ACSM-CEP practice test, 58 clinical cases

A patient with end-stage renal disease presents for testing. Which laboratory finding below presents the greatest risk for acute cardiac arrhythmia during exercise?

1. Chloride (Cl-) Level
   Chloride is within its reference range.
2. All pose equal risk
   Sodium and chloride are normal, so the values clearly do not carry equal risk.
3. Potassium (K+) Level
   Potassium of 6.1 mEq/L is hyperkalemia, which destabilizes cardiac conduction and can trigger dangerous arrhythmias, especially with exercise.
4. Blood Urea Nitrogen
   BUN is high, as expected in kidney failure, but it does not directly cause arrhythmias.
5. Sodium (Na+) Level
   Sodium of 136 mEq/L is within range.

A patient undergoing chemotherapy presents with the hematology results shown below. Why is maximal exercise testing contraindicated for this patient at this time?

1. Impaired thermoregulatory cooling capacity
   Anemia does not chiefly impair heat loss; the limiting problem is oxygen delivery.
2. Acute susceptibility to opportunistic infections
   Infection risk follows low white cells, which are not reported here.
3. Substantially reduced oxygen transport capacity
   Hemoglobin of 7.2 g/dL is severe anemia: the blood carries too little oxygen to meet the demand of maximal exercise.
4. Increased blood viscosity leading to thrombosis
   Low hematocrit makes blood thinner, not more viscous.
5. High risk of spontaneous bleeding and bruising
   Bleeding risk comes from low platelets; the count here is normal.

A 72-year-old male with stable angina and 3.5 METs capacity requests an endurance program. Which setting is appropriate for initiating exercise therapy?

1. Unsupervised home walking
   With angina and very low capacity, starting alone removes monitoring when risk is highest.
2. Independent mall walking
   Mall walking is unsupervised and suits a later, stable phase.
3. Self-guided interval training
   Self-directed intervals add intensity without supervision.
4. Medically supervised program
   An older patient with angina and a capacity of 3.5 METs starts in a supervised clinical program where ECG and symptoms are watched.
5. Community fitness center
   General fitness staff are not set up to monitor angina in a high-risk patient.

A 68-year-old male with CAD presents for an exercise test. He started flecainide two days ago and reports new lightheadedness. What is the appropriate course of action?

1. Use reduced intensity
   Lighter exercise still stresses a heart that could be reacting to the drug.
2. Monitor ECG then test
   A resting ECG check does not resolve a possible drug-induced arrhythmia.
3. Perform walk test only
   Changing the test does not answer the safety question.
4. Use submaximal protocol
   A submaximal test still exercises the patient before the symptom is explained.
5. Seek medical clearance
   A new class IC antiarrhythmic with new lightheadedness raises concern for proarrhythmia, so the physician evaluates before any test.

A 50-year-old male with diabetes and PAD is referred for a maximal treadmill test to evaluate ischemia. Considering his clinical risk and test intensity, what is the appropriate monitoring level?

1. Remote clinical monitoring
   Remote oversight cannot respond quickly enough during a maximal test.
2. Direct medical supervision
   A maximal diagnostic test in a patient with diabetes and PAD is a higher-risk test, so it is run with a physician immediately available.
3. Patient self-monitoring
   Self-monitoring has no place in a maximal clinical test.
4. Unsupervised test protocol
   A clinical maximal test is never run unsupervised.
5. Intermittent observation
   A maximal test needs continuous monitoring, not periodic checks.

During a symptom-limited graded exercise test, a 64-year-old male presents with the following signs and symptoms. According to ACSM guidelines, which is the absolute indication to stop the test immediately?

1. Heart rate response (tachycardia)
   Reaching 85% of predicted maximum is an expected response, not a stopping criterion.
2. ECG findings (ST depression)
   Downsloping depression of 1.5 mm is below the 2 mm relative criterion.
3. Blood pressure response (hypertension)
   The pressure in the table does not reach the level that ends a test.
4. RPE reaching 15 on Borg scale
   RPE is not in the table, and 15 would not be a reason to stop.
5. Subjective CNS symptoms (lightheadedness)
   Lightheadedness and confusion are central nervous system symptoms, one of the absolute reasons to stop a test.

A patient with unexplained dyspnea undergoes CPET. Based on the profile below, which pathology is most likely?

1. Pulmonary vascular disease
   A very high VE/VCO2 slope, low end-tidal CO2 and exercise desaturation together point to a pulmonary vascular cause, such as pulmonary hypertension.
2. Metabolic muscle disease
   Muscle disease limits peripherally without this degree of ventilatory inefficiency or desaturation.
3. Severe deconditioning
   Deconditioning lowers VO2peak but leaves the VE/VCO2 slope and saturation near normal.
4. Ischemic heart disease
   Ischemia shows as ECG changes or an O2-pulse plateau, and rarely with desaturation.
5. Obstructive lung disease
   Obstruction shows up as low breathing reserve; it does not typically drive the slope this high with low end-tidal CO2.

