleus or spasticity of the pretibial muscles.
3. Weakness of both the gastrocnemius-soleus and the pretibial muscles.
4. Severe spasticity of the hamstrings or weakness of the gastrocnemius-soleus.
680 Examination B

Teaching Points

Correct Answer: 1
Severe spasticity of the quadriceps will pull the knee strongly into extension and recurvatum. The patient
with a weak quadriceps muscle will compensate by fixing the knee in full extension (recurvatum) during
stance, rather than maintaining the knee in a small amount of knee flexion at midstance.

Incorrect Choices:
Weakness of the gastrocnemius-soleus would result in lack of push-off at end of stance. Spasticity of the
pretibial muscles or hamstrings is highly unlikely because spasticity typically occurs in antigravity muscles
(extensors, adductors, and plantarflexors). Weakness of the pretibial muscles results in drop foot and swing
phase difficulties.

Type of Reasoning: Inductive

This question requires one to utilize clinical judgment to arrive at the correct conclusion. Questions that
draw upon diagnostic thinking and judgment require inductive reasoning skill. In this case, the test taker
uses this judgment to determine the cause for the patient's recurvatum during stance, which is from weakness
or severe spasticity of the quadriceps .

8106
•
Integumentary I Evaluation, Diagnosis

A patient with hemiplegia and a drop foot is referred for physical therapy gait training. Examination reveals a
pressure ulcer on the patient's right heel (pictured) . The ulcer has dry eschar without edema, erythema, fluctu-
ance, or drainage. The patient is afebrile. The BEST choice for intervention for this patient is:

Choices:
1. Enzymatic debridement.
2. Refer for an arterial bypass graft.
3. Sharp debridement.
4 . Use an AFO with heel pressure relief.

Teaching Points

Correct Answer: 4
The AFO helps to prevent plantarflexion contractures, while the heel pressure relief prevents further damage
to the heel and promotes healing.

Incorrect Choices:
This pressure ulcer, based on the examination findings, is stable and needs to be monitored, not debrided
(choices 1 and 3). Arterial bypass grafts are needed if circulation is compromised. There is no indication that
this is the case.
 Examination B 681

Type of Reasoning: Analysis

In this question, one must determine the best course of action for the patient with a pressure ulcer on the
heel. When one must determine the meaning of visual information presented, such as the picture, analytical
reasoning skills are utilized. If this question was answered incorrectly, review information on the treatment
of pressure ulcers.

Muscu loskeletal I Exam ination

A patient presents with an acute sprain of the right ankle. According to the patient, this has occurred fairly
frequently over the past 5 years. The clinical test that the physical therapist should use to examine the laxity of
the anterior talofibular ligament is

Choices:
1. Anterior drawer test.
2. Talar tilt.
3. Thompson's test.
4. Morton's test.

Teaching Points

Correct Answer: 1
The anterior drawer test is specifically designed to assess the integrity of the anterior talofibular ligament.

Incorrect Choices:
The talar tilt assesses the integrity of the calcaneofibular ligament. Thompson's test assesses the integrity of
the Achilles tendon. Morton's test assesses for the presence of a stress fracture or a neuroma in the forefoot.

Type of Reasoning: Deductive

This question provides a diagnosis and the test taker must recall the testing guidelines to confirm the diag-
nosis. This necessitates factual recall of information, which is a deductive reasoning skill. For this scenario,
the test for laxity of the anterior talofibular ligament is confirmed via the anterior drawer test. Review testing
guidelines for the ankle if answered incorrectly, especially the anterior drawer test.

Musculoskelet al I Evaluat io n , Diagnos is

A patient with left knee degenerative joint disease (DJD) complains of left-sided knee pain of 2 months'
duration. The patient has been followed by outpatient physical therapy for 3 weeks, and feels this condition
is worsening. Pain has increased during weight-bearing activities, and the patient can no longer fully extend
the left knee. Examination findings include increased swelling, decreased knee AROM into extension, and an
antalgic gait. The PT should:

Choices:
1. Immediately return the patient to the referring physician with documentation indicating that treatment was
ineffective.
2. Continue therapy for another week to ensure that all interventions have been attempted, and then return
the patient to the referring physician.
3. Continue physical therapy for another 2 weeks, because there is uncertainty whether the patient under-
stands or is complying with the home exercise program.
4. Tell the patient to see an orthopedic surgeon for possible immediate surgical intervention.
682 Examination B

Teaching Points

Correct Answer: 1
In this case, it would be best to send the patient back to the referring physician with an explanation of
what was done, the ineffectiveness of the treatment, and any suggestions for further follow-up .

Incorrect Choices:
The therapist should not continue to treat a patient if the therapist feels no further benefit would be
derived by continuing care because doing so contradicts the American Physical Therapy Association's
(APTA's) Code of Ethics. Suggesting the patient needs immediate surgery is outside the scope of the PTs
practice.

Type of Reasoning: Evaluation

One must rely on professional conduct principles and apply value judgments to the case situation de-
scribed in order to arrive at the correct decision. This type of question, in which value judgments are
needed to make a decision, necessitates the use of evaluative reasoning skill. In situations in which a
patient demonstrates decline in status despite ongoing treatment, it is best to refer the patient back to the
physician for follow-up and document the findings regarding this situation.

8109
Genitourinary I Interventions

A postpartum patient with stress incontinence is referred for physical therapy. The therapist instructs the pa-
tient in pelvic floor exercises. The BEST choice for initial exercise is:

Choices:
1. Hooklying, bridge and hold for 5 seconds.
2. Supine, squeeze the sphincters and hold for 10 seconds.
3. Supine, squeeze the sphincters and hold for 3 seconds.
4 . Sitting on toilet, stop and hold the flow of urine for 5 seconds during urination.

Teaching Points

Correct Answer: 4
The stop exercise consists of sitting on the toilet and stopping and holding the flow of urine for 5 seconds
before starting the flow again. The exercise is repeated several times in this gravity-assisted position.

Incorrect Choices:
While bridge and hold promotes lower trunk stability, it is not part of pelvic floor (Kegel's) exercises. Practic-
ing sphincter control in supine is more difficult than practicing control during urination while sitting on the
toilet. Both long and short contractions should be practiced but not initially in supine.

Type of Reasoning: Inductive

One must recall the common intervention strategies for stress incontinence in order to arrive at a correct
conclusion. This necessitates inductive reasoning skill, where clinical knowledge and judgment is paramount
to drawing a correct conclusion. For this situation, sitting on toilet, stop and hold the flow of urine for 5
seconds during urination is a best initial approach. Review treatment strategies for stress incontinence if
answered incorrectly.
 •
Exa min ation B 683

Neuromuscula r I Interventions

A patient with stroke demonstrates early recovery in the right upper extremity (RUE) with moderate spasticity
in the biceps and finger flexors. Voluntary movement is evident in elbow flexors and shoulder abductors only
(through 112 range). The BEST choice for initial exercise is:

Choices:
l. Weight bearing on an extended RUE with wrist and fingers extended.
2 Facilitation of early movements in the flexor synergy pattern.
3 Prolonged positioning of the RUE in a hemisling.
4 Functional activities emphasizing ADL using the less-affected UE.

Teaching Points

Correct Answer: 1
Early intervention should focus on stretching and positioning the RUE into extension with the wrist and
fingers extended. This helps decrease the developing flexor spasticity. Weightbearing on the limb promotes
extensor activity in the triceps and shoulder stabilizers.

Incorrect Choices:
Obligatory synergistic patterns are never encouraged. Prolonged positioning is contraindicated because
the patient may stiffen up with excess tone. Activities that utilize only the less-affected side are discouraged
(compensatory training). Prolonged use of a sling can promote contractures.

Type of Reasoning: Inference

Effective intervention guidelines after stroke are based on the stage of recovery and presenting symptoms.
This requires one to make assumptions based on facts, which is an inferential reasoning skill. If this ques-
tion was answered incorrectly, review information on techniques and guidelines of stroke rehabilitation .

•
Nonsystem I Equipment , Devices, Therapeut ic Modalities

A 4-year-old child with moderate spastic diplegia is referred to physical therapy for an adaptive equipment
evaluation. Which device/apparatus would be CONTRAINDICATED?

Choices:
1. Bilateral KAFOs.
2. Prone stander.
3. Tone-reducing AFOs.
4. Posture-control walker (posterior walker) .

Teaching Points

Correct Answer: 1
The knees would not need to be braced using bilateral KAFOs in spastic diplegia because moderate extensor
tone can provide antigravity support.

Incorrect Choices:
Tone-reducing AFOs are indicated to stabilize the foot and prevent plantarflexion. A posterior walker and
prone stander may both enhance function.
684 Examination B

Type of Reasoning: Analysis

The test taker must evaluate all of the adaptive devices listed in this question and then determine which de-
vice is contraindicated given the child's diagnosis. In this situation, bilateral KAFOs are not appropriate. In
order to arrive at the correct conclusion, one must analyze each of the devices for their therapeutic value and
then determine which device provides the least value.

Neuromuscular I Interventions

An ambulatory patient recovering from a left CVA is wearing a plastic AFO to stabilize the right foot. During
gait analysis, the therapist observes lateral trunk bending toward the right as the patient bears weight on the
right leg at midstance. The BEST intervention to correct this problem is:

Choices:
1. Provide a lift on the shoe of the involved leg.
2. Strengthen hip flexors on the right side.
3. Strengthen hamstrings on the right side.
4 . Strengthen the hip abductors on the right side.

Teaching Points

Correct Answer: 4
The lateral trunk bending (Trendelenburg gait) is the result of weak hip abductors on the right (a common prob-
lem for patients recovering from stroke). Strengthening of the abductors on the involved right side is indicated.

Incorrect Choices:
The other choices do not address the problem of lateral trunk bending. Weakness of the hip flexors or
hamstrings would present as swing phase deficits (inability to shorten the leg so it can clear the floor) . The
patient is likely to compensate with circumduction. A lift on the left foot might be considered for patients
with this problem but is not the intervention of choice.

Type of Reasoning: Inductive

This question requires one to utilize clinical judgment to determine the best choice to correct the Trendelen-
burg gait. Questions that encourage diagnostic thinking and clinical judgment utilize inductive reasoning
skill. In this situation, the patient's gait pattern indicates weak hip abductors. If this question was answered
incorrectly, review information on intervention approaches for Trendelenburg gait.

Musculoskeletal I Interventions

A lO-year-old boy, who plays catcher on a baseball team, complains of bilateral knee pain that is exacerbated
with forceful quadriceps contraction. Examination reveals pain and swelling at the distal attachment of the
patellar tendon. The BEST early physical therapy intervention is:

Choices:
1. Modalities to decrease inflammation.
2. Strengthening exercises for the quadriceps femoris to prevent disuse atrophy.
3. Decreased loading of the knee by the quadriceps femoris muscle.
4. Casting followed by decreased loading of the knee.
 Examination B 685

Teaching Points

Correct Answer: 3
Baseball catchers must make forceful contractions of the quadriceps muscles each time they stand up to
throw the ball to the pitcher. This may precipitate Osgood-Schlatter disease in the adolescent or preadoles-
cent boy. Early intervention of this condition focuses on reduction of the loading by the quadriceps, but still
retaining normal lower extremity function .

Incorrect Choices:
Modalities may provide temporary relief of pain; however, it will not improve the underlying condition.
Strengthening will lead to continued excess loading of the structures. Casting may lead to restriction of nor-
mal movement.

Type of Reasoning: Inductive

In this question, the test taker must determine the best intervention approach for a child with bilateral knee
pain related to playing catcher. This requires clinical judgment, which is an inductive reasoning skill. One
must have an understanding of the nature of this activity on the quadriceps muscles, especially the need for
forceful contractions each time the catcher stands up, to arrive at the correct conclusion .

•
Integumentary I Interventions

A patient presents with a decubitus ulcer of 3 months' duration on the lateral ankle. The ankle is swollen,
red, and painful, with a moderate to high amount of wound drainage (exudate) . The BEST dressing for this
wound is:

Choices:
1. Calcium alginate dressings.
2. Gauze dressings.
3. Semipermeable film dressings.
4. Hydrogel dressings.

Teaching Points

Correct Answer: 1
Wounds with moderate to high exudate benefit from calcium alginate dressings. The dressings absorb large
amounts of exudate (up to 20 times their weight) and form a gel, which maintains the moist wound envi-
ronment while maintaining good permeability to oxygen.

Incorrect Choices:
Gauze and semipermeable film dressings require a secondary dressing and offer poor conformability to deep
wounds. Hydrogel dressings are not recommended for wounds with heavy exudate.

Type of Reasoning: Inference

One must infer or draw conclusions based on the information presented in the patient's case, which draws
upon inferential reasoning skill. In this situation, calcium alginate dressings are ideal for wounds with
moderate to high exudate present. If this question was answered incorrectly, refer to information on wound
dressings.
 •
686 Examination B

8115
M usc ul os k e leta l I Examination

A patient was diagnosed with a bulging disc at the right LS-S1 spinal level without nerve root compression.
The impairment MOST LIKELY to be documented is:

Choices:
1. Centralized gnawing pain with loss of postural control during lifting activities.
2. Radicular pain to the right great toe with a compensated gluteus medius gait.
3. Centralized gnawing pain with uncompensated gluteus medius gait.
4. Radicular pain to the right great toe with difficulty sitting for long periods.

Teaching Points

Correct Answer: 1
Discal degeneration without nerve root compression would likely be exhibited as a centralized gnawing pain
with loss of proprioception.

Incorrect Choices:
Because there is no nerve compression, there will not be any type of radicular pain and/or decrease in spe-
cific muscle function (beyond the lumbar spine region), so one should not see a decrease in the function of
the gluteus medius.

Type of Reasoning: Inference

This question provides the diagnosis, and the test taker must determine the most likely symptoms to be pre-
sent. This type of question in which symptoms must be determined from a diagnosis draws upon inferential
reasoning skill. To arrive at the correct answer, the test taker must have a good understanding of the nature of
LS-S1 discal degeneration.

8116
Neuro m usc u la r I Inte rve n tio n s

High-level training for an individual recovering from traumatic brain injury (TBI) who demonstrates Rancho
Cognitive Function Level VII should focus on:

Choices:
1. Providing a high degree of environmental structure to ensure correct performance.
2. Providing assistance as needed using guided movements during training.
3. Involving the patient in decision-making and monitoring for safety.
4. Providing maximum supervision as needed to ensure successful performance and safety.

Teaching Points

Correct Answer: 3
As patients with TBI recover, structure and guidance must be gradually reduced and patient involvement in
decision-making increased. Safety must be maintained while increasing levels of independence are fostered .
Patients at stage VII of recovery often exhibit rote movements (robot syndrome) indicative of the highly
structured training utilized for patients during earlier stages of recovery.

Incorrect Choices:
A high degree of structure, assistance, and maximum supervision is not therapeutic at this stage of recovery.
 Examination B 687

Type of Reasoning: Deductive

Although this question does require one to utilize clinical judgment, the majority of skill required to answer
this question correctly relies upon the recall of the Rancho Cognitive Function Levels and the guidelines for
treatment provided within these levels. This is factual information and recalL which ultimately requires de-
ductive reasoning ability to successfully choose the best type of training for the patient. If this question was
answered incorrectly, refer to the Rancho Cognitive Function Levels.

Neuromuscular I Interventions

To correct for the problem of a forward festinating gait in a patient with Parkinson's disease (PO), the thera-
pist should:

Choices:
1. Increase cadence using a metronome.
2. Increase stride length using floor markers.
3. Use a toe wedge.
4. Use a heel wedge.

Teaching Points

Correct Answer: 3
A festinating gait is an abnormal and involuntary increase in the speed of walking in an attempt to catch up
with a displaced center of gravity due to the patient's forward lean. The most appropriate intervention would
be to use a toe wedge, which would help to displace the patient's center of gravity backward.

Incorrect Choices:
Increasing cadence or stride length would serve only to increase, not decrease, the problem, as will the use of
a heel wedge.

