Adult and Older Adult Cardiorespiratory Answers to Sample Cases

Case A

Question 1. CORRECT: 4

1 – Incorrect – the PT should pursue further the reason why the patient is refusing, as the patient may not fully understand the consequences of declining physiotherapy.
2+3 – Incorrect –  it is the responsibility of the PT to explain the purpose and benefits of physiotherapy and not rely on the doctor or family.
4 – Correct – because you are ensuring informed patient consent explaining to the patient the rationale for treatment, the potential risks of not having treatment, and the benefits of receiving treatment.

Question 2. CORRECT: 4, 5, 7

1 – Incorrect – standing alone will not sufficiently inform the PT about respiratory status.
2 – Incorrect- huffing on its own does not provide sufficient information about respiratory status.
3 – Incorrect – active cycle breathing does not provide sufficient information about respiratory status.
4 – Correct – supports minimum treatment requirement to assess / auscultate prior to treatment; will also confirm if your treatment is successful; an outcome measure pre and post treatment; the physical therapist should not rely on the nurse’s verbal report to the PT.
5 – Correct – supports minimum treatment requirement of assessing the patient which includes reviewing the chest X-ray prior to treatment; the physical therapist should not rely on the nurse’s verbal report to the PT.
6 – Incorrect – a bedside assessment using pulse oximetry, auscultation, and chest X-ray is sufficient unless the patient deteriorates further.
7 – Correct – bedside pulse oximetry can be done by the PT and will provide information on the patient’s oxygen saturation.

Question 3. CORRECT: 2, 6, 7, 8

1 – Incorrect – ROM is not appropriate at this time to improve lung function.
2 – Correct – active cycle of breathing will help to open the atelectatic area.
3 – Incorrect – CPAP is not the first line of treatment for acute ateletasis.
4 – Incorrect – mechanical vibrations is not the first treatment of choice due to surgical incision and efficacy of this technique.
5 – Incorrect – postural drainage in prone is not the first treatment choice and may be difficult to tolerate post-op day 1.
6 – Correct – providing support over the incision can reduce pain and improve the effectiveness of the cough.
7 – Correct – evidence based practice on deep breathing and coughing and good early intervention will mobilize secretions and increase ventilation to the atelectatic area.
8 – Correct – mobilizing the patient is the first line of treatment to improve ventilation and secretion clearance; supported as best practice.

Question 4. 1 False 2 True 3 False 4 True 5 True 6 True

1 – False – shoulder ROM is not relevant to respiratory treatment, although will later be a component of treatment because of surgical incision.
2 – True – auscultation is a key component of the PT’s respiratory assessment.
3 – False – past medical history is part of the initial assessment but not essential to repeat each PT session.
4 – True – response to treatment is essential to document for efficacy of treatment and to inform plan for next treatment session.
5 – True – consent to treatment is required prior to each session, not only the first time.
6 – True – documentation of incision integrity provides information about the treatment area, healing status, and will influence treatment plan.

Question 5. CORRECT: 1, 4, 7

1 – Correct – auscultation is an essential measure to validate increased air entry into the atelectatic area.
2 – Incorrect – a visual numeric pain scale is not the best choice to measure change in pain status.
3 – Incorrect – Borg measures level of fatigue in response to activity and does not measure respiratory status.
4 – Correct – chest expansion can objectively measure improved ventilation to the lower lobes.
5 – Incorrect – heart rate is not the among the first three key indicators to measure response to respiratory physiotherapy treatment.
6 – Incorrect – TUG does not measure respiratory status.
7 – Correct – respiratory rate is a key outcome measure to evaluate the patient’s response to treatment.

 

 

 

 

Case B

Question 1. CORRECT: 1

1 – Correct – The right hemidiaphragm becomes obscured with the presence of the silhouette sign on chest X-ray (CXR).
2 – Incorrect – the right heart border should remain visible on CXR.
3 – Incorrect – the aortic knob will remain visible on CXR with the presence of the silhouette sign.
4 – Incorrect – the ascending aorta will remain visible on CXR with a silhouette sign.

 

Question 2. CORRECT: 1

1 – Correct – This is the correct method for providing an abdominal thrust to provide an assisted cough.
2 – Incorrect – Prone lying is an excessive stress for the patient, and not a classic position for assisted cough, rather supine or fowlers. It will also be easier to coordinate with the patient’s cough in these other positions.
3 – Incorrect – Placing the patient in sidelying only enables the physical therapist to provide rib cage compression on one side.
4 – Incorrect – This is not a recognized method of providing assisted cough and could lead to trauma of the patients wrists.

Question 3. 1 False 2 False 3 False 4 True 5 True

1 – False – The physical therapist needs to obtain informed consent from this patient prior to participating in the treatment intervention.
2 – False – Showing the patient pictures and then proceeding with the treatment makes an assumption that the patient understood the pictures.
3 – False – Informed consent with the patient agreeing with the treatment must be obtained.
4 – True – If the patient understands an alternate technique that is effective and the patient understands, then consent can be obtained.
5 – True – This would be the ideal scenario to enable informed consent and likely the pursuit of the most effective treatment intervention.

