PATH 370 | Quiz 6 | Practice Questions

A patient presenting with a severe, pounding headache accompanied by nausea and photophobia is likely experiencing a ________ headache. - tension - migraine - sinus - chronic

migraine Typical signs of a migraine headache include severe unilateral pounding or throbbing pain that may be accompanied by nausea, vomiting, photophobia, phonophobia, and lacrimation. A severe, pounding headache with nausea and photophobia is likely to be a migraine headache. A sinus headache is not typically associated with nausea and photophobia. Pain is considered chronic when it lasts more than several months beyond the expected healing time.

Anticholinesterase inhibitors may be used to manage - muscular dystrophy. - myasthenia gravis. - fibromyalgia. - rheumatoid arthritis.

myasthenia gravis. Anticholinesterase inhibitors may be used to manage myasthenia gravis. Anticholinesterase agents are not used to manage muscular dystrophy, fibromyalgia, or rheumatoid arthritis.

It is recommended that women of childbearing age take folic acid daily for prevention of - neural tube defects. - seizure disorders. - cerebral palsy. - hydrocephalus.

neural tube defects. The use of folic acid during the period prior to conception has been shown to significantly decrease the risk of having a child with a neural tube defect. Folic acid does not prevent seizure disorders. An etiologic factor in the development of cerebral palsy is mechanical trauma before, during, or after birth. Hydrocephalus is not prevented with the use of folic acid.

Bone healing may be impaired by - excessive vitamin C. - nicotine use. - a high-protein diet. - immobilization.

nicotine use. Nicotine can delay bone healing. Vitamin C, protein, and immobilization are necessary for bone healing.

"Please explain the pathophysiology of osteoarthritis to me," says another nurse. "Is it just wear and tear so that the cartilage wears out?" Your best response is - "Yes; repeated use just wears out the cartilage, until it becomes thin and denuded. That causes pain and will eventually cause joint inflammation." - "Yes; with increasing age, the inflammation from repeated joint use accumulates and causes the cartilage to get thin and ragged until it disappears." - "No; cells in bone, cartilage, and the synovial membrane all get activated and secrete inflammatory mediators that destroy cartilage and damage bone." - "No; autoimmune cells infiltrate the joint and collect on the cartilage in a mass called 'pannus' that eventually thins and destroys the cartilage."

"No; cells in bone, cartilage, and the synovial membrane all get activated and secrete inflammatory mediators that destroy cartilage and damage bone." Osteoarthritis involves a complex interaction between osteoclasts, osteoblasts, chondrocytes, and synoviocytes that eventually destroy cartilage and damage subchondral bone. Repeated use of a joint and pannus are not the causes of osteoarthritis. Inflammatory mediators, not inflammation from repeated joint use, are the cause of osteoarthritis.

What type of seizure usually occurs in children and is characterized by brief staring spells? - Epileptic - Idiopathic - Partial - Absence

Absence Absence or petite mal seizures usually occur only in children. They are very brief (2 to 10 seconds), and episodes are characterized by staring spells that last only seconds. Epilepsy refers to recurrent seizures. Idiopathic seizures are those that have no explanation for the disorder. Partial seizures are those in which activity is restricted to one brain hemisphere.

Which neurologic disorder is commonly referred to as Lou Gehrig disease? - Multiple sclerosis - Parkinson disease - Alzheimer disease - Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis ALS is also known as Lou Gehrig disease, after the famed "Iron Man" of the New York Yankees, who died from the disease. Multiple sclerosis, Parkinson disease, and Alzheimer disease are not named after Lou Gehrig.

Which treatment is helpful in neuropathic pain but not used for acute pain? - Narcotic analgesics - Nonsteroidal anti-inflammatory drugs and aspirin - Anticonvulsants - Nonnarcotic analgesics

Anticonvulsants Management of pain associated with neuralgia includes antiseizure medications. Narcotic analgesics are discouraged for long-term therapy. NSAIDs and aspirin are not indicated for treatment of neuropathic pain. Management of neuralgia includes topical and systemic therapies.

Which group of clinical findings indicates the poorest neurologic functioning? - Spontaneous eye opening, movement to command, oriented to self only - Eyes open to light touch on shoulder, pupils briskly reactive to light bilaterally - Assumes decorticate posture with light touch, no verbal response - No eye opening, responds to painful stimulus by withdrawing

Assumes decorticate posture with light touch, no verbal response Decorticate posturing is an abnormal flexor response of the arms and wrists, with legs and feet extended and internally rotated. This occurs as the neurologic functioning deteriorates. Normal response occurs with spontaneous eye opening, movement on command and orientation to self. Eye opening to touch is not indicative of poor neurologic functioning. A lower neurologic functioning is indicated by a patient who is able to withdraw from painful stimulus and localize the source of pain.

________ edema occurs when ischemic tissue swells because of cellular energy failure. - Interstitial - Osmotic - Vasogenic - Cytotoxic

Cytotoxic Cytotoxic edema occurs when ischemic tissue swells because of cellular energy failure. A lack of ATP allows Na+ to accumulate in the cell, creating an osmotic force to draw in water. Interstitial edema is usually secondary to increased capillary pressure, damage to the capillary endothelium from a chemical injury, or sudden increase in vascular pressure beyond autoregulatory limits. A lack of ATP allows Na+ to accumulate in the cell, creating an osmotic force to draw in water. Vasogenic edema is a consequence of stroke, ischemia, and severe hypertension, and may occur surrounding brain tumors.

A tool used to assess levels of consciousness is - magnetic resonance imaging (MRI). - intracranial pressure (ICP) monitoring. - Glasgow Coma Scale (GCS). - central perfusion pressure (CPP).

Glasgow Coma Scale (GCS). The Glasgow Coma Scale (GCS) is a standardized tool developed for the purpose of assessing the level of consciousness in acutely brain-injured patients. An MRI is useful in evaluating a patient with an increase in ICP or change in mental status. ICP monitoring is useful in monitoring and treating patients with head trauma or other sources of excessive CSF. Central perfusion pressure is a useful tool in guiding therapy along with ICP.

What type of fracture generally occurs in children? - Greenstick - Stress - Nightstick - Colles

Greenstick Greenstick fractures occur most often in the growing bones of children. Stress fractures can occur at any age. Nightstick and Colles fractures occur most often in adults.

One of the most common causes of acute pain is - headache. - fibromyalgia. - malignancy. - trigeminal neuralgia.