Type of Reasoning: Inductive

One must use clinical judgment to determine which approach would best decrease a forward festinating gait
pattern in PD. The test taker must understand that forward festination results from forward displacement
of center of gravity, which can be improved through the use of a toe wedge to displace the patient's gravity
backward. The judgment in this case, utilizing one's knowledge of festinating gait pattern and the interven-
tion approaches proposed, encourages use of inductive reasoning skill.

Musculoskeletal I Interventions

A patient presents with difficulty with fast movement speeds and fatigues easily. The therapist decides on a
strength training program that specifically focuses on improving fast-twitch fiber function . The optimal exer-
cise prescription to achieve this goal is:

Choices:
1. Low-intensity workloads for short durations.
2. Low-intensity workloads for long durations.
3. High-intensity workloads for long durations.
4. High-intensity workloads for short durations.
688 Examination B

Teaching Points

Correct Answer: 4
High-intensity exercises at fast contraction speeds for shorter durations «20 repetitions) are needed to train
the highly adaptable fast-twitch lIa fibers.

Incorrect Choices:
Performing workloads at low intensity and slow contraction speeds will challenge slow-twitch (type I) fibers .
High-intensity workloads at long durations are contraindicated.

Type of Reasoning: Analysis

This question requires one to refer to knowledge of exercise physiology to recall the optimal method of
improving fast-twitch fiber function . In order to arrive at the correct solution, one must analyze the infor-
mation presented and determine its meaning, which is an analytical reasoning skill. If this question was
answered incorrectly, refer to information on exercise physiology and fast-twitch fiber exercise.

Musculoskeletal I Examination

A cross-country runner presents with a complaint of pain in the proximal one-third of the right tibia with an
insidious onset 4 weeks ago. The pain is present intermittently, and running exacerbates the symptoms. Liga-
mental testing and soft tissue examination of the knee and leg are unremarkable. Which imaging studies are
recommended to be performed INITIALLY in order to help establish a diagnosis?

Choices:
l. Radiograph and Tl MRI .
2. Bone scan and T2 MRI.
3. Radiograph and bone scan.
4. cr scan and T2 MRI.

Teaching Points

Correct Answer: 3
This case represents the typical presentation of a stress fracture. Plain radiographs are an inexpensive and
quick method to diagnose fractures and healing rates. Stress fractures may take 2-8 weeks before they can
be visualized on plain films . If the plain films were negative, then a bone scan is performed (stress fracture,
bone bruising) .

Incorrect Choices:
If a bone scan is negative, then an MRI (meniscal, bone bruising, soft tissue) or cr scan (small, bony irregu-
larities) is ordered. Both MRIs and cr scans are expensive and! or time-consuming. This is most likely a stress
fracture, and is best diagnosed by a radiograph and bone scan.

Type of Reasoning: Inductive

One must determine the most likely imaging studies to be initially recommended based on a patient's
symptoms. This requires clinical judgment and knowledge of the diagnosis, which necessitate inductive
reasoning skill. For this situation, it is likely that a radiograph and bone scan will be recommended, due to
the patient's symptoms of stress fracture. If this question was answered incorrectly, review symptoms of stress
fractures, especially imaging tests for stress fractures.
 Examination B 689

Neuromuscular I Evaluation, Diagnosis

A physical therapy functional goal for a 5-year-old child with a high lumbar lesion (myelomeningocele, L2
level) and minimal cognitive involvement would be:

Choices:
1. Community ambulation with HKAFOs and Lofstrand crutches.
2. Household ambulation with a reciprocating gait Olthosis (RCO) and Lofstrand crutches.
3. Community ambulation with an RCO and Lofstrand crutches.
4. Household ambulation with KAFOs and rollator walker.

Teaching Points

Correct Answer: 2
A child with a high-level myelomeningocele will be able to ambulate for limited (household) distances with
an RCO and Lofstrand crutches. Physiological benefits include improved cardiovascular and musculoskeletal
functions .

Incorrect Choices:
The child will not be able to be a community ambulator because of the high-energy expenditure necessary
with this level of lesion. An RCO is the best choice. The hips are joined by metal cables that prevent inad-
vertent hip flexion (possible using KAFOs) during a reciprocal two- or four-point gait.

Type of Reasoning: Inductive

This question requires the test taker to assess the value of each of the orthoses and assistive devices presented
and then apply their value to the patient's specific diagnosis. This requires one to utilize clinical judgment,
in which the test taker uses diagnostic reasoning to determine which solution will be most beneficial for the
patient. In this case, an RCO and Lofstrand crutches are most beneficial for household ambulation.

Musculoskeletal I Examination

A patient with traumatic onset (motor vehicle accident) of neck pain presents with subjective complaints
of frank upper cervical spine instability. One test that would safely assist in identifying the integrity of the C 1-
C2 articulation would be:

Choices:
1. Vertebral artery test.
2. Maximum cervical compression test.
3. Transverse ligament stress test.
4. Hautant's test.

Teaching Points

Correct Answer: 3
The transverse ligament stress test is specifically designed to assess the integrity of the transverse ligament,
which maintains the position of the dens of C2 with the anterior arch of C 1.
690 Examination B

Incorrect Choices:
The vertebral artery test is utilized to assess the status of the vertebrobasilar arterial system and the maxi-
mum cervical compression test is utilized to identify dysfunction in the cervical facet joints. The motions as-
sociated with these two tests would be contraindicated for a patient who was suspected of having bony/joint
instability. Hautant's test is utilized to differentiate between a vascular dysfunction in the vertebrobasilar
system and a dysfunction of the vestibular system.

Type of Reasoning: Inductive

This question requires the test taker to utilize clinical judgment in order to determine the cervical test that
would be safe for upper cervical spine instability. This necessitates clinical judgment, which is an inductive
reasoning skill. For this situation, the therapist should perform the transverse ligament stress test. Review
cervical testing guidelines, especially the transverse ligament stress test, if answered incorrectly.

Cardiovascular/Pulmonary and Lymphatic I Examination

The therapist is reading a recent report of arterial blood gas analysis with the following values:
Fraction of inspired oxygen (Fi0 2) = 0 .21
Arterial oxygen pressure (Pa0 2 ) = 53 mm Hg
Arterial carbon dioxide pressure (PaC0 2) = 30 mm Hg
pH = 7.48
Bicarbonate ion = 24 mEqjL
This would indicate the patient is in:

Choices:
1. Metabolic alkalosis.
2 . Respiratory alkalosis.
3. Respiratory acidosis.
4. Metabolic acidosis.

Teaching Points

Correct Answer: 2
This arterial blood gas shows an increased pH, which is an alkalosis. When looking at arterial blood gas
values, carbon dioxide can be viewed essentially as an acid. If the carbon dioxide level is low, then you have
less acid, or a resulting alkalosis. This is, therefore, a respiratory alkalosis.

Incorrect Choices:
Because the blood pH is higher than normal (7.35-7.45), the condition is an alkalosis, not an acidosis. If
the increased pH was due to a metabolic disorder, a high bicarbonate value would be anticipated. As the
HC0 3 is normal (24 mEqjdL), the alkalosis is not from a metabolic cause.

Type of Reasoning: Analysis

One must make sense of the information presented in this question and recall the normal laboratory values.
This requires analytical reasoning skill, in which one must make an interpretation of information. It is most
beneficial to understand the values that indicate respiratory alkalosis to arrive at the correct conclusion. If
this question was answered incorrectly, refer to information on arterial blood gas analysis.
 Examination B

•
691

Metabolic/Endocrine I Evaluation, Diagnosis

A retired patient is referred to a cardiac exercise group after a mild MI. From the intake questionnaire, the
therapist learns the patient has type 1 insulin-dependent diabetes mellitus (IDDM) , controlled with twice-
daily insulin injections. In order to minimize the risk of a hypoglycemic event during exercise, the therapist
should have the patient:

Choices:
1. Avoid exercise during periods of peak insulin activity.
2. Have the patient decrease carbohydrate intake for 2 hours before the exercise session.
3. Monitor blood glucose levels carefully every week during the rehabilitation program.
4. Exercise daily for 40-50 minutes to achieve proper glucose control.

Teaching Points

Correct Answer: 1
The patient should monitor blood glucose levels frequently when initiating an exercise program and avoid
exercise during periods of peak insulin activity (2-4 hours after injection) . The therapist should use RPE in
addition to HR to monitor exercise intensity.

Incorrect Choices:
A carbohydrate snack should be eaten before and during prolonged exercise bouts. Blood glucose levels
should be monitored frequently throughout the day, not weekly. Exercise should begin with daily sessions,
20 minutes twice a day, not 40- to 50-minute sessions. (Source: ACSM's Guidelines for Exercise Testing and
Prescription, 8th ed.)

Type of Reasoning: Inference

This question requires one to understand when peak insulin activity occurs in order to choose the best
solution. For patients with IDDM, peak insulin activity occurs between 2 and 4 hours after injection, and
therefore, exercise should be avoided during this time frame. One answers this question using inferential
reasoning skill by drawing conclusions based on the information presented and making inferences about
this information.

Neuromuscular I Evaluation, Diagnosis

An elderly resident of a community nursing home is diagnosed with Alzheimer's type dementia. In formulat-
ing a plan of care, it is important to understand that the patient:

Choices:
1. Can usually be trusted to be responsible for own daily care needs.
2 . Is more likely to remember current experiences than past ones.
3. Can usually be trusted with transfers with appropriate positioning of the wheelchair.
4. Will likely be resistant to activity training if unfamiliar activities are used.
692 Examination B

Teaching Points

Correct Answer: 4
Activity training is most likely to be successful if done with familiar activities.

Incorrect Choices:
A patient with Alzheimer's disease cannot be trusted to safely perform IADLs or functional mobility skills.
Memory for past events may be retained initially, but eventually all memory becomes impaired.

Type of Reasoning: Evaluation

This question requires one to make assumptions about the information presented and then determine the
believability of the statements that are made. In this case, it is important to recall that patients with Alzhei-
mer's disease can be resistant to trying unfamiliar activities and should, therefore, have training with familiar
activities. When one needs to assess the value of statements made to choose the correct solution, evaluative
reasoning skills are utilized .

8125
•
Neuromuscular I Interventions

A patient with a spinal cord injury is having difficulty learning how to transfer from mat to wheelchair. The
patient just cannot seem to get the idea of how to coordinate this movement. In this case, the MOST effective
use of feedb ack during early motor learning is to:

Choices:
1. Provide feedback only after a brief (S-sec) delay.
2. Focus on knowledge of results and visual inputs.
3. Focus on guided movement and proprioceptive inputs.
4. Focus on knowledge of performance and proprioceptive inputs.

Teaching Points

Correct Answer: 2
During the early stage of motor learning (cognitive stage), learners benefit from seeing the whole task cor-
rectly performed. Dependence on visual inputs is high. Developing a reference of correctness (knowledge of
results) is critical to ensure early skill acquisition (cognitive mapping) .

Incorrect Choices:
Focus on proprioceptive inputs is important during the middle (associative) stage of motor learning. Delayed
feedback may be used during later learning.

Type of Reasoning: Inference

One must infer information presented in this question, specifically, which approach is most effective during
early motor learning. Visual inputs are key during early motor learning with a focus on knowledge of results.
To answer this question successfully, one must recall effective teaching principles applied to early learning
situations.
 •
Examination B 693

Musculoskeletal I Interventions

A patient presents with pain and paresthesia over the first two metatarsal heads of her right foot. Pain is
worse after prolonged periods of weight bearing. She typically wears shoes with 3-inch heels and pointed
toes. The BEST intervention is a:

Choices:
1. Pad placed distal to the metatarsal heads.
2. Scaphoid pad to support the medial longitudinal arch.
3. Thomas heel to support the medial longitudinal arch.
4. Pad placed proximal to the metatarsal heads.

Teaching Points

Correct Answer: 4
Compression of the digital nerves in the forefoot results in sensory symptoms of pain and paresthesia
(metatarsalgia). It is typically the result of excessively tight shoes. The best intervention is to wear larger
shoes, with a metatarsal pad placed proximal to the metatarsal heads to elevate the transverse (anterior)
arch and separate the metatarsals. Custom orthotics can also be molded to decrease load. Wearing of
high heels should be discouraged. Stretching of plantarflexors may also be helpful.

Incorrect Choices:
A pad placed distal to the metatarsal heads will not provide effective relief of pressure. A scaphoid pad
and Thomas heel are used to support the longitudinal arch and prevent pes valgus, not metatarsalgia.

Type of Reasoning: Inference

The test taker must understand and infer what the cause is for the patient's symptoms and then under-
stand the indications for each of the courses of action. In this case, the patient's tight high-heeled shoes
are contributing to compression of the digital nerves in the forefoot. Having a thorough understanding of
indications for using metatarsal pads, scaphoid pads, and a Thomas heel is key to arriving at the correct
conclusion.

Musculoskeletal I Evaluation, Diagnosis

A patient developed right throbbing shoulder pain after painting the kitchen. Passive and active glenohumeral
motions increase pain. The BEST INITIAL intervention for this acute shoulder condition is:

Choices:
1. Manual therapy techniques and modalities to reduce pain as the result of subdeltoid bursitis.
2 . Correction of muscle imbalances to allow healing of right shoulder supraspinatus tendinitis.
3. Stretching of the pectoralis minor muscle after acromioclavicular joint inflammation.
4. Rotator cuff strengthening exercises to allow ADL function after biceps tendinitis.
694 Examination B

Teaching Points

Correct Answer: 1
Because pain occurs with both AROM and PROM, bursitis is the most likely cause of dysfunction. Initial
interventions should focus on reducing pain and inflammation. Modalities and manual therapy are the best
choices.

Incorrect Choices:
Supraspinatus and/or bicipital tendonopathy would be most painful with AROM, not both AROM and
PROM. An inflammatory condition of the acromioclavicular joint would not be improved by stretching the
pectoralis minor muscle.

Type of Reasoning: Inductive

The test taker must determine the best initial intervention for the patient, given one's understanding of the
diagnosis and typical intervention approaches. In order to choose the best solution, one must recognize
the symptoms as indicative of subdeltoid bursitis and then recognize that modalities and manual therapy
techniques to reduce pain and inflammation are the best initial approaches. This decision-making process
utilizes inductive reasoning skill, in which clinical judgment is paramount to finding the correct solution.

8128
System Interactions I Evaluation, Diagnosis

A patient has a 5-year history of acquired immunodeficiency syndrome (AIDS). The caseworker reports a
gradual increase in difficulty with walking. The patient rarely goes out anymore. A referral to PT is initiated.
Examination findings reveal typical neuromuscular changes associated with AIDS. These deficits would
likely include:

Choices:
1. Paraplegia or tetraplegia.
2. Widespread sensory loss resulting in sensory ataxia.
3. Motor ataxia and paresis with pronounced gait disturbances.
4. Progressive rigidity and akinesia with severe balance disturbances.

Teaching Points
Correct Answer: 3
Alterations in memory, confusion, and disorientation are characteristic of AIDS dementia complex, a
common central nervous system (CNS) manifestation of human immunodeficiency virus (HIV) infection.
Motor deficits may include ataxia, paresis with gait disturbances, and loss of fine motor coordination.
Patients may also develop peripheral neuropathy with distal pain and sensory loss.

Incorrect Choices:
Paraparesis, not paraplegia, might be a finding . Widespread sensory loss, progressive rigidity, and akinesia
are not typical findings.

Type of Reasoning: Evaluation

One must evaluate these statements and then recall knowledge of the neuromuscular changes associ-
ated with AIDS to arrive at the correct conclusion. This requires determination of the believability of the
statements as true of someone with the diagnosis of AIDS, which is an evaluative reasoning skill. If this
question was answered incorrectly, refer to information regarding neuromuscular changes associated with
AIDS.
 Examination B 695

Nonsystem I Safety, Professional Responsibilities, Research

A patient is referred by an orthopedist with a diagnosis of impingement syndrome of the shoulder. The
initial PT examination reveals signs and symptoms that are not consistent with this diagnosis and are more
consistent with thoracic spine pain and dysfunction. The therapist treats the patient consistent with PT
findings without communicating with the referring physician. Months later, the therapist is sued by the
patient's estate. The patient died of undiagnosed metastatic lung cancer. The therapist is:

Choices:
1. Not responsible for diagnosing metastatic cancer, therefore cannot be held responsible for the patient's
death.
2. Responsible for making the diagnosis of possible cancer consistent with the PT examination of the
patient.
3. Responsible for communicating PT examination results to the referring physician.
4. Not responsible for the incorrect diagnosis because treatment was appropriate for the PT findings .