Question 4. CORRECT: 1

1 – Correct – As the physical therapist should protect themselves from airborne as well as contact organisms.
2 – Incorrect – Handwashing on its own is insufficient; it should also follow the precautions used in answer number one.
3 – Incorrect – The patient has not been designated to be on airborne precautions.
4 – Incorrect – Proper infection control should be followed such that this workload management is not necessary.

 

 

 

 

Case C

Question 1. CORRECT: 1- True, 2- True, 3- True, 4- False

1 – True – Early mobilization of a surgical patient will optimize ventilation of poorly ventilated areas and clearance of potential secretions postoperatively, as well as offset the development of orthostatic intolerance.
2 – True – Ambulation with a walker would aid the patient to mobilize when they may feel somewhat unsteady postoperatively. Ambulation would go beyond sitting on the edge of the bed and enhance the physiological effects and treatment outcomes.
3 – True – Teaching the patient how to splint their cough will limit their pain, thus increasing cough efficacy and preventing secretion accumulation. This would be done best in a sitting position.
4 – False – The patient would unlikely tolerate this positioning and limit their tidal volumes even further, while increasing their respiratory rate as well. Further, this intervention is not indicated at this point where mobilization is possible and the patient is likely responding positively.

Question 2. CORRECT: 2

1 – Incorrect – The patient is only safely able to negotiate one step and has 3 stories in his home. He is thus not ready for discharge.
2 – Correct – Discussing the patient’s safety risks would assure that the patient is not discharged home in his current state, but rather should be referred for rehabilitation and a combination of home assessment and modification.
3 – Incorrect – The patient’s shoulder function is unlikely the primary cause of the patient’s inability to perform the stairs.
4 – Incorrect – The team would make the necessary arrangements and you as an acute surgical therapist, would not be the health care provider to visit their home.

Question 3. CORRECT: 1- False, 2- True, 3- True

1 – False – As a mobility expert you have suggested a 2-wheeled walker for the patient and a wheelchair could lead to further immobility and loss of function.
2 – True – The physical therapist should ensure that this patient is able to use a 2-wheeled walker safely. It would be ideal to have his daughter witness one of these treatment sessions.
3 – True – Once the PT has ensured that the patient can safely mobilize with a 2-wheeled walker they would want to provide the daughter with the rationale for use of the walker. Again, if the daughter could attend a treatment session they could see the patient mobilizing safely with this device and not necessitating a wheelchair.

Question 4. CORRECT: 1, 3, 4

1 – Correct – By performing this exercise, the patient will maintain and improve his strength and functional mobility.
2 – Incorrect – The patient’s lungs at this stage are not a concern and do not require this intervention. However, the mobilization that the patient is performing will continue to enhance his lung function.
3 – Correct – Performing these squats will enhance muscle strength and function as well as the patient’s balance.
4 – Correct – Performing this exercise activity and progressing it gently will enhance the patient’s cardiopulmonary function over time (with a longer duration of activity) as well as again enhance his strength and functional mobility.
5 – Incorrect – This intervention is not indicated and once again, the patient’s active rehab program will also enhance the function of his cardiopulmonary system and maintain its integrity.
6 – Incorrect – The patient’s hand function is not of concern and thus this intervention is not indicated.

 

 

 

 

Case D

Question 1. CORRECT: 1, 2, 6

1 – Correct – physician orders should be noted to gather a full clinical picture of the patient’s health status.
2 – Correct – arterial blood gases (ABGs) provide a good baseline measure to help the PT determine the efficacy of their treatment plan, response to treatment, and follow up plan.
3 – Incorrect – name of physician is not a key finding needed to initiate treatment.
4 – Incorrect – transfer plan is not a piece of information needed to initiate treatment.
5 – Incorrect – information about a recent bowel movement is not an immediate contraindication to assessment or treatment of the acute respiratory issue.
6 – Correct – a chest X-ray (CXR) is a key assessment finding for a PT to review prior to treatment; a follow up CXR can show changes as a response to PT treatment.

Question 2. CORRECT: 4

1 – Incorrect – other secretion clearance techniques should be used before resorting to deep suctioning, using deep suctioning to stimulate a cough may cause additional respiratory distress.
2 – Incorrect – arm elevation may assist with thoracic expansion but it is not the most efficient method to quickly mobilize and remove secretions; assisted cough technique is effective but not on its. own.
3 – Incorrect – nasal pharyngeal suctioning is not the first choice of secretion removal intervention, and the PT should be able to support the patient without having to call an RT.
4 – Correct – using a combination of postural drainage with vibrations followed with assisted coughing is the treatment of choice for secretion removal and clearance.

Question 3. CORRECT: 2

1 – Incorrect – no identified underlying lung pathology prior to admission to suggest an abscess.
2 – Correct – a large mucous plug in a main bronchus will cause an acute collapse/white out of the lung causing increase respiratory distress.
3 – Incorrect – pneumothorax of the right lung will appear as an large area of blackness not a whiteout.
4 – Incorrect – no identified underlying pathology to suggest pleural effusion; not normally associated with acute Guillain-Barre.

Question 4. CORRECT: 3

1+4 – Incorrect – confidential patient information can not be shared with others without consent of the patient or their substitute decision maker.
3 – Correct – if the patient is unable to provide consent to share personal information with a co-worker/friend, the patient’s substitute decision maker can give consent.
2 – Incorrect – no client specific information can be shared with others (family or friends) without the patient’s consent; suggesting he could receive this information from the social worker is wrong.