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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 knee d) Injury to the meniscus Explanation correct ... instability of the knee 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. 1. 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 2. 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/Management3. 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. 2. 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 Explanation 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. 3. 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 Explanation correct Impaired joint mobility and renal damage 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. 4. All of the following factors are associated with a higher risk of osteopenia and osteoporosis except: a) Excessive alcohol intake and cigarette smokingb) Asian or Caucasian ancestry c) Obesity d) Older age Explanation 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. 5. 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 Explanation correct 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 pain—known as flares—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). 1. 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 Explanation correct cChecking 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. 2. 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 Explanation correct a This positive side effect of thiazides results in a decrease in calcium bone loss and an increase in bone mineral density. 3. 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 Explanation correct 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. 4. 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 ruptured) Patellar tendon rupture Explanation 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. 5. 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 Explanation correct 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. 6. Carpal tunnel syndrome is due to inflammation of the: a) Ulnar nerve b) Radial nerve c) Brachial nerve d) Median nerve Explanation 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. 7. 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 Explanation correct aCommercial 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. 8. Which of the following conditions is considered a radiculopathy? a) Polymyalgia rheumatica b) Sciatica c) Stroke d) Dementia Explanation 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. 9. 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 Explanation correct 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. 10.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 Explanation.correct bGlucosamine 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. 11.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 Explanation correct 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. 12.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 Explanation correct 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. 13.The Phalen test is used to evaluate: a) Inflammation of the median nerve b) Rheumatoid arthritis c) Degenerative joint changes d) Chronic tenosynovitis Explanation correct 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 nervewithin the carpal tunnel. Characteristic symptoms (burning; tingling; numbness over the thumb, index, middle, and ring fingers) convey a positive test result. 14.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 Explanation correct 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). 15.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 Explanation correct 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. 16.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 Explanation correct 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.17.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 Explanation correct 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. 18.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 Explanation. Correct 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. 19.Kyphosis is a late sign of: a) Rheumatoid arthritis b) Osteopenia c) Osteoporosis d) Osteoarthritis Explanation. Correct cKyphosis is a curvature of the spine that causes a rounding of the back, which leads to a slouching posture. Severe thinning of the bones (osteoporosis) contributes to this curvature in the spine. Symptoms that may occur with severe cases of kyphosis include difficulty breathing, fatigue, and back pain. 20.A 60-year-old female truck driver presents to the outpatient urgent care clinic of a hospital complaining of the worsening of her low-back pain the past few days. Pain is accompanied by numbness in the perineal area. She describes the pain as "sharp and burning" and points to the left buttock. She reports that the pain started on the midbuttock of the left leg and recently started to go down the lateral aspect of the leg toward the top of the foot. During the physical exam, the ankle jerk and the knee jerk reflex are 1+ on the affected leg and 2+ on the other leg. The pedal, posterior tibialis, and popliteal pulses are the same on both legs. Which of the following tests should the nurse practitioner consider for this patient? a) Order an MRI scan of the lumbosacral spine as soon as