Teaching Points

Correct Answer: 3
When a referral relationship exists with another health care professional, it is the ITs responsibility to
communicate with the referring practitioner regarding the physical therapy examination, treatment plan,
and management of the referred patient. This is particularly crucial when the findings are inconsistent
with the referrer's diagnosis.

Incorrect Choices:
The therapist cannot diagnose metastatic cancer but can be held responsible for not communicating with
the primary physician.

Type of Reasoning: Evaluation

This question encourages one to review the actions of the therapist, determine the value of those actions,
and then decide whether they were appropriate, which necessitates evaluative reasoning. In this scenario,
the therapist should have communicated the findings to the physician for follow-up, especially when they
are inconsistent with the physician's findings . Questions that require value judgments are challenging
because they move beyond factual knowledge to promote judgment, prudence, and ethical principles .

•
Neuromuscular I Evaluation, Diagnosis

A PT is treating a 2-year-old child with Down syndrome who frequently uses a W sitting position. The main
reason to discourage W sitting in this child is that it may cause:

Choices:
1. Abnormally low tone because of reflex activity.
2. Femoral antetorsion and medial knee stress.
3. Developmental delay of normal sitting.
4. Hip subluxation and lateral knee stress.
696 Examination 8

Teaching Points

Correct Answer: 2
W sitting is a stable and functional position, but may cause later orthopedic problems of femoral antetorsion
and knee stress. Children with Down syndrome typically exhibit low tone and hyperextensibility.

Incorrect Choices:
W sitting is not likely to affect low tone or reflex activity. It should also not promote delay of normal sitting.
Hip subluxation is unlikely.

Type of Reasoning: Inference

One must infer the possible future occurrences from W sitting in order to arrive at the correct answer. First,
one must have knowledge of what W sitting is and then understand the stresses that are placed upon the
lower extremities, specifically the knees, from this sitting position. One infers these stresses, which utilizes
inferential reasoning skill, to choose the correct answer. If this question was answered incorrectly, refer to
information on W sitting and knee stresses .

8131
•
Neuromuscular I Examination

A patient is being examined for impairments after stroke. When tested for two-point discrimination on the
right hand, the patient is unable to tell whether the therapist is touching with one or two points. The therapist
determines that there is impaired function in the:

Choices:
1. Dorsal column/lemniscal pathways and somatosensory cortex.
2. Anterior spinothalamic tract and thalamus.
3. Lateral spinothalamic tract and somatosensory cortex.
4 . Spinotectal tract and somatosensory cortex.

Teaching Points
Correct Answer: 1
Discriminative touch, proprioceptive sensibility, and vibration sense are carried in the posterior white
columns (fasciculus cuneatus for the upper extremity and fasciculus gracilis for the lower extremity). The
long ascending tracts cross the medulla (sensory decussation) and form the medial lemniscus, which then
travels to the thalamus (ventral posterolateral nucleus) and finally to the cortex (postcentral gyrus) . Loss of
two-point discrimination could result from an insult affecting any of these component parts. Parietal lobe or
internal capsule lesions are the most common sites.

Incorrect Choices:
The anterolateral system pathways (spinothalamic tracts) convey pain and temperature. The spinotectal tract
conveys information for spinovisual reflexes.

Type of Reasoning: Analysis

To answer this question, one must refer to knowledge of applied neuroanatomy, specifically spinal pathways
that process discriminative touch of the upper extremity. This requires analysis of the information presented,
utilizing analytical reasoning skill to arrive at the conclusion that the dorsal column/ lemniscal pathways and
somatosensory cortex is impaired. If this question was answered incorrectly, refer to discriminative touch
processing of the upper extremity.
 Exam in ation B 697

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

An elderly patient has a history of two myocardial infarctions (MIs) and one episode of recent congestive
heart failure (CHF). The patient also has claudication pain in the right calf during an exercise tolerance test.
An INITIAL exercise prescription that BEST deals with these problems is walking:

Choices:
1. Five times a week using continuous training for 60 minutes.
2. Three times a week using continuous training for 40-minute sessions.
3. Daily, using interval training for 10- to IS-minute periods.
4. Three times a week using interval training for 30-minute periods.

Teaching Points

Correct Answer: 3
An appropriate initial exercise prescription for a patient with a history of CHF and claudication pain in
the right calf should include low-intensity exercise (walking), low to moderate duration (10 - 15 min),
and higher frequencies (daily) . The exercise session should carefully balance activity with rest (interval or
discontinuous training).

Incorrect Choices:
All other choices include durations that are too long (60, 40, or 30 min) and do not provide adequate
rest periods.

Type of Reasoning: Inductive

One must utilize clinical judgment and diagnostic thinking (an inductive reasoning skill) to choose the
best initial exercise prescription for this patient. This requires knowledge of CHF and claudication pain in
order to arrive at the best solution. In this case, it is best to balance rest with activity because of the nature
of CHF and limited tolerance to exercise .

•
Musculoskeletal I Examination

A patient presents with signs and symptoms consistent with sacroiliac dysfunction. The cluster of special tests/
findings that has the highest diagnostic accuracy for sacroiliac dysfunction would be:

Choices:
1. SI gapping, sacroiliac compression, thigh thrust test (P4), sacral thrust, and Gaenslen's test.
2. Thigh thrust test, Gillet's test, stork test, and Patrick's test.
3. Fortin finger test, torsion test, supine-to-sit test, and Gaenslen's test.
4. Anterior superior iliac spine asymmetry, posterior iliac spine asymmetry, pubic symphysis pain with palpa-
tion, and sacral inferior lateral angle asymmetry.

Teaching Points

Correct Answer: 1
It was found that if these 5 tests were clustered together as a group and at least 3/5 had a positive finding,
they were found to have a high diagnostic accuracy.
698 Examination B

Incorrect Choices:
There have been no outcome studies that support the grouping/clustering for any of these other choices
as diagnostic for sacroiliac dysfunction.

Type of Reasoning: Inference

One must infer or draw a reasonable conclusion about the tests that are likely to have the highest diag-
nostic accuracy. This requires one to determine what is most likely to be true of a situation, which is an
inferential reasoning skill. For this case, SI gapping, sacroiliac compression, thigh thrust test (P4), sacral
thrust, and Gaenslen's test have the highest diagnostic accuracy. If answered incorrectly, review SI testing
guidelines .

8134
•
S ystem Interactions I Eval uati o n, Di a gnosis

A patient demonstrates postpartum sacral pain. The patient complains that pain is increased with pro-
longed walking, ascending or descending stairs, and rising from sit-to-stand. The intervention that is MOST
beneficial for this problem is:

Choices:
1. Cryotherapy and TENS to promote normal healing.
2. Performing mobilization followed by cryotherapy to restore normal motion to the SI joint.
3. Increasing non- weight bearing with ambulation training and stabilization using a lumbosacral orthosis.
4. Manual therapy techniques of the SI joint to provide relief of symptoms, and therapeutic exercise to
restore normal function of the pelvic girdle.

Teaching Points
Correct Answer: 4
Ligamentous laxity and pain during pregnancy secondary to hormonal influences (relaxin) most com-
monly affects the SI joint. This ligamentous laxity continues to occur for up to 3 months after pregnancy
and leaves the pelvic area vulnerable to injury. SI pain is aggravated by prolonged weight bearing and
stairs. Manual therapy techniques are effective for reducing pain and therapeutic exercise is beneficial to
restore normal muscle function.

Incorrect Choices:
Modalities may provide temporary relief of pain, but will not promote any significant impact on healing.
Promoting non- weight bearing does not allow the patient to return to normal function . Mobilization will
further stretch joint structures that are already lax.

Type of Reasoning: Inference

One must infer the intervention that is most beneficial for a patient with postpartum sacral pain to arrive
at the correct conclusion. Questions that encourage one to draw conclusions from evidence utilize infer-
ential reasoning skill. One must understand the nature of postpartum sacral pain from ligamentous laxity
and the intervention approach that is most effective in order to arrive at the correct conclusion.
 Examination B 699

Musculoskeletal I Evaluation, Diagnosis

A patient complains of right shoulder pain since falling onto the right shoulder 3 weeks ago. There was no
dislocation and x-rays were negative. AROM is 35 ° of flexion and abduction with scapular elevation noted.
Passive ROM is nearly full with mild pain and muscle guarding at the end of range. Resisted abduction is
weak with pain noted in the anterior and lateral deltoid region. There is no atrophy. Based on the above
findings, the physical therapist should MOST LIKELY suspect:

Choices:
1. Rotator cuff tear.
2. Adhesive capsulitis.
3. Supraspinatus tendinitis.
4. Axillary nerve palsy.

Teaching Points
Correct Answer: 1
A rotator cuff tear would be provoked by resisted testing because it is a contractile lesion. The patient
would not be able to raise the arm over the head because of lack of force transmission secondary to the
tear. Also, the mechanism of injury (trauma) could cause a tear.

Incorrect Choices:
A patient with supraspinatus tendinitis would likely be able to raise the arm overhead with a painful arc
of motion or pain at end range. It is also more typically caused by overuse. An adhesive capsulitis would
exhibit only a small amount of more passive range than active because the tight capsule is restricting
ROM. An axillary nerve palsy is typically caused by a dislocation and would cause marked atrophy of the
deltoid.

Type of Reasoning: Analysis

This question provides a group of symptoms and the test taker must determine the most likely diagnosis.
This is an analytical reasoning skill, in which pieces of information are weighed in order to draw conclu-
sions. For this situation, the symptoms are indicative of a rotator cuff tear. Review signs and symptoms of
rotator cuff tear if answered incorrectly.

•
Musculoskeletal I Examination

A patient presents with neck pain, which is a result of a motor vehicle accident (hit from behind while the car
was at rest). To determine the function of the deep cervical flexors, the physical therapist decides to perform a
muscle function test utilizing the cranio-cervical flexion test. Findings of a normal test would be:

Choices:
1. During active chin tuck the patient is able to hold the head 1 inch above the table for 30 seconds.
2. During active chin tuck, the pressure in the stabilizer cuff increases to 22 and the patient can hold this posi-
tion for 10 seconds.
3. When palpating the anterior cervical musculature during the active chin tuck the sternocleidomastoid mus-
cle activates prior to the longus colli muscle.
4. During active chin tuck, the patient is able to maintain the normal cervical lordosis for 10 seconds.
700 Examination B

Teaching Points

Correct Answer: 2
During an active chin tuck the pressure in the stabilizer cuff increases to 22 and the patient can hold this
position for 10 seconds.

Incorrect Choices:
Holding for 30 seconds is reflective for the endurance test, not the cranio-cervical flexion test. While
performing this test the sternocleidomastoid muscle should remain inactive. During this procedure, the
cervical spine should assume a flexed position so it loses its normal lordosis intentionally.

Type of Reasoning: Inference

This question requires one to infer the most likely findings from performing a cranio-cervical flexion test.
Questions of this nature often necessitate one determining what is most likely to be true of a situation,
which is an inferential reasoning skill. A normal finding during the cranio-cervical flexion test would
show that during an active chin tuck the pressure in the stabilizer cuff increases to 22 and the patient can
hold this position for 10 seconds. If answered incorrectly, review guidelines for performing cranio-cervical
flexion testing .

•
Metabolic/Endocrine I Evaluation, Diagnosis

An elderly and frail older adult has low vision. The patient recently returned home from a 2-week hospitali-
zation for stabilization of diabetes. The PT's goal is to mobilize the patient and increase ambulation level
and safety. The BEST intervention strategy for this patient is to :

Choices:
1. Keep window shades wide open to let in as much light as possible.
2. Practice walking by having the patient look down at all times.
3. Color-code stairs with pastel shades of blue and green to highlight steps.
4. Practice walking in areas of high illumination and low clutter.

Teaching Points

Correct Answer: 4
Effective intervention strategies for the elderly patient with diabetes and low vision include ensuring
adequate lighting. Vision and safety decrease dramatically in low lighting. Reducing clutter in the home is
also an important strategy to improve safety during ambulation.

Incorrect Choices:
The patient should not continuously look down at the feet, because this poses a safety hazard. This
restricts avoidance strategies for environmental objects. Visual acuity decreases dramatically with bright
glare from sunlit windows. Color-coded stairs might help if they are well lit and if strong colors, not pas-
tels, are used.

Type
1
of Reasoning: Inference
This question requires one to recall the guidelines for intervention approaches with people who have low
vision. Adequate lighting and low clutter are important to successful and safe navigation in the patient's
living spaces. Using the skills of inferential reasoning, the test taker must draw conclusions from the evi-
dence presented and make assumptions about that information.
 Exa min ati o n B 701

Cardiovascular/Pulmonary and Lymphatic I Evaluation , Diagnosis

The patient has a history of angina pectoris and limited physical activity. As the patient participates in the
second exercise class, the PT suspects that angina is unstable and may be indicative of a preinfarction state.
The therapist determines this by the presence of:

Choices:
1. Angina that responds to rest and interval training but not to continuous training.
2. Arrhythmias of increasing frequency, especially atrial arrhythmias.
3. Angina of increasing intensity that is unresponsive to the nitroglycerin or rest.
4. Prolonged cessation of pain following the administration of nitroglycerin for angina.

Teaching Points

Correct Answer: 3
Preinfarction or unstable angina pectoris is unrelieved by rest or nitroglycerin (measures that typically
reduce most angina) . The pain is described as increasing in intensity. Unstable angina is an absolute con-
traindication to exercise.

Incorrect Choices:
Angina that decreases with rest and interval training along with nitroglycerin is considered stable. Increas-
ing atrial arrhythmias may be a comorbidity, but is not expected with angina.

Type of Reasoning: Evaluation

In this question, the test taker must evaluate the merits of the statements presented and determine which
statements seem most indicative of unstable angina. Relying on knowledge of angina pectoris and the in-
dications for unstable angina, the test taker uses evaluative reasoning skill to arrive at the correct conclu-
sion. If this question was answered incorrectly, review information on unstable angina .

•
Neuromuscular I Interventions

A patient with a left CVA exhibits right hemiparesis and strong and dominant hemiplegic synergies in the
lower extremity. Which activity would be BEST to break up these synergies?

Choices :
1. Supine-lying, hip extension with adduction.
2. Foot tapping in a sitting position.
3. Bridging, pelvic elevation.
4. Supine, PNF D2F with knee flexing, and D2E with knee extending.

Teaching Points

Correct Answer: 3
The typical lower extremity synergies are effectively broken up using bridging (combines hip extension
from the extensor synergy with knee flexion from the flexion synergy).
702 Examination B

Incorrect Choices:
Supine hip extension with adduction and foot tapping in the sitting position are in-synergy activities
(lower extremity flexion and extension synergies). Supine, lower extremity PNF D2F with knee flexing, and
D2E with knee extending moves the lower extremity in a pattern closely aligned with the typical flexion
and extension synergies.

Type of Reasoning: Inference

This question requires one to determine what will best help a patient to break up a lower extremity syn-
ergy pattern after a stroke. Drawing conclusions based on the information presented, the test taker utilizes
inferential reasoning to make the determination of which approach will benefit the patient. If this ques-
tion was answered incorrectly, refer to information on limb synergy patterns and activities that promote
this pattern.