Headache. Headache is one of the most common causes of acute pain, accounting for approximately 13 million visits each year in the Unites States to physician's offices, urgent care clinics, and emergency departments. Fibromyalgia syndrome is a chronic pain syndrome. Cancer pain is a subcategory of chronic pain, although it may be acute. Trigeminal neuralgia is a form of neuropathic pain.

_________ is a form of spina bifida in which a saclike cyst filled with CSF protrudes through the spinal defect but does not involve the spinal cord. - Spina bifida occulta - Meningocele - Myelomeningocele - Meningomyelocele

Meningocele In the meningocele form of spina bifida cystica, a saclike cyst filled with CSF protrudes through the spinal defect but does not involve the spinal cord. In spina bifida occulta, the posterior vertebral laminae have failed to fuse. A myelomeningocele or meningomyelocele deformity contains meninges, CSF, and a portion of the spinal cord that protrudes from the vertebral defect in a cystlike sac.

________ occurs when a brainstem impaired patient exhibits a persistent rhythmic or jerky movement in one or both eyes. - Nystagmus - Dysconjugate movement - Ocular palsy - Doll's eye

Nystagmus Nystagmus is a persistent rhythmic or jerky movement in one or both eyes. Dysconjugate movements occur when the eyes do not move together in the same direction. Ocular palsies occur when one or more cranial nerves are dysfunctional such that motor paralysis of the eye muscles impairs movements in one or more directions. The doll's-eyes test is performed by holding open the patient's eyelids and rotating the head from one side to the other. If the brainstem is intact, the eyes will turn in a direction opposite to the direction of head rotation.

Which disorder usually causes skeletal pain and involves significant bone demineralization from vitamin D deficiency? - Osteomalacia - Osteopenia - Osteomyelitis - Osteoporosis

Osteomalacia Osteomalacia is inadequate mineralization of bone tissue, most commonly caused by vitamin D deficiency, and it usually causes skeletal pain. Osteopenia, osteomyelitis, and osteoporosis are not caused by vitamin D deficiency.

The disorders characterized by softening and then enlargement of bones is referred to as - osteomyelitis. - osteoporosis. - Paget disease. - rickets.

Paget disease. Paget disease is characterized by excessive bone resorption and formation, causing fractures and deformities. Osteomyelitis, osteoporosis, and rickets do not involve softening and then enlargement of bones.

Orthostatic hypotension may be a manifestation of - Alzheimer disease. - multiple sclerosis. - Parkinson disease. - amyotrophic lateral sclerosis.

Parkinson disease. In patients with Parkinson disease, involvement of the autonomic nervous system may result in orthostatic hypotension. Alzheimer disease is not typically associated with orthostatic hypotension. Orthostatic hypotension is not associated with multiple sclerosis. Amyotrophic lateral sclerosis is not manifested by orthostatic hypotension.

The earliest manifestation of scleroderma is - thick, tight, shiny skin. - skin hyper/hypopigmentation. - renal impairment. - Raynaud phenomenon.

Raynaud phenomenon. Raynaud phenomenon with blanching of the digits in response to cold is the earliest manifestation. Thick, tight, shiny skin and hyper/hypopigmentation are not the earliest manifestation. Renal impairment is a late manifestation.

What effect do demyelinating disorders such as multiple sclerosis have on neurotransmission? - Slower rate of action potential conduction - Increased rate of action potential conduction - Facilitation of action potential initiation - Faster rate of repolarization

Slower rate of action potential conduction The inflammation and scarring that occur with MS slow or interrupt the conduction of nerve impulses. Multiple sclerosis does not have an increased rate of action potential conduction on neurotransmission. Action potential initiation is not facilitated in demyelinating disorders. There is not a faster rate of repolarization in demyelinating disorders such as MS.

Which statement is true about the incidence of multiple sclerosis? - The age of onset ranges from 20 to 50 years. - MS is more common in men than women. - There is a higher incidence of MS in military veterans. - There is a higher rate of MS in African-Americans.

The age of onset ranges from 20 to 50 years. The age of onset of MS ranges from 20 to 50 years. MS is two to three times more common in women than in men. There is a higher incidence of ALS in military veterans, especially those of the Persian Gulf. MS occurs at a higher rate among individuals from Caucasian northern European descent and those who live in northern latitudes.

Although skin manifestations may occur in numerous locations, the classic presentation of systemic lupus erythematosus (SLE) includes - lesions affecting the palms of hands and the soles of feet. - dry, scaly patches in the antecubital area and behind the knees. - cracked, scaly areas in the webs of fingers. - a butterfly pattern rash on the face across the bridge of the nose.

a butterfly pattern rash on the face across the bridge of the nose. The classic presentation of SLE includes a butterfly pattern rash on the face across the bridge of the nose. The classic presentation does not involve lesions affecting the palms of the hands and the soles of the feet; dry, scaly patches in the antecubital area and behind the knees; or cracked, scaly areas in the webs of the fingers.

Parkinson disease is associated with - demyelination of CNS neurons. - a pyramidal nerve tract lesion. - insufficient production of acetylcholine in the basal ganglia. - a deficiency of dopamine in the substantia nigra.

a deficiency of dopamine in the substantia nigra. Parkinson disease results from degeneration of the pigmented dopaminergic neurons found in the substantia nigra. Demyelination of CNS neurons is not associated with Parkinson disease. Parkinson disease is not associated with a pyramidal nerve tract lesion. Decreased acetylcholine synthesis has been found in some studies related to Alzheimer disease.

Most muscle strains are caused by - a tear in an adjoining tendon. - abnormal muscle contraction. - muscle asymmetry. - bleeding into the muscle.

abnormal muscle contraction. Most muscle strains are caused by abnormal muscle contraction. A muscle strain can be caused by a tear in the muscle. A tendon strain can be as a result of a tear in the tendon. Muscle asymmetry is not the cause of muscle strains. Muscle strains are not caused by bleeding into the muscle.

The stage of spinal shock that follows spinal cord injury is characterized by - reflex urination and defecation. - autonomic dysreflexia. - absent spinal reflexes below the level of injury. - motor spasticity and hyperreflexia below the level of injury.

absent spinal reflexes below the level of injury. Spinal shock may occur after injury to the spinal cord, and can last from a few hours to a few weeks. Symptoms below the level of injury include flaccid paralysis of all skeletal muscles; loss of all spinal reflexes; loss of pain, proprioception, and other sensations; bowel and bladder dysfunction with paralytic ileus; and loss of thermoregulation. Bowel and bladder dysfunction may occur with spinal shock. Spinal shock is not characterized by autonomic dysreflexia. Spinal shock is generally associated with flaccid paralysis and loss of spinal reflexes.