possible b) Write a prescription for ibuprofen 800 mg PO QID with a muscle relaxant and advise the patient to follow up with her primary care provider within 3 days c) Refer the patient to an orthopedic surgeon d) Ordering an imaging study of the spine is premature because the majority of low back pain cases resolve within 10 to 12 weeks Explanation. Correct a The patient has new-onset numbness of the perineal area (saddle anesthesia), the sciatica is worsening, and the deep tendon reflexes of the lower extremity are decreased on the affected side. Rule out cauda equine syndrome and order an MRI (preferred test). The MRI can detect nerve root compression, herniated disk, cancer, and spinal stenosis (narrowing of the spinal canal). In addition, the patient needs to follow up with a neurologist as soon as possible. 21.Hypovolemic shock would most likely occur with fractures of the: a) Spine b) Pelvis c) Femur d) Humerus Explanation. correct b Hemorrhagic (hypovolemic) shock is due to acute blood or body fluid loss. Hypovolemic shock can occur from a fractured pelvis secondary to internal bleeding from a fractured bone fragment that lacerates an artery or vein. The amount of blood loss after trauma isoften difficult to determine; consequently, hemorrhage after blunt trauma is often underestimated. A femoral closed fracture, for example, may lose 1 to 2 liters of blood, a pelvic fracture can lose more than 2 liters of blood, whereas a simple rib fracture can lose up to 125 mL. The abdominal cavity can accommodate a large amount of blood without distension; initially the blood does not irritate the peritoneum, making the diagnosis of hemoperitoneum difficult to establish. 22.A 45-year-old woman is complaining of generalized morning stiffness, especially in both her wrist and hands. It is much worse in the morning and lasts for a few hours. She also complains of fatigue and generalized body aches that have been present for the past few months. Which of the following is most likely? a) Osteoporosis b) Rheumatoid arthritis c) Osteoarthritis d) Gout Explanation. Correct b When rheumatoid arthritis is active, symptoms can include fatigue, loss of energy, depression, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. During flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining of the tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovitis). 23.A 40-year-old nurse complains of new-onset back pain secondary to her job on the medical-surgical floor of a hospital. She reports lifting some obese patients while working the previous night shift. She reports to the worker's compensation clinic where she was referred. She describes the pain as starting in her right buttocks area and radiating down the back of her thigh. It becomes worse when she sits down for long periods. You would suspect: a) Sciatica b) Acute muscle spasm c) Cauda equina syndrome d) Acute muscle strain Explanation. Correct a Sciatica is defined as pain that begins in the buttock area and radiates down one leg. Other symptoms include weakness and tingling sensation. Acute muscle spasm and strain do not cause tingling down the leg. Cauda equina syndrome is an emergent issue, in which there isneurological involvement and the patient complains of weakness and loss of bladder and bowel control. 24.The result of a postmenopausal woman's dual-energy x-ray absorption (DXA) scan shows osteopenia. Which of the following T-scores is indicative of osteopenia? a) T-score of -1.0 or higher b) T-score between -1. 0 to -2.5 c) T-score of less than -2.5 d) T-score of -2.50 to -3.50 e) Normal results Explanation. Correct b Osteopenia is defined as a T-score between -1. 0 and -2.5. Osteoporosis is defined as a Tscore of -2.5 or below. 25.What type of cast is used to stabilize a fracture of the scaphoid bone? a) Long arm cast b) Thumb spica cast c) Short leg cast d) Leg cylinder cast Explanation. Correct b The scaphoid bone is located on the radial aspect of the wrist (same side as the thumb). Another term for scaphoid fracture is navicular space fracture of the wrist. In patients with this injury, palpating in the anatomic snuffbox area reveals local tenderness. A thumb spica cast is used to stabilize fractures of the wrist. It is applied below the elbow (forearm in neutral position) and extends to the hand (wrist and thumb are immobilized). Sometimes, this type of fracture is stabilized with a screw (surgery) because it has a higher rate of nonunion. 26.Podagra is associated with which of the following? a) Rheumatoid arthritis b) Gout c) Osteoarthritis d) Septic arthritis Explanation. Correct b Gout (also known as podagra when it involves the big toe) is characterized by recurrent attacks of acute inflammatory arthritis—a red, tender, hot, swollen joint. The metatarsalphalangeal joint at the base of the big toe is the most commonly affected (approximately 50% of cases). Pain occurs due to the accumulation of uric acid and salts in the joint.27.A 53-year-old crossing guard complains of twisting his right knee while working that morning. The knee is swollen and tender to palpation. The nurse practitioner diagnoses a grade II sprain. The initial treatment plan includes which of the following? a) Intermittent application of cold packs the first 24 hours followed by applications of low heat at bedtime b) Elevation of the affected limb and intermittent applications of cold packs for the next 48 hours c) Rechecking the knee in 24 hours and encouraging isometric exercises d) Application of an elastic bandage wrap to the affected knee Explanation. Correct b Elevation of the injured knee above the heart will reduce the amount of swelling that can occur. Use of ice packs immediately after the injury is most effective and will reduce swelling in the tissue. Ice the affected area for 15 to 20 minutes at a time intermittently to prevent frostbite and further damage to tissue. Allowing 30 to 45 minutes between icing of the limb is recommended. 