Integumentary I Evaluation, Diagnosis

An elderly and frail resident of a nursing home has developed a stage III pressure ulcer. The wound is open
with necrosis of the subcutaneous tissue down to the fascia. This elderly patient when compared with a
younger patient with the same type of ulcer can be expected to demonstrate:

Choices:
1. Increased scarring with healing.
2. Decreased vascular and immune responses resulting in impaired healing.
3. Increased elasticity and eccrine sweating.
4. Increased vascular responses with significant erythema.

Teaching Points

Correct Answer: 2
Age-associated changes in the integumentary system include decreased vascular and immune responses
that result in impaired healing. Rate of healing is considerably slower.

Incorrect Choices:
In the elderly, scarring is typically less than in a younger individual. Both elasticity and eccrine sweating
are decreased in the elderly. Vascular responses are typically decreased, not increased.

Type of Reasoning: Inference

One must infer or draw a reasonable conclusion about the likely healing abilities of an older adult with
a pressure ulcer. This requires inferential reasoning skill. For this case, considering the patient's age as
compared with a younger patient, one could expect decreased vascular and immune responses that impair
healing. If this question was answered incorrectly, review age changes associated with changes in the
integumentary system of older adults.
 Examination 8 703

•
Neuromuscular I Examination

The therapist is examining a patient recovering from stroke for the expected pattern of spastic hypertonia in
the more involved upper extremity. The therapist expects to find abnormally increased resistance to PROM
in:

Choices:
1. Shoulder adductors; forearm pronators; and flexors of the elbow, wrist, and hand.
2. Shoulder retractors and abductors and flexors of the elbow, wrist, and hand.
3. Shoulder adductors, forearm pronators, and elbow extensors.
4. Shoulder flexors and flexors of the elbow and hand.

Teaching Points

Correct Answer: 1
The typical pattern of spasticity in the UE of the patient recovering from stroke is shoulder adductors;
forearm pronators; and flexors of the elbow, wrist, and hand (antigravity muscles) .

Incorrect Choices:
Spasticity is strong in shoulder adductors, not abductors. Spasticity is strong in elbow flexors, not exten-
sors. Spasticity is not typically strong in shoulder flexors (the elbow is typically held in flexion, with arm
adducted to the side) .

Type of Reasoning: Inference

This question provides a diagnosis and the test taker must infer the typical pattern of spasticity. This re-
quires one to determine what is likely to be true for a patient with a stroke, which is an inferential reason-
ing skill. In this situation, the patient is likely to display increased resistance to passive range of motion in
the sho ulder adductors; forearm pronators; and flexors of the elbow, wrist, and h and. Review information
of spasticity patterns after stroke if answered incorrectly.

Gastrointestinal I Evaluation, Diagnosis

An elderly patient has been hospitalized for 3 weeks after a surgical resection of carcinoma of the colon. The
patient is very weak and is currently receiving physical therapy to improve functional ambulation. During the
initial sessions, the patient complains of pain in the left shoulder that is aggravated by weight bearing when
using the walker. The therapist decides to:

Choices:
l. Notify the physician immediately.
2. Apply pulsed US to decrease pain.
3. Apply heat in the form of a hot pack before ambulation.
4. Ambulate the patient in the parallel bars considering age and diagnosis.
704 Examination B

Teaching Points

Correct Answer: 1
The risk of metastatic disease is present; the therapist should notify the physician immediately.

Incorrect Choices:
Monitoring or modifying the plan of care to reduce pain should be considered only after consultation with
the physician. If metastatic disease is present, the US would be contraindicated. Ambulating in the parallel
bars exerts the same weight-bearing forces through the upper extremities as does a walker.

Type of Reasoning: Inductive

This question requires one to use clinical judgment and diagnostic thinking to make a determination of the
cause for the patient's shoulder pain and then what is the best course of action based on this knowledge.
In this situation, based on the patient's medical history, it is important to notify the physician immediately
because of the risk of metastatic disease. Questions that require clinical judgment to make a determination
of a best course of action utilize inductive reasoning skill .

•
Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient sprained the left ankle 4 days ago. The patient complains of pain (4/10), and there is moderate
swelling that is getting worse. At this time, which intervention would be BEST to use?

Choices:
1. Intermittent compression followed by elevation.
2. Contrast baths followed by limb elevation.
3. Cold whirlpool followed by massage.
4. Cold/intermittent compression combination with the limb elevated.

Teaching Points

Correct Answer: 4
The combination of RICE (rest, elevation, compression, elevation) is best. Cold to decrease pain along
with intermittent compression and elevation to facilitate fluid drainage provides the best intervention.
Rest is required.

Incorrect Choices:
Contrast baths and whirlpool place the ankle in a dependent position, which might tend to increase
edema. The interventions of intermittent compression and elevation should be combined, not
sequential.

Type of Reasoning: Inference

In this question, the test taker must draw conclusions based on the information presented in the patient's
case, which utilizes inferential reasoning skill. The patient's symptoms in this case indicate that cold and
intermittent compression with limb elevation are best to relieve pain and facilitate fluid drainage. If this
question was answered incorrectly, refer to information on intervention for acute ankle sprain.
 Examination B 705

Musculoskeletal I Examination

A patient diagnosed with left lateral epicondylitis has no resolution of symptoms after 2 weeks of treat-
ment. The PT reexamines the patient and finds the left biceps reflex is 1+. The therapist should NEXT
perform a complete examination of the:

Choices:
1. Mid cervical region.
2. Cervicothoracic region.
3. Upper cervical region.
4. Cervicocranial region.

Teaching Points

Correct Answer: 1
The patient has symptoms (diminished reflex) of a possible left C5 nerve root compression in the mid
cervical spine. Any reflex change suggests nerve root irritation or compression. Lateral epicondylitis fre-
quently involves the extensor carpi radialis brevis, which is innervated by spinal nerves emanating from
the mid cervical region.

Incorrect Choices:
The presenting symptoms cannot be linked to involvement of the regions listed in the other choices.

Type of Reasoning: Analysis

This question provides the symptoms, and the test taker must determine the diagnosis or root cause,
which relies primarily on analytical reasoning skill. The test taker must recall knowledge of neuroanato-
my to recognize that a 1+ reflex in the left biceps is indicative of possible nerve root compression at the
C5 level. If this question was answered incorrectly, refer to information on nerve root compressions of the
cervical spine.

Cardiovascular/Pulmonary and Lymphatic I Examination

Which measure of aerobic capacity is supported as a reliable and valid functional capacity measure with re-
ported minimal detectable change scores in patients with heart failure?

Choices:
1. Bruce protocol treadmill test.
2. Canadian Aerobic Fitness Step test.
3. 6-minute walk test.
4. Lower extremity ergometer test.

Teaching Points

Correct Answer: 3
Only the 6-minute walk test (6MWT) has minimal detectable change (MDC) scores associated with it.
706 Examination B

Incorrect Choices:
All of these tests have literature to support that they are reliable (test-retest, intra-tester, and inter-tester
reliability) and valid (concurrent, construct, and predictive validity), but cannot report minimal detectable
changes.

Type of Reasoning: Deductive

For this question, the test taker must recall factual information about measures of aerobic capacity in
order to arrive at a correct conclusion. This necessitates deductive reasoning skill, where facts are recalled
to draw reasonable conclusions. For this scenario, the 6MWT is the only test that has minimal detectable
change scores associated with it. Review measures of aerobic capacity, especially reliability and validity
information, if answered incorrectly.

•
Musculoskeletal I Examination

A patient underwent a right total hip replacement (THR) 4 months ago. The patient is now referred to physi-
cal therapy for gait evaluation. The patient demonstrates shortened stride length on the right. This patient
MOST LIKELY has:

Choices:
l. Contracted hip flexors.
2. Contracted hamstrings.
3. Weakened hip flexors.
4. Weakened quadriceps.

Teaching Points

Correct Answer: 1
Patients are less active after surgery and spend less time in standing and more time in sitting. The iliopsoas
muscles become shortened with increased time in sitting. The contracted iliopsoas limits the patient's ability
to extend the hip, which effectively shortens the stride length on the affected side.

Incorrect Choices:
Contracted hamstrings or weak quadriceps result in decreased knee extension during stance and an unstable
knee. Weak hip flexors produce decreased limb shortening during swing, typically compensated by circum-
duction.

Type of Reasoning: Analysis

This question provides the symptoms and the test taker must determine the cause for the symptoms, which
encourages analytical reasoning skill. In this case, the patient most likely has a contracted iliopsoas muscle,
which will shorten the stride length on the right. One must recall reasons for decreased stride length, espe-
cially after THR surgery, in order to arrive at the correct conclusion.
 Examination B 707

Neuromuscular I Interventions

A child with spastic cerebral palsy is having difficulty releasing food from the hand to the mouth. Once the
child has brought the food to the mouth, it would be helpful for the caregiver to:

Choices:
1. Slowly stroke the finger flexors in a distal-to-proximal direction.
2. Apply a quick stretch to the finger flexors.
3. Slowly stroke the finger extensors in a proximal-to-distal direction.
4. Passively extend the fingers.

Teaching Points

Correct Answer: 3
Slowly stroking the finger extensors will help to facilitate opening of the hand and allow the child to
release the food into the mouth.

Incorrect Choices:
Stimulation of spastic finger flexors (slow stroking, quick stretch) is contraindicated. Passive extension of
the fingers will not enhance the activity of feeding.

Type of Reasoning: Evaluation

One must evaluate the merits of the four statements presented to make a determination of the best ap-
proach to facilitate finger extension. Using knowledge of neurorehabilitation techniques, the test taker
should conclude that stroking the fingers proximal to distal will be most effective in encouraging finger
extension. Evaluative reasoning skill is used in this question because the test taker must evaluate the value
of statements made to make a judgment for the best course of action.

Integumentary I Examination

During the examination of the cervical spine of a client for CS radiculopathy, small groupings of nevi are
noted near the superior angle of the left scapula. The NEXT action the therapist should take is:

Choices:
1. Contact the physician immediately.
2. Ask the patient about any history of moles and examine them closely.
3. Photograph the area in order to provide baseline documentation for the patient's record.
4. Perform a vertebral artery because the nevi are obviously benign growths.

Teaching Points

Correct Answer: 2
Nevi (moles) should be examined for asymmetry, border irregularities, color, and diameter (>6 mm) . It is
not uncommon to have a group of moles and they are usually benign, but if there is a transformation of a
nevus (plural, nevi), then the primary care physician should be contacted. In this situation, the therapist
needs to establish a baseline (history and physical examination) of the moles, and then determine whether
there is an indication to contact the physician.
708 Examination B

Incorrect Choices:
A photograph can be part of the examination, but this does not replace a thorough history and visual
inspection. There are no indications for a vertebral artery examination. A vertebral artery examination is
performed before manual or mechanical techniques of the cervical spine or if the client exhibits signs or
symptoms of vertebral artery compromise.

Type of Reasoning: Evaluation

This question requires the test taker to determine the significance of nevi. In order to determine how sig-
nificant they are (if at all), the next course of action (setting priorities) would be to ask the patient about
any history of moles and then examine them closely. In order to arrive at a correct conclusion, one must
evaluate the merits of each of the four possible courses of action presented and decide which action most
adequately addresses patient well-being, while being prudent in approach .

8149
•
Musculoskeletal I Examination

In reference to the figure, when lifting a constant load using either a stoop lift or a squat lift posture, the
MOST significant contributing factor for increasing lumbar spine compression forces in addition to the
weight of the load is:

Stoop Lilt Deep Squat Uft

Muscu loskeleta l Disorders in the Workplace: Principles and Practice. Nordin M, Andersson G, Pope M (1997). St Louis, Inc.,
page 122, Figure 10-1 , with permi ssion.

Choices:
1. The height of the load from the ground.
2. Performing the lift with the lumbar spine in a neutral position rather than in a lordotic posture.
3. The distance of the load from the base of the spine.
4. Performing the lift with the lumbar spine in a kyphotic posture.

Teaching Points

Correct Answer: 3
Manual lifting biomechanical models have demonstrated high lumbar spine moments, especially when
the load is not held close to the body.

Incorrect Choices:
The height of the load from the ground may decrease the overall work but is not the key factor in reducing
lumbar compressive forces . The spine should be held in its normal position. A lumbar neutral position
may change the biomechanics slightly but will not reduce lumbar compressive forces . Kyphosis occurs in
the thoracic region, not lumbar.
 Examination B 709

Type of Reasoning: Analysis

Questions that require one to analyze information presented in pictures often encourage the use of analyti-
cal reasoning skill. In this question, one must analyze how the information presented in the picture best
depicts how the distance of the load from the base of the spine is the most significant contributing factor for
increasing lumbar spine compression forces. If this question was answered incorrectly, review information
on biomechanics of lifting .

•
Musculoskeletal I Interventions

Nearly 2 months ago, a patient noticed left shoulder pain after walking the dog. This pain has progressively
worsened. The patient now is unable to move the left upper extremity overhead while performing ADLs. An
orthopedic surgeon diagnosed the problem as adhesive capsulitis. The MOST effective direction for gleno-
humeral mobilization for this patient would be:

Choices:
1. Posteroinferior translatory glides.
2. Posterosuperior translatory glides.
3. Anterosuperior translatory glides.
4. Anteroinferior translatory glides.

Teaching Points

Correct Answer: 1
The diagnosis is left shoulder adhesive capsulitis. Inferior glides will improve the abduction and flexion
(overhead motion) . Posterior glides have been shown to be the most effective glide to increase gleno-
humeral external rotation.

Incorrect Choices:
Superior glides will improve extension, not elevation. Based on the concave-convex rule, it seems that
anterior glides would be best to promote external rotation at the glenhohumeral joint.

Type of Reasoning: Inference

This question requires one to determine the most effective treatment approach in glenohumeral mobili-
zation techniques for adhesive capsulitis. This requires one to have a firm understanding of the nature of
adhesive capsulitis, capsular patterns, and joint mobilization techniques of the shoulder to arrive at the
correct conclusion. This question utilizes inferential reasoning skill because the test taker must draw a
conclusion based on the evidence presented for a best course of action.

System Interactions I Evaluation, Diagnosis

A elderly patient is referred to physical therapy for an examination of functional mobility skills and safety
in the home environment. The family reports that the patient is demonstrating increasing forgetfulness and
some memory deficits. From the examination, the therapist would expect to find:

Choices:
1. Impairments in short-term memory.
2. Periods of fluctuating confusion.
3. Significant impairments in long-term memory.
4. Periods of agitation and wandering, especially in the late afternoon.
710 Examination B

Teaching Points

Correct Answer: 1
Elderly patients with memory impairments typically demonstrate intact immediate recall (e.g., can repeat
words); impairments are often noted in memory for recent events (e.g., Why did I come into this room?
Who came to see me yesterday?) . Long-term memory is usually intact.

Incorrect Choices:
Periods of fluctuating confusion are typically found in delirium, an acute state of disorientation and
confusion. Hallucinations or delusions are common (not present in this case) . Periods of agitation and
wandering (sundowning) are seen in patients with Alzheimer's disease. Whereas the disease begins with
mild memory loss (stage I), agitation and wandering typically do not occur until stage II.

Type of Reasoning: Analysis

In this situation, the test taker must analyze the patient's symptoms and make a determination of the
root cause for them in order to decide what the therapist's findings may be. Analytical questions require
one to interpret information and determine the precise meaning of that information. If this question was
answered incorrectly, review information regarding age-related memory deficits.

Neuromuscular I Examination

A therapist is examining a patient with vestibular dysfunction. The patient is asked to assume a long sitting
position with the head turned to the left side. The therapist then quickly moves the patient backward so
that the head is extended over the end of the table approximately 30° below horizontal. This maneuver
causes severe dizziness and vertigo. A repeat test with the head turned to the right produces no symptoms.
The therapist reports these findings as a:

Choices:
1. Positive right Hallpike-Dix test.
2. Positive sharpened Romberg's test.
3. Positive left Hallpike-Dix test.
4. Positive positional test.

Teaching Points

Correct Answer: 3
The test described is the Hallpike-Dix. It is a left positive test because, with the head turned to the left, the
change in position produces the patient's symptoms.