Myasthenia gravis is an autoimmune disease in which - neuronal demyelination disrupts nerve transmission. - muscles become increasingly bulky but weakened. - acetylcholine receptors are destroyed or dysfunctional. - acetylcholine release from motor neurons is disrupted.

acetylcholine receptors are destroyed or dysfunctional. Myasthenia gravis is an autoimmune disease in which acetylcholine receptors are destroyed or dysfunctional. Multiple sclerosis is an autoimmune disease in which neuronal demyelination disrupts nerve transmission. Muscles become weak, but not bulky, in myasthenia gravis. Acetylcholine receptors are destroyed or dysfunction in myasthenia gravis.

Risk factors for hemorrhagic stroke include - therosclerosis. - dysrhythmias. - acute hypertension. - sedentary lifestyle.

acute hypertension. Intracerebral hemorrhage is a hemorrhage within the brain parenchyma and usually occurs in the context of severe and often longstanding hypertension. Risk factors for stroke are similar to those for other atherosclerotic vascular disease. Cardiac disease complicated by atrial fibrillation is an important risk factor for embolic stroke. Sedentary lifestyle is not a risk factor for hemorrhagic stroke.

The complication which is not likely to result from a compound, transverse fracture of the tibia and fibula is - bone infection. - fat emboli. - air embolus. - compartment syndrome.

air embolus. Air embolus is not likely to occur secondary to this fracture. Bone infection is likely, because it is an open fracture. Fat emboli are likely because the fracture is in a long bone. Compartment syndrome is likely because of the extent of soft-tissue injury.

Upper extremity weakness in association with degeneration of CNS neurons is characteristic of - multiple sclerosis. - Guillain-Barré syndrome. - myasthenia gravis. - amyotrophic lateral sclerosis.

amyotrophic lateral sclerosis. Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disease affecting both the upper and lower motor neurons characterized by muscle wasting and atrophy of the hands, arms, and legs. Symptoms of multiple sclerosis include double vision, weakness, poor coordination, and sensory deficits. Patients with Guillain-Barré syndrome have progressive ascending weakness or paralysis that usually begins in the legs. Upper extremity weakness associated with degeneration of CNS neurons is not characteristic of myasthenia gravis.

A patient who experiences early symptoms of muscle twitching, cramping, and stiffness of the hands may be demonstrating signs of - Guillain-Barré syndrome. - amyotrophic lateral sclerosis. - Parkinson disease. - hydrocephalus.

amyotrophic lateral sclerosis. Most patients with ALS demonstrate muscle weakness and atrophy. The earliest symptoms may be muscle twitching, cramping, and stiffness. Often the hands or upper extremities are affected first. Guillain-Barré syndrome is characterized by ascending weakness that usually begins in the legs. Tremors at rest are usually the earliest symptoms of Parkinson disease. Hydrocephalus is characterized by abnormal accumulation of CSF in the cerebral ventricular system.

Rheumatoid arthritis is commonly associated with the presence of rheumatoid factor autoantibodies in the bloodstream. This indicates that rheumatoid arthritis is likely to be - caused by bacterial infection. - an autoimmune process. - an infective process. - because of an enzymatic defect.

an autoimmune process. The presence of rheumatoid factor autoantibodies indicates that RA is an autoimmune process. The presence of rheumatoid factor autoantibodies does not indicate infection, an infective process, or an enzymatic defect.

The most common source of osteomyelitis is - an infection that migrates via the bloodstream. - direct invasion from a fracture. - surgical contamination. - a joint prosthesis.

an infection that migrates via the bloodstream. Hematogenous osteomyelitis (via the blood stream) is the most common type of osteomyelitis. Direct invasion of infection from a fracture, infection of a bone resulting from surgical contamination, and a joint prosthesis are not the most common sources of osteomyelitis.

Systemic lupus erythematosus (SLE) is a rheumatic disease attributed to - wear and tear on weight-bearing joints. - septic joint inflammation and necrosis. - unknown etiologic factors. - autoimmune mechanisms.

autoimmune mechanisms. Systemic lupus erythematosus (SLE) is a rheumatic disease attributed to autoimmune mechanisms. Wear and tear on weight-bearing joints and septic joint inflammation and necrosis do not lead to SLE. SLE is known to be attributed to autoimmune mechanisms.

To avoid the progression of cutaneous lesions, a patient diagnosed with systemic lupus erythematosus (SLE) should - avoid sun exposure. - avoid excessive use of moisturizers. -refrain from washing the affected areas. - apply warm, wet compresses daily.

avoid sun exposure. To avoid the progression of cutaneous lesions, a patient with SLE should avoid sun exposure. Avoiding excessive use of moisturizers, refraining from washing the affected areas, and applying warm, wet compresses daily will not deter the progression of lesions.

Inflammation of the sacs that overlie bony prominences is called - epicondylitis. - arthritis. - tendinitis. - bursitis.

bursitis. Bursitis is inflammation of the bursal sacs that protect the skin over bony protuberances. Epicondylitis is inflammation of an epicondyle. Arthritis is inflammation of one or more joints. Tendinitis is inflammation of a tendon.

Leakage of CSF from the nose or ears is commonly associated with - epidural hematoma. - temporal skull fracture. - basilar skull fracture. - cerebral aneurysm.

basilar skull fracture. Sometimes fractures at the base of the skull are not visible on the routine CT scan, but allow drainage of CSF into the nasal sinuses. Head-injured patients who have drainage of clear fluid from the ears or nose should be evaluated for basilar skull fracture. Epidural hematomas are not associated with leakage of CSF from the nose or ears. Fracture of the temporal bone commonly results in an acute epidural hemorrhage. Cerebral aneurysm is not associated with leakage of cerebrospinal fluid.

It is true that encephalitis is usually - because of a bacterial infection in the CNS. - fatal. - because of a viral infection in brain cells. - asymptomatic.

because of a viral infection in brain cells. Encephalitis is an inflammation of the brain which is caused by a variety of agents. Viral causes account for the majority of encephalitis cases. Bacteria can be responsible for the inflammation of the brain associated with encephalitis. Death occurs in 5% to 20% of encephalitis cases. Clinical manifestations of HSV encephalitis typically evolve over several days.