28.Which of the following T-scores is indicative of osteoporosis? a) T-score of 0 to -1.0 b) T-score of -1.0 to -2.0 c) T-score of -2.5 or less d) Diagnosis is based on an x-ray series of the spine Explanation correct c Osteoporosis is defined as having a T-score of -2.5 or less. Risk factors should also be considered when interpreting T-scores for diagnosis. 29.Heberden's nodes are commonly found in which of the following diseases? a) Rheumatoid arthritis b) Degenerative joint disease c) Psoriatic arthritis d) Septic arthritis Explanation correct b Heberden's nodes are bony nodules on the distal interphalangeal joints, commonly seen in degenerative joint disease. 30.You note bony nodules located at the proximal interphalangeal joints on both the hands of your 65-year-old female patient. Which of the following is most likely? a) Bouchard's nodes b) Heberden's nodesc) Osteoarthritic nodules d) Tophi deposits Explanation Bony nodules at the proximal interphalangeal joints of the hands are called Bouchard's nodes. Heberden's nodes are nodules on the distal interphalangeal joints. Tophi deposits are seen with gout, in which high levels of uric acid occur in the blood and cause nodules in the joint that can eventually destroy the bone. Osteoarthritic nodules develop in the joints of the hands. 31.A middle-aged man with a body mass index (BMI) of 28 is complaining of sharp burning pain that starts at the middle of the right buttock and radiates down the posterior aspect of the thigh and lower leg. He is complaining of weakness of the ankle and foot that is interfering with walking. The pain started 3 months ago and is becoming more frequent and severe. It is aggravated by prolonged sitting, which is interfering with his job as a truck driver. His past medical history is positive for hypertension and metabolic syndrome. The patient is taking lisinoprilhydrochlorothiazide (Zestoretic) 10 mg/12.5 mg once a day. Which of the following tests is appropriate to further evaluate the patient's symptoms? a) Straight leg raising test b) McMurray test c) Lachman test d) Markle test Explanation The straight leg raising test is used to evaluate for sciatica. Classic findings are mid-buttock burning or sharp pain, which may radiate down the thigh, lower leg, and foot. A severe case of sciatica can result in "foot drop," which is why the patient is complaining of weakness of the foot that interferes with walking. This type of sciatica patient needs to be referred to a neurologist to rule out nerve root compression. Sciatica is a type of lumbar radiculopathy. The imaging test of choice is an MRI of the lower spine. The McMurray test is used toassess meniscus damage of the knees. The Lachman test assesses damage to the anterior cruciate ligament. The Markle test (or heel jar test) is used to assess for pelvic inflammatory disease or peritonitis. 32.A 65-year-old carpenter complains of stiffness and pain in both his hands and right knee shortly after waking and worsens in the afternoon. He feels some relief with rest. On exam, the nurse practitioner notices the presence of Heberden's nodes. Which of the following is most likely? a) Osteoporosis b) Rheumatoid arthritis c) Osteoarthritis d) Reiter's syndrome Explanation Signs of osteoarthritis (OA) include stiffness of joints, typically worse in the afternoon and early evening. The pain is typically worse with activity and improves with rest. Visible signs of OA are an element in the diagnosis. (Rheumatoid arthritis and gout often rely more heavily on lab tests.) Heberden's nodes (bony overgrowths) are classic signs of OA. They are located at the distal interphalangeal joints. They are felt as hard, nontender nodules usually 2 to 3 cm in diameter but sometimes encompass the entire joint. Enlargement of the middle joint of a finger is called a Bouchard's node. 33.Which treatment would you recommend to a 65-year-old arthritic patient who complains of a new onset of a painful, swollen left knee caused by overworking in the garden for 2 days? a) Quadriceps-strengthening exercises of the left knee followed by the application of cold packs for 20 minutes four times a day b) Rest the joint and apply cold packs intermittently for the next 48 hours c) Passive range of motion and cold packs d) A cool tub bath with warm packs on the knee to avoid stiffening of the joint Explanation. Correct b New onset of a painful, swollen left knee (inflammation) should be treated using RICE: Rest the knee/joint, use alternating ice packs for the first 24 to 48 hours, use compression if knee feels unstable, and elevate the limb to decrease swelling. 