What does a positive posterior drawer sign in a 10-year-old soccer player signify?
a) Normal knee
b) Instability of the knee c) Swelling on the
... [Show More] knee
d) Injury to the meniscus - ANS: B
The drawer test is used to identify mediolateral or anteroposterior plane instability of the knee. The test is performed on the unaffected and affected knee for comparison. The anterior drawer test evaluates the anterior cruciate ligament (ACL). To perform the test, the patient lies supine and the knee is placed at 90-degree flexion. Grasp the posterior aspect of the tibia over the upper calf muscle; then, with a steady force, try to push the lower leg forward and backward. Anterior or posterior movement of the knee is positive. With the leg extended, stabilize the femur with one hand and the ankle with the other. Try to abduct and adduct the knee. There should be no medial or lateral movement.
A patient injures an ankle while playing soccer and reports rolling the foot inward while falling with immediate pain and swelling of the lateral part of the joint. The patient is able to bear weight and denies hearing an audible sound at the time of injury. What does this history indicate?
a. Likely ankle sprain with a possible fracture b. Mild ankle injury without fracture
c. Mild soft tissue injury only
d. Serious ankle injury with certain fracture - ANS: A
Immediate swelling of the joint raises the index of suspicion for a fracture or a substantial amount of joint involvement. Without radiographs, none of these possibilities can be confirmed.REF: Clinical Presentation
A patient who is a distance runner reports pain in one heel that is worse in the morning and seems to improve with exercise. The provider notes localized swelling and a bony prominence at the heel. What is the initial treatment for this condition?
a. Cessation of all sports activities and exercise b. Crutches and partial weight bearing
c. Physical therapy for ultrasound therapy
d. Referral to an orthopedist for MRI and evaluation - ANS: A
This patient has symptoms consistent with Achilles tendonitis. Immediate cessation of sports and exercise is the first step in management. Crutches and partial weight bearing may be indicated if symptoms do not improve with rest and NSAIDs. Physical therapy is
used as adjunctive therapy. Symptoms that do not improve require referral.REF: Achilles Tendonitis/Management
A patient reports elbow pain and the examiner elicits pain with resisted wrist flexion, forearm pronation, and passive wrist extension on the affected side. What is a likely cause of this pain?
a. Lateral epicondylitis
b. Medial collateral ligament instability c. Medial epicondylitis
d. Ulnar neuritis - ANS: C
Medial epicondylitis will produce pain as described above. Lateral epicondylitis may result in pain with passive wrist flexion and active wrist extension.
A 19-year-old male athlete complains of acute knee pain after a football game. The nurse practitioner elicits McMurray's sign, which is positive on the patient's injured knee. This is a test for:
a) Meniscal injury
b) Inflammation of the knee joint c) Osteophytes of the knee joint d) Tenosynovitis - ANS: A
With an acute knee injury, the knee should be assessed using McMurray's sign. A positive McMurray's sign indicates a meniscal injury. Inflammation of the knee, osteophytes, and tenosynovitis would not elicit a positive McMurray's sign.
The complications of untreated gout include:
a) Impaired joint mobility and renal damage b) Impaired joint mobility and liver damage c) An increased risk of urinary tract infections d) Bladder cancer - ANS: A
Left untreated, gout can develop into a painful and disabling chronic disorder. Persistent gout can destroy cartilage and bone, causing irreversible joint deformities and loss of motion. High urate levels can deposit in the kidney and also lead to kidney stones.
All of the following factors are associated with a higher risk of osteopenia and osteoporosis except:
a) Excessive alcohol intake and cigarette smoking b) Asian or Caucasian ancestry
c) Obesity
d) Older age - ANS: C
Obesity is not a risk factor for bone loss. But being female, older age, in menopause, having a small thin frame, being of Caucasian or Asian race, family history of osteoporosis, excessive alcohol use, and long-term cigarette smoking are risk factors.