The most important preventive measure for hemorrhagic stroke is - anticoagulation. - blood pressure control. - thrombolytics. - management of dysrhythmias.

blood pressure control. Hemorrhagic stroke is a hemorrhage that is usually the result of longstanding hypertension. Blood pressure control is the most important preventive measure. Anticoagulation would be useful for preventing embolic stroke. Risk reduction strategies for thrombotic stroke are aimed at reducing atherosclerosis. Dysrhythmias are not related to a risk of hemorrhagic stroke.

People who have osteoporosis are at risk for - rhabdomyolysis. - osteomyelitis. - osteomalacia. - bone fractures.

bone fractures. Osteoporosis weakens the bone structure and increases the risk of bone fractures. Rhabdomyolysis, osteomyelitis, and osteomalacia are completely different conditions.

The most common symptom of multiple myeloma is - pathologic fracture. - fever. - bone pain. - osteomyelitis.

bone pain. The most common symptom of multiple myeloma is bone pain. Although pathologic fractures occur in multiple myeloma, bone pain is the most common symptom. Fever and osteomyelitis are not common in multiple myeloma.

A compound, transverse fracture is best described as a bone that is - broken in two or more pieces. - cracked but not completely separated. - broken along the long axis. - broken and protruding through the skin.

broken and protruding through the skin. The type of fracture described is broken and protruding through the skin. A comminuted fracture is one that is broken in two or more pieces. An incomplete fracture is cracked but not completely separated. A longitudinal fracture is broken along the long axis.

Subarachnoid hemorrhage is usually managed with volume expansion and blood pressure support to enhance cerebral perfusion. This is necessary because subarachnoid hemorrhage predisposes to - cerebral vasospasm. - hypotension. - excessive volume loss. - increased intracranial pressure.

cerebral vasospasm. In patients experiencing subarachnoid hemorrhage as a consequence of ruptured aneurysm, the complications of cerebral vasospasm and hydrocephalus must be monitored and managed. Vasospasm can be managed by keeping blood volume and blood pressure at normal to high levels. Vasospasm is managed by keeping blood volume and blood pressure at normal to high levels. Subarachnoid hemorrhage does not predispose to excessive volume loss. Subarachnoid hemorrhage is not associated with predisposition to increases in intracranial pressure.

Pain in fibromyalgia involves - muscle inflammation. - autoimmune destruction of muscle tissue. - nerve inflammation. - changes in pain transmission in the spinal cord.

changes in pain transmission in the spinal cord. Pain in fibromyalgia involves changes in pain transmission in the spinal cord that are called central sensitization. Muscle inflammation, nerve inflammation, and autoimmune destruction of muscle tissue do not cause the pain in fibromyalgia.

It is true that epidural bleeding is - associated with widespread vascular disruption. - located between the arachnoid and the dura mater. - usually because of venous leakage. - characterized by a lucid interval immediately after injury.

characterized by a lucid interval immediately after injury. The source of bleeding in most epidural hematomas is arterial. The patient may suffer only a brief period of disturbed consciousness followed by a period of normal cognition (lucid interval). Then consciousness rapidly deteriorates as the epidural hematoma expands and compresses brain structures. As the epidural hematoma expands, pressure is placed on the brain structures. The bleeding associated with an epidural hematoma occurs between the inner surface of the skull and the dura mater. The source of bleeding in most epidural hematomas is arterial.

A fracture in which bone breaks into two or more fragments is referred to as - comminuted. - open. - greenstick. - stress.

comminuted. A fracture in which the bone breaks into two or more fragments is called a comminuted fracture. Open fractures, greenstick fractures, and stress fractures do not involve two or more bone fragments.

The gate control theory of pain transmission predicts that activity in touch receptors will - enhance perception of pain. - decrease pain signal transmission in the spinal cord. - activate opioid receptors in the CNS. - increase secretion of substance P in the spinal cord.

decrease pain signal transmission in the spinal cord. The gate control theory is used to explain how stimulation of large "touch" neurons could inhibit the transmission of nociceptor impulses. Central to the gate control theory is the capacity for interneurons in the spinal cord to modify the transmission of nociceptor impulses. The gate control theory is not based on a theory that activity in touch receptors will enhance perception of pain. Opioid receptors are thought to be the mediators of presynaptic inhibition. One way to inhibit synaptic transmission is through presynaptic inhibition of substance P release from nociceptor neurons.

The chief pathologic features of osteoarthritis are - stress fractures of the epiphysis, inflammation of the diaphysis, and accumulation of excessive synovial fluid. - autoimmune damage to the synovium, destruction of articular cartilage by pannus, and thickening of synovial fluid. - degeneration of articular cartilage, destruction of the bone under the cartilage, and thickening of the synovium. - thinning of the joint capsule, resorption of bone, excessive formation of new bone, and formation of bone spurs.

degeneration of articular cartilage, destruction of the bone under the cartilage, and thickening of the synovium. The chief pathologic features of osteoarthritis are degeneration of articular cartilage, destruction of the bone under the cartilage, and thickening of the synovium. Although osteoarthritis does involve formation of bone spurs, all the other answer choices listed do not occur with osteoarthritis.

A patient diagnosed with diabetes, smokes a pack of cigarettes daily and eats very few green leafy vegetables. After experiencing a fractured toe, this patient is at risk for - delayed healing. - malunion. - nonunion. - dysunion.

delayed healing. Fracture healing that does occur but takes longer than expected is called delayed healing. The situation is not an example of malunion or nonunion. Dysunion is not a term used to describe healing complications.

The dementia of Alzheimer disease is associated with structural changes in the brain, including - deposition of amyloid plaques in the brain. - degeneration of basal ganglia. - hypertrophy of frontal lobe neurons. - significant aluminum deposits in the brain.

deposition of amyloid plaques in the brain. The hallmark pathophysiologic changes associated with Alzheimer disease include intracellular neurofibrillary tangles and extracellular amyloid plaques. Degeneration of the basal ganglia is not associated with dementia of Alzheimer disease. Brain atrophy occurs as a result of the amyloid plaques in the brain. Aluminum deposits in the brain are not responsible for dementia of Alzheimer disease.