34.A 62-year-old woman complains of chronic severe low-back pain. She also reports mild episodes of fecal incontinence and numbness to her lower legs over the past week. You would suspect which of the following? a) Fracture of the lower spine b) A herniated disk c) Cauda equina syndrome d) Ankylosing spondylitisExplanation Cauda equina is a serious condition caused by compression of the lumbar, sacral, or coccygeal nerve roots in the lower portion of the spinal cord. It is considered a surgical emergency. If left untreated, acute pressure causes ischemia and can lead to permanent nerve damage, including loss of bowel and bladder control and paralysis of the legs. Signs and symptoms include a change in bowel and bladder control (incontinence), saddle-pattern anesthesia (perineum), sciatica, low-back pain, and loss of sensation or movement below level of the lesion. Causes include disk herniation, abscess, tumor, inflammation, and others. 35.A middle-aged woman has been experiencing low-back pain that recently started to radiate to both buttocks and down her legs. She complains of leg weakness and problems with walking. Along with these symptoms she reports new onset of urinary incontinence, in which she leaks a small amount of urine at random. She also reports numbness on her perineal area, which is new. She denies trauma but reports that she recently moved to a new apartment and has been lifting and moving furniture. Which of the following is best described? a) Sciatica b) Acute muscle spasm c) Cauda equina syndrome d) Acute muscle strain Explanation Acute cauda equina syndrome is a surgical emergency. It requires decompression surgery of the spine to prevent permanent nerve damage of the affected nerve roots. The cauda equina contains 18 nerve roots. MRI is the best imaging test. The most common cause of compression is a herniated nucleus pulposus. Most herniations occur either at L4-L5 or L5- S1. The spinal nerves can also become infected (e.g., in tuberculosis, herpes, cytomegalovirus infections). Symptoms include low-back pain, sciatica (unilateral or bilateral), saddle pattern paresthesias, bladder and/or bowel incontinence, and lower extremity motor and sensory abnormalities. Sciatic pain is typically described as sharp or searing, rather than dull; some patients experience a "pins-and-needles" sensation, numbness or weakness, or a prickling sensation down the leg. 36.Which of the following tests would be the initial choice for evaluating for possible fractures on the right lower leg? Plain radiographs of the right lower leg, ankle, and foot Ultrasound of the right lower leg MRI of the right ankle Radiograph of the right ankle and knee with special view of the hip Explanation Plain radiographs or x-rays are the first exam ordered for suspected or obvious bony fractures. Severe pain on weight bearing and bruising of the right ankle is highly suggestiveof a fracture. MRI scan is not an initial test because it is very expensive. MRIs are preferred for joints and soft tissue. 37.An elderly woman with a history of rheumatoid arthritis reports to the nurse practitioner that she had been taking ibuprofen twice daily for many years. All of the following organ systems are at risk of damage from chronic nonsteroidal antiinflammatory drug (NSAID) use except: a) Cardiovascular system b) Pulmonary system c) Gastrointestinal system d) Renal system Explanation Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with increased risk of ulcers, perforation, and bleeding of the gastrointestinal tract, heart attacks, cardiovascular damage, strokes, acute interstitial nephritis and kidney injury, and liver damage. It does not affect the lungs or the pulmonary system. 38.A 65-year-old woman's bone density result shows severe demineralization of cortical bone. All of the following pharmacological agents are useful in treating this condition except: a) Raloxifene (Evista) b) Calcitonin (Miacalcin) c) Medroxyprogesterone (Depo-Provera) d) Calcium with vitamin D Explanation. CORRECT C Long-term use (>3 years) of medroxyprogesterone (Depo-Provera) increases risk of bone loss. Avoid with osteopenia, osteoporosis, long-term amenorrhea, or in underweight women with anorexia. First-line treatment of osteoporosis is the biphosphanates. Lifestyle measures are weight-bearing exercises and adequate calcium and vitamin D intake. 20. The Lachman maneuver is used to detect which of the following? A) Knee instability B) Nerve damage of the knee due to past knee injuries C) The integrity of the patellar tendon D) Tears on the meniscus of the knee 20. A) Knee instability The Lachman maneuver is a test performed to assess for knee instability. Knee instability indicates a tear of the anterior cruciate ligament. 24. Mr. Brown is a 65-year-old carpenter complaining of morning stiffness and pain in both his hands and right knee upon awakening. He feels some relief after warming up. On exam, the nurse notices the presence of Heberden's nodes. Which of the fol- lowing is most likely? A) OsteoporosisB) Rheumatoidarthritis C) Degenerative joint disease D) Reiter'ssyndrome 24. C) Degenerative joint disease Heberden's nodes are commonly seen in degen- erative joint disease. Heberden's nodes are bony nodules located on the d [Show More]

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