A patient takes metoprolol tartrate at 8:00 AM for hypertension. A diagnostic symptom-limited Bruce protocol test is performed at 9:00 AM. How does this timing primarily affect the test interpretation?

1. Reduced ischemic sensitivity
   Taken an hour before, metoprolol caps heart rate and myocardial oxygen demand, so ischemia may not appear and a false-negative result becomes more likely.
2. Higher chronotropic response
   Metoprolol blunts the heart rate rise.
3. Enhanced diagnostic accuracy
   Beta-blockade lowers, not raises, the test's ability to provoke ischemia.
4. Higher peak systolic pressure
   Beta-blockers lower peak systolic pressure.
5. Increased false positive rates
   The concern with beta-blockers is missing disease, not flagging it falsely.

A stable, asymptomatic 68-year-old male with CAD exhibits frequent unifocal PVCs (6/min) during a stress test. What is the most appropriate response?

1. Reduce the workload to the previous stage
   Backing off is not needed for stable unifocal ectopy and compromises the test.
2. Initiate emergency cardiac arrest procedures
   The patient is stable and asymptomatic; nothing suggests arrest.
3. Immediately terminate the test and notify the physician
   Ending the test for isolated unifocal PVCs loses diagnostic information without a safety gain.
4. Administer sublingual nitroglycerin prophylactically
   Nitroglycerin treats angina, not PVCs, and needs an order.
5. Continue monitoring and proceed with the test
   Frequent unifocal PVCs without symptoms or hemodynamic change are not a stopping criterion; watch for couplets, multifocal beats or runs.

Which of the following would be considered a contraindication to maximal exercise testing?

1. Mild knee osteoarthritis
   Mild arthritis can shape the test mode but does not rule out testing.
2. Body mass index of 29
   Being overweight is not a contraindication.
3. Well-controlled type 2 diabetes
   Controlled diabetes is a reason for monitoring, not for withholding the test.
4. Symptomatic uncontrolled arrhythmia
   An uncontrolled arrhythmia causing symptoms or hemodynamic compromise is an absolute contraindication to maximal testing.

You are selecting an exercise test protocol for a patient with severe heart failure and low functional capacity. Why is a small-increment ramp protocol preferred over a standard Bruce protocol for this patient?

1. Provides greater diagnostic sensitivity
   The protocol choice changes how capacity is measured, not how well ischemia is detected.
2. Requires less sophisticated equipment
   A ramp needs equipment that can increase load continuously, which is no simpler.
3. Facilitates uniform hemodynamic responses
   Small, steady increments raise workload smoothly, so heart rate, pressure and VO2 climb evenly instead of jumping between large stages.
4. Eliminates the need for gas analysis
   Ramp protocols are often paired with gas analysis; they do not remove it.
5. Guarantees a shorter total test duration
   Ramps aim for about 8–12 minutes; they do not guarantee a shorter test.

Which of the following ECG abnormalities is an absolute indication to terminate an exercise test?

1. Sustained ventricular tachycardia
   Sustained VT is an absolute reason to stop because it can deteriorate into ventricular fibrillation.
2. Occasional premature ventricular contractions (PVCs)
   Occasional PVCs are common and not a reason to stop.
3. Atrial ectopy
   Isolated atrial ectopic beats are benign.
4. ST segment depression of 1 mm
   One millimeter of depression is below the 2 mm relative criterion.

A 45-year-old patient with suspected mitochondrial myopathy undergoes CPET. Based on the results below, which physiological mechanism is the primary limitation?

1. Chronotropic incompetence
   Heart rate reached 90% of predicted, which is an adequate rise.
2. Peripheral limitation
   Effort was maximal, heart rate reached 90% and breathing reserve is ample, yet VT1 came very early: the muscles cannot use the oxygen delivered.
3. Poor patient effort
   A peak RER of 1.15 and 90% of predicted heart rate indicate a maximal effort.
4. Obstructive pulmonary disease
   A breathing reserve of 45% shows ventilation was far from its limit.
5. Primary ventilatory limitation
   Large breathing reserve rules out a ventilatory ceiling.

When prescribing resistance training for an individual with osteoporosis, what exercise selection is MOST important to minimize fracture risk?

1. Non-weight-bearing machine exercises only
   Removing weight bearing removes much of the bone-building stimulus.
2. Multi-joint weight-bearing lifts without loaded flexion
   Weight-bearing multi-joint work loads bone, and avoiding loaded spinal flexion protects the vertebrae, where fractures are most common.
3. High-impact plyometric jumping drills
   High impact raises fracture risk in osteoporotic bone.
4. Heavy isolation exercises for the arms only
   Single-joint arm work does little for the hip and spine.