Tophi are - renal calculi composed of uric acid. - deposits of urate crystals in tissues. - painful edematous joints. - spots that coalesce in a malar rash.

deposits of urate crystals in tissues. Tophi are deposits of urate crystals in tissues that occur in gout. Tophi are not renal calculi, painful edematous joints, or a type of rash.

Muscular dystrophy includes a number of muscle disorders that are - genetically transmitted. - easily prevented and managed. - autoimmune in nature. -demyelinating focused.

genetically transmitted. Muscular dystrophy includes a number of muscle disorders that are genetically transmitted. Muscular dystrophy is not easily prevented or managed. It is not an autoimmune disease or a demyelinating disease.

Following a bone fracture, the most likely event to occur is - development of a blood clot beneath the periosteum. - leukocyte infiltration into bone tissue. - blood vessel growth at the fracture site. - migration of osteoblasts to the fracture site.

development of a blood clot beneath the periosteum. The first step in bone healing is hematoma formation. Leukocyte infiltration into bone tissue, blood vessel growth at the fracture site, and migration of osteoblasts to the fracture site are not the first steps in bone healing.

The pain of nonarticular rheumatism ("growing pain") is worse - during activity. - following strenuous exercise. - upon awakening. - during the night.

during the night. Growing pains are worse at night in the calves, shins, and thighs. Growing pains are not worse during activity or following strenuous exercise. Growing pains are worse at night, not upon awakening.

A risk factor for osteoporosis is - endometriosis. - early menopause. - late menopause. - ovarian cysts.

early menopause. Early menopause and late menarche are risk factors for osteoporosis. Endometriosis, late menopause, and ovarian cysts are not risk factors for osteoporosis.

Modulation of pain signals is thought to be mediated by the release of - histamine. - endorphins. - cholecystokinin. - glutamine.

endorphins Pain modulation occurs not only at the cord level but also in the brain itself. Opioids such as endorphins produced in the brain are thought to be important modulators of pain perception. Histamine is a chemical mediator of pain which is involved in the transduction phase. Cholecystokinin is a substance involved in synaptic transmission in the spinal cord. The excitatory neurotransmitter glutamate is involved in carrying the nociceptive message from primary afferent fibers to secondary neurons.

Paget's disease is characterized by - overactivity of osteoblasts leading to multiple bone tumors. - excessive bone resorption followed by excessive formation of fragile bone. - inflammatory disorder resulting in fusion of spine joints. - failure of resorption by osteoclasts resulting in hard bones.

excessive bone resorption followed by excessive formation of fragile bone. Paget's disease is characterized by excessive bone resorption followed by excessive formation of fragile bone. Overactivity of osteoblasts that lead to multiple bone tumors is not the cause of Paget's disease. Paget's disease is not characterized by the fusion of spine joints. Fragile bone, not hard bone, is a characteristic of Paget's disease.

Pain that waxes and wanes and is exacerbated by physical exertion is likely related to - neuralgia. - intermittent claudication. - fibromyalgia syndrome. - neuropathy.

fibromyalgia syndrome. Patients complain of pain that waxes and wanes and that does not follow a dermatomal pattern in fibromyalgia syndrome. The pain tends to be exacerbated by physical exertion. Trigeminal neuralgia is a form of neuropathic pain that can be quite disabling for patients. It is sudden, momentary, but excruciating pains along the second and third divisions of the trigeminal nerve. In the early stages, intermittent claudication is associated with physical activity and alleviated with rest and has a cramping quality. In severe cases, ischemic neuropathy may ensue and cause a more consistent burning, shooting pain in the leg or foot. In pain related to neuropathy, patients complain of burning pain in the distal bilateral lower extremities that is frequently worse at night.

Acceleration-deceleration movements of the head often result in polar injuries in which - injury is localized to the site of initial impact. - widespread neuronal damage is incurred. - bleeding from venules fills the subdural space. - focal injuries occur in two places at opposite poles.

focal injuries occur in two places at opposite poles. Polar injuries occur as a consequence of the brain shifting within the skull and meninges during the course of an acceleration-deceleration movement resulting in local injury at two opposite poles of the brain. Focal injuries are those that are localized to the site of impact to the skull. Diffuse injuries occur when movement of the brain causes widespread neuronal damage. An intracranial hematoma is a localized collection of blood within the cranium.

Prosthetic joint infection is most often because of - defective replacement material. - injury to the joint. - hematogenous transfer. - arthritis.

hematogenous transfer. Prosthetic joint infection is often because of bacterial spread to the joint via the blood stream. Defective replacement material is not the cause of prosthetic joint infection. Injury to the joint may lead to the implementation of a prosthetic joint, but the injury itself is not the cause of prosthetic joint infection. Arthritis may lead to the need for a prosthetic joint, but arthritis is not the cause of prosthetic joint infection.

The most common type of osteomyelitis is - hematogenous. - contiguous focus. - Brodie abscess. - direct invasion.

hematogenous. Hematogenous osteomyelitis is the most common type of osteomyelitis. Contiguous focus osteomyelitis is not the most common type. Brodie abscess is when an infection becomes enclosed by fibrotic tissue. Osteomyelitis may be caused by a direct invasion of organisms into the bone, but this is not the most common cause.

Autonomic dysreflexia is characterized by - hypertension and bradycardia. - hypotension and shock. - pallor and vasoconstriction above the level of injury. - extreme pain below the level of injury.

hypertension and bradycardia. Autonomic dysreflexia is a potentially life-threatening complication that may occur any time after spinal shock has resolved. It is characterized by a sudden episode of hypertension, headache, bradycardia, upper-body flushing and lower body vasoconstriction, piloerection, and sweating. Autonomic dysreflexia is associated with hypertension and lower body vasoconstriction. Extreme pain below the level of injury is not characteristic of autonomic dysreflexia.

An example of inappropriate treatment for head trauma would be - head elevation. - free water restriction. - hypoventilation. - bed rest.

hypoventilation. Hyperventilation, not hypoventilation, is indicated in the management of an acute elevation of intracranial pressure. Elevating the head is aimed at maintaining intracranial pressure and cerebral blood flow. Normal intravascular volume is indicated in the management of intracranial pressure. Bed rest would be indicated for the head trauma patient.

