NU 673 FINAL EXAM REVIEW-with 100% verified solutions-2024.docx, Exams of Nursing

Download NU 673 FINAL EXAM REVIEW-with 100% verified solutions-2024.docx and more Exams Nursing in PDF only on Docsity! NU 673 FINAL EXAM REVIEW-with 100% verified solutions-2024 Chapter 5 Which of the following statements is true concerning mental health disorders in primary care? a)Alcohol and substance abuse are not considered mental health disorders. b)Somatic symptom disorder (DSM‐5) is distinctly uncommon in this setting and constitutes less than 5% of these disorders. c) Mood disorders make up ~25% of all diagnoses. d)The prevalence for mental disorders is estimated to be ~10%, of which only 25% are not diagnosed. e)Anxiety disorders are the most prevalent of all diagnoses in this setting. c) Mood disorders make up ~25% of all diagnoses. Mood disorders make up ~25% of all diagnoses. Mental health disorders of various types ranging from major mental illness to personality disorders are very common diagnoses encountered in primary health care. Approximately 20% of primary care patients are thought to suffer from mental disorders, of which 50%-75% goes undetected. Somatoform disorders are relatively common in the range of 10%-15%, while alcohol and substance abuse are important contributors to patient dysfunction and are considered under the broad designation of mental health disorders Which of the following complaints/findings is considered to be a patient identifier for mental health screening? a) High use of health services due to chronic unstable medical diagnoses b)Acute pain syndromes of 10 days' duration that require opiates for relief c)A patient with type I diabetes and neuropathic pain d)Symptoms lasting for >2 weeks e) Substance abuse e) Substance abuse The answer is substance abuse. High use of health services in an unstable patient is frequently indicated; however, it is those without demonstrable problems that may require further evaluation, that is, mental health screening. Symptoms of a more chronic nature, namely 6 weeks, might warrant referral, but not 2 weeks. Acute pain should be managed in the context of the patient presentation, and type I diabetics frequently suffer from difficult to manage neuropathic pain, which is not easily treated but medically based and well‐described clinically. The CAGE questionnaire is a short screening examination administered in the office to evaluate for which of the following? a) Bipolar disorder b)Risk for illicit substance abuse c)Alcohol misuse d)Major depressive disorder of the following statements is true about this abnormality? a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. b)They include false perceptions associated with dreaming and occurring with falling asleep and awakening. c) Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint. d)Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects. e) By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature. a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. Hallucinations may be associated with a number of different primary diagnoses. By definition, they exclude perceptions occurring with dreaming or close to falling asleep or awakening. As hallucinations are a subjective patient self‐ reported complaint, objective testing is not available. Alcohol is a known cause of hallucinations, and abnormal perceptions may include ones of a gustatory, olfactory, and tactile nature. A 24‐year‐old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic attacks. In persons with trauma‐ and stress‐related disorders as well as other disorders that may be associated with hallucinations and illusions, which of the following statements is true that distinguishes these two entities from each other? a) Illusions occur only when awake, whereas hallucinations can occur both while awake and while sleeping. b) Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli. c) Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary. d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. e) Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint. d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Trauma‐ and stress‐related disorders are an increasingly recognized and appreciated cause of moderate‐to‐severe dysfunction both in the military as well as civilian populations. Both illusions and hallucinations may be associated with the disorder; however, the correct distinction between the two is contained in the correct answer. Both are subjective in nature; therefore, there is no objective testing available. The clinician relies on the patient history in the context of the clinical setting to discern the correct designation. The incorrect answers all contain components that are inaccurate descriptions based on their accepted definitions. Abstract thinking is an important component of the human thought process. A person's ability to understand questions that test his or her ability to answer appropriately is dependent upon a e) It is best characterized by slurred speech with an associated defect in language control. b) It is defined as an inability to produce or understand language. Aphasia, the inability to produce or understand language, includes two common subtypes: receptive and expressive. A loss of the voice or hoarseness defines aphonia and dysphonia, respectively. Slurred speech with intact language is dysarthria. Involuntary movements as described are characteristic for oral-facial dyskinesias. Because writing a sentence involves both understanding the question and executing the task (expressive), by definition, maintenance of language production and understanding effectively rules out aphasia. Chapter 11 An overweight 26‐year‐old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light‐headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β‐human chorionic gonadotropin (β‐hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? a)Acute cholecystitis b)Ruptured appendix c) Ruptured ovarian cyst d)Ruptured tubal (or ectopic) pregnancy e) Perforated bowel wall d)Ruptured tubal (or ectopic) pregnancy The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β‐hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra‐abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery. Ruptured ectopic pregnancies can lead to life‐ threatening intra‐abdominal bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities, the positive β‐hCG testing and her unstable vital signs make ruptured ectopic pregnancy more likely. A 63‐year‐old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ‐glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow‐up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? a) Liver span of 11 cm at the midclavicular line b)Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration c) Dullness to percussion over a span of 11 cm at the midclavicular line d)Dullness to percussion over a span of 8 cm at the midsternal line e) Liver span of 8 cm at the midsternal line b) Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the valid screening option, but again screening is not routinely recommended for patients age >75 years. An