A patient with COPD undergoes a 6-minute walk test on room air. SpO2 drops to 85% at a walking speed of 3.0 mph but remains at 91% at 2.0 mph. How should the exercise prescription be documented?

1. Teach pursed-lip breathing at 3.0 mph
   Breathing technique eases dyspnea but will not reliably stop the desaturation seen at that pace.
2. Prescribe 3.0 mph to improve tolerance
   Training at a pace that drops saturation to 85% exposes the patient to repeated hypoxemia.
3. Refer for pulmonary rehabilitation only
   A referral does not replace setting a safe intensity now.
4. Cap the exercise intensity at 2.0 mph
   At 2.0 mph saturation holds at 91% on room air, so that pace is the safe ceiling for now.
5. Order arterial blood gases at 3.0 mph
   Ordering blood gases is a physician's decision, not part of documenting the prescription.

For a client with osteoarthritis of the hip, which form of aerobic exercise would be MOST appropriate?

1. High-impact aerobics
   Impact choreography loads the hip heavily.
2. Running
   Running repeatedly loads the arthritic hip with impact.
3. Swimming
   Buoyancy unloads the hip, so the patient can do aerobic work with little joint stress.
4. Jump rope
   Jumping is high impact and aggravates hip arthritis.

A 30-year-old recreational athlete with physician-diagnosed fibromyalgia reports widespread pain and fatigue that worsen for 2 days after hard workouts. Which exercise prescription is MOST appropriate?

1. Stretching only until pain resolves
   Waiting for pain to resolve before doing aerobic work leads to deconditioning.
2. Heavy resistance training with long rest
   Heavy loads are what provoke this patient's two-day flares.
3. Gradually progressed moderate aerobic exercise
   In fibromyalgia, starting low and progressing slowly improves pain and fatigue without the post-exertion flares that hard sessions bring.
4. High-intensity interval training on alternate days
   Hard intervals repeat the workouts that already worsen symptoms.

For a patient with symptomatic Peripheral Artery Disease (PAD), which intensity target is most effective for improving claudication pain distance?

1. Arm ergometry to avoid leg symptoms
   Arm work helps fitness but does not train the legs, where the limitation is.
2. Walking at an intensity below the pain threshold
   Pain-free walking helps, but walking into moderate claudication improves walking distance more.
3. Walking until claudication pain is moderate
   Walking until claudication reaches a moderate level, resting, then repeating gives the largest gains in pain-free and total walking distance.
4. Cycling at 40-50% of heart rate reserve
   Cycling uses different muscles and gives smaller gains in walking distance.
5. Walking at a constant RPE of 11-13
   In PAD, intensity is set by claudication, not general exertion.

For a deconditioned patient with COPD and a history of coronary artery disease beginning an exercise program, which method of determining aerobic exercise intensity is most appropriate following ACSM guidelines?

1. RPE plus symptoms from a symptom-limited test
   With COPD and CAD, intensity is set from a symptom-limited test and guided by RPE and symptoms, which cover both breathlessness and ischemia.
2. A fixed percentage of maximal heart rate
   Predicted maximal heart rate is unreliable here and ignores dyspnea.
3. Treadmill speed and duration targets alone
   Fixed workloads do not adjust to how the patient responds day to day.
4. Target VO2 from metabolic equations alone
   Equations ignore symptoms, which limit this patient first.

A patient recovering from a recent cardiac event returns to exercise. To safely titrate intensity without a new stress test, the clinician should:

1. Calculate target heart rate using the Karvonen formula
   Karvonen needs a reliable maximal heart rate, which is unknown after a cardiac event.
2. Rely exclusively on resting heart rate variability
   Resting HRV is not a guide for exercise intensity.
3. Prescribe exercise at 60% of age-predicted maximum
   Age-predicted values are unreliable, especially with cardiac medications.
4. Replicate the exact workload used prior to the event
   The pre-event workload is no longer a safe reference.
5. Monitor symptoms at submaximal workloads
   Without a current test, intensity is built up from submaximal work while watching symptoms, RPE and vital signs.

During a supervised session, a 68-year-old male collapses. EMS arrives as you are performing CPR. Which handoff statement provides the most critical information immediately?

1. Patient has hypertension and collapsed after walking
   Medical history matters less than the arrest timeline and interventions.
2. Collapsed 4 mins ago; VFib on AED; one shock delivered
   EMS first needs the timing, the rhythm and what has been done, which guide their next steps.
3. Patient record #55432; no known allergies or issues
   A record number and allergies are not the priority during an active arrest.
4. Started CPR after he fell; wife is in the waiting room
   This omits time and rhythm, and family location is secondary.
5. Felt dizzy, sat down, then lost consciousness and pulse
   The story helps later but leaves out the rhythm, timing and treatment given.