The pathophysiology of rheumatoid arthritis involves - immune cells accumulating in pannus and destroying articular cartilage. - free radicals attaching to the synovial membrane and tunneling into articular cartilage. - excessive wear and tear and microtrauma that damage articular cartilage. - cysts developing in subchondral bone and creating fissures in articular cartilage.

immune cells accumulating in pannus and destroying articular cartilage. In rheumatoid arthritis, immune cells accumulate in pannus and destroy articular cartilage. Free radicals do not attach to membranes; they damage them by removing electrons from them. Rheumatoid arthritis is not caused by excessive wear and tear. Subchondral cysts and fissures in articular cartilage are not characteristic of rheumatoid arthritis.

The pathophysiology of osteomalacia involves - increased osteoclast activity. - collagen breakdown in the bone matrix. - crowding of cells in the osteoid. - inadequate mineralization in the osteoid.

inadequate mineralization in the osteoid. Osteomalacia is characterized by inadequate or delayed mineralization in the osteoid. Osteomalacia does not involve increased osteoclast activity, collagen breakdown in the bone matrix, or crowding of cells in the osteoid.

Gouty arthritis is a complication of - group A streptococcal infection. - autoimmune destruction of joint collagen. - excessive production of urea. - inadequate renal excretion of uric acid.

inadequate renal excretion of uric acid. Gouty arthritis is a complication of inadequate renal excretion of uric acid. Rheumatic fever-related arthritis is related to group A streptococcal infection. Gout is not an autoimmune disorder. Gout is because of inadequate renal excretion of uric acid, not excessive production of urea.

Dopamine precursors and anticholinergics are all used in the management of Parkinson disease, because they - increase dopamine activity in the basal ganglia. - induce regeneration of neurons in the basal ganglia. - prevent progression of the disease. - produce excitation of basal ganglia structures.

increase dopamine activity in the basal ganglia. The mainstay of Parkinson therapy has been aimed at increasing the level of dopamine in the CNS. Anticholinergics and dopamine precursors are not related to regeneration of neurons. Preventing the progression of Parkinson disease is not the mechanism of action in medications used to treat the disease. Excitation of basal ganglia structures is not produced with dopamine precursors and anticholinergics.

It is true that scleroderma involves - inflammation and fibrosis of connective tissue. - autoantibodies against acetylcholine receptors. - infection by beta-hemolytic streptococcus. - inflammation caused by antigenic fragments of dead organisms.

inflammation and fibrosis of connective tissue. Scleroderma involves fibrosis of connective tissue. Myasthenia gravis involves autoantibodies against acetylcholine receptors. Rheumatic fever involves infection by beta-hemolytic streptococcus. Lyme disease is thought to involve inflammation caused by antigenic fragments of dead organisms.

Ankylosing spondylitis is characterized by - inflammation, stiffness, and fusion of spinal joints. - loss of articular cartilage in weight-bearing joints. - excessive bone remodeling leading to soft bone. - immune mechanisms leading to widespread joint inflammation.

inflammation, stiffness, and fusion of spinal joints. Ankylosing spondylitis is characterized by inflammation, stiffness, and fusion of spinal joints. Osteoarthritis involves loss of articular cartilage in weight-bearing joints. Paget's disease involves excessive bone remodeling leading to soft bone. RA involves immune mechanisms leading to widespread joint inflammation.

Enteropathic arthritis is associated with - irritable bowel syndrome. - inflammatory bowel disease. - chronic constipation. - chronic diarrhea.

inflammatory bowel disease. Enteropathic arthritis is associated with inflammatory bowel disease (Crohn disease and ulcerative colitis). Irritable bowel syndrome, chronic constipation, and chronic diarrhea are not symptoms of enteropathic arthritis.

It is useful to conceptualize pain physiology according to the four stages because each stage provides an opportunity for - education. - stimulation. - intervention. - documentation

intervention. It is clinically useful to conceptualize pain physiology according to these four processes, because each stage provides an opportunity for intervention in the pain experience. It is more useful to provide intervention for the patient experiencing pain. Stimulation may actually increase the pain level for the patient. Documentation of findings is appropriate, but taking measures to reduce or stop the pain is more advantageous.

Ankylosing spondylitis causes - intervertebral joint fusion. - instability of synovial joints. - costal cartilage degeneration. - temporomandibular joint degeneration.

intervertebral joint fusion. Ankylosing spondylitis causes joint fibrosis, ossification, and fusion, most commonly of the intervertebral and sacroiliac joints. Ankylosing spondylitis does not cause instability of synovial joints, degeneration of cartilage, or temporomandibular joint degeneration.

The stroke etiology with the highest morbidity and mortality is - intracranial hemorrhage. - intracranial thrombosis. - intracranial embolization. - cardiac arrest.

intracranial hemorrhage. Intracerebral hemorrhage is a hemorrhage within the brain parenchyma and usually occurs in the context of severe and often longstanding hypertension. It carries a 38% mortality, with death usually occurring within minutes to hours. Ischemic strokes are the most common and include thrombotic and embolic types. Embolic and ischemic strokes are the most common type. Stroke is the third leading cause of death in the United States. Cardiac arrest is not the stroke etiology with the highest morbidity and mortality.

The most important determinant for prescribing therapy for acute stroke is - location of ischemia. - thrombotic versus embolic cause. - ischemic versus hemorrhagic cause. - age of the patient.

ischemic versus hemorrhagic cause. Treatment pathways differ between ischemic and hemorrhagic stroke. The goals of therapy for ischemic stroke are to minimize infarct size and preserve neurologic function. Secondary prevention for thrombotic stroke includes lifestyle modification to address risk factors. It is critical to prevent further hypoxia or ischemia after ischemic stroke regardless of the age of the patient.

Clinical manifestations of a stroke within the right cerebral hemisphere include - cortical blindness. - right visual field blindness. - expressive and receptive aphasia. - left-sided muscle weakness and neglect.

left-sided muscle weakness and neglect. Manifestations of ischemic stroke are related to the cerebral vasculature involved and the area of brain tissue the vessel supplies. Contralateral hemiplegia is a usual finding. Contralateral hemiplegia, hemisensory loss, and contralateral visual field blindness are usual manifestations of stroke. Left visual blindness would be more indicative of a stroke affecting the right cerebral hemisphere. Aphasia is an integrative language disorder that occurs with brain damage to the dominant cerebral hemisphere (usually left) and involves all language modalities.

