Certified Neuroscience Registered Nurse

Questions from Springers exam book and more. #letsgetthisCNRN

What type of pain is frequently described as shooting or burning pain?

neuropathic pain, It is caused by damage to the nervous system, often resulting from conditions such as diabetes or nerve injuries.

What type of patient is at risk for Thalamic Pain Syndrome?

a post-stroke patient.

Thalamic Pain Syndrome

A condition characterized by severe pain following a thalamic stroke, often described as spontaneous burning or aching pain on the affected side of the body.

The _____ is the primary pain center in the brain.

Thalamus

What is peripheral neuropathy pain involving multiple nerves called?

Polyneuropathy

Peripheral pain is initiated or caused by a primary ____ or dysfunction in the peripheral nervous system.

lesion

polyneuropathy

A condition characterized by pain, numbness, or weakness resulting from damage to multiple peripheral nerves.

mononeuropathy

A condition affecting a single peripheral nerve, resulting in localized pain, numbness, or weakness.

Radiculalgia

Pain that radiates from the back or neck along a nerve due to compression or irritation of a spinal nerve root.

What infections are a common cause of neuropathic pain?

Infections such as herpes zoster (shingles), Lyme disease, and HIV can lead to neuropathic pain by damaging peripheral nerves.

What surgical procedure is a common cause of neuropathic pain?

Amputations as well as nerve related surgeries, such as carpal tunnel release surgeries.

(TN) Trigeminal Neuralgia

A chronic pain condition affecting the trigeminal nerve, characterized by severe facial pain episodes, often triggered by light stimuli.

What is the most common cause of trigeminal neuralgia (TN) which presents at a younger age?

Multiple sclerosis (MS)

Although TN is typically caused by a dysfunction in the trigeminal nerve itself, a lesion within the ____ nervous system may also cause similar problems.

Central

What is the most common chronic benign headache?

Migraine

Name some types of benign recurrent headaches;

migraine

tension

cluster

chronic daily

What is the most common benign headache is the male population?

Cluster headaches

Which of the following tumor types will have a higher incidence in pediatric populations and have a decreased incidence with age?

A.

Glioblastoma

B.

Pilocytic astrocytoma

C.

Central nervous system lymphoma

D.

Metastatic brain tumor

B

Rationale: Both pilocytic astrocytoma and medulloblastoma brain tumors are more commonly found in the younger population. The incidence of these tumors will decrease with age. Glioblastomas are more frequently found in young adults. CNS lymphoma and metastasis will have an increased incidence with age.

A patient presents with progressive neurological deficits and has a recent history of transient neurological attack. This patient is most likely experiencing which of the following types of stroke?

A.

Thrombotic stroke

B.

Embolic stroke

C.

Subarachnoid hemorrhage

D.

Vasospasms

A

Rationale: Thrombotic strokes frequently present as a worsening neurological status over a short period of time. Patients may have experienced episodes of transient ischemic attacks (TIAs) before the onset of the ischemic strokes. Embolic strokes tend to have a more sudden onset without progression in symptoms. Subarachnoid hemorrhages (SAHs) are a sudden onset of headache without the history of transient neurological deficits. Vasospasms are associated with SAH, and symptoms occur most commonly between 7 and 10 days after thet SAH.

Which of the following best describes a coup injury?

A.

Injury occurs at the point of impact.

B.

Injury occurs on the contralateral side of impact.

C.

It is an acceleration injury.

D.

It is a deceleration injury

A

Rationale: A coup injury occurs at the point of impact, and a contracoup injury occurs on the contralateral side. The mechanism of injury for acceleration injuries is commonly defined as a moving object hitting a stationary head, whereas a deceleration injury involves a moving head hitting a stationary object.

A patient is admitted to the ICU with persistent epileptic seizures lasting beyond 90 minutes. Which of the following best describes the seizure activity?

A.

Epileptic seizure

B.

Epilepsy

C.

Refractory seizure

D.