Staff conduct a pre-session safety briefing, assigning roles and verifying AED function. Which other critical component must be included in this briefing?

1. Review of patient-specific risk flags or status changes
   Staff need to know which patients have new symptoms, medication changes or special precautions before the session starts.
2. Calibration of metabolic carts for future VO2 max testing
   Equipment for future testing does not affect this session's safety.
3. Verification of insurance billing codes for the session
   Billing is not a safety item.
4. Scheduling of staff lunch breaks for the afternoon
   Break scheduling is administrative and has no bearing on patient safety.
5. Distribution of marketing materials for upcoming programs
   Marketing has no place in a safety briefing.

In a supervised cardiac rehabilitation group session, what is the primary role of the designated secondary observer?

1. Prescription of exercise intensity
   Setting intensity belongs to the clinician leading the program.
2. Adjustment of equipment settings
   Adjusting equipment pulls the observer away from surveillance.
3. Documentation of billing codes
   Billing is not the observer's job during exercise.
4. Continuous visual surveillance
   The secondary observer keeps eyes on the room so a patient in trouble is noticed at once.
5. Leading the group cool-down phase
   Leading an activity takes attention away from watching patients.

What is the MOST effective way to monitor ECG changes during a cardiac rehabilitation exercise session?

1. Monitor only during peak exercise
   Changes can occur during warm-up or recovery as well.
2. Use continuous ECG telemetry
   Continuous telemetry shows rhythm and ST changes as they happen, throughout the session.
3. Rely on patient-reported symptoms
   Many arrhythmias and ischemic episodes are silent.
4. Check the leads between exercises
   Lead checks keep the signal clean but do not monitor the rhythm.

A CEP administers a 2-minute step test to a new Phase III cardiac rehabilitation group. How should the results primarily influence the exercise prescription?

1. Determine maximum treadmill velocity
   A step test does not measure treadmill capacity.
2. Calculate precise heart rate reserve
   HRR needs a measured or reliable maximal heart rate, which a step test does not give.
3. Stratify by functional capacity
   A simple step test sorts a new group by fitness so starting workloads can be set for each patient.
4. Identify immediate referral needs
   A submaximal step test is not a diagnostic screen for referral.
5. Exclude patients with limited mobility
   Using the test to exclude patients runs against adapting the program to them.

What is the MOST appropriate response when a client shows signs of exercise-induced asthma during a session?

1. Switch to stretching exercises
   Continuing any activity without treating the airways leaves the bronchospasm untreated.
2. Stop and use the prescribed inhaler
   Stopping exercise and taking the prescribed reliever is the first response to exercise-induced bronchoconstriction.
3. Increase ventilation in the room
   Fresh air does not reverse bronchospasm.
4. Continue at a lower intensity
   Exercising through wheeze risks worsening the attack.

A client's blood glucose reading is 75 mg/dL before exercise. What is the MOST appropriate action?

1. Give a carbohydrate snack first
   Below about 90 mg/dL before exercise, 15–30 g of carbohydrate is taken first so glucose does not fall into hypoglycemia.
2. Increase the exercise intensity
   More intense work burns more glucose when it is already low.
3. Cancel today's exercise session
   A modestly low reading is corrected with carbohydrate; it does not require canceling.
4. Proceed with exercise as planned
   Starting at 75 mg/dL without carbohydrate risks a low during the session.

When leading an industrial rehabilitation program, what is the MOST important factor to consider?

1. Including job-specific movements
   Industrial rehabilitation aims at return to work, so training reproduces the lifting, carrying and postures the job demands.
2. Maximizing workout intensity
   Intensity for its own sake does not prepare the worker for job tasks.
3. Using complex equipment
   Fancy equipment does not make training transfer to the job.
4. Following one standard protocol
   A generic protocol ignores the demands of the specific job.

When educating a patient with limited health literacy about their condition, which phrase is the most appropriate plain-language alternative for "myocardial ischemia"?

1. Hemodynamic compromise of the coronaries
   Technical wording that a patient with limited literacy would not follow.
2. Occlusion causing ventricular dysfunction
   This is more technical than the original term.
3. Mismatch in oxygen supply and demand
   Accurate, but abstract; it does not tell the patient that the heart muscle is short of blood.
4. Lack of blood flow to the heart muscle
   Short everyday words describe ischemia accurately without medical jargon.
5. Pathological narrowing of the vessel lumen
   'Pathological' and 'lumen' are jargon, and narrowing is the cause rather than the condition.

Following a patient fall in the exercise clinic, the CEP completes an incident report. According to legal and administrative best practices, where should this specific document be filed?

1. Patient's discharge summary
   A discharge summary describes care, not internal incident reviews.
2. Patient's medical record
   The chart describes the event and care given but does not hold or mention the incident report.
3. Administrative risk files
   Incident reports are internal quality and risk documents, kept separately from the medical record.
4. Insurance claim documentation
   Incident reports are not part of claims paperwork.
5. Referring physician's notes
   The referring physician's notes are their own records.