The initial treatment of an individual experiencing a seizure is concentrated on - maintaining an airway. - administering anticonvulsant medication. - documenting the seizure pattern. - obtaining an EEG.

maintaining an airway. Treatment of an individual experiencing a seizure is concentrated on maintaining an airway and protecting the individual from injury. If the seizures are because of irreversible or unidentifiable factors, anticonvulsant medications specific to the type of seizure are the best management. Recording the course of the seizure episode is useful, but is not the initial focus of care. EEG studies may be useful in determining abnormalities which elicit the pathologic mechanism.

Healing of a fractured bone with a poor alignment is called - malunion. - nonunion. - disunion. - delayed union.

malunion. Malunion is a complication that occurs when the bone fails to align correctly during the healing process. Nonunion and delayed union are different complications of bone healing. Disunion is not the term used for fracture healing with poor alignment.

The physiologic mechanisms involved in the pain phenomenon are termed - nociception. - sensitization. - neurotransmission. - proprioception.

nociception. The physiologic mechanisms involved in the pain phenomenon are termed nociception. Sensitization is not the physiologic mechanism of pain phenomena. Neurotransmission is not related to the physiologic pain mechanism. The physiologic mechanisms involved in the pain phenomenon are not known as proprioception.

Pain with passive stretching of a muscle is indicative of - noncontractile tissue injury. - contractile tissue injury. - vascular insufficiency. - skeletal muscle damage.

noncontractile tissue injury. Pain with passive stretching of a muscle is indicative of noncontractile tissue injury. Pain with passive stretching of a muscle is not an indication of a contractile tissue injury, vascular insufficiency, or skeletal muscle damage.

A malignant bone-forming tumor is referred to as a(n) - rhabdosarcoma. - liposarcoma. - osteosarcoma. - chondrosarcoma.

osteosarcoma. An osteosarcoma is a malignant bone-forming tumor. Rhabdo- refers to skeletal muscle. Lipo- refers to fat. Chondro- refers to cartilage.

Before making a diagnosis of Alzheimer disease - a brain biopsy demonstrating organic changes is necessary. - biochemical tests for aluminum toxicity must be positive. - other potential causes of dementia must be ruled out. - increased protein is found in a lumbar puncture.

other potential causes of dementia must be ruled out. All manageable causes for dementia or delirium should be ruled out before diagnosing Alzheimer disease. Neuroimaging may be useful in ruling out other neurologic diagnoses. A brain biopsy is not indicated. Evaluation of blood chemistry does not include the presence of aluminum. Increased protein in a lumbar puncture is not indicative of Alzheimer dementia.

It is true that Bell palsy is a - permanent facial paralysis after stroke. - painful neuropathic pain affecting the trigeminal nerve. - paralysis of the muscles innervated by the facial nerve. - herpetic outbreak in a facial dermatome.

paralysis of the muscles innervated by the facial nerve. Bell palsy is an acute idiopathic paresis or paralysis of the facial nerve involving an inflammatory reaction. Bell palsy patients generally recover facial nerve function spontaneously within 3 weeks. Patients with Bell palsy may complain of a heavy sensation in their face. Bell palsy is not related to a herpetic outbreak.

The most common presenting sign/symptom with rheumatic fever is - cardiac murmur. - polyarthritis. - rash. - painless nodules.

polyarthritis. Polyarthritis is the most common presenting symptom of RF. A cardiac murmur is only present if carditis ensues, and this is a late sign. The rash and the painless nodules of RF are not the earliest signs/symptoms.

The classic manifestations of Parkinson disease include - intention tremor and akinesia. - rest tremor and skeletal muscle rigidity. - ataxia and intention tremor. - skeletal muscle rigidity and intention tremor.

rest tremor and skeletal muscle rigidity. Tremor is often the first symptom of Parkinson disease that prompts patients to seek treatment. The tremor is generally at rest, unilateral affecting distal extremities. Difficulty initiating and controlling movements results in akinesia, tremor, and rigidity. The clinical manifestations of cerebellar disorders primarily include ataxia, hypotonia, intention tremors, and disturbances of gait and balance. Skeletal muscle rigidity and intention tremors are not the classic manifestations of Parkinson disease.

The disease that is similar to osteomalacia and occurs in growing children is - rickets. - osteosarcoma. - Paget disease. - osteopenia.

rickets. Rickets is similar to osteomalacia in that it is caused by vitamin D deficiency and leads to soft, deformable bones. Rickets occurs in growing children. Osteosarcoma, Paget disease, and osteopenia are not similar to osteomalacia.

The first indication of brain compression from increasing intracranial pressure (ICP) may be - decorticate posturing. - absence of verbalization. - sluggish pupil response to light. - Glasgow Coma Scale score of 13.

sluggish pupil response to light. Careful monitoring of the pupillary response to light during the acute phase is critical, as a failing response may be the first indication of brain compression from increasing ICP. Mild dilation of a pupil with sluggish or absent light response is ominous. Decorticate posturing is related to a deteriorating motor status. Absence of verbalization is not the first indication of brain compression. A GCS score of 13 is not the first indication of brain compression. Although, acute changes in level of consciousness should be further investigated.

Compartment syndrome occurs secondary to - bone infarction. - soft-tissue damage. - muscle necrosis. - breakdown of RBCs.

soft-tissue damage. Compartment syndrome occurs because of severe soft-tissue damage. Bone infarction and the breakdown of RBCs do not cause compartment syndrome. Muscle necrosis does not cause compartment syndrome, but can result from it.

In the acute phase of stroke, treatment is focused on - stabilization of respiratory and cardiovascular function. - risk factor modification. - prevention of bedsores and contractures. - neurologic rehabilitation.

stabilization of respiratory and cardiovascular function. The primary consideration in the acute phase of stroke is assuring the patient's airway, respiratory, and cardiovascular function. In the acute phase of stroke, risk factor modification is not appropriate. Treatment aimed at preventing bedsores and contractions is not a typical consideration in the acute phase. Neurologic rehabilitation is not the focus of treatment in the acute phase.

Cerebral aneurysm is most frequently the result of - embolic stroke. - subarachnoid hemorrhage. - subdural hemorrhage. - meningitis.

subarachnoid hemorrhage. Although trauma is an important cause of subarachnoid hemorrhage, it is more commonly associated with rupture of cerebral aneurysms. Embolic stroke is usually from a cardiac source. Subdural hematomas are related to trauma. Meningitis is caused by microbial invasion of the CNS.