Incorrect Choices:
The right Hallpike-Dix test with head turned to the right is negative. The sharpened Romberg's test is used
to assess standing balance (disequilibrium) with the eyes closed and feet in a tandem (heel-toe) position.
The Hallpike-Dix test is a positional test; a positive positional test.

Type of Reasoning: Deductive

This question requires one to determine which clinical test is represented by the information in the sce-
nario. This requires factual recall of information related to protocols, which is a deductive reasoning skill.
In this situation, the scenario describes administration of the Hallpike-Dix maneuver. If this question was
answered incorrectly, review information on the Hallpike-Dix maneuver.
 Examination B 711

Neuromuscular I Interventions

A therapist is instructing a patient with a stroke in gait training. The therapist determines that learning is
going well because the patient's errors are decreasing and overall endurance is improving. The BEST strat-
egy to promote continued motor learning at this point in the patient's rehabilitation is to:

Choices:
1 . Provide continuous feedback after every walking trial.
2. Have the patient practice walking in varying environments.
3. Have the patient continue to practice in the parallel bars until all errors are extinguished.
4. Intervene early whenever errors appear before bad habits become firmly entrenched.

Teaching Points

Correct Answer: 2
This patient demonstrates the associative stage of motor learning (errors are decreasing and movements
are becoming organized). It is appropriate to gradually progress this patient toward ambulating in a more
open (varied) environment.

Incorrect Choices:
Continuous feedback may improve performance, but delays motor learning. Practicing until errors are
extinguished or intervening early whenever errors appear are also inappropriate strategies for the associa-
tive stage of learning. Some trial and error learning is the goal.

Type of Reasoning: Inductive

One must utilize clinical judgment to determine the best strategy to promote continued motor learning
with the patient. Use of clinical judgment to make a determination of a best course of action is an induc-
tive reasoning skill. It is important to know the stages of motor learning in order to arrive at the correct
conclusion, which should be reviewed if this question was answered incorrectly.

•
Cardiovascular/Pulmonary and Lymphatic I Interventions

A young child with newly diagnosed cystic fibrosis is being seen by a PT in the home. Which intervention
should be considered for this patient?

Choices:
1. Teach the parents secretion removal techniques to all segments of all lobes of both lungs once or twice a
day.
2. Teach the child active cycle of breathing technique (ACBT) to be done once or twice a day to clear
retained secretions.
3. Teach the child use of the acapella device in postural drainage positions to be performed once or twice a day.
4. Teach the child autogenic drainage for secretion removal to be performed once or twice daily.

Teaching Points
712 Examination B

Correct Answer: 1
For a child this age, proper at-home interventions include secretion removal techniques including manual
techniques performed by an adult once or twice a day.

Incorrect Choices:
The use of an acapella device, ACBT, and/ or autogenic drainage can be helpful in clearing secretions in
patients with cystic fibrosis; however, these three techniques are not appropriate for a child this young,
because they rely on independent use and an ability to self-monitor secretion clearance to know how long
and how often to perform the techniques.

Type of Reasoning: Inference

The test taker must understand the nature of cystic fibrosis and home interventions for the condition to
determine what is an acceptable intervention for a YOUNG child. Arriving at the correct conclusion re-
quires inferential reasoning, which requires one to draw conclusions from information and form assump-
tions about the information. If this question was answered incorrectly, review home therapy interventions
for young children with cystic fibrosis.

8155
Genitou r inary I Interventions

A middle-aged woman is referred to a women's clinic with problems of stress incontinence. She reports loss
of control that began with coughing or laughing, but now reports problems even when she exercises (aero-
bics 3 times/wk) . The BEST intervention for this patient is:

Choices:
l. Kegel's exercises several times a day.
2 . Biofeedback 1 hour/ wk to achieve appropriate sphincter control.
3. Functional electrical stimulation 3 times/wk.
4. Behavioral modification techniques to reward proper voiding on schedule.

Teaching Points

Correct Answer: 1
Symptoms of stress incontinence can be successfully managed through a variety of techniques. Pelvic floor
exercises (Kegel's exercises) are the mainstay of treatment and must be performed daily, several times a
day, in order to be effective.

Incorrect Choices:
Biofeedback and E-Stim offered weekly or 3 times/wk are not likely to be effective because of insufficient
frequency. A voiding schedule does not address the primary impairment.

Type of Reasoning: Inductive

This question requires one to understand the nature of stress incontinence and the appropriate interven-
tions for this condition in order to choose the best intervention approach. Using clinical judgment (an
inductive reasoning skill), the test taker determines the best course of action for the patient. If this ques-
tion was answered incorrectly, review intervention strategies for stress incontinence.
 Exa min at ion B 713

Neuromuscular I Evaluation, Diagnosis

An elderly patient suffered a cerebral thrombosis 4 days ago and presents with the following symptoms:
decreased pain and temperature sensation of the ipsilateral face, nystagmus, vertigo, nausea, dysphagia,
ipsilateral Horner's syndrome, and contralateral loss of pain and temperature sensation of the body. The
MOST LIKELY site of the thrombosis is the:

Choices:
1. Posterior cerebral artery.
2. Anterior cerebral artery.
3. Posterior inferior cerebellar artery.
4. Internal carotid artery.

Teaching Points

Correct Answer: 3
This patient presents with lateral medullary (Wallenberg's) syndrome, which can result from occlusion
of the PICA, which is usually a branch of the vertebral artery. It involves the descending tract and nucleus
of CN V, the vestibular nucleus and its connections, CN IX and CN X nuclei or nerve fibers, cuneate and
gracile nuclei, and spinothalamic tract.

Incorrect Choices:
The symptoms in this case clearly indicate brainstem (cranial nerve) involvement, not cortical involve-
ment (anterior or posterior cerebral artery). An internal carotid artery stroke produces symptoms of com-
bined middle cerebral and anterior cerebral artery strokes.

Type of Reasoning: Analysis

This question requires one to recall the symptoms that indicate involvement of the PICA. This requires
the test taker to analyze the information presented and interpret it in order to determine that the symp-
toms are directly indicative of PICA thrombosis. It is important for one to recall applied neuroanatomy
related to strokes in order to choose the best answer.

Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient with a 2-inch stage II decubitus ulcer over the left lateral malleolus is referred for physical therapy.
The therapist notes a greenish, pungent exudate at the wound site. The therapist decides to use electrical
stimulation. The BEST choice of polarity and electrode placement is:

Choices:
1. Anode placed in the wound.
2. Cathode placed in the wound.
3. Anode placed proximal to wound.
4. Cathode placed proximal to wound.
714 Examination B

Teaching Points
Correct Answer: 2
It is purported that the bactericidal effect produced by negative current is a result of substrate depletion
or alteration of the internal processes of the microorganisms. Neutrophils are also attracted to the wound
area by chemotaxis to purge the bacteria. The cathode should be placed directly in contact with the
wound to cover as much treatment area as possible.

Incorrect Choices:
The anode is used to promote healing in clean uninfected wounds, and placement of an electrode in the
wound ensures current will be delivered throughout the wound.

Type of Reasoning: Deductive

This question requires one to recall the protocol for electrical stimulation in treatment of infected decubi-
tus ulcers. Questions that require one to recall protocols and guidelines require deductive reasoning skill.
For this clinical situation, the cathode should be placed in the wound to promote healing. If this question
was answered incorrectly, review protocols for electrical stimulation for wound healing.

8158
Cardiovascular/Pulmonary and Lymphatic I Examination

A patient arrives for outpatient cardiac rehab 10 weeks after a coronary artery bypass graft. The postoperative
course was complicated by atrial fibrillation, which has been controlled with medications prescribed by a
cardiologist. The patient's resting vital signs are HR = 90 in atrial fibrillation, BP = 116/74, RR = 14, and Sp02 =
99% on room air. Should the physical therapist proceed with a symptom-limited exercise test as planned?

Choices:
l. No, a patient in atrial fibrillation should not complete an exercise test.
2 . No, the patient is tachycardic at rest and has an arrhythmia.
3. Yes, the patient is managed by a cardiologist and has no symptoms now.
4. Yes, the heart rate is well controlled and the cardiologist is aware of the arrhythmia.

Teaching Points
Correct Answer: 4
It is appropriate to perform an exercise test on a patient who is on medication to control his/her rate
with atrial fibrillation CAP). A normal heart rate is between 60-100 beats per minute, which is where this
patient's heart rate falls.

Incorrect Choices:
Patients can be asymptomatic with AF, so it is best to use objective measures to assess their response to
activity. It is safe to exercise a patient who is in AFIt is a concern if the patient's heart rate is ~1l5-120
beats per minute. This is the point at which diastolic filling time is decreased, which places a person in AF
at risk of not maintaining his/ her cardiac output with increased demand.

Type of Reasoning: Evaluation

This question provides symptoms and the test taker must determine the best course of action for a client
based on knowledge of cardiac exercise guidelines and safety in providing treatment. This is an evaluative
reasoning skill, as the test taker must weigh the four options provided and determine what is prudent for
the patient's current status and needs. In this case, the patient's rate is well controlled and the cardiologist
is aware of the arrhythmia, so the therapist should proceed with symptom-limited exercise testing. Review
cardiac exercise guidelines if the question was answered incorrectly.
 Examination B 715

System Interactions I Evaluation, Diagnosis

A patient presents with a complete TlO paraplegia. An extensive neurological workup has failed to reveal a
specific cause for the paraplegia. The physician has determined a diagnosis of conversion disorder. During
physical therapy, it would be BEST to:

Choices:
l. Initiate ROM and strength training after the patient receives psychological counseling.
2. Discuss possible underlying causes for the paralysis with the patient in an empathetic manner.
3. Initiate functional training consistent with the level of injury.
4. Use functional electrical stimulation as a means of demonstrating to the patient that the muscles are
functional.

Teaching Points
Correct Answer: 3
A conversion disorder (hysterical paralysis) represents a real loss of function for the patient. The therapist
should treat this patient the same as any patient with spinal cord injury with similar functional deficits.
Early intervention is crucial.

Incorrect Choices:
A psychologist or psychiatrist is best able to help the patient understand the cause of the patient's paraly-
sis. The therapist should be empathetic; however, counseling should not be the main focus of interven-
tion in IT. Confrontation (using E-Stim to prove the patient has functioning muscles) is contraindicated.

Type of Reasoning: Evaluation

This question requires one to make a value judgment about the best course of action for this patient who
has a conversion disorder. It is beneficial to understand what a conversion disorder is and the appropri-
ate role for the PT in order to choose the best response. These types of questions, which require evaluative
reasoning, are challenging because of the need to evaluate the believability of statements and make deci-
sions based on values.

8160
Nonsystem I Safety, Professional Responsibilities, Research

A certified cardiopulmonary clinical specialist was moved off the coronary care unit to treat a patient who re-
cently had a surgical repair of a lacerated index finger flexor tendon. The therapist had dealt almost exclusively
with patients with cardiovascular disease; however, the department was very short-staffed. During treatment,
the patient felt a "pop," which was the result of a rupture of the newly repaired tendon. The IT in this case
should have:

Choices:
1. Taken a medical history and asked another therapist to develop the treatment plan.
2. Treated the patient as requested, because the diagnosis was straightforward.
3. Used heat prior to the treatment to increase tendon extensibility.
4. Refused to treat this patient.
716 Examination B

Teaching Points

Correct Answer: 4
Malpractice is considered professional negligence as a result of wrongs or injuries that may occur through
professional/patient relationships. Negligence is the failure to do what a reasonable practitioner would
have done or not done in a similar circumstance. A supervisor's request to treat a patient can be refused if
the therapist feels it is outside the scope of his/her expertise.

Incorrect Choices:
It is inappropriate to ask another therapist to develop a treatment plan or to treat the patient if the thera-
pist does not feel competent to deal with the problem.

Type of Reasoning: Evaluation

This question requires the test taker to rely on his/her value system to determine what would h ave been
the best course of action for this therapist to take. Using one's knowledge, experience, and ethical guide-
lines, it would have been best for this therapist to refuse to treat the patient because of limitations in
knowledge of this area. As a result, negligence has occurred, because the patient has sustained an injury.

8161
•
Neuromuscular I Examination

Which is NOT considered a normal finding during an examination of a newborn infant?

Choices:
1. Symmetry in ROM.
2. Response decrement to repetitive stimuli.
3. Continuous tremulousness.
4 . Dramatic skin color changes with change of state.

Teaching Points

Correct Answer: 3
Continuous tremulousness is an abnormal finding, but occasional tremulousness is not.

Incorrect Choices:
All the other choices are normal findings in a newborn infant.

Type of Reasoning: Inference

This question requires one to understand normal activity and responses of infants in order to determine
what is NOT a normal finding . The test taker must use inferential reasoning, which requires one to draw
conclusions and make assumptions from the information presented. If this question was answered incor-
rectly, review information on abnormal findings in examinations of newborns.
 •
Examination B 717

Neuromuscular I Evaluation, Diagnosis

A patient with long-standing traumatic brain injury (TBI) comes into an outpatient clinic using a standard
wheelchair. The patient demonstrates sacral sitting with a rounded, kyphotic upper back. The therapist sus-
pects the cause of this posture is:

Choices:
1. Uneven weight distribution on the thighs and ischial seat.
2. Decreased floor to seat height.
3. Excessive leg length from seat to the foot plate.
4. Excessive seat width.

Teaching Points

Correct Answer: 3
Excessive leg length on a wheelchair can result in sliding forward in the wheelchair to reach the foot plate.
This results in a posterior tilt of the pelvis and sacral sitting.

Incorrect Choices:
All other choices are not likely to produce these postural deficits.

Type of Reasoning: Inference

One must determine the most likely result of excessive leg length from the seat to the foot plate when sit-
ting in a wheelchair. This requires inferential reasoning, in which the test taker must draw conclusions from
the information presented. In this situation, the most likely result is sacral sitting and sliding forward in the
chair.

Integumentary I Examination

A patient presents with a large sacral decubitus ulcer that is purulent and draining. The therapist needs to take
a representative sample of the infected material in order to obtain a laboratory culture. The method to culture
this wound is to obtain samples from the:

Choices:
1. Exudate in the wound.
2. Dressing, exudate, and surrounding bed linen.
3. Dressing and exudate in the wound.
4 . Exudate in the wound and the surrounding tissues.

Teaching Points

Correct Answer: 1
The specimens must be collected from the wound site with a minimum of contamination by material from
adjacent tissues. The exudate provides the best culture.
718 Examination B

Incorrect Choices:
The margins of cutaneous lesions or pressure ulcers are usually contaminated with environmental bacte-
ria. Using the dressing for a specimen sample would also contain contaminated tissues.

Type of Reasoning: Inductive

The test taker must use clinical judgment applied to a patient circumstance (an inductive reasoning skill)
to determine the best method to obtain a sample culture of a wound. In this situation, it is best to mini-
mize contamination by sampling the exudate in the wound. If this question was answered incorrectly,
refer to information on methods for obtaining laboratory cultures .

•
Cardiovascular/Pulmonary and Lymphatic I Interventions

A phase 2 outpatient cardiac rehabilitation program uses circuit training with different exercise stations for
the 50-minute program. One station uses arm ergometry. For arm exercise as compared with leg exercise, at
a given workload, the PT can expect:

Choices:
1. Higher systolic and diastolic BP.
2. Higher HR and systolic/diastolic BP.
3. Reduced exercise capacity owing to higher stroke volumes.
4. Higher HR and lower systolic BP.

Teaching Points

Correct Answer: 2
Arm ergometry uses a smaller muscle mass than leg ergometry, with resulting lower maximal oxygen
uptake. In upper extremity exercise, both HR and BP will be higher than for the same level of work in the
lower extremities.

Incorrect Choices:
The other choices do not correctly identify the expected changes with arm exercise.

Type of Reasoning: Inference

This question requires one to draw conclusions about arm ergometry and its impact on HR and BP, espe-
cially as it relates to leg ergometry. For this scenario, HR and systolic/ diastolic BP will be higher with arm
ergometry. To arrive at the correct conclusion, one must rely on knowledge of the impact of ergometry on
cardiovascular activity, which should be reviewed if this question was answered incorrectly.