Which documentation practice is required when modifying a patient's exercise prescription?

1. Update at next scheduled review
   Delaying documentation leaves the record wrong in the meantime.
2. Changes noted in personal records, not the chart
   Personal notes are not the medical record.
3. Verbal notification to the patient
   Telling the patient does not document the change for other staff.
4. Date, time, change, and rationale
   Each prescription change is charted with when it was made, what changed and why.

A patient in the maintenance stage is anxious about losing progress during an upcoming two-week family vacation. Which strategy best addresses potential relapse risks?

1. Create a scaled-down plan to follow on the trip
   Planning ahead for a high-risk situation with a realistic, reduced routine is relapse prevention.
2. Accept a temporary break and restart upon return
   An open-ended break makes a full relapse more likely.
3. Focus solely on dietary restrictions during the trip
   Diet is a separate behavior and leaves exercise unplanned.
4. Commit to maintaining the full routine every day
   An all-or-nothing goal sets up failure on vacation.
5. Increase exercise intensity before leaving home
   Training harder beforehand does not prevent lapses during the trip.

A 48-year-old female with type 2 diabetes and mild depression reports feeling overwhelmed by her daily responsibilities and expresses doubt that exercise will improve her health. In developing a behavior change plan, which approach most appropriately integrates motivational interviewing with cognitive behavioral strategies?

1. Lecture on exercise benefits without exploring barriers
   Lecturing runs against MI and does not address her doubts.
2. Explore her doubts and then set small specific goals
   MI explores her doubts and readiness; cognitive-behavioral techniques then turn that into specific, achievable steps she can manage.
3. Rely on group classes without individual planning
   Social support helps, but it does not address her beliefs or set personal goals.
4. Prescribe a fixed regimen and skip her concerns
   Ignoring her doubts and overload makes adherence unlikely.

Which communication technique is most effective when discussing sensitive health topics?

1. Direct confrontation of beliefs
   Confrontation provokes defensiveness.
2. Steering away from the topic
   Avoidance leaves important issues unaddressed.
3. Rapid, closed-ended questioning
   Rapid questions feel like an interrogation and shut down disclosure.
4. Active listening with empathy
   Listening closely and reflecting feelings makes it safe to discuss sensitive topics openly.

Which approach is most effective when teaching stress management techniques?

1. Written handouts to read
   Reading about a technique is not the same as practicing it.
2. A lecture on stress theory
   Listening to theory does not build the skill.
3. Guided practice with feedback
   Skills such as breathing or relaxation are learned by doing them with coaching on technique.
4. Group discussion by itself
   Discussion without practice leaves the technique untried.

During a pre-exercise assessment, a patient's resting blood pressure is measured at 152/95 mmHg. Using the standard formula, what is the calculated Mean Arterial Pressure (MAP)?

1. 133 mmHg
   This adds two-thirds of the pulse pressure instead of one-third.
2. 105 mmHg
   This adds only a sixth of the pulse pressure; the formula uses one-third.
3. 124 mmHg
   This is the simple average of systolic and diastolic, which overstates MAP because diastole lasts longer.
4. 152 mmHg
   This is the systolic value, not the mean.
5. 114 mmHg
   MAP ≈ diastolic + (systolic − diastolic) ÷ 3 = 95 + 57 ÷ 3 = 114 mmHg.

A 65-year-old female is referred for maximal exercise testing. She takes warfarin for a mechanical heart valve and reports occasional dizziness. Which testing modality is most appropriate to mitigate specific safety concerns for this patient?

1. Functional step test
   Stepping adds balance demands and fall risk.
2. Seated cycle ergometer
   A seated test removes the risk of a fall from a moving belt, which matters most when anticoagulation makes any fall a bleeding risk.
3. Treadmill walking with incline
   An incline adds load but keeps the fall hazard.
4. Standard treadmill protocol
   A treadmill fall in a dizzy, anticoagulated patient could cause serious bleeding.
5. Field walking assessment
   Walking tests are submaximal and carry the same fall risk on foot.

A 70-year-old taking metoprolol (resting HR 52 bpm) reaches RPE 19 and a peak HR of 118 bpm on a maximal exercise test. This low peak heart rate most likely reflects:

1. Pathological chronotropic incompetence
   On beta-blockers the threshold is under 62% of heart rate reserve; this patient used 67%.
2. Submaximal effort from the patient
   RPE 19 is a near-maximal effort.
3. A normal response to medication
   Beta-blockade lowers peak heart rate; the patient used 67% of heart rate reserve, above the 62% cutoff applied on beta-blockers, so the low peak is the drug effect.
4. Equipment error in monitoring
   A lower peak on a beta-blocker is expected and needs no equipment explanation.
5. An invalid test requiring a re-test
   An RPE of 19 shows a maximal effort, so the test is valid as performed.