The displacement of two bones in which the articular surfaces partially lose contact with each other is called - subluxation. - subjugation - sublimation. - dislocation.

subluxation. Subluxation is partial dislocation of a joint. Subjugation, sublimation, and dislocation are not the terms for partial loss of contact of articular surfaces.

Rupture of a cerebral aneurysm should be suspected if the patient reports - ringing in the ears. - transient episodes of numbness. - transient episodes of vertigo. - sudden, severe headache.

sudden, severe headache. Warning leaks may occur before an aneurysm ruptures and often produce severe headache, which is typically described by the patient as "the worst headache I have ever had." Ringing in the ears is not a symptom associated with rupture of a cerebral aneurysm. Transient episodes of numbness are not indicative of a cerebral aneurysm rupture. Transient episodes of vertigo are not indicative of a cerebral aneurysm rupture.

Manifestations of acute brain ischemia (Cushing reflex) are due primarily to - parasympathetic nervous system activation. - sympathetic nervous system activation. - autoregulation of body systems. - loss of brainstem reflexes.

sympathetic nervous system activation. An extreme increase in ICP can precipitate an intense reaction by the sympathetic nervous system as it attempts to maintain cerebral perfusion through the compressed blood vessels. This has been termed an ischemic response or Cushing reflex. Manifestations of acute brain ischemia are because of sympathetic nervous system activation. The sympathetic nervous system activates to attempt to lower the intracranial pressure accompanied by acute brain ischemia. The Cushing reflex generally is viewed as a "last-ditch" effort by the brain to reestablish cerebral perfusion but is not as a result of loss of brainstem reflexes.

In contrast to osteoarthritis, rheumatoid arthritis may be associated with - debilitating joint pain and stiffness. - improvement in symptoms with aspirin therapy. - changes in activities of daily living. - systemic aching in the musculoskeletal system.

systemic aching in the musculoskeletal system. Rheumatoid arthritis is associated with systemic aching in the musculoskeletal system, but osteoarthritis is not. Osteoarthritis also causes debilitating joint pain and stiffness. Aspirin therapy will improve symptoms in both disorders. Both disorders can lead to changes in activities of daily living.

A unique characteristic feature of fibromyalgia is the presence of - tender point pain. - head pain. - contractures. - muscle atrophy.

tender point pain. Tender point pain is a unique characteristic feature of fibromyalgia. Headache, contractures, and muscle atrophy are not unique characteristic features of fibromyalgia.

Complete healing of a bone fracture occurs when - no movement of the break is detectable. - the callus has been completely replaced with mature bone. - the fracture site and surrounding soft tissue are pain free. - a cast is no longer required to stabilize the break.

the callus has been completely replaced with mature bone. Complete healing of a bone fracture occurs when the callus has been completely replaced with mature bone. A lack of detectable movement of the break does not indicate that the fracture is healed. Even when a bone fracture is healed, pain at the fracture site and surrounding soft tissue may be present. The patient may progress from a cast to a splint, sling, or brace as the bone fracture continues to heal.

The primary reason that prolonged seizure activity predisposes to ischemic brain damage is that - neurons are unable to transport glucose. - cardiovascular regulation is impaired. - the brainstem is depressed. - the lack of airway maintenance can lead to hypoxia.

the lack of airway maintenance can lead to hypoxia. Status epilepticus is a continuing series of seizures without a period of recovery between seizure episodes. Irreversible brain damage and possible death from hypoxia, cardiac arrhythmias, or lactic acidosis can occur if the airway is not maintained and seizure activity is not halted. Prolonged seizure activity is unrelated to glucose transportation by neurons. Status epilepticus can cause cardiac arrhythmias, but the primary concern of prolonged seizure activity is maintaining a proper airway. Brainstem depression is not the primary reason that prolonged seizure activity causes ischemic brain damage.

The ________ is the level of painful stimulation required to be perceived. - perception - tolerance - expression - threshold

threshold Pain threshold is the level of painful stimulation required to be perceived and is remarkably similar from one individual to another. Perception includes an awareness and interpretation of the meaning of the sensation. Pain perception is influenced by attention, distraction, anxiety, fear, fatigue, and previous experience and expectations. Pain tolerance is the degree of pain that one is willing to bear before seeking relief. Pain tolerance varies widely among individuals and within the same individual under differing conditions. Pain expression is the way in which the pain experience is communicated to others. Pacing, writhing, jaw clenching, facial grimacing, muscle guarding, crying, moaning, groaning, and verbal descriptions may be used to express pain.

Slow pain sensation is transmitted primarily by - group Ia afferents. - α motor neurons. - unmyelinated C fibers. - Aδ fibers.

unmyelinated C fibers. The majority of pain sensations travel via C fibers and project to areas of the brain that evoke emotional responses such as displeasure and anxiety. Unmyelinated C fibers transmit pain more slowly. Pain transmitted by C fibers is poorly localized and has a dull or aching quality that lingers long after the initial sharp pain abates. Group Ia afferents are not the source of slow pain sensation. Slow pain sensation is not transmitted by α motor neurons. The nature of the pain carried by the fast-traveling Aδ fibers is characterized as sharp, stinging, and highly localized.

"Tell me again the name of that chemical that makes crystals when my gout flares up," asks the client. The nurse's best response is - calcium phosphate. - urea. - uric acid. - beta-hydroxybutyric acid.

uric acid. Gout occurs when uric acid crystals form in joints. Calcium phosphate and beta-hydroxybutyric acid do not lead to crystal formation in gout. Uric acid, not urea, leads to crystal formation in gout.

Rickets is characterized by soft, weak bones resulting from a deficiency of - calcium. - estrogen. - phosphate. - vitamin D.

vitamin D. Rickets is characterized by soft, weak bones resulting from vitamin D deficiency. Rickets is not caused by poor calcium intake or phosphate deficiency. Estrogen deficiency is related to osteoporosis, not rickets.

Referred pain may be perceived at some distance from the area of tissue injury, but generally felt on the same side of the body. with slightly less intensity. - within the same dermatome. within 10 to 15 cm area.

within the same dermatome. Referred pain is perceived in an area other than the site of the injury. It is often felt at some distance from the point of nociceptor activation. Pain is generally referred to other structures in the same sensory dermatome. The brain cannot differentiate the two sources of pain signals and tends to attribute the visceral pain to a body surface location regardless of on which side of the body the injury occurs and on which side of the body the referred pain is felt. Referred pain is not felt with less intensity. Referred pain is not perceived at a distance that is within 10 to 15 cm.