otherwise healthy 31‐year‐old accountant presents to an outpatient clinic with a 3‐year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over‐the‐ counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a) Functional change in bowel movement b)A large, firm fecal mass in the rectum c) Spasm of the external sphincter d)Decreased fecal bulk e) Impairment of autonomic innervations a) Functional change in bowel movement Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment. A 65‐year‐old farmer who rarely seeks medical care but does have a remote history of coronary bypass surgery presents to the office with a 2‐day history of increasing shortness of breath and abdominal discomfort. On exam, a protuberant abdomen and lower extremity edema is noted. The clinician is concerned about possible right‐ sided heart failure and associated ascites and decides to proceed with further physical exam techniques to assess for possible ascites. Which of the following findings will be supportive of ascites? a)Tapping on one flank sharply transmits an impulse to the opposite flank b)Dullness to percussion throughout the abdomen c)Tympany predominant throughout the abdomen d)Border between tympany and dullness to percussion that does not shift with position e) Dullness to percussion of the upper quadrants and tympany in the lower quadrants a)Tapping on one flank sharply transmits an impulse to the opposite flank Tapping on one flank sharply transmitting an impulse to the opposite flank is a positive fluid wave test finding and is suggestive of ascites, but neither sensitive nor specific for ascites. With ascites, the dependent portions of the abdomen tend to be dull to percussion while the top portions are tympanic. One would not expect a difference in percussion to upper and lower quadrants. Tympany predominant throughout the abdomen suggests a gas filled abdomen and not ascites. Shifting dullness is characterized by dullness to percussion shifting to the dependent side and tympany shifting to the top with changes in position and is supportive of ascites. Dullness to percussion throughout the abdomen would be characteristic of a stool filled abdomen, a large mass, or enlarged organ. A 23‐year‐old woman comes to the respirology clinic for follow‐up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a)Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b)A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration c) Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line d)Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease e) Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation a)Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis. An otherwise healthy 28‐year‐old lawyer presents to the Emergency Department with a 1‐day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a)Abdominal pain that increases with hip flexion b)Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c) Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus d)Pain with internal rotation of the right hip e) Voluntary contraction of the abdominal wall that persists over several examinations b)Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often now. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married and has four children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? A) Stress incontinence B) Urge incontinence C) Overflow incontinence A) Stress incontinence A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple "spider angiomas" at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? A) Infectious diarrhea B) Mallory-Weiss tear C) Esophageal varices C) Esophageal varices Upgrade to remove ads Only $1/month A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What is most likely the etiology of her diarrhea? A) Secretory infections B) Inflammatory infections C) Irritable bowel syndrome D) Malabsorption syndrome C) Irritable bowel syndrome A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation? A) Large bowel obstruction B) Irritable bowel syndrome B) Irregular, large liver A 26-year-old sports store manager comes to your clinic, complaining of severe right- sided abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? A)Acute appendicitis B)Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia A)Acute appendicitis 15-year-old high school freshman is brought to the clinic by his mother because of chronic diarrhea. The mother states that for the past couple of years her son has had diarrhea after many meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. You collect a stool sample for further study. What is the most likely explanation for this patient's chronic diarrhea? A) Malabsorption syndrome B) Osmotic diarrhea C) Secretory diarrhea B) Osmotic diarrhea A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have? A) Kidney pain (from pyelonephritis) B) Ureteral pain (from a kidney stone) C) Musculoskeletal pain D) Ischemic bowel pain B) Ureteral pain (from a kidney stone) Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? A) Peptic ulcer B) Cholecystitis C) Pancreatitis D)Appendicitis D) Appendicitis Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered? A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D)All of the above D) All of the above Upgrade to remove ads Only $1/month Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? A) Colon cancer B) Cholecystitis C) Inflammatory bowel disease D) Irritable bowel syndrome D) Irritable bowel syndrome im is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect? A) Bleeding from a diverticulum B) Bleeding from a peptic ulcer C) Bleeding from a colon cancer D) Bleeding from cholecystitis B) Bleeding from a peptic ulcer A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D A) Hepatitis A Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation? A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst C) Ureteral stone D) Physical abuse C) Ischemia Chapter 12 A 68‐year‐old retired administrative assistant complains of a 3‐month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid‐calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following? a) Neurogenic claudication b)Abdominal aortic aneurysm c) Peripheral arterial disease (PAD) d)Venous stasis e)Acute arterial occlusion a)Neurogenic claudication Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is typically relieved simply by sitting or by leaning forward. Many patients with spinal stenosis of the lumbar spine have pain that originates in the spinal region and radiates into the areas noted. PAD is not typically relieved just by sitting alone and usually will take some time. PAD also does not typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however, they typically do not have the same palliating factors. A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located? a) Iliac pudendal b)Popliteal c)Aortorenal d)Superficial femoral e) Common femoral a) Iliac pudendal The internal pudendal artery, which is a branch off of the internal iliac artery, is the major blood supply for the penis. A lesion in the aortorenal region would be unlikely to cause isolated symptoms of ED. The