A patient is 6 weeks post-heart transplant and presents for cardiac rehabilitation. Resting heart rate is 100 bpm. Which monitoring parameter provides the most accurate guide for exercise intensity?

1. Target HR 20 bpm above rest
   A heart rate target is unreliable when the rate lags behind the workload.
2. Heart rate variability (HRV)
   HRV is reduced after transplant and is not used to set training intensity.
3. ECG ST-segment displacement
   ST changes signal ischemia; they do not set intensity.
4. Borg RPE of 11–14
   The transplanted heart is denervated, so heart rate rises slowly on circulating catecholamines; perceived exertion tracks effort better.
5. Target HR at 60–70% of HRR
   HRR assumes a normal heart rate response, which the denervated heart lacks.

Based on the table, how do beta-blockers primarily alter the heart rate-oxygen uptake relationship compared to an unmedicated state?

1. Blunted heart rate; unchanged submaximal VO2
   Beta-blockers lower the heart rate at each workload, but the oxygen cost of a given submaximal workload stays the same.
2. Blunted heart rate; reduced submaximal VO2
   Heart rate falls, but VO2 at a fixed submaximal workload does not.
3. Elevated heart rate; increased submaximal VO2
   Both parts run opposite to what beta-blockade does.
4. Unchanged heart rate; increased submaximal VO2
   The table shows heart rate falls, and the oxygen cost of a workload does not rise.
5. Unchanged heart rate; reduced submaximal VO2
   Heart rate is decreased, and submaximal VO2 is set by the work being done.

A patient with severe diabetic sensory neuropathy and fall history begins treadmill training. Which staffing ratio and supervision strategy is appropriate?

1. 1:3 supervision with visual monitoring
   Watching from across the room does not prevent a fall.
2. Independent exercise with safety rails
   Rails do not stop a fall when the patient cannot feel foot placement.
3. 1:5 supervision with remote monitoring
   A shared staff member at a distance cannot catch a stumble in time.
4. 1:1 supervision with direct proximity
   With lost foot sensation and a fall history, a staff member stays within arm's reach on the moving belt.
5. Group supervision using video cameras
   Cameras record a fall; they do not prevent it.

A CEP is reviewing a patient's heart rate trends on a secure tablet in a quiet corner of the clinic gym. Another patient walks by unexpectedly and glimpses the screen. Under HIPAA, this event is best classified as:

1. An incidental disclosure
   A glimpse that happens despite reasonable safeguards, such as a quiet corner, is an incidental disclosure that HIPAA permits.
2. Administrative negligence
   Negligence would need a failure of reasonable safeguards, which the scenario does not show.
3. Unsecured privacy infraction
   This is not a HIPAA category; the event is an incidental disclosure.
4. Reportable HIPAA breach
   Incidental disclosures with reasonable safeguards are not reportable breaches.
5. Security rule violation
   The device was secure; a passer-by's glimpse is not a security failure.

A patient with exertional calf pain has the resting pressures below. What is the ankle-brachial index for the right leg?

1. 0.69
   This combines the lower ankle pressure with the right arm (88 ÷ 128), two errors at once.
2. 0.80
   This divides by the right arm (102 ÷ 128); the denominator is the higher of the two arms.
3. 0.65
   This uses the lower ankle pressure (88 ÷ 136); the higher ankle pressure is used for that leg.
4. 1.33
   This inverts the ratio (136 ÷ 102); the ankle pressure goes on top.
5. 0.75
   The ABI divides the higher ankle pressure of that leg (102) by the higher of the two arm pressures (136): 102 ÷ 136 ≈ 0.75, consistent with PAD.

A patient with a continuous-flow left ventricular assist device (LVAD) arrives for an exercise session. How should resting blood pressure be measured?

1. Doppler probe with a manual cuff
   Continuous flow leaves little or no pulse pressure, so a Doppler opening pressure is used; it approximates mean arterial pressure.
2. Radial pulse palpation with a cuff
   Continuous flow leaves a weak or absent pulse, so palpation gives no reading.
3. Reading it off the pump speed display
   Pump speed is a device setting, not a blood pressure.
4. Finger pulse oximeter waveform
   An oximeter does not measure blood pressure and often cannot read without a pulse.
5. Stethoscope over the brachial artery
   Korotkoff sounds depend on pulsatile flow, which a continuous-flow pump lacks.

A patient on hemodialysis has an arteriovenous fistula in the left forearm. Where should blood pressure be measured before exercise?

1. Above the fistula site
   Compressing the same arm above the fistula still obstructs flow through it.
2. On the left arm
   Inflating a cuff over the fistula arm risks occluding the access.
3. On the right arm
   Cuff pressure can damage or clot a fistula, so pressures are taken on the arm without the access.
4. Over the fistula itself
   Pressure directly on the fistula is the most likely way to damage it.
5. On either arm alike
   The access arm is protected; the arms are not interchangeable.