Nonepileptic seizure

C

Rationale: An epileptic seizure, which persists for greater than 90 minutes despite administration of anticonvulsants is called a refractory seizure. An epileptic seizure indicates the presence of EEG wave changes during the seizure activity. Epilepsy refers to repetitive seizures without a reversible cause such as hyponatremia. Nonepileptic seizure is the presence of seizure activity without the EEG changes

Which of the following would be the best technique to use to assess for cerebrospinal fluid in bloody drainage from the nose following a traumatic brain injury?

A.

Glucose test

B.

Halo test

C.

Send to lab for hemoglobin level

D.

Litmus test

B

Rationale: Halo test (a positive result produces a yellow ring) is more accurate than a glucose test, especially with the presence of bloody drainage. A glucose test has been used to distinguish between sinus drainage and cerebrospinal fluid (CSF) because CSF has glucose but sinus drainage does not. But in this scenario, the drainage was “bloody,” and blood has glucose. Bloody drainage may give a false positive with a glucose test. Testing for hemoglobin in the drainage does not determine the presence of CSF. Litmus test is used to test a pH of a fluid and is not used to distinguish CSF from nasal drainage.

Which of the following is the most common cause of an embolic stroke?

A.

Atrial septal defect

B.

Atrial fibrillation

C.

Calcified lesion

D.

Angioplasty

B

Rationale: Atrial fibrillation (AF) is the most common cause of an embolic stroke. Atrial septic defect (ASD) and calcified lesions can also result in embolic strokes but are significantly less common than AF. A complication of angioplasty can be distal embolization but again is not the most common cause of an embolic stroke.

Cranial nerve (CN) VII (facial nerve) is commonly involved with Bell’s palsy. Where does this CN originate?

A.

Pons

B.

Medulla

C.

Midbrain

D.

Basal ganglia

A

Rationale: Cranial nerve (CN) V (trigeminal nerve), VI (abducens nerve), VII (facial nerve), and VIII (acoustic nerve) originate from the pons. CNs IX (hypoglossal nerve), X (vagus), XI (spinal accessory nerve), and XII (hypoglossal nerve) originate from medulla. CNs III (oculomotor nerve) and IV (glossopharyngeal nerve) originate from the midbrain. No cranial nerves originate from the basal ganglia.

Which of the following electrolyte abnormalities is LESS likely to result in a seizure?

A.

Hyponatremia

B.

Hyperkalemia

C.

Hypocalcemia

D.

Hypomagnesemia

B

Rationale: Hyponatremia is one of the most common electrolyte abnormalities that can cause a seizure. Hypocalcemia and hypomagnesemia can also cause seizures. Potassium is more likely to affect the myocardial electrical system, resulting in arrhythmias

A patient in the ICU following a severe traumatic brain injury suddenly demonstrates profuse sweating, sustained tachycardia, hypertension, and fever. Which of the following is the most likely cause?

A.

Neurogenic fever

B.

Diencephalic seizure

C.

Paroxysmal sympathetic hyperactivity

D.

Cerebral salt wasting syndrom

C

Rationale: Traumatic brain injury (TBI) patients can experience “sympathetic storms” called paroxysmal sympathetic hyperactivity. The symptoms include fever, tachycardia, hypertension, profuse sweating, agitation, and increase respiratory rate. The “storm” is thought to be due to intermittent stimulation of the sympathoexcitatory centers located in upper brainstem and diencephalon. Diencephalic seizure is an incorrect term for the symptoms because the EEG is negative. Neurogenic fevers can occur following TBI but is not associated with the other symptoms of hypertension and tachycardia. Cerebral salt wasting syndrome (CSWS) is the loss of sodium through the kidneys and results in hypovolemic hyponatremia.

In severe cases of cerebral palsy, there may be a delay in growth and development. Which of the following conditions can occur in these cases?

A.

Coagulopathy

B.

Immunocompromise

C.

Failure to thrive

D.

Locked-in syndrome

C

Rationale: Failure to thrive is a complication of moderate to severe cerebral palsy (CP). It can result in malnutrition and death. CP is not associated with immunocompromise or coagulopathies. CP involves abnormal motor movements associated with spasticity or flaccidity, but does not develop locked-in syndrome.