common femoral, superficial femoral, and popliteal arteries are all distal from the iliac arteries and would not cause symptoms as described. Upgrade to remove ads Only $1/month A 73‐year‐old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x‐ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms? a) Pulmonary embolism (PE) b)Myocardial infarction (MI) c) Dorsalis pedis d)Femoral e) Popliteal c) Dorsalis pedis The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively. A 61‐year‐old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says is been there for about a week but is worsening. On physical examination, 2+ edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. What is the chief concern with this patient? a)Acute arterial occlusion b)Pulmonary embolism (PE) c) Superficial thrombophlebitis d)Ovarian metastasis e)Acute lymphangitis b)Pulmonary embolism (PE) Cancer patients are at high risk of deep venous thrombosis (DVT), and, with the presenting symptoms of swelling and pain in her groin, along with recent history of cough and shortness of breath, this patient's presentation is suspicious for PE. Patients with DVT in the proximal leg veins are at high risk of thromboembolism. Acute arterial occlusion should not cause significant edema, and pulses would likely be absent. The constellation of symptoms and history in this patient also does not suggest an acute arterial occlusion. Superficial thrombophlebitis typically only causes mild local swelling, redness, and warmth along with a subcutaneous cord. Acute lymphangitis typically presents with red streaks from an infection passing through lymph channels. A 32‐year‐old cabdriver complains of pain in his left leg. He has a history of type 2 diabetes, is a smoker, and recently was diagnosed with hypertension. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid‐shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent? a)Thrombus formation in a superficial vein b)Dilated arterioles c) Occluded arterial vessels d)Dilated veins secondary to incompetent valves e) Draining lymphatic channels e) Draining lymphatic channels Acute lymphangitis is typically caused from an acute bacterial infection of the skin that causes red streaks from distal drainage through the lymphatic system. The streaks are typically flat, not palpable cords as found in thrombus formation in a superficial vein. Dilated veins also are not flat. Occluded arterial vessels are not superficial or visible. Dilated arterioles are still too small to be visible at the skin surface. A clinician, evaluating a patient for valvular competency in the communicating veins of the saphenous system, starts with the patient supine, then elevates one leg to about 90° to empty it of venous blood. Next, the great saphenous vein in the upper part of the thigh is occluded with noted. PAD is not typically relieved just by sitting alone and usually will take some time. PAD also does not typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however, they typically do not have the same palliating factors. A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located? a) Iliac pudendal b)Popliteal c)Aortorenal d)Superficial femoral e) Common femoral a) Iliac pudendal The internal pudendal artery, which is a branch off of the internal iliac artery, is the major blood supply for the penis. A lesion in the aortorenal region would be unlikely to cause isolated symptoms of ED. The common femoral, superficial femoral, and popliteal arteries are all distal from the iliac arteries and would not cause symptoms as described. A 73‐year‐old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x‐ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms? a) Pulmonary embolism (PE) b)Myocardial infarction (MI) c) Coarctation of the aorta d)Pericarditis e) Dissecting aortic aneurysm e) Dissecting aortic aneurysm Patients with dissecting aortic aneurysms typically present with chest pain, many times described as a "tearing" type pain. They are usually elderly, and, due to the dissection of the aorta, asymmetric pulses in blood pressures in the extremities may be present. Coarctation of the aorta can also cause similar symptoms; however, it would be unlikely due to the patient's age as this is a congenital defect. MI, PE, and pericarditis are also common causes of concerning chest pain; however, neither typically will cause asymmetric blood pressures or pulses in the extremities. A 19‐year‐old carwash attendant sustained a laceration to the ulnar aspect of his mid‐forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy? a) Epitrochlear nodes b)Cervical chain nodes c) Infraclavicular nodes d)Central axillary nodes e) Lateral axillary nodes a) Epitrochlear nodes The epitrochlear nodes are the first nodes in the drainage region from the ulnar surface of the forearm and hand, little and ring fingers, and adjacent surface of the middle finger. Axillary nodes, infraclavicular nodes, and cervical chain nodes are all distal to this area and may show evidence of lymphadenopathy as well; however, that would be secondary after the epitrochlear nodes. When assessing for the femoral pulse, where should the clinician begin deeply palpating? a) Below the inguinal ligament, just medial to the anterior superior iliac spine b)Above the inguinal ligament, just medial to the anterior superior iliac spine c)Above the inguinal ligament, just lateral to the symphysis pubis d)Below the inguinal ligament, just lateral to the symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis The clinician would begin deeply palpating below the inguinal ligament, midway between the anterior superior iliac spine in the symphysis pubis. The external iliac artery transitions into the femoral artery at the level of the inguinal ligament. Therefore, palpating above the inguinal ligament would be assessing the external iliac artery. The femoral artery is typically located midway between the anterior superior iliac spine in the symphysis pubis in most patients. The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed? a)Arterial arch of the foot b)Posterior tibial c) Dorsalis pedis d)Femoral e) Popliteal c) Dorsalis pedis The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively. A 61‐year‐old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says is been there for about a week but is worsening. On perfusion of the hand from the ulnar and radial arteries. The straight‐leg raise test is used to evaluate for radiculopathy from the lumbosacral regions. Romberg is a test for position sense A 44‐year‐old retail salesperson has noticed an increasing dilatation of the veins in her legs. Upon inspection, it is noted that she has significant varicosities on the posterior aspects of both legs which begin in the lateral side of the foot and pass upward along the posterior calf. The remainder of the veins in the legs appears normal at this time. Which veins are currently affected? a) Great saphenous b)Small saphenous c) Femoral d)Perforating e) Dorsal venous arch b) Small saphenous The small saphenous vein typically runs in the described pattern. The great saphenous vein originates