B165
Nonsystem I Safety, Professional responsibilities, Research

A therapist is working in a major medical center and is new to the acute care setting. An orientation session
for new employees concerns infection control. The therapist recognizes that the most common infection
transmitted to health care workers is:

Choices:
1. Hepatitis A.
2. Human immunodeficiency virus (HN) .
3. Hepatitis B.
4. Tuberculosis.
 Examination B 719

Teaching Points

Correct Answer: 3
Health care workers are most likely to contract hepatitis B (estimated incidence 300,000 new acute cases
in the United States each year) . Transmission is through exposure to blood and blood products and infect-
ed body fluids.

Incorrect Choices:
While the other three conditions listed require infection control, they are not the most common infec-
tions identified.

Type of Reasoning: Deductive

This question requires recall of the most common infection transmitted to health care workers. This is
factual information, which necessitates deductive reasoning skill. Through recall of infection control
information, one should conclude that hepatitis B is the most common infection to be transmitted. If
answered incorrectly, refer to infection control guidelines, especially transmission of hepatitis B.

Gastroin t est inal I In t erven ti ons

Before liver transplantation, a patient had a body mass index (BMI) of 17 and generalized muscle atrophy,
and completed the 6-minute walk with 65% of age-predicted distance. Surgery was 10 days ago, and the
patient is able to complete bed mobility with an overhead trapeze, walk independently for short distances
with a rolling walker, and complete deep breathing and lower extremity AROM exercises for two sets of 10
repetitions. The patient is being discharged home with family assistance today. Home care physical therapy
is scheduled to begin in 1 week. The BEST choice for discharge home exercise program is:

Choices:
l. Independent ambulation, elastic resistance lower extremity exercise, and active abdominal strengthen-
ing.
2. Breathing exercises, ambulation with walker, and AROM lower extremity exercises.
3. Stationary cycling and lower extremity resistance exercises using a 5-lb weight cuff.
4. Independent bed mobility exercises, elastic resistance extremity exercise, and partial sit-ups.

Teaching Points

Correct Answer: 2
The in-hospital program should be continued until the home care therapist can make his/her own assess-
ment and plan of care. The postoperative goals of improved ventilation, assisted mobility, and AROM are
appropriate for the 3-week postoperative time period, considering the debilitation before surgery and the
abdominal surgery.

Incorrect Choices:
The other choices essentially change the exercise prescription and introduce unsupervised resistance exer-
cises, which can be harmful to this debilitated patient.

Type of Reasoning: Inductive

This question requires one to consider the benefits of a home exercise program after liver transplantation.
Given the patient's current status, the test taker must determine which exercise program will best address
the patient's symptoms and result in functional improvement. This requires clinical judgment and predic-
tion of what results will be yielded in the future, which is an inductive reasoning skill.
720 Examination B

Neuromuscular I Examination

Based on the pictured cr scan, this patient is LIKELY to manifest:

Image from: http://www. med-ed.virginia .edu/courses/ rad/ headct/ index. html

Choices:
1. Broca's aphasia.
2. Ataxia.
3 . Left-sided unilateral neglect.
4 . Wernicke's aphasia.

Teaching Points

Correct Answer: 2
The arrow is pointing to a hemorrhage in the cerebellum. Damage to this area results in difficulty with
movement, postural control, eye-movement disorders, and muscle tone. Ataxia is a common finding.

Incorrect Choices:
Aphasia is more typical of a left cerebral infarct, and left-sided unilateral neglect is typically due to a right
cerebral injury. cr scans and MRls can help the therapist predict clinical manifestations based on the area of
injury.

Type of Reasoning: Analysis

This question requires the test taker to determine the most likely presentation of symptoms based on the
cr image. Questions that require analysis of pictures and graphs often necessitate analytical reasoning
skill. In this case, the patient has experienced a hemorrhage in the cerebellum and will most likely display
ataxia. If this question was answered incorrectly, review signs and symptoms of cerebellar hemorrhages.
 Examination B 721

Nonsystem I Safety, P rotection, P rofess io n al Respo n si bi liti es , Re sea rc h

A PT and PTA are conducting a cardiac rehabilitation class for 20 patients. The therapist is suddenly called
out of the room. The MOST appropriate action in this situation is to:

Choices:
1. Terminate the exercises and have the patients monitor their pulses until the therapist returns.
2. Have the PTA supervise the class using the outlined exercise protocol until the therapist returns.
3. Have the patients switch to less intense exercise until the therapist returns.
4. Have the PTA take over the class and teach modified activities.

Teaching Points

Correct Answer: 2
The PTA can supervise the class using the outlined exercise protocol approved by the PT.

Incorrect Choices:
The class should not be terminated, leaving the patients on their own to monitor their pulses. The PTA or
patient should not change the plan of care.

Type of Reasoning: Evaluation

This question requires the test taker to determine the appropriate supervision of PTAs when conducting a
group session. This requires recall of supervisory guidelines for personnel, as well as prudence in delegat-
ing duties to such personnel, which is an evaluative reasoning skill. In this situation, it is appropriate for
the PTA to supervise the class until the therapist returns. If this question was answered incorrectly, review
information on supervision of PTAs.

Musc u loskeletal I Int erventions

The most efficient intervention to regain biceps brachii strength if the muscle is chronically inflamed and has a
painful arc of motion is:

Choices:
1. Isometric exercises at the end range of movement only.
2. Active concentric contractions through partial ROM.
3. Active eccentric contractions in the pain-free range.
4. Isokinetic exercises through the full ROM.

Teaching Points

Correct Answer: 3
For a muscle that is chronically inflamed, focus should be placed on eccentric contractions, because there
is less effort and stress placed on the contractile units than with concentric contractions at the same level of
work. The exercise should be performed in the pain-free portion of the range.
722 Examination B

Incorrect Choices:
Isokinetic, isometric, and isotonic exercises do not allow for pain-free muscle contractions and can cause
further inflammation of the muscle.

Type of Reasoning: Inductive

For this question, it is important to have knowledge of kinesiology, exercise physiology, and appropriate
exercise for chronically inflamed muscles in order to choose the best exercise approach. This requires di-
agnostic thinking and clinical judgment, which is an inductive reasoning skill. For this situation, the most
appropriate exercise is active eccentric contractions in the pain-free range to avoid further inflammation
of the muscle. If this question was answered incorrectly, refer to information on appropriate exercises for
various forms of muscle pathology.

8170
Nonsyst em I Equipment, Devices , The rapeuti c Modal ities

During an ultrasound (US) treatment, the patient flinches and states that a strong ache was felt in the treat-
ment area. To address this patient's concern, it would be BEST to:

Choices:
1. Increase the size of the treatment area.
2. Add more transmission medium.
3. Decrease the US intensity.
4. Decrease the US frequency.

Teaching Points

Correct Answer: 3
Acoustical energy is reflected from the bone into the bone-tissue interface, resulting in rapid tissue tem-
perature elevation and stimulation of the highly sensitive periosteum of the bone. A reduction in intensity
is indicated if a strong ache is felt.

Incorrect Choices:
The question assumes that the treatment size of the area is correct. Increasing the size of the treatment
area would minimize the ability to elevate the tissue temperature. Thus, the patient would not experience
a strong ache from rapid tissue temperature elevation. Adding more transmission medium would encour-
age transmission of acoustical energy, and thus potentiate the rapid tissue temperature elevation, contrib-
uting to the patient's symptom. The frequency has to do with the depth of penetration of the US energy,
not the rate/speed at which the tissue temperature is being elevated.

Type of Reasoning: Evaluation

This question requires one to determine the cause for the patient's discomfort during US treatment, and
then to determine an appropriate course of action, which is an evaluative reasoning skill. For this patient,
it is best to decrease the US intensity because the strong ache indicates it is a result of too high an intensi-
ty. If this question was answered incorrectly, review information on US guidelines and symptoms warrant-
ing change of protocol.
 Examination B 723

Musculoskeletal I Interventions

A patient is referred for postoperative rehabilitation following a Type II SLAP repair performed 1 week ago.
The physical therapist should:

Choices:
1. Defer intervention during the maximum protection phase.
2 . Focus on biceps brachii stretching and strengthening.
3. Perform careful ROM of the shoulder external rotators.
4. Perform careful ROM of the shoulder internal rotators.

Teaching Points

Correct Answer: 4
Internal rotation ROM does not create the peel back mechanism that increases stress to the repair. Given
the nature of this repair, an understanding of the postoperative precautions is paramount to a successful
surgical outcome. Early rehabilitation within the postoperative precautions correlates to a quicker overall
recovery and improved outcomes.

Incorrect Choices:
Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the
tendon of the long head of the biceps brachii that results in instability of the biceps-Iabral anchor. The
surgery requires reattachment of the labrum and biceps anchor. Given the repair of the biceps, contrac-
tion and stretching of the biceps should be avoided during the maximum protection phase. In addition,
external rotation ROM/stretching should be avoided given the peel back mechanism and increased stress
to the repair.

Type of Reasoning: Inductive

This question requires one to use clinical judgment to determine a best course of action. Questions of this
nature often necessitate inductive reasoning skill. For this case, the therapist should choose to perform
careful ROM to the internal rotators of the shoulder with a Type II SLAP repair. Review protocols for reha-
bilitation after SLAP lesions if answered incorrectly.

Integumentary I Interventions

A patient is recovering from deep partial-thickness burns over the posterior thigh and calf that are now healed.
The therapist's examination reveals local tenderness with swelling and pain on movement in the hip area.
While palpating the tissues, the therapist detects a mass. The therapist's BEST course of action is to:

Choices:
1. Continue with ROM exercises but proceed gently.
2. Report these findings promptly to the physician.
3. Use RICE to quiet down the inflammatory response.
4. Use petrissage to work on this area offocal tenderness.
724 Examination B

Teaching Points

Correct Answer: 2
These signs and symptoms are characteristic of heterotopic ossification (HO), an abnormal bone growth
typically around a joint. While the etiology is unknown, its presence can lead to serious ROM limitations.
These findings should be reported promptly to the physician.

Incorrect Choices:
Petrissage and aggressive ROM exercises could exacerbate the condition. Ice does decrease metabolic activity;
however, more in-depth medical management is required.

Type of Reasoning: Inductive

This question requires one to utilize clinical judgment to determine the reason for the patient's symptoms
and then determine the best course of action, which is an inductive reasoning skill. In this situation, the
findings indicate HO and the therapist should notify the physician promptly. If this question was answered
incorrectly, review information on HO.

8173
Musculoskeletal I Examination

A patient presents with complaint of neck pain on the right. During the AROM examination, the physical
therapist observes the following osteokinematic neck motions-full side-bending left, full rotation to the
left, full forward flexion, limited and painful extension, limited and painful right side-bending, and limited
and painful right rotation. Based on this pattern, what is the arthrokinematic restriction?

Choices:
1. Restriction with downglide of a facet on the right.
2. Restriction with upglide of a facet on the right.
3. Restriction with downglide of a facet on the left.
4. Restriction with upglide of a facet on the left.

Teaching Points

Correct Answer: 1
If a facet on the right was restricted with downgliding (arthrokinematic restriction), then the osteokin-
ematic motions that would be limited would be rotation and side-bending to the right with limited exten-
sion. The fact that there is pain on the right supports that the restriction is on the right.

Incorrect Choices:
The osteokinematic limitation could also be seen with a facet restricted with upglide on the left, but the
differentiator is the fact that the pain is on the right, indicating that the restriction is on the right. The
arthrokinematic restrictions in the other choices do not correlate with the osteokinematic findings of the
exam.

Type of Reasoning: Analysis

This question requires the test taker to analyze the symptoms presented in order to determine the most
likely arthrokinematic restriction. Questions that require one to analyze pieces of information in order to
draw conclusions often require analytical reasoning skill. For this situation, the arthrokinematic restriction
is restriction with downglide of a facet on the right. Review arthrokinematics of the neck and restrictions if
answered incorrectly.
 •
Exa m ination B 725

Cardiovascular/Pulmonary and Lymphatic I Examination

ECG changes that may occur with exercise in an individual with coronary artery disease (CAD) and prior
myocardial infarction (MI) include:

Choices:
1. Bradycardia with ST segment elevation.
2. Significant arrhythmias early on in exercise with a shortened QRS.
3. Bradycardia with ST segment depression >3 mm below baseline.
4. Tachycardia at a relatively low intensity of exercise with ST segment depression.

Teaching Points
Correct Answer: 4
The typical exercise ECG changes in the patient with CAD include tachycardia at low levels of exercise inten-
sity. The ST segment becomes depressed (> 1 mm is significant) . In addition, complex ventricular arrhythmias
(multifocal or runs ofPVCs) may appear, and are associated with significant CAD and/or a poor prognosis.

Incorrect Choices:
The other choices do not accurately describe the expected ECG changes with exercise. Chronotropic incom-
petence is indicated by an HR that fails to rise; bradycardia (slowing of HR) is not expected. ST segment
elevation with significant Q waves can occur and is indicative of aneurysm or wall motion abnormality.

Type of Reasoning: Inference

In order to answer the question correctly, the test taker must recall typical ECG changes for patients who
have myocardial ischemia and CAD. Therefore, the test taker must draw conclusions about the patient's
diagnosis, which is an inferential reasoning skill. For this patient, one would expect tachycardia and ST seg-
ment depression, which should be reviewed if this question was answered incorrectly.

8175
•
Musculoskeletal I Interventions

A patient with long-term postural changes exhibits an excessive forward head, and complains of pain and diz-
ziness when looking upward. The MOST effective physical therapy intervention is:

Choices:
1. Manual therapy techniques to provide pain relief and postural reeducation.
2. Anterior cervical muscle stretching and postural reeducation to relieve vertebral artery compression.
3. Strengthening exercises to the posterior cervical musculature.
4. Postural reeducation to reduce compression of the cervical sympathetic ganglia.

Teaching Points

Correct Answer: 1
Long-term postural changes with forward head posture include shortening of the posterior muscles, potential
joint restrictions, with possible vertebral artery compromise at the occiput. Restoration of normal movement
throughout the cervical region and postural reeducation is the best choice for this condition.

Incorrect Choices:
The anterior cervical muscles are most likely already lengthened. Strengthening the posterior muscles will not
provide full restoration to the movement restrictions. In addition, the anterior muscle will also benefit from the
reconditioning exercises. Postural reeducation by itself will not promote restoration of normal function.
726 Examination B

Type of Reasoning: Inference

This question provides symptoms and the test taker must determine first what the diagnosis is in order to
determine the most effective intervention to remedy the symptoms. Questions that require one to determine
a most effective approach in therapy often utilize inferential reasoning skill. If this question was answered
incorrectly, refer to information on treatment for vertebral artery compression.

8176
Card iova scular/Pul m onary and Lym phatic I Exami n atio n

A patient with idiopathic dilated cardiomyopathy is on the cardiac unit with telemetry ECG monitoring af-
ter a recent admission for decompensated heart failure. Figure 1 depicts this patient's resting telemetric ECG
recording, and Figure 2 depicts the patient's exercise (ambulating 2.5 mph on a flat surface in the hallway)
telemetric ECG recording. The appropriate interpretation of the change between recordings is:
Figure 1

Figure 2

Choices:
1. Bradycardia, indicating abnormal response to increasing work demands and high risk.
2. Preventricular contractions, indicating abnormal response to increasing work demands and high risk.
3. Ventricular tachycardia, indicating abnormal response to increasing work demands and moderate risk.
4. Tachycardia, indicating normal response to increasing work demands and normal risk.

Teaching Points

Correct Answer: 2
New onset of preventricular contractions (wide complex, lack of a P or Twave) indicates an abnormal
response to increasing work demands, and indicates high risk for cardiac patients based on American College
of Physicians and American Association of Cardiovascular and Pulmonary Rehabilitation risk stratification.

Incorrect Choices:
The rhythm in Figure 2 is not indicative of bradycardia, ventricular tachycardia, or tachycardia.