Which of the following best describes the penumbra in an ischemic stroke?

A.

Irreversibly damaged tissue

B.

Normal healthy tissue

C.

Presence of vasogenic cerebral edema

D.

Reversible ischemic tissue

D

Rationale: The penumbra is the area surrounding an infarction that is ischemic or reversible ischemic tissue. Irreversibly damaged tissue is the area of tissue infarction and is the core of the infarction. Vasogenic cerebral edema is an increase in interstitial edema or fluid and is typically found surrounding the penumbra. Normal, healthy tissue is the area of brain tissue not affected by the ischemia or injury.

A patient is admitted to the trauma ICU following a traumatic brain injury due to vehicle rollover. The patient is hypotensive and tachycardic. Which of the following is the most accurate statement?

A.

Hypotension following traumatic brain injury (TBI) indicates presence of epidural hematoma.

B.

Hypotension is sign of blood loss but is not considered a sign of TBI.

C.

Scalp lacerations can be easily controlled with direct compression.

D.

Neurogenic shock following TBI results in hypotension.

B

Rationale: Traumatic brain injury (TBI) patients can experience additional systemic injuries. Hypotension indicates hypovolemia from blood loss in trauma patients, but cerebral injury, even epidural hematoma, cannot account for the volume of blood loss. Scalp lacerations bleed profusely and may require sutures or staples to stop the bleeding. Neurogenic shock is associated with spinal cord injuries. Symptoms include hypotension and bradycardia (not tachycardia).

Which of the following has been found to be the most effective in preventing embolic strokes due to atrial fibrillation?

A.

Aspirin

B.

Low-molecular-weight heparin

C.

Warfarin (Coumadin)

D.

Clopidogrel (Plavix)

C

Rationale: Studies have shown warfarin is the best at preventing an embolic stroke but is associated with a greater risk of bleeding. Aspirin is also used in primary prevention of embolic strokes but has less efficacy in preventing embolic strokes. Aspirin has a lower risk of bleeding than anticoagulation therapy. Low-molecular-weight heparin (LMWH) and Plavix are not currently recommended in preventing embolic strokes.

Which of the following scales are used to determine the overall prognosis in patients with a brain tumor?

A.

PedsQL

B.

Functional Iindependence Measure

C.

CHADS2 score

D.

Karnofsky Performance Status Scale

C

Rationale: Karnofsky Performance Status Scale (KPS) is used to determine overall prognosis in patients with a brain tumor. It is used along with histopathology of the tumor, completeness of resection, presence of necrosis, and tumor size and location. CHADS2 score is used to determine the stroke risk of atrial fibrillation. Functional Independence Measure (FIM) is used to evaluate stroke patients in rehabilitation. PedsQL is a tool used to assess quality of life in pediatric patients with brain tumors but is not used for overall prognosis.

Which of the following best describes a radiculopathy?

A.

Compression of the cord with central stenosis

B.

Inflammation of bone and cartilage of joint

C.

Compression of nerve roots with foraminal stenosis

D.

Symptomatic degenerative changes of osteoarthritis

C

Rationale: Radiculopathy is compression of nerve roots due to the narrowing of foraminal processes. Osteoarthritis is the inflammation of bone and cartilage of the spinal joints. Myelopathy is compression of the spinal cord due to central stenosis. Spondylosis is the symptomatic degenerative change that occurs in osteoarthritis.

Your patient presents with left upper extremity weakness and facial droop. Which of the following vessels is most likely involved in this stroke?

A.

Anterior cerebral artery

B.

Middle cerebral artery

C.

Posterior cerebral artery

D.

Basilar artery

B

Rationale: The middle cerebral artery (MCA) supplies blood to the lateral portion of the cerebral cortex, which is where the motor strip for the upper extremities and face is located. The anterior cerebral artery (ACA) supplies blood to the medial portion of the cerebral cortex, which is where the motor strip for the lower extremities is located (results in lower-extremity weakness). The posterior cerebral artery (PCA) supplies blood to the occipital lobe, which results in visual deficits. The basilar artery is in the posterior circulation (brainstem) and may present with quadriplegia or “locked-in” syndrome.