on the dorsum of the foot it passes just anterior to the medial malleolus and continues of the medial aspect of the leg joining the femoral vein of the deep venous system below the inguinal ligament. Perforating veins are not visible as they connect the deep and superficial veins. The femoral is proximal as described, and the dorsalis pedis vein is distal to the described area. A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? a) Imbalanced Nutrition b) Impaired Skin Integrity c) Risk for Skin Breakdown d)Fear of Loss of Extremity Correct response: Impaired skin integrity. Explanation: This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 469. When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive? a)Activity intolerance related to pain and claudication with ambulation b)Pain related to decreased blood flow and altered tissue perfusion c) Risk for peripheral neurovascular dysfunction d)Altered tissue perfusion, arterial related to reduced blood flow Correct response: Altered tissue perfusion, arterial related to reduced blood flow Explanation: Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 22: Assessing Peripheral Vascular System, p. 451. Which area of the arm drains to the epitrochlear nodes? a) Radial surface of the forearm and hand, thumb and index finger, and radial middle finger b)Ulnar surface of the forearm and hand; second, third, and fourth fingers c) Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger d)Radial surface of the forearm and hand; second, third, and fourth fingers Correct response: Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger Explanation: The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of generalized lymphadenopathy as seen in syphilis and HIV infection. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 450. If palpable, superficial inguinal nodes are expected to be: a) Fixed, tender, and at 2.5 cm in diameter b)Fixed, nontender, and 1.5 cm in diameter c) Discrete, tender, and 2 cm in diameter d)Nontender, mobile, and 1 cm in diameter Correct response: Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 461. A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test? a) Firmly compress the lower portion of the varicose vein. b)Place the second hand 3 to 4 inches above the first hand. c) Feel for a pulsation to the fingers in the lower hand. d)Ask the client to sit on a chair for the examination. Correct response: Firmly compress the lower portion of the varicose vein. Explanation: The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 467 After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) communicating b)popliteal c) saphenous d) iliofemor al Explanatio n: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Peripheral Vascular System, p. 462. Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. a) Family history b)Smoking c) Ethnicity d)Overweight e) Lack of exercise Correct response: •Smoking •Overweight •Lack of exercise Explanation: Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 45 The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? a) Lymphedema b)Varicose veins c) Peripheral arterial disease d)Venous stasis Explanation: Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins. Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 22: Assessing Peripheral Vascular System, pg. 456. A nurse performs the Trendelenburg test for a client with varicose veins. Which action accurate? a) "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD." b) "It's critical that you come to get screening tests twice annually." c) "If you develop swelling in your ankles or feet, then you should seek emergency care." d)"Quitting smoking and keeping good control of your blood sugar levels are important." Correct : "Quitting smoking and keeping good control of your blood sugar levels are important." Explanation: Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 455. A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two- pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? a) Knee pain b)Shortness of breath c) Chest pressure with exertion d) Intermittent claudication Correct response: Intermittent claudication Explanation: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 451. While completing the past history of a patient's peripheral vascular and lymphatic systems, the nurse is concerned that the patient is at risk for peripheral vascular disorders. What did the nurse assess in this patient? (Select all that apply.) a) Body mass index 30 b)Blood pressure 178/90 mm Hg c) Currently smokes one pack per day d)Heart attack 5 years ago e) Mother diagnosed with diabetes at age 70 Correct response: •Currently smokes one pack per day •Body mass index 30 Explanation: Risk factors for the development of peripheral vascular disease include smoking and obesity. The history of a heart attack and current blood pressure would be documented under the patient's past history. The mother being diagnosed with diabetes at the age of 70 would be documented under family history. Having had a heart attack, having hypertension, and a family history of diabetes are not considered risk factors for the development of peripheral vascular disease. Reference: Correct response: Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 457. Upgrade to remove ads Only $1/month A 77-year-old retired nurse has an ulcer on a lower extremity. All the following diseases are responsible for causing ulcers in the lower extremities except for: a) Hypertension b)Arterial insufficiency c) Venous insufficiency d)Diminished sensation in pressure points Correct response: Hypertension Explanation: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 455. A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency? a) Irregular-shaped ulcer on the inner aspect of the ankle b)Ulcer located on medial malleolus c) Pallor of foot occurs with elevation d)Reports of aching, cramping pain Correct response: Pallor of foot occurs with elevation Explanation: The ulcers due to arterial insufficiency would have elevation pallor of the foot due to poor blood supply. Aching and cramping pain is present in ulcers caused by venous insufficiency. Irregular- shaped ulcers and ulcers located on the medial malleolus are characteristics of venous insufficiency ulcers. (less) Reference: Weber, J., & Kelley, J. H. (2014. Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 470. A nurse is working with a patient who has been confined to bed rest in the hospital for the past 2 weeks. Which areas of the body are most likely to develop ulcers due to arterial insufficiency? Select all that apply. a)Tips of toes b)Anterior tibial area c) Heels d)Toe webs e) Medial ankle Correct response: •Tips of toes •Toe webs •Heels Explanatio n: Ulcers caused by arterial insufficiency are typically located on the tips of toes, toe webs, heels, or other pressure areas if confined to bed. Ulcers caused by venous insufficiency are typically located on the medial ankle or anterior tibial area. (less) Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, pp. 470-471. Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? a) Prevention of varicose veins b)Significance of cardiac dysrhythmias c) Extent of tobacco use and exposure d)Exercise tolerance Correct response: Extent of tobacco use and exposure Explanation: Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 453. What pulse is located in the groove between the medial malleolus and the Achilles tendon? a) Femoral b)Popliteal c) Dorsalis pedis d)Posterior tibial Correct response: Posterior tibial Explanation: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 463. A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? a) Calcium deficiency b)Diabetes mellitus The nurse should complete the inspection process before going on to the other physical assessment techniques. After inspecting asymmetry of the legs, the nurse should measure the calves to determine the exact difference in diameter. Then the nurse can palpate for edema and temperature, and notify the health care provider with the information once it is all gathered. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 460. The nurse is assessing the client's skin an ulcer is identified. What would indicate to the nurse it is a venous ulcer? a)The ulcer is superficial and pale. b)The extremity is without a pulse. c)The ulcer is necrotic. d)The client voices pain related to the ulcer. Correct response: The ulcer is superficial and pale. Explanation: A venous ulcer is superficial and pale. Arterial ulcers have a deep necrotic base, are painful and are related to decreased blood flow or pulselessness. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 22: Assessing Peripheral Vascular System, pg. 452. A nurse assists the client to perform the position change test for arterial insufficiency. While dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test? a) Delayed b) Inconclusive c) Normal d)Brisk Correct response: Normal. Explanation: Return of a pink color to the legs after elevation should take less than 10 seconds. This test does not demonstrate arterial insufficiency. Delayed would be greater than 10 seconds for color to return. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 464. Chapter 14 A 45‐year‐old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding? a) Bartholin gland enlargement b)Ovarian mass c) 4‐Month pregnancy d)Large colonic stool e) Fibroids Fibroids, also known as myomas, are very common benign uterine tumors that can become quite enlarged. Large colonic stool is incorrect. Stool cannot be easily palpated in the abdomen except in a very thin person. Ovarian mass is incorrect. The mass palpated is in the midline and ovarian masses will generally be in the adnexal area. In this case, the adnexal area had no palpable mass. Four‐ month pregnancy is incorrect. This patient's husband has had a vasectomy, and this patient had menses last week. Bartholin gland enlargement is incorrect. An enlarged Bartholin gland is noted in the labial area and not in the abdomen. e) Fibroids A 32‐year‐old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility? a) Prior Bartholin gland infection b)Prior pelvic inflammatory disease (PID) c) Metabolic disorder with subsequent hormonal irregularities leading to anovulation d)Secondary amenorrhea e) Prior herpes infection PID is a genital infection caused by gonorrhea, chlamydia, and other organisms. If not treated early enough it can lead to tubal pregnancies or infertility. Prior Bartholin gland infection is incorrect. Although Bartholin cyst infections can be from sexually transmitted infections, they are only located on the labia and do not lead to fertility issues. Prior herpes infection is incorrect. Herpes generally only affects the labial tissues, vagina, and cervix. Although a baby delivered through an outbreak can suffer complications from maternal herpes, it does not affect fertility. Metabolic disorder with subsequent hormonal irregularities leading to anovulation is incorrect. Although metabolic disorder does lead to anovulation and infertility problems, this patient relates being regular all of her life so most likely has no hormonal abnormalities. Secondary amenorrhea is incorrect. Secondary amenorrhea occurs when a woman having periods stops having them for some reason. This woman has not had an absence of her menses. d)Strawberry cervix (small red granular spots or petechiae) e) Raised friable or lobed lesions Warts or condylomata are raised lesions that are often lobed in appearance. With addition of acetic acid, they will often turn white. Several shallow ulcers with a red base is incorrect. These are associated with herpetic infections. Translucent nodules is incorrect. This is a description of retention cysts or nabothian cysts. Bright red, soft lesion arising from the cervical canal is incorrect. This is a description of a cervical polyp. Strawberry cervix (small red granular spots or petechiae) is incorrect. This is a common description of the cervix with a Trichomonas infection. e) Raised friable or lobed lesions A 23‐year‐old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam? a) She is on her menses. b)She has only one current partner and does not need STI testing. c) She has been using condoms. d)She should not be sexually active. e) She had a normal Pap smear within the last 3 years. For best results with either a Pap smear or STI testing it is best to not have the patient menstruating. On conventional Pap smears, blood masks the cytology. For STI testing, the vaginal sample results are not always valid. Some practices do use urine STI testing but this is not yet universally available. She has only one current partner and does not need STI testing is incorrect. Until the age of 25 years, high‐risk individuals with a history of several partners are still tested yearly. She had a normal Pap smear within the last 3 years is incorrect. Although she does not need a Pap smear at this time, she still needs STI testing. She should not be sexually active is incorrect. This is a personal judgment of the provider and should not be involved in decision making for the patient's care. She has been using condoms is incorrect. As long as a patient has not used a condom for the last 48 hours, there is no need to postpone a speculum exam due to general condom usage. a) She is on her menses. An 18‐year‐old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID? a) Bartholin gland opening b)Posterior fornix c) Cervical os d)Anterior fornix e) Skene gland opening An infection in the uterus, tubes, and ovaries would drain through the cervix and out of the os. Posterior fornix is incorrect. Any discharge in the fornix may be from the cervix, or it may be from a vaginal infection. Anterior fornix is incorrect. Again any discharge in the fornix may be from the cervix, or it could be from a vaginal infection. Skene gland opening is incorrect. This gland is within the labia minor and surrounds the urethral opening. Discharge from PID comes from the uterus so would be coming from the os within the introitus. Bartholin gland opening is incorrect. This opening is just within the introitus near the 4 and 8 o'clock positions of the labia minora. Discharge from PID would be