At intake, which approach gives the most accurate medication reconciliation?

1. Wait for the pharmacy's dispensing history, then reconcile
   Dispensing records show what was filled, not what the patient actually takes.
2. Copy the medication list from the referral note into the chart
   Referral lists are often outdated and miss drugs started or stopped since.
3. Ask the patient to name their heart medications from memory
   Recall misses doses, timing and non-cardiac drugs that also affect exercise.
4. Review every bottle the patient brings, including OTC products
   Comparing the actual containers, doses and timing with the record catches omissions, duplicates and unlisted over-the-counter products.
5. Record only prescription drugs that affect heart rate or blood pressure
   Over-the-counter decongestants, supplements and diabetes drugs also change exercise safety.

A patient's post-bronchodilator spirometry shows FEV1 of 1.6 L and FVC of 2.8 L. What does this result indicate?

1. Restrictive pattern (FEV1/FVC 0.85)
   Restriction keeps the ratio normal or high; 0.57 is low.
2. Airflow obstruction (FEV1/FVC 0.57)
   1.6 ÷ 2.8 = 0.57, below the 0.70 cutoff that confirms persistent airflow obstruction.
3. Normal lung function (FEV1/FVC 0.75)
   The ratio is 0.57, not 0.75, and it falls below the 0.70 cutoff.
4. Normal lung function (FEV1/FVC 0.57)
   A ratio of 0.57 is below 0.70, which is not normal.
5. Airflow obstruction (FEV1/FVC 0.75)
   The arithmetic is wrong: 1.6 ÷ 2.8 is 0.57.

A patient completes 9 minutes of the Bruce protocol with 2 mm of ST depression and angina that did not limit the test. What are the Duke Treadmill Score and risk category?

1. −1, moderate risk
   This leaves out the angina term (9 − 10); non-limiting angina still subtracts 4 × 1.
2. +5, low risk
   This leaves out the ST term (9 − 4 = +5); the 2 mm of ST depression must be subtracted as 5 × 2.
3. −9, high risk
   This counts non-limiting angina as test-limiting (9 − 10 − 8 = −9), and −9 is still moderate; high risk is −11 or lower.
4. +3, low risk
   This subtracts the raw 2 mm instead of 5 × 2 (9 − 2 − 4); +3 would still be moderate, since low risk needs +5 or more.
5. −5, moderate risk
   9 − (5 × 2) − (4 × 1) = −5; scores from −10 to +4 fall in the moderate-risk band.

A patient with multiple sclerosis reports that leg weakness and blurred vision appear when they get hot during exercise and fade after rest. Which adjustment is most appropriate?

1. Train in a heated pool to relax the legs
   Warm water raises body temperature and brings the symptoms on.
2. Stop exercising until the next MRI scan
   Short-lived symptoms that resolve with cooling are not a relapse and do not require stopping exercise.
3. Exercise in a cool room with cooling aids
   Heat temporarily slows conduction in demyelinated nerves; keeping body temperature down lets the patient train without these symptoms.
4. Add layers to keep the muscles warm
   Extra clothing traps heat, which triggers the symptoms.
5. Raise intensity to finish sessions sooner
   Higher intensity produces more heat and worsens the symptoms.

A patient with an implantable cardioverter-defibrillator programmed to detect tachycardia at 150 bpm begins aerobic training. What is the appropriate upper heart rate limit?

1. 145–150 bpm
   This range reaches the detection rate, where a normal sinus rhythm could set off a shock.
2. 100–105 bpm
   Such a low ceiling discards safe training range below the margin.
3. 160–165 bpm
   This is well above the cutoff the device uses to detect tachycardia.
4. 135–140 bpm
   The training ceiling sits at least 10–15 beats below the detection rate so sinus tachycardia does not trigger the device.
5. 150–155 bpm
   Training above the detection rate invites inappropriate shocks.

A patient with COPD becomes short of breath when washing their hair and reaching into cupboards. Which addition to the program best targets this limitation?

1. Upper-limb endurance and strength training
   Arm work recruits accessory breathing muscles; training the arms lowers the ventilatory cost of overhead daily tasks.
2. Static stretching of the hamstrings
   Hamstring flexibility has no bearing on breathlessness with arm tasks.
3. Longer treadmill walking sessions alone
   Leg training improves walking but does little for dyspnea during arm activities.
4. Lower-body resistance training alone
   Leg strength does not transfer to unsupported arm work.
5. Avoiding overhead tasks entirely
   Avoidance leads to further deconditioning and loss of independence.

A patient with type 1 diabetes does resistance and aerobic exercise in the same session and often drops low partway through. How should the session be ordered?