Your patient has sustained a traumatic brain injury and a basilar skull fracture. The physician has ordered a nasogastric tube (NG) be placed. Which of the following is your best response?

A.

Place the NG according to the physician’s order.

B.

Discuss with the physician the need to place an enteral feeding tube.

C.

Insert the gastric tube orally.

D.

Ask the physician to place the NG.

C

Rationale: Never place a gastric tube nasally in a patient with a basilar skull fracture. The nasogastric (NG) tube may go through the cribriform fracture and enter the brain. A gastric tube can be placed orally, just not nasally. An enteral feeding tube may not be indicated at this time. Having the physician place the NG tube is not appropriate because the tube should not be placed nasally.

During a stroke assessment, the patient has been found to have a deviated gaze. Which of the following would be the most correct statement regarding the gaze?

A.

Dysconjugate gaze

B.

Upward gaze

C.

Gaze toward the affected side

D.

Gaze away from affected side

C

Rationale: The gaze abnormality in a middle cerebral artery (MCA) stroke is deviated toward the affected side. Seizures result in gaze away from the affected side. A dysconjugate or upward gaze is frequently associated with cranial nerve abnormalities but not commonly associated with strokes.

What type of seizure is an aura classified as?

A.

Simple partial

B.

Complex partial

C.

Generalized

D.

Nonconvulsive

A

Rationale: An aura is a simple partial seizure typically involving somatosensory symptoms such as hallucinations. People are aware of the aura prior to having a generalized seizure. Complex partial seizures result in a loss of awareness and are frequently manifested as motor or automatism behavior. Generalized seizures occur across both hemispheres at once and are most frequently tonic–clonic. Nonconvulsive seizure patients have epileptic EEGs, but no physical signs of a seizure.

Your patient presents with the diagnosis of Guillain–Barré syndrome. Which of the following is the priority of care for this patient?

A.

Assessment of vital capacity

B.

Reassurance of the patient

C.

Preparing for electromyography testing

D.

Obtaining CT scan of the spine

A

Rationale: Airway and breathing are the priorities of care. The ascending loss of muscle contraction can include the diaphragm and respiratory muscles. Vital capacity is commonly used to assess the effectiveness of ventilation in neuromuscular disorders. Electromyogram (EMG) testing may be ordered; the patient should be reassured, but the priority of care is airway and breathing. A CT of the spine may be ordered to rule out cord compression, but is not a priority over assessment of ventilatory capability.

A patient sustained cervical fractures at the C4 and C5 level from a motor vehicle collision. In the ED, initially he was moving all extremities equally. He suddenly became hemiplegic on the left side. Which of the following is the most likely cause for this neurological change?

A.

Carotid artery dissection

B.

Spinal cord injury

C.

Spinal epidural hematoma

D.

Cerebral edema

A

Rationale: Carotid artery dissections are associated with traumatic injuries at the cervical level. The flexion/extension mechanism of injury that causes vertebral fractures and spinal cord injuries can also cause carotid and vertebral dissections. Carotid dissections can cause cerebral infarctions with symptoms of contralateral motor loss of upper and lower extremities. Spinal cord injury and epidural hematoma would result in paralysis bilateral. There is no justification within the scenario to suspect cerebral edema as the cause of the symptoms

Which of the following therapeutic interventions is frequently recommended to manage a cerebrospinal fluid (CSF) leak?

A.

Drain CSF with a lumbar drain.

B.

Administer mannitol.

C.

Limit fluid intake.

D.

Maintain head-of-the-bed elevation greater than 30 degrees.

A

Rationale: Cerebrospinal fluid (CSF) leak is frequently managed by placing a lumbar drain to remove CSF. This lowers the CSF pressure and decreases the drainage. Mannitol is used to manage cerebral edema and increased intracranial pressure (ICP). Limiting fluid intake does not affect the CSF leak and is not recommended; head of the bed (HOB) is maintained flat, not elevated, to decrease the CSF leak.