Type of Reasoning: Analysis

Questions that require the test taker to interpret information presented in the form of graphs or charts test an-
alytical reasoning skill. In this situation, the ECG strip indicates PVCs or preventricular contractions with high
risk. If this question was answered incorrectly, review information on ECG interpretation, especially PVCs.
 Examination B 727

Nonsystem I Safety, P rofessio n al Respo n s ibiliti e s, Researc h

During the course of the physical therapy treatment in the ICU, a radial artery line gets pulled (comes out
ofthe artery). The FIRST thing the PI should do is:

Choices:
1. Elevate the arm above heart level to stop the bleeding.
2. Push the code button in the patient's room, because this is a cardiac emergency.
3. Place a BP cuff on the involved extremity and inflate the cuff until the bleeding stops.
4. Reinsert the arterial catheter into the radial artery and check the monitor for an accurate tracing.

Teaching Points
Correct Answer: 3
A radial arterial line is a catheter placed in the artery itself. If it becomes dislodged during treatment, the
artery is now open to bleeding. This arterial bleeding needs to be stopped immediately, although it is not
considered a cardiac emergency. Place a BP cuff above the site of bleeding and inflate the cuff to above
systole to stop the bleeding or place enough manual pressure on the site to stop the bleeding. Then call
for help.

Incorrect Choices:
Elevating the site of bleeding above heart level will not be as effective, because this is an arterial bleed . As
long as the heart is pumping with adequate pressure, the site will continue to bleed. This is not a cardiac
emergency. Never replace any line that has become disconnected. The line is no longer sterile, and should
not be reinserted into the patient. A new, sterile catheter will need to be used if the radial line is to be
replaced.

Type of Reasoning: Evaluation

This question requires one to use judgment to evaluate the strength of the statements made in order to
arrive at a decision for the first course of action with this patient. In this situation, it is important to stop
the bleeding in the most effective manner possible, which is to inflate a BP cuff on the involved extremity
until the bleeding stops. Questions such as these can be challenging because one must use a value judg-
ment to make the best decision.

Metabolic/Endocrine I Evaluation, Diagnosis

A therapist working in an outpatient clinic examines a patient referred for exercise conditioning. During the
initial examination, the therapist finds unusual swelling and enlargement in the anterior neck with mild
tenderness. The patient does not have any hoarseness or difficulty swallowing. The therapist's BEST course
of action is to:

Choices:
1. Document the findings in the medical record.
2. Take girth measurements of the neck.
3. Notify the referring physician.
4. Initiate the plan of care.
728 Examination B

Teaching Points

Correct Answer: 3
This patient is likely exhibiting hyperthyroidism (Graves' disease) and should be referred to the physician
of record. Additional manifestations of hyperthyroidism include cardiopulmonary changes (increased HR
and respiratory rate, palpitations, dysrhythmias, breathlessness), CNS changes (tremors, hyperkinesias,
nervousness, increased DTRs), musculoskeletal changes (weakness, fatigue, atrophy), and integumentary
effects (heat intolerance).

Incorrect Choices:
Documenting the findings in the medical record without notifying the physician delays medical interven-
tion. Taking girth measurements at this time is not useful information. This disorder should be treated
before beginning an exercise program. The patient will exhibit exercise intolerance and reduced exercise
capacity.

Type of Reasoning: Evaluation

This question requires the test taker to determine a best course of action based on the patient's symptoms.
Questions such as these necessitate weighing of information to determine its significance and ultimately
the best response. In this case, given the significance of the symptoms, the therapist should notify the
patient's physician for follow-up . If this question was answered incorrectly, review symptoms of Graves'
disease.

. 8179

Nonsystem I Safety, Professional Responsibilities, Research

A patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection has been discharged from an
isolation setting with an open wound of the buttocks. The patient is now returning to physical therapy as
an outpatient. The precaution that needs to be adhered to is:

Choices:
1. Treatment can be performed in the therapy gym if contact surfaces are covered.
2. An open wound must be contained within a dressing.
3. Direct contact with the patient should be avoided.
4. Gloves are needed only with dressing changes.

Teaching Points

Correct Answer: 2
Staphylococcal organisms are spread by contact. Open wounds must be well contained with a dressing.
Standard germicidal cleaning measures (hand washing) should be fo llowed. The therapist should be
gloved for any direct contact with the patient's intact skin or surfaces or articles in close proximity to the
patient. All equipment should be cleaned with an approved germicidal agent before and after use.

Incorrect Choices:
Isolation in a private room is not required; in ambulatory settings, the patient should be placed in an ex-
amination room or cubicle as soon as possible. Treatment in an open gym is inappropriate for patients with
MRSA.

Type of Reasoning: Deductive

The test taker must recall standard precautions for MRSA infection in order to choose the best response. This
type of recall is factual and dependent upon knowledge of protocols and guidelines, which is a deductive
reasoning skill. If this question was answered incorrectly, review standard precaution guidelines for MRSA.
 •
Examination B 729

Gastrointestinal I Evaluation, Diagnosis

After examining a patient who was referred to physical therapy for posterior thoracic pain, the therapist
finds no musculoskeletal causes for the patient's symptoms. Pain may be referred to this thoracic region
from the:

Choices:
1. Appendix.
2. Ovary.
3. Gallbladder.
4. Heart.

Teaching Points

Correct Answer: 3
Dysfunction of the gallbladder often refers pain to the thorax.

Incorrect Choices:
The commonly observed referral pattern of the heart is to the chest and upper extremity, the ovaries to the
low back and the appendix to the right lower quadrant.

Type of Reasoning: Analysis

This question requires one to refer to knowledge of physiology and of common referred patterns of pain.
The test taker must recognize that pain referred to the posterior thoracic region is typical of problems
with the gallbladder. To arrive at the correct conclusion, the test taker must analyze the information pre-
sented and determine the meaning of that information, which is an analytical reasoning skill .

8181
•
Nonsystem I Equipment, Devices, Therapeutic Modalities

An elderly patient with a transfemoral amputation is being fitted with a temporary prosthesis containing a
SACH (solid ankle cushion heel) prosthetic foot. This prosthetic foot:

Choices:
1. Absorbs energy through a series of bumpers, permitting sagittal plane motion only.
2. Allows limited sagittal plane motion with a small amount of mediolateral motion.
3. Is an articulated foot with multiplanar motion.
4. Allows full sagittal and frontal plane motion.

Teaching Points

Correct Answer: 2
The SACH foot is the most commonly prescribed type of prosthetic foot. It provides for sagittal plane motion
(primarily plantarflexion) and very limited frontal plane motion (mediolateral motion).

Incorrect Choices:
Articulated feet (joined by a metal bolt or cable to the lower shank section) have rubber bumpers that absorb
shock and control plantarflexion excursion. An anterior stop resists dorsiflexion. Full sagittal and frontal
plane motions are not allowed.
730 Examination B

Type of Reasoning: Analysis

One must recall the properties of a SACH foot in order to choose the correct solution. This requires
knowledge of prostheses and their indications. The test taker must analyze the information presented and
determine the meaning of that information, which is an analytical reasoning skill. If this question was
answered incorrectly, refer to information on properties of prosthetic feet.

•
Neuromuscular I Interventions

An elderly patient demonstrates significant proprioceptive losses in both lower extremities, distal greater
than proximal. The BEST strategy to assist in compensatory gait training is to have the patient:

Choices:
1. Use light touch-down support on available furniture.
2. Look at the feet for placement while walking.
3. Practice walking on smooth tile floors .
4. Count out loud during each step.

Teaching Points

Correct Answer: 2
Selection of compensatory strategies for sensory losses is dependent upon careful assessment of the sen-
sory systems contributing to balance (somatosensory, visual, and vestibular). Control should be refocused
to use available intact sensory systems. In this case, proprioception is impaired while vision is intact.

Incorrect Choices:
Use of counting can aid gait rhythm, but not foot placement. Light touch-down support can aid balance,
but training using available furniture is a bad idea. Walking on smooth tile floors does not address the
need for compensatory training.

Type of Reasoning: Inference

One must draw conclusions or infer information presented in this question in order to make the determi-
nation for the best course of action for this patient. In this case, it is best to have the patient look at his/
her feet while walking. Knowledge of compensatory strategies for sensory loss is important for arriving at
the correct conclusion, and should be reviewed if this question was answered incorrectly.

6183
•
Cardiovascular/Pulmonary and Lymphatic I Examination

A patient in the ICU is referred to physical therapy and presents with significant shortness of breath.
Notable on physical examination is a deviated trachea to the left. Which of the following processes would
account for such a finding?

Choices:
1. Right hemothorax.
2. Left pneumothorax.
3. Left pleural effusion.
4 . Right lung collapse.
 Examination B 731

Teaching Points

Correct Answer: 1
A right hemothorax (blood was in the pleural space) takes up space in the right hemithorax, shifting the
trachea to the left.

Incorrect Choices:
A left pneumothorax and a left pleural effusion take up space in the left thorax. The air (pneumothorax)
or the sterile fluid (effusion) in the pleural space would push contents of the left hemithorax, includ-
ing the trachea, to the right. A lung collapse, or a volume loss phenomenon, on the right would pull the
trachea over toward the right.

Type of Reasoning: Inference

This question requires the test taker to make a determination for the patient's symptoms, which necessi-
tates use of inferential reasoning. In this situation, the deviated trachea to the left is due to a right hemo-
thorax. One must rely on knowledge of pulmonary pathology to arrive at a correct conclusion, which
should be reviewed if this question was answered incorrectly.

Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient complains of pain (7/ 10) in the shoulder region secondary to acute subdeltoid bursitis. As part of
the plan of care during the acute phase, the therapist elects to use conventional TENS, which will modulate
the pain primarily through:

Choices:
1. Ascending inhibition.
2. Descending inhibition.
3. Stimulation of endorphins.
4. Gate control mechanisms.

Teaching Points

Correct Answer: 4
The gate control mechanism is activated by the application of conventional (high-rate) TENS at the spinal
cord level.

Incorrect Choices:
Ascending inhibition occurs after the gate control mechanism has been activated. Low-rate TENS, having
a stronger stimulus and a longer pulse duration, activates the descending inhibition, stimulating endor-
phin production mechanisms.

Type of Reasoning: Deductive

This question requires one to recall the properties of conventional TENS and how pain is modulated. This
primarily requires recall of the properties of conventional TENS, which is factual knowledge and encour-
ages deductive reasoning skills. Review information on TENS properties and neurophysiological effects if
this question was answered incorrectly.
732 Examination B

8185
Musculoskeletal I Evaluation, Diagnosis

A patient described a sudden onset of back pain while trying to lift a heavy barrel. The patient described
this pain as constant, unremitting at an intensity of 10/ 10 over the past 3 days, and unresponsive to pain
medications. The patient is unable to work, but is able to drive to the clinic for treatment unaided. There is
no history of other back-related symptoms in the past. The symptomatology is MOST LIKELY related to :

Choices:
1. Discal dysfunction.
2. Neoplastic disease.
3. Early degenerative osteoarthritis.
4 . Secondary gain.

Teaching Points
Correct Answer: 4
A patient who is able to drive to the clinic for treatment and relates a pain level of 10/ 10 is not providing
consistent subjective data. Secondary gain in this case, and not working, is a likely factor.

Incorrect Choices:
Pain from a disc pathology is typically worse in the morning and will decrease (at least slightly) when the
patient gets out of bed and begins to walk around . The diagnosis is unlikely to be a neoplastic condition
secondary to the acute, traumatic onset. Degenerative osteoarthritis is described as stiffness in the morning
with worsening pain as the activity level increases throughout the day.

Type of Reasoning: Inductive

The test taker must utilize diagnostic thinking and clinical judgment to determine the most likely cause
for the patient's symptoms, which is an inductive reasoning skill. In this case, the patient's inconsistency
in engagement in activities (driving but not being able to work) most likely has secondary gain involved.
If this question was answered incorrectly, review information on secondary gain in patient care.

Cardiovascular/Pulmonary and Lymphatic I Evaluation, Diagnosis

After myocardial infraction (MI) , a patient was placed on medications that included a beta-adrenergic block-
ing agent. When monitoring this patient's response to exercise, the therapist expects this drug will cause HR
to:

Choices:
1. Be low at rest and rise very little with exercise.
2. Be low at rest and rise linearly as a function of increasing workload.
3. Increase proportionally to changes in systolic BP.
4. Increase proportionally to changes in diastolic BP.
 Examination B 733

Teaching Points

Correct Answer: 1
Beta-adrenergic blocking agents (e.g., propranolol [Inderal]) are used to treat hypertension, prevent angi-
na pectoris, and prevent certain arrhythmias. In individuals taking these drugs, HR is low at rest and rises
very little with exercise (blunted response). These changes, therefore, invalidate the use of HR to monitor
exercise responses. A more sensitive measure would be RPE.

Incorrect Choices:
HR does not rise linearly with exercise in patients on propranolol. The medication is used for treatment of
hypertension. Both resting and exercise BP are suppressed.

Type of Reasoning: Analysis

This question requires one to recall the indications for beta-adrenergic agents and effects on cardiovascu-
lar function. This requires one to interpret information and determine the meaning of that information,
which necessitates analytical reasoning skill. If this question was answered incorrectly, review information
on effects of beta-blockers on cardiovascular function .

Musculoskeletal I Interventions

An individual presents with chronic TMJ dysfunction. Which of the following muscles should be addressed
with inhibitory or soft tissue lengthening techniques to help restore limited lateral movement of the man-
dible to the right as a result of muscular tightness?

Choices:
1. Right digastric muscle.
2. Right medial pterygoid muscle.
3. Right temporalis muscle.
4. Right geniohyoid muscle.

Teaching Points

Correct Answer: 2
Lateral excursion of the mandible is produced by the contralateral medial and lateral pterygoids and ipsi-
lateral temporalis muscles. Tightness of the ipsilateral pterygoids or contralateral temporalis muscles may
need lengthening in order to allow full lateral mandibular excursion. The right medial pterygoid would
be one of the muscles targeted for interventions restoring sufficient length.

Incorrect Choices:
The digastrics and geniohyoid muscles are mandibular depressors and would not be targets for muscle
lengthening techniques. The left temporalis may need lengthening.

Type of Reasoning: Inductive

One must use clinical judgment to determine a best course of action in order to arrive at a correct conclu-
sion. This often necessitates inductive reasoning skill. For this case, the therapist should focus treatment
on the right medial pterygoid muscle to restore length. Review treatment approaches for TMJ dysfunction
if answered incorrectly.
 •
734 Exam ination B

8188
Metabolic/Endocrine I Interventions

A patient has a 20-year history of diabetes. Notable on the examination are the following: vascular insuf-
ficiency and diminished sensation of both feet with poor healing of a superficial skin lesion. It is important
that the patient understand the precautions and guidelines on foot care for people with diabetes. Which
recommendation is CONTRAINDICATED to include in patient care instructions?

Choices:
1. Wash the feet daily and hydrate with moisturizing lotion.
2. Inspect the skin daily for inflammation, swelling, redness, blisters, or wounds.
3. Use daily hot soaks and moisturize the skin.
4. Wear flexible shoes that allow adequate room and change shoes frequently.

Teaching Points

Correct Answer: 3
Daily hot soaks are contraindicated because of the increased risk of thermal injury. The patient with diabe-
tes typically has loss of protective sensations.

Incorrect Choices:
All other instructions are correct and important to include in a well-balanced program of foot care.

Type of Reasoning: Inference

This question requires one to determine the recommendation to a patient with diabetes that is contrain-
dicated. In this circumstance, one should NOT recommend hot soaks because of the risk of thermal injury
from loss of protective sensations in the feet. Questions that require one to draw conclusions and formu-
late opinions based on information presented encourage use of inferential reasoning. If this question was
answered incorrectly, refer to guidelines for diabetic foot care.