1. Split the two into separate weekly days
   Separating them is possible, but it does not answer how to order a combined session.
2. Resistance exercise first, then aerobic
   Doing resistance work first limits the fall in glucose during the aerobic part that follows.
3. Drop resistance work from the program
   Removing resistance training loses its benefits without addressing the lows.
4. Alternate the order at random each week
   Random ordering gives no consistent protection against lows.
5. Aerobic exercise first, then resistance
   Starting with aerobic work produces the steeper early fall the patient already experiences.

A patient with a T4 spinal cord injury develops a pounding headache, facial flushing, and BP of 186/104 mmHg during arm ergometry. What is the immediate action?

1. Sit upright, loosen clothing, check the bladder
   Autonomic dysreflexia is a reflex surge from a stimulus below the injury; sitting up lowers pressure and the trigger, most often the bladder, is found and removed.
2. Give fluids, then recheck in 20 minutes
   Waiting lets dangerous hypertension continue untreated.
3. Lay the patient flat, then raise the legs
   Lying flat with legs up raises pressure further; the patient should sit upright.
4. Continue at a lower arm workload
   Exercise does not relieve the reflex hypertension; the trigger must be removed.
5. Apply ice to the head and neck
   Cooling does not address the noxious stimulus driving the reflex.

A patient develops angina during a session and has a nitroglycerin prescription. Which recent medication must be asked about before it is used?

1. A statin such as atorvastatin
   Statins do not interact with nitroglycerin in a dangerous way.
2. A metformin dose taken at breakfast
   Metformin has no meaningful interaction with nitroglycerin.
3. A proton pump inhibitor for reflux
   Acid suppressants do not interact with nitrates.
4. A daily low-dose aspirin tablet
   Aspirin is safe and often encouraged in suspected ischemia.
5. A PDE-5 inhibitor such as sildenafil
   Combining a nitrate with sildenafil (within about 24 h) or tadalafil (about 48 h) can cause profound hypotension.

A breast cancer survivor refuses arm strengthening because she believes lifting will cause lymphedema. Which explanation is accurate?

1. Heavy loads, started early, prevent it best
   Starting heavy skips the gradual progression that makes training safe.
2. Lifting is safe only if the arm is wrapped in ice
   Ice has no role in preventing lymphedema during exercise.
3. Gradual, supervised lifting does not raise the risk
   Trials show that gradually progressed, supervised resistance training is safe for survivors with or at risk of lymphedema and does not worsen it.
4. Lifting with the affected arm should be avoided for life
   Lifelong avoidance is outdated advice and leads to weakness and deconditioning.
5. Leg exercises are the safe choice after breast cancer
   Upper-body training is safe and helps restore arm function.

A low-risk patient after a recent MI says he cannot attend center-based cardiac rehabilitation because of rotating work shifts and a 90-minute drive. Which option best supports participation?

1. Have him exercise only on days he feels strong
   Unstructured, mood-based exercise lacks progression and monitoring.
2. Offer a structured home-based rehabilitation program
   Home-based cardiac rehabilitation is a reasonable alternative for low- to moderate-risk patients who cannot attend a center.
3. Discharge him with a pamphlet and no follow-up
   A pamphlet without a structured program and contact gives none of the benefits of rehab.
4. Tell him rehabilitation must be done at the center
   Insisting on the center format ignores a recognized alternative and likely means no rehab at all.
5. Suggest he wait until his job schedule changes
   Waiting delays a benefit that is greatest soon after the event.

During walking practice, a patient with Parkinson disease freezes when starting to walk and at doorways. Which strategy best helps the patient keep walking?

1. Walk faster to push through the freeze
   Hurrying shortens steps further and tends to trigger more freezing and falls.
2. Keep the arms still to save energy
   Holding the arms still removes arm swing and does nothing to restart stepping.
3. Add a weighted vest for stability
   Extra load does not cue stepping and adds strain on poor balance.
4. Stop practice whenever freezing occurs
   Ending practice at each freeze avoids the training the patient needs to manage it.
5. Step to a metronome or rhythmic beat
   An external rhythm gives the step timing that the basal ganglia no longer supply, which helps start and keep stepping through freezing.

A patient with diabetes has an unhealed plantar ulcer on the right forefoot. Which aerobic option fits ADA guidance until the ulcer heals?

1. Treadmill walking in cushioned shoes
   Cushioning does not remove the plantar pressure that keeps an ulcer from healing.
2. Low-impact step aerobics class
   Low impact is still weight bearing on the ulcerated foot.
3. Stair stepping at a slow cadence
   Stepping loads the forefoot with every step, right where the ulcer is.
4. Brisk walking on soft grass
   Any walking is weight bearing, and uneven ground adds shear to the wound.
5. Seated upper-body arm ergometry
   Weight-bearing activity is avoided while an ulcer is open, and arm ergometry trains the heart without loading the foot.