A 36-year-old man presents to the nurse practitioner complaining of a history of cervical and upper back pain for many months. On examination, the range of motion of the patient's spine is limited, especially with lateral flexion. The other joints in the patient's body are normal. Only the spine seems to be affected. The patient reports that a laboratory test from a previous doctor showed increased ESR(erythrocyte sedimentation rate), negative antinuclear antigen (ANA), and negative rheumatoid factor. Which of the following is best described?
a) Rheumatoid arthritis b) Lupus erythematosus
c) Degenerative joint disease of the spine d) Ankylosing spondylitis - ANS: D
Ankylosing spondylitis (AS) is a lifelong autoimmune disease and form of arthritis that causes inflammation, pain, and stiffness, mainly in the spinal joints. The typical patient is a young adult. In the early stages of AS, the pain and stiffness often start in the lower back, but over time may move up the spine and into the neck. Most people with AS experience episodes of acute painâ€"known as flaresâ€"followed by periods when symptoms temporarily subside. There are no specific lab tests to identify ankylosing spondylitis. The erythrocyte sedimentation rate (ESR) is increased by the inflammation. There is a high risk of uveitis (red eyes, blurred to decreased vision, photophobia, floaters).
A 55-year-old woman brings her mother, who is 82 years of age, to the emergency department of a local hospital. She reports she found her mother on the floor when she checked on her that morning. Her mother was awake and oriented, but needed help getting up. Her mother states that she thinks she passed out. She is being evaluated by a physician who orders an EKG and x-rays of both hips. Regarding laboratory testing, which of the following tests is important to perform initially?
a) Urinalysis
b) Serum electrolytes c) Blood glucose
d) Hemoglobin and hematocrit - ANS: c
Checking the blood glucose is indicated for patients with syncopal and near-syncopal episodes. The nurse practitioner should also perform a thorough history of the incident. Possible causes of syncope are cardiac arrhythmia, vasovagal, hypoglycemia, orthostatic hypotension, seizure, accidental fall, and others.
Thiazide diuretics have been shown to have a beneficial effect on the bones, making them a desirable treatment option in hypertensive women with osteopenia or osteoporosis. What is the mechanism of action for their effect on the bones?
a) Thiazide diuretics decrease calcium excretion by the kidneys and stimulate osteoblast production
b) Thiazide diuretics increase both calcium and magnesium retention by the kidneys c) Thiazide diuretics increase bone mineral density (BMD)
d) Thiazide diuretics influence electrolyte excretion by the kidneys - ANS: A
This positive side effect of thiazides results in a decrease in calcium bone loss and an increase in bone mineral density.
A 36-year-old woman complains of fatigue and headaches accompanied by widespread muscle and joint pain that started 6 months ago. She reports insomnia and feeling tired even with adequate sleep. She was diagnosed with major depression 1 year ago and is currently on escitalopram (Lexapro) 20 mg PO daily. She is also taking B-complex vitamins and melatonin at bedtime for sleep. During the physical exam, the nurse practitioner notes bilateral areas of tender points on the neck, jaw, shoulders, chest, upper back, and greater trochanter. The symptoms and physical exam findings are highly suggestive of which condition?
a) Rheumatoid arthritis b) Osteoarthritis
c) Fatigue syndrome
d) Fibromyalgia - ANS: D
The American College of Rheumatology (2010) uses several criteria to diagnose fibromyalgia: widespread pain index, symptoms present at a similar level for at least 3 months, and presence of pain or tenderness at certain body sites. The locations in the body (widespread pain index) are neck, jaw, shoulder girdle, upper and lower arm, chest, abdomen, upper and lower back, upper and lower leg, and hip (trochanters). Other criteria include fatigue, sleep problems, and cognitive symptoms. The exact cause of fibromyalgia is unknown. Treatment is symptomatic.
What is the significance of a positive Lachman sign?
a) Instability of the knee caused by damage to the anterior cruciate ligament of the knee b) Posterior cruciate ligament laxity which may cause locking of the knee
c) Achilles tendon rupture
d) Patellar tendon rupture - ANS: A
A positive Lachman sign is highly suggestive of damage to (i.e., rupture of) the anterior cruciate ligament (ACL) of the knee. The anterior drawer sign may also be positive. The examiner notes laxity of the abnormal knee joint compared with the normal knee. The Lachman test or maneuver is considered more sensitive for ACLdamage than the anterior drawer test.
Which of the following individuals is most likely to be at higher risk for osteoporosis?
a) 70-year-old woman of African ancestry who walks daily for exercise
b) 42-year-old obese woman from Cuba who has been taking prednisone 10 mg daily for the past 12 years to control her severe asthma
c) 55-year-old Caucasian woman who is an aerobics instructor
d) 45-year-old Asian woman who has been on high-dose steroids for 1 week - ANS: B
Risk factors for osteoporosis include postmenopause, early menopause, use of chronic steroids, smoking, excessive use of alcohol, sedentary lifestyle, insufficient intake of calcium and vitamin D in the diet, and being an Asian or Caucasian female.