8189
Musculoskeletal I Evaluation, Diagnosis

After completing an examination of a patient with shoulder pain, the PT concludes that the cause is sub-
scapularis tendinitis. The clinical finding supportive of this conclusion is:

Choices:
1. Pain provoked with active glenohumeral external rotation.
2 . Pain provoked with passive glenohumeral external rotation.
3. Tenderness at the greater tubercle ofthe humerus.
4. Painful resisted shoulder adduction.

Teaching Points
Correct Answer: 2
The subscapularis is an internal rotator of the humerus. It will be painful if passively stretched into ex-
ternal rotation and irritated when contracting or being resisted when the shoulder internally rotates. The
muscle inserts onto the lesser tubercle of the humerus and plays no role in shoulder adduction.
 Examination B 735

Incorrect Choices:
Active glenohumeral external rotation does not require activation of the subscapularis muscle. The subscapu-
laris attaches to the lesser tuberosity. The subscapularis is not the primary mover for shoulder adduction, so
is not likely to be painful with resisted shoulder adduction.

Type of Reasoning: Inductive

This question requires diagnostic reasoning and clinical judgment, which is an inductive reasoning skill.
Knowledge of upper extremity orthopedics, especially rotator cuff impairments, is needed to answer this
question. One must recall the typical positions and motions that will evoke pain for patients with subscapu-
laris tendinitis in order to arrive at the correct conclusion, which should be reviewed if this question was
answered incorrectly.

•
Musculoskeletal I Interventions

A soccer player sustained a grade II inversion ankle sprain 2 weeks ago. The BEST intervention in the early
subacute phase of rehabilitation would most likely include:

Choices:
l. Plyometric-based exercise program.
2. Closed-chain strengthening and proprioceptive exercises.
3. Functional soccer-related drills.
4. Mobilization at the talocrural and subtalar joints.

Teaching Points

Correct Answer: 2
The most effective treatment for this athlete would involve closed-chain exercises and proprioceptive
training, appropriate interventions for early subacute phase management.

Incorrect Choices:
The other choices are not appropriate or timely for early subacute phase management. These approaches
may be useful later in the rehabilitation of this athlete.

Type of Reasoning: Inference

One must infer or draw conclusions for the best early intervention approach, given the injury and knowl-
edge of rehabilitation techniques for this injury. This requires inferential reasoning skill, in which the test
taker applies this knowledge and formulates conclusions about the patient for a best course of action. If
this question was answered incorrectly, review information on early treatment for inversion ankle sprain.
736 Exam ination B

8191
Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient is referred for outpatient care after a tendon transfer of the extensor carpi radialis longus. The
muscle strength tests poor (2/ 5) in spite of previous intensive therapy. The therapist elects to apply biofeed-
back to assist in progressively increasing active motor recruitment. Initially, the EMG biofeedback protocol
should consist of:

Choices:
1. High-detection sensitivity with recording electrodes placed close together.
2. High-detection sensitivity with recording electrodes placed far apart.
3. Low-detection sensitivity with recording electrodes placed close together.
4. Low-detection sensitivity with recording electrodes placed far apart.

Teaching Points

Correct Answer: 1
High-detection sensitivity is needed to detect low-amplitude signals generated by a small number of mo-
tor units such as in a weak extensor carpi radialis longus.

Incorrect Choices:
Wide electrode placement would pick up signals from more than one muscle and might invalidate the
procedure. Low-detection sensitivity may not pick up the necessary motor unit signals.

Type of Reasoning: Deductive

This question requires application of knowledge of EMG biofeedback protocols in order to determine the
best approach to early biofeedback intervention. This encourages deductive reasoning skilL which encour-
ages recall of factual knowledge of protocols to apply information to a specific case situation of extensor
carpi radialis longus tendon transfer. If this question was answered incorrectly, review information on
EMG biofeedback guidelines .

•
System Interactions I Evaluation, Diagnosis

A PT receives a home care referral from the nurse case manager. An elderly man has lost functional inde-
pendence after the recent death of his wife. His past medical history includes stroke with minimal residual
disability. Currently, he no longer goes out of his house and rarely even gets out of his chair anymore. Dur-
ing the initial session, the therapist determines that depression may be the cause of his increasing inactivity
based on the presence of:

Choices:
1. Sleep apnea and weight gain.
2. Complaints of increasing dizziness and palpitations.
3. Low scores on the Geriatric Depression Scale.
4. Weight loss and social withdrawal.

Teaching Points
Correct Answer: 4
Depression is associated with symptoms of withdrawaL fatigue, and weight loss.
 Examination B

Incorrect Choices:
Sleep apnea is a potentially lethal disorder in which breathing stops for 10 seconds or more, many times
a night. It is associated with obesity and anatomical obstruction. Increasing dizziness and palpitations are
suggestive of cardiovascular problems. The Geriatric Depression Scale is a valid measure of depression in the
elderly. High, not low, scores (>8 of a possible 30) are indicative of depression.

Type of Reasoning: Inference

One must recall the typical symptoms associated with depression in the elderly to arrive at the correct con-
clusion. This requires one to draw conclusions and make assumptions based on the information presented,
which is an inferential reasoning skill. If this question was answered incorrectly, review symptoms of depres-
sion, especially symptoms in the elderly.

Nonsystem I Safety, Professional Responsibilities, Research

A PT, practicing in a sports and orthopedic clinic, is scheduled to see a child with bilateral knee pain. The
patient arrives for the initial examination, and it is immediately evident that the patient also presents with
spastic cerebral palsy and dysarthria. The therapist has no pediatric experience. The PT should:

Choices:
1. Complete the initial examination and, before the next visit, search the Internet for appropriate interven-
tions.
2. Inform the parent that he/she will need to find another more specialized PT.
3. Inform the parent of the issue of no pediatric experience, and refer the patient to a PT with appropriate
expertise.
4. Complete the initial examination and then advise the parent to see another more specialized PT.

Teaching Points

Correct Answer: 3
PTs are accountable for making sound professional judgments. The Code of Ethics obligates PTs not only
to make judgments within their scope of practice but also to consider their level of expertise. PTs are also
obligated to collaborate with or refer to peers when necessary. The treatment of this patient is beyond the
therapist's level of expertise; therefore, the PT is obligated to refer to a colleague with the appropriate level
of expertise.

Incorrect Choices:
The PT should not perform the initial examination, because this patient's needs exceed the therapist's
level of expertise. Although researching interventions is an option to supplement a foundation of inter-
ventions, it should not be the resource that determines the plan of care. The PT is obligated to refer the
patient to another therapist and not just refuse to see the patient because this may be viewed as abandon-
ment.

Type of Reasoning: Evaluation

The question requires one to identify the limited knowledge of the PT in examining and treating this
patient with specific issues and diagnoses. This necessitates evaluative reasoning skill, which is often
utilized in ethical situations. In order to answer this question correctly, the test taker needs to identify the
limitations in the therapist's scope of practice and level of expertise in relationship to this specific patient,
then identify the need for referral when the care required is outside the scope or level of expertise. If this
question was answered incorrectly, review the Code of Ethics.
738 Exa mination B

Cardiovascular/Pulmonary and Lymphatic I Examination

A patient has been on bedrest for 4 days following complications after revascularization surgery involving a
triple coronary artery bypass graft. During the first therapy session, the patient complains of tenderness and
aching in the right calf. The therapist should immediately examine for:

Choices:
1. Bradycardia.
2. Homan's sign.
3. Lowered body temperature.
4. Swelling in the calf or ankle.

Teaching Points
Correct Answer: 4
Deep vein thrombophlebitis (DVT) is characterized by classic signs of inflammation (tenderness, aching,
and swelling), typically in the calf. Rapid screening is possible with Doppler ultrasonography. Color flow
venous duplex scanning is the primary diagnostic test for detection of DVT.

Incorrect Choices:
Tachycardia, not bradycardia, may be present. Slight fever can be present, as part of the inflammatory
reaction, not lowered temperature. Homan's sign is pain in the calf perceived with squeezing the calf and
dorsiflexion; this is not considered reliable and lacks specificity and sensitivity.

Type of Reasoning: Evaluation

This question requires one to evaluate the approaches presented and determine which approach has the
most merit, given the patient's current symptoms. This requires evaluative reasoning skill, in which the
test taker must weigh arguments and statements made and formulate a conclusion about the strength of
these approaches. If this question was answered incorrectly, review symptomatology of DVT.

8195
Musculoskeletal I Evaluation, Diagnosis

A patient is referred for physical therapy with jaw pain and dysfunction . The patient has experienced three
episodes of jaw locking in an open position in the past week. The MOST LIKELY cause of this problem is:

Choices:
l. Impingement of the temporomandibular ligament.
2. Disc displacement.
3. Lateral pterygoid muscle spasm.
4. Entrapment of the retrodiscallamina.

Teaching Points
Correct Answer: 2
This patient is experiencing temporomandibular joint dysfunction (TMJ) . The jaw becomes locked in an
open position when the disc is displaced . The muscles influence lateral deviation of the jaw with opening.
 Examination B 739

Incorrect Choices:
The temporomandibular ligament cannot become impinged. The lateral pterygoid muscle would not cause
the mouth to be locked open if it experienced a spasm. Entrapment of the retrodiscallamina is painful, but
it is a consequence of a TMJ being locked open secondary to a disc displacement, not a cause.

Type of Reasoning: Analysis

This question requires knowledge ofTMJ anatomy and typical dysfunction of the joint associated with TMJ
disorder. The jaw locking in an open position most likely indicates that the disc has been displaced. Through
analytical reasoning, one must interpret or analyze the information presented and determine which prob-
lem seems to be the most likely cause. If this question was answered incorrectly, review information on TMJ
disorders.

System Interactions I Evaluation, Diagnosis

An elderly patient is referred to physical therapy after a fall and ORIF for a fracture of the right wrist. Dur-
ing the initial examination, the therapist observes that the patient's skin and eyes have a yellowish hue. The
therapist's BEST course of action is to:

Choices:
1. Continue with the treatment; a yellowish hue is an expected finding 3-4 days post-ORIF.
2. Treat the problem with whirlpool and massage and reevaluate skin color posttreatment.
3. Document the findings and consult with the surgeon immediately after treatment.
4. Send a copy of the examination results to the referring surgeon, emphasizing the skin hue.

Teaching Points

Correct Answer: 3
This patient is most likely experiencing jaundice as a result of liver dysfunction. The therapist's best course
of action is to document the findings and consult with the surgeon immediately, preferably by phone.

Incorrect Choices:
All other choices delay consulting with the primary physician. The symptoms indicate liver dysfunction
and jaundice, which warrant immediate contact with the surgeon.

Type of Reasoning: Evaluation

The test taker must determine first what the patient's symptoms are indicative of and then determine what
should be the appropriate course of action. Questions such as these, in which value judgments must be
made, encourage evaluative reasoning skill.
740 Examination B

8197
Musculoskeletal I Evaluation, Diagnosis

An older adult received a cemented total hip replacement (THR) 2 days ago . The physical therapy plan of
care should have as its INITIAL priority:

Choices:
l. AROM exercises and early ambulation using a walker, non-weight bearing.
2. Patient education regarding positions and movements to avoid.
3. PROM exercises and gait training using crutches, weight bearing to tolerance.
4. Proper technique for transferring to the toilet.

Teaching Points

Correct Answer: 2
Education regarding positions and movements to avoid is the number one priority. Standard hip precau-
tions stress avoiding excessive flexion, internal rotation, and adduction.

Incorrect Choices:
Patients with cemented THRs should initially be weight bearing to tolerance using a walker. Transfer train-
ing should occur, but it is not the first initial priority.

Type of Reasoning: Inductive

One must utilize clinical judgment and diagnostic thinking (an inductive reasoning skill) to determine
the number one priority for this patient with a recent THR. In this situation, it is important to educate the
patient regarding positions and movements to avoid, which if not followed could cause potential disloca-
tion of the hip. If this question was answered incorrectly, refer to guidelines for early care of patients with
THR.

8198
Musculoskeletal I Examination

A patient with recent trauma presents with restricted movement of the right hand. There is decreased mo-
tion at the third right MCP joint. To differentiate as to whether this is joint restriction or some other type of
tightness (not joint), which examination procedure should be employed?

Choices:
1. Tight retinacular test.
2. Finkelstein's test.
3. Froment's sign.
4. Bunnel-Littler test.

Teaching Points

Correct Answer: 4
The Bunnel-Littler test is specifically utilized to determine if there is a joint restriction present at the MCP
joints.
 Examination B 741

Incorrect Choices:
The retinacular test is used to determine if there is a restriction at the PIP joint. Finkelstein's test is used to
assess for a tenosynovitis of the abductor pollicis longus and/or extensor pollicis brevis. Froment's sign is
utilized to identify an ulnar nerve dysfunction.

Type of Reasoning: Deductive

This question provides a diagnosis and the test taker must recall the specific test that confirms the diagno-
sis. This necessitates factual recall of guidelines, which is a deductive reasoning skill. For this situation, the
Bunnel-Littler test is the correct test to confirm joint restriction present at the MCP joints. Review differen-
tial testing for hand injuries if answered incorrectly, especially the Bunnel-Littler test.

Cardiovascular/Pulmonary and Lymphatic I Interventions

A patient with stage II primary lymphedema of the right lower extremity is referred for physical therapy.
Examination reveals increased limb girth with skin folds/flaps evident. An important component of lymph-
edema management is manual lymphatic drainage. This procedure should include:

Choices:
1. Decongesting the distal portions of the limb first and working proximally.
2. Decongesting the trunk after the limb segments.
3. Decongesting the proximal portions of the limb first and working distally.
4 . Deep tissue friction massage for several minutes on fibrotic areas.

Teaching Points

Correct Answer: 3
Lymphedema is a swelling of the soft tissues that occurs with an accumulation of protein-rich fluid in
the extracellular spaces. Causes of primary lymphedema include developmental abnormalities, heredity,
surgery, or unknown etiology. Stage II lymphedema is characterized by nonpitting edema with connec-
tive scar tissue and clinical fibrosis. Lymphatic drainage is assisted by manual stroking (e.g., Vodder,
Leduc's, Foldi's, Casley-Smith pressure techniques). All techniques use cardinal principles: proximal limb
segments before distaL trunk segments before limb segments, and directing the flow of the lymphatics
centrally toward the lymphatic ducts.

Incorrect Choices:
The other choices do not adhere to the cardinal principles of lymphatic drainage as explained.

Type of Reasoning: Deductive

This question requires one to recall factual knowledge-that of manual lymphatic drainage techniques
for patients with primary lymphedema. This encourages deductive reasoning skill, in which the test taker
must recall the protocols and guidelines for this technique. If this question was answered incorrectly,
review information on manual lymphatic drainage techniques.
742 Exa mination B

8200
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\Y
Nonsystem I Equipment, Devices, Therapeutic Modalities

A patient with a lO-year history of multiple sclerosis (MS) demonstrates 3+ extensor tone in both lower
extremities. The therapist needs to order a wheelchair. It would be BEST to recommend a(n) :

Choices:
1. Standard wheelchair with a 30° reclining back.
2. Tilt-in-space wheelchair with a pelvic belt.
3. Electric wheelchair with toe loops.
4. Standard wheelchair with elevating legrests.

Teaching Points

Correct Answer: 2
A patient with strong extensor tone needs controls over the hips (pelvic belt) to maintain the hips in flex-
ion. The tilt-in-space design best assists in keeping the patient from coming out of the chair when exten-
sor spasms are active.
The other choices do not adequately address these problems. A reclining back would only increase ex-
tensor tone and extensor spasms. Elevating legrests assist circulatory flow in the lower extremities but may
increase, not decrease, extensor tone. Toe loops function to keep the feet on the foot pedals. In the event
of an extensor spasm, they would not control for proximal tone.

Type of Reasoning: Inductive

The test taker must utilize clinical judgment to determine the best recommendation for this patient, given
the diagnosis and symptoms. For this patient, a tilt-in-space wheelchair with a pelvic belt would best ad-
dress the patient's extensor tone in the lower extremities. If this question was answered incorrectly, review
wheelchair prescription for patients with the presence of extensor tone.