from the os within the introitus and not from just inside the introitus. a) Levatori ani b)Pubis symphysis c) Bulbocavernosus muscle d) Ischiocavernosus muscle e)Anal sphincter The levatori ani muscle group consisting of the pubococcygeus muscle and the iliococcygeus muscle is responsible for the support of the pelvic floor. Weakening can cause prolapse of the pelvic organs. Weakness of the anal sphincter is incorrect. Weakness of this muscle can lead to anal incontinence of stool. Weakness of the pubis symphysis is incorrect. Although there can be slight separation of the pubis symphysis following childbirth, it usually returns to its normal state afterward and does not lead to weakening of the pelvic musculature. Weakness of the ischiocavernosus or bulbocavernosus muscles is incorrect. Weakness of these muscles can lead to urinary incontinence. a) Levatori ani Chapter 15 A 49‐year‐old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? a) Both internal and external anal sphincter are under voluntary control. b)The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. c) Both internal and external anal sphincter are under involuntary control. d)The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control. e) Control of the anal sphincters is variable between individuals. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Together, these two muscles hold the anal sphincter closed until the individual is ready to defecate. The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control; both internal and external anal sphincter are under voluntary control; and both internal and external anal sphincter are under involuntary control are incorrect because, as above, the internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Control of the anal sphincters is variable between individuals is incorrect because this anatomic and neurological arrangement is not typically variable between individuals, although these pathways may be interrupted by derangements of normal physiology such as spinal cord injuries. b)The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control A 62‐year‐old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may explain this patient's experience of discomfort? a)The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort. b)The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. c)The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient's discomfort. d)The dentate or pectinate line does not differentiate any neurological input, making the area either proximal or distal to the line equally responsible for this patient's discomfort. e) Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient's pain. The anal canal is characterized by somatosensory innervation, whereas the rectum has little such nerve supply. Thus, the patient's discomfort likely occurred due to the stretch of the anal canal rather than disruption of the more proximal rectal mucosa. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient's discomfort is incorrect because the anal canal is more richly innervated with somatosensory nerves than the rectum. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort is incorrect because, although the anal canal is the most likely site of the patient's lies circumferentially in the rectum. It is visible on proctoscopic examination but is not palpable on digital rectal examination. Uterine fundus is incorrect because, although the cervix is palpable through the anterior rectal wall on digital examination, the fundus of the uterus is generally too proximal to palpable. Prostate is incorrect because this patient is female, making the presence of a prostate notably unlikely. d) Cervix A 45‐year‐old female executive reports to her primary care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at age 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient? a) New‐onset anal fissures b) Recent history of black, tarry stools c) Long‐term history of hemorrhoids d) Recent onset of small‐caliber stools e) Remote history of anal pruritus Small‐caliber stools may be caused by narrowing of the colon due to a mass. Colonoscopy should be performed to rule out such pathology, especially in a patient with such a notable family history. Long‐ term history of hemorrhoids is incorrect because hemorrhoids are not directly associated with colon cancer. However, bleeding from hemorrhoids should be evaluated carefully in high‐risk patients, as bleeding attributed to hemorrhoids is virtually indistinguishable from fresh blood from the lower gastrointestinal (GI) tract. A low threshold for ordering colonoscopy should be maintained in patients with risk factors for colon cancer, including age >50 years and strong family history. Recent history of black, tarry stools is incorrect because black, tarry stools ("melena") generally represent blood in the GI tract, whereas melanotic stools usually have a source in the upper tract, not the colon. Although this should be thoroughly investigated, it is not likely to have colon cancer as a source. Remote history of anal pruritus is incorrect because it may be due to hemorrhoids, proctitis, receptive anal intercourse, pinworms, and a variety of other sources. Anal pruritus is not typically associated with colon cancer. New‐onset anal fissures is incorrect because anal fissures may be associated with constipation and Crohn disease, but they are not generally indicative of colon cancer. d) Recent onset of small‐caliber stools A 49‐year‐old customer service representative presents to his gastroenterologist for follow‐up of his long‐standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and has had irregular care for this condition since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are healthy. Which of the following is true about recommended screening for colon cancer in this patient? a) The patient is due for routine age‐based colon cancer screening by colonoscopy regardless of his risk factors. b) The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years. c) The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer. d) The patient's condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely. e) The patient should begin screening for colon cancer 10 years prior to the age of onset of his father's prostate cancer. The two forms of IBD (UC and Crohn disease) increase the risk of colon cancer and do warrant increased screening at shortened intervals. The patient should begin screening for colon cancer 10 years prior to the age of onset of his father's prostate cancer is incorrect because family history of breast, ovarian, or colon cancer increases an individual's risk of colon cancer, whereas family history of prostate cancer alone does not increase an individual's risk of colon cancer and thus does not indicate increased screening. (Of note, prostate cancer may rarely be a manifestation of the BRCA genetic mutation that would put this patient at higher risk for many types cancer, but this would usually be accompanied by a family history of many cancers, especially breast and ovarian cancer in the female line.) The patient is due for routine age‐ based colon cancer screening by colonoscopy regardless of his risk factors is incorrect because routine age‐based screening by colonoscopy begins at age 50 years. Younger patients may require colonoscopy for diagnosis of symptomatic disease or for screening due to high‐risk histories. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years is incorrect because even with a benign family history, routine colon cancer screening by colonoscopy, sigmoidoscopy, and/or fecal occult blood testing is recommended at age 50 years, not at age 60 years. The patient's condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely is incorrect. Although risks and benefits should always be considered before any procedure, this patient's risks for colon cancer (and thus benefit from screening) outweigh his risks of a major adverse event from colonoscopy. c) The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer A 49‐year‐old male with well‐controlled HIV undergoes a proctoscopic examination as routine screening for anal cancer. The patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under direct visualization, the clinician observes a clear, circumferential demarcation of proximal versus distal tissue. This demarcation was not palpable on digital rectal examination (DRE) prior to proctoscopy. What is the most likely origin of this finding? a) Carcinoma b)Pathological constriction of the anal canal c) Normal anatomy of the mucosal surface d)External anal sphincter e) Valve of Houston The circumferential border between the anal canal and rectum is visible on proctoscopic examination but is not palpable on DRE. This demarcation is known as the dentate or pectinate line. Pathological constriction of the anal canal is incorrect because the patient has no complaints regarding defecation, and this change in tissue between the anal canal and rectum is a normal finding. Carcinoma is incorrect because neoplastic tissue is unlikely to present as a regular, circumferential demarcation between tissues. Valve of Houston is incorrect because the valves of Houston are three inward foldings of the rectal wall; although they are palpable on deep DRE, they do not appear as distinct types of tissue on proctoscopic examination. External anal sphincter is incorrect because the internal and external anal sphincters are distal to the pectinate line and are not superficially visible on internal examination of the anal canal and rectum. c) Normal anatomy of the mucosal surface A 34‐year‐old female reports anal pain with defecation. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find? a) Inflammatory bowel disease (IBD) b)Lymphogranuloma venereum c) Human papillomavirus (HPV) all that common in African American populations, this issue should still be addressed with appropriate screening recommended for both prostate cancer and the BRCA gene itself. a) This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider. A 64‐year‐old retired architect presents to his primary care provider with a magazine article about prostate cancer screening that states, "You should talk to your doctor about the ups and downs of prostate cancer screening." The patient hands this to the clinician and states, "Tell me about the ups and down of prostate screening." Which of the following is true about prostate cancer screening? a) Setting normal cut‐offs for prostate‐specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. b) The prostate‐specific antigen (PSA) cut‐off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer. c) Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease. d) The prostate‐specific antigen (PSA) effectively differentiates aggressively malignant prostate tumors from indolent cases. e) Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms. Setting normal cut‐offs for PSA testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis is a very common theme among screening tests: If the norms of a given test are set too tightly, chances are that true cases of the disease will be missed (loss of sensitivity). Conversely, setting looser norms captures more true positives but also captures more patients with normal variant results near the ends of the bell curve (loss of specificity). This problem is increased in screening tests in which there are numerous normal conditions that cause the target result; PSA testing for prostate cancer is notorious for this complication, as is the CA‐125 tumor marker for ovarian cancer. Screening tests without clear norms are very problematic in the interpretation of results—a particularly frustrating factor in ovarian cancer screening in which most patients with the disease present at an advanced stage and the need for a good early screening test is clear. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease is incorrect because the decision to screen should be undertaken on a case‐by‐case basis with each individual patient. The PSA effectively differentiates aggressively malignant prostate tumors from indolent cases is incorrect because PSA has almost no role in differentiating indolent from aggressive prostate tumors—in fact, PSA can be elevated in conditions that are not cancerous at all, such as benign prostatic hyperplasia, urinary retention, and recent ejaculation. The PSA cut‐off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer is incorrect because, as above, the PSA is neither particularly sensitive nor specific for prostate cancer of any kind. Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms is incorrect because most prostate cancers identified via biopsy are nonpalpable and asymptomatic. Of note, screening for diseases that are symptomatic in early stages is rarely necessary, as patients can easily report symptoms before the disease becomes dangerous. Unfortunately, a large number of malignant diseases are asymptomatic until local spread or distant metastases have occurred—making effective screening techniques for asymptomatic patients important to long‐term survival rates. In the case of prostate cancer, a test that effectively separates indolent from aggressive lesions is ideal but not yet forthcoming. a) Setting normal cut‐offs for prostate‐specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. Musculoskeletal System Chapter 16 Articular structures: include joint capsule and articular cartilage, synovium and synovial fluid, intra- articular ligaments, and juxta-articular bone Extra-articular structures: include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin Ligaments: ropelike bundles of collagen fibrils that connect bone to bone Tendons: collagen fibers connecting muscle to bone Cartilage: collagen matrix overlying bony surfaces Bursae: pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures Tests to Assess carpel tunnel: • Weak abduction of the thumb: most sensitive test • Tinel's sign • Phalen's sign If pain or swelling, use maneuvers to test stability of ligaments and integrity of menisci: MCL- abduction or valgus stress test LCL - adduction or varus stress test Anterior cruciate ligament (ACL) - anterior drawer sign, Lachman test Posterior cruciate ligament (PCL) - posterior