Carpal tunnel syndrome is due to inflammation of the:
a) Ulnar nerve b) Radial nerve c) Brachial nerve
d) Median nerve - ANS: D
Compression of the median nerve within the carpal tunnel produces characteristic symptoms"burning; tingling; numbness over the thumb, index, middle, and ring fingers. The Phalen maneuver is a diagnostic test for carpal tunnel syndrome. It is performed by pushing the back of the hands together for 1 minute. Eliciting carpal tunnel symptoms indicates a positive result for the test.
All of the following measures have been found to help lower the risk of osteoporosis except:
a) Drinking organic orange juice b) Eating low-fat dairy foods
c) Performing weight-bearing exercises d) Vitamin D supplementation - ANS: A
Commercial orange juice is fortified with calcium and vitamin D. But organic products usually do not have any additives such as calcium. Vitamin D levels must be sufficient for the body to absorb calcium. Eating foods high in vitamin D and calcium along with calcium and vitamin D supplements is advised to protect the bones and prevent bone loss.
Performing weight-bearing exercises daily also increases bone strength. Which of the following conditions is considered a radiculopathy?
a) Polymyalgia rheumatica b) Sciatica
c) Stroke
d) Dementia - ANS: B
Sciatica is a radiculopathy of the sciatic nerve, which is part of the sacral nerves of the cauda equina. A radiculopathy is spinal nerve root irritation or inflammation that is caused
by compression of one (or more) of the five spinal nerve roots. Some of the most common causes of sciatica are protruding or ruptured disk, osteoarthritis of the spine, and metastases. Radiculopathy symptoms include burning pain or sensation, numbness, tingling, and/or weakness.
A menopausal woman with osteopenia is attending a dietary education class. Which of the following foods are recommended?
a) Yogurt and sardines b) Spinach and red meat c) Cheese and red meat
d) Low-fat cheese and whole grain - ANS: A
Postmenopausal women are advised to increase their dietary intake of calcium and vitamin D to help protect their bones from osteopenia and osteoporosis. Good sources of calcium include low-fat dairy products (yogurt), dark leafy vegetables, canned salmon or sardines with bones, soy products, and calcium-fortified cereals and orange juice. Just 3 ounces of canned sardines, including bones, drained of oil, provides 324 mg of calcium.
Glucosamine sulfate is a natural supplement that is used for which of the following conditions?
a) Rheumatoid arthritis b) Osteoarthritis
c) Osteoporosis
d) Metabolic syndrome - ANS: B
Glucosamine sulfate has been found to have a beneficial effect on cartilage growth and repair. It may also have an anti-inflammatory effect. Many patients with OAwho take it claim that it helps to relieve joint pain. Effects may not be felt for 1 to 3 months after starting the medicine. Glucosamine is a compound made up of glucose and an amino acid.
The gold-standard test for visualizing a torn meniscus or joint abnormalities is the:
a) Computed tomography (CT) scan
b) Magnetic resonance imaging (MRI) scan
c) X-ray with special views of the affected knee d) Lachman's maneuver - ANS: B
MRIs provide good visualization of soft tissues of the body (most cancers, brain, cartilage, muscles, inflammation, etc.). They are best used to evaluate tissues with high water content. Patients with metal implants, such as cochlear implants and cardiac pacemakers, should be carefully screened. The MRI does not use radiation, but uses strong magnetic and radio waves to visualize body structures.
The best form of aerobic exercise for a patient with severe rheumatoid arthritis is:
a) Yoga
b) Swimming
c) Riding a bicycle
d) Passive range of motion - ANS: B
The American College of Rheumatology states that exercise is beneficial for everyone, including those with rheumatoid arthritis, and currently recommends 150 minutes of moderate-intensity aerobic activity each week. Safe forms of aerobic exercise, such as walking and aquatic exercise, help arthritis patients to control weight, and improve sleep, mood, and overall health.
The Phalen test is used to evaluate:
a) Inflammation of the median nerve b) Rheumatoid arthritis
c) Degenerative joint changes
d) Chronic tenosynovitis - ANS: A
The Phalen maneuver is a diagnostic test for carpal tunnel syndrome. The test is performed by pushing the back of the hands together for 1 minute. This compresses the median nerve within the carpal tunnel. Characteristic symptoms (burning; tingling; numbness over the thumb, index, middle, and ring fingers) convey a positive test result.
The Lachman maneuver is used to detect which of the following?
a) Instability of the knee
b) Nerve damage of the knee due to past knee injuries c) Integrity of the patellar tendon
d) Tears on the meniscus of the knee - ANS: A
The Lachman maneuver is a test performed to assess for knee instability (i.e., damage to the motion of anterior translation [laxity] of the anterior cruciate ligament [ACL]) or tear of the ACL. The maneuver should be tested on both knees, comparing the injured and the opposite knee, the uninjured knee is used as the "control." The test is positive if the injured knee slips back further (laxity). Perform the test by bending the knee 30 degrees. Stabilize the femur with one hand. Place the other hand under the proximal tibia at the level of the joint line and then pull forward. The laxity is graded on a 0 (normal)-to-3 scale (1.0-1.5 cm of translation).
A positive straight leg raising test is indicative of which of the following?
a) Myasthenia gravis
b) Inflammation of the sciatic nerve/herniated disk c) Multiple sclerosis
d) Parkinson's disease - ANS: B
To perform the straight leg test, have the patient lie supine on an exam table. Lift the patient's leg toward his or her head while the knee is straight. If the patient experiences sciatic pain when the straight leg is at an angle between 30 and 70 degrees, then the test is positive and a herniated disk is likely to be the cause of the pain. The straight leg test should be done on the pain-free side first to find out which range of movement is normal and to enable the patient to distinguish between "normal" stretching of muscles and a different sort of pain.
Bouchard's nodes are associated with which of the following conditions? a) Osteoarthritis and rheumatoid arthritis
b) Osteoporosis and osteopenia c) Degenerative joint disease
d) Autoimmune disorders - ANS: A
Bouchard's nodes are seen in both osteoarthritis (or degenerative joint disease) and rheumatoid arthritis. They are located on the proximal interphalangeal (PIP) joints on the hands.
All of the following signs and/or symptoms are seen in patients with rhabdomyolysis except:
a) Myalgias and generalized weakness b) Bone pain
c) Muscles that are tender on palpation d) Dark-colored urine - ANS: B
Rhabdomyolysis is the rapid breakdown of skeletal muscle; it releases large amounts of myoglobin, which is toxic to the kidneys. It can result in acute kidney injury or acute renal failure. There are many causes such as severe exercise, traumatic crush injuries, medicines (statins, fibrates especially if combined), illicit drugs, and others. The signs and symptoms of rhabdomyolysis are muscle pain (shoulders, thighs, calves, lower back), muscle weakness, dark-red or brown urine, fever, tachycardia, and/or decreased urination. Almost half of patients report no muscular symptoms.
A 76-year-old woman reports that for the previous 4 months, she has noticed severe stiffness and aching in her neck and both shoulders and hips that is worsened by movement. She reports having a difficult time getting out of bed because of the severe stiffness and pain. It is difficult for her to put on a jacket or blouse or to fasten her bra. Along with these symptoms, she also has a low-grade fever, fatigue, loss of appetite, and weight loss. Starting yesterday, the vision in her right eye has progressively worsened. She has annual eye exams and denies that she has glaucoma. Which of the following conditions is most likely?
a) Rheumatoid arthritis (RA) b) Degenerative joint disease
c) Polymyalgia rheumatica (PMR)
d) Fibromyalgia - ANS: C
PMR is a rheumatic condition that involves joints and arteries. It is associated with a high risk of giant cell arteritis (GCA) or temporal arteritis (15%-30%). The new onset of vision loss and the location of the pain (neck, both shoulders/hips) are the most important clues. Temporal arteritis can cause permanent blindness. Patients with PMR have a very high (40- 100 mm/hr) sedimentation rate. Almost all will have elevated C-reactive protein levels (up to 99%). These patients are managed by rheumatologists by means of long-term steroids.
Kyphosis is a late sign of:
a) Rheumatoid arthritis b) Osteopenia
c) Osteoporosis
d) Osteoarthritis - ANS: C [Show Less]