drawer sign Medial and lateral menisci - McMurray test A patient presents to you with shoulder pain after falling during an ice storm. On examination, he exhibits localized shoulder pain when you perform the "crossover test" (arm moved across the chest toward the opposite side while extended at the elbow). Which of the following is the most likely site of injury? Rotator cuff Bicipital tendon Glenohumeral joint Acromioclavicular joint A patient who presents to clinic complaining of hand pain says she was told by a friend that it is most likely carpal tunnel syndrome. Upon assessing the patient, you note the following findings. Which would be suggestive of carpal tunnel syndrome? Hand pain when holding both hands in acute extension Numbness and tingling when tapping over the course of the radial nerve Symptoms related to compression are evident in all of the fingers None of the above None of the above Obtundation Shake the patient gently, as if awakening a sleeper. An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. Stupor Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli are needed.) A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment. You suspect an ACL tear. Which test is the most helpful to you in assessing the ACL? What is Lachman test, Anterior Drawer Sign Ask the patient to move actively against your opposing resistance; assign Grade? if the patient overcomes your opposing movement Grade 5, Normal muscle strength = 5 If the patient can only move against gravity, assign Grade? Grade 3 Test coordination, Loss of balance when eyes closed is a positive test Romberg test Reflexes are usually graded on a 0 to 4+ scale 4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension) 3+ Brisker than average; possibly but not necessarily indicative of disease 2+ Average; normal 1+ Somewhat diminished; low normal Movements include: Shoulder extension and flexion • Internal and external rotation of the humerus at the shoulder • Scapular abduction and adduction Apley scratch test tingling with tapping over the median nerve as it enters the carpal tunnel Tinel's sign numbness or tingling with pressing backs of hands together in acute flexion for 60 seconds Phalen's sign Test for tear or laxity of Medial Collateral Ligamen Abduction (Valgus) Stress Test Test for tear or laxity of Lateral Collateral Ligament Adduction (Varus) Stress Test Test for Tear in Medial or Lateral Meniscus McMurray Test Weak Abduction of Thumb Carpal Tunnel A thin, 58‐year‐old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign? a) Malignancy b)Ankylosing spondylitis c) Osteoporosis d)Torticollis e) Infection lateral deviation. Spondylolisthesis is incorrect; spondylolisthesis is the slippage between vertebrae and does not present with the head rotated laterally and downward. OA is incorrect. Although it can cause a stiff and painful neck, it would not cause the head to be laterally deviated toward the shoulder and rotated. Thoracic kyphosis is incorrect; thoracic kyphosis is increased flexion of the thoracic vertebrae and occurs with aging. Ankylosing spondylitis is incorrect; ankylosing spondylitis does not present with the head rotated laterally and downward. A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis? a)Assess the lateral bending movement of his neck b)Assess his ability to touch his toes c) Compare the strength of his trapezia muscles d)Check for listing of his trunk e)Assess his ability to extend his back c) Compare the strength of his trapezia muscles One cause of winged scapula is the contralateral weakness of the trapezius muscle. As this patient has had his left arm immobilized for 8 weeks, he may have muscle wasting and weakness of the left trapezius relative to his right side. Assess his ability to touch his toes is incorrect; touching toes assesses the muscles that flex the back as well as looks for scoliosis (differences in the height of scapulae). Assess the lateral bending movement of his neck is incorrect; this action assesses the function of the scalene and small intrinsic neck muscles. Assess his ability to extend his back is incorrect; this action assesses the function of the deep intrinsic muscles of the back. Check for listing of his trunk is incorrect; this sign may be present with a herniated disk. During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)? a) Prevertebral muscles b)Sternocleidomastoid (SCM) c) Scalenes d)Splenius capitis e) Splenius cervicis b)Sternocleidomastoid (SCM) The action is rotation of the neck. The muscles responsible for rotation of the neck are the SCM and the small intrinsic neck muscles. Scalenes is incorrect; the action of the scalene muscle is to flex the neck. The scalenes also laterally bend the neck. Splenius capitis is incorrect; the action of the splenius capitis muscle is to extend the neck. Prevertebral muscles is incorrect; the action of the prevertebral muscles is to flex the neck. Splenius cervicis is incorrect; the action of the splenius cervicis muscle is to extend the neck. During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group? a) Rotation of the spine b)Rotation and lateral bending of the spine c) Flexion of the spine d)Lateral bending of the spine e) Extension of the spine e) Extension of the spine The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extend the spine. Rotation of the spine is incorrect; the muscles that rotate the spine are the abdominal muscles and the intrinsic muscles of the back. Flexion of the spine is incorrect; the muscles that flex the spine are the psoas major and minor, quadratus lumborum, and the abdominal muscles. Lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. Rotation and lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. The clinician is seeing a middle‐aged patient who has a diagnosis of lumbar spinal stenosis. The patient's history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis? a)Thoracic kyphosis b)Pelvic tilt or drop c) Positive straight‐leg raise d)Flexed forward posture with lower extremity weakness e) Hyperreflexia of the lower limb d)Flexed forward posture with lower extremity weakness The physical signs of lumbar spinal stenosis include flexed forward posture and weakness of the lower extremities. Hyperreflexia of the lower limb is incorrect; hyporeflexia of the lower extremities is consistent with lumbar spinal stenosis. Pelvic tilt or drop is incorrect; weakness of the pelvic stabilizers—the gluteus medius and minimus are not consistent with lumbar spinal stenosis. Thoracic kyphosis is incorrect; thoracic kyphosis is not associated with lumbar spinal stenosis. Positive straight leg raise is incorrect; the straight‐leg test is usually negative in lumbar spinal stenosis. The clinician is seeing a 58‐year‐old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem? a) Polymyalgia rheumatica b)Rheumatoid arthritis (RA) c) Osteoarthritis (OA) d) Gout e) Psoriatic arthritis c) Osteoarthritis (OA) The common locations of joints involved with OA are the knees, hips, hands, wrists, neck, and lower back. RA is incorrect; the common locations of joints involved with RA are