The mother of a 6-year-old girl just diagnosed with pilocytic astrocytoma asks the nurse what her child’s prognosis is. Which of the following would be the best response by the nurse?

A.

This type of tumor has a good prognosis and can usually be managed with surgery.

B.

The tumor is malignant and frequently metastasizes to the spine.

C.

This tumor is associated with poor prognosis. I would encourage you to speak with a palliative care physician.

D.

The prognosis is not well known. She will probably require long-term chemotherapy.

A

Rationale: The prognosis of pilocytic astrocytoma is good, with over a 90% survival rate in 10 years. It is commonly located in the cerebellum and can be surgically resected. It may not require follow-up radiotherapy if resection is complete. The tumor is not typically malignant.

Which of the following cerebral arteries is most likely involved in the presentation of “locked-in” syndrome during a stroke?

A.

Anterior cerebral artery

B.

Posterior communicating artery

C.

Internal carotid artery

D.

Basilar artery

D

Rationale: The basilar artery provides blood to the ventral portion of the pons. The basilar artery is involved in the stroke, resulting in locked-in syndrome. The internal carotid artery typically presents with unilateral paresis or paralysis. The posterior communicating artery or anterior cerebral artery does not present with quadriplegia.

Following a minor brain injury (concussion), the patient may experience which of the following symptoms over the next 6 months?

A.

Periods of aphasia

B.

Swallowing deficits

C.

Difficulty concentrating

D.

Ataxia

C

Rationale: Following a minor brain injury (concussion), patients may experience postconcussion syndrome. This is self-limiting, with neurological deficits that may last 6 months to a year after injury. Symptoms of postconcussion syndrome include (but not limited to) memory deficits, emotional outbursts, and difficulty concentrating. Periods of aphasia would be more likely transient ischemia attack. Swallowing deficit and ataxia are not associated with postconcussion syndrome and may indicate another neurological issue.

A patient presents with signs of occipital headache and abnormal motor strength. The MRI found herniation of the cerebellar tonsils, vermis, and fourth ventricle. How would this Chiari malformation be classified?

A.

Type I

B.

Type II

C.

Type III

D.

Type IV

B

Rationale: A type II Chiari malformation is the downward displacement of cerebellar tonsils and inferior vermis, fourth ventricle, choroid plexus, and medulla

Chiari malformation type I

is characterized by the displacement of the cerebellar tonsils without significant brainstem involvement, typically presenting with headaches and cerebellar symptoms.

chiari malformation type II

is characterized by the downward displacement of cerebellar tonsils, inferior vermis, and fourth ventricle, often associated with neurological deficits.

chiari malformation type III

is a severe form involving herniation of the cerebellum through an opening in the skull and is often associated with significant neurological complications.

chiari malformation type IV

is characterized by the absence of the cerebellum and severe neurological impairments, often leading to a fatal outcome.

The patient presents in the ED with expressive aphasia and paralysis of the right arm and leg. He has a decreased level of consciousness and rapid respiration. Which of the following is your priority of care?

A.

Obtain a STAT CT scan.

B.

Administer alteplase immediately.

C.

Perform a baseline National Institutes of Health Stroke Scale (NIHSS).

D.

Secure an airway and ensure ventilation.

D

Rationale: Priority of care is always airway and breathing. Patients presenting with a decreased level of consciousness (LOC) may be unable to maintain an airway, requiring the airway to be secured. The patient will need a CT scan and a National Institutes of Health Stroke Scale (NIHSS) assessment and may be a candidate for thrombolytic therapy, but airway and breathing are the priorities of care.

A patient presents with low-back pain. Upon review of the spinal radiographs, multiple levels of osteophytes are noted. Which of the following best describes an osteophyte?

A.

Inflammation of synovial joints

B.

Degeneration of vertebral body with increased bone formation

C.

Stenosis of the nerve root as exits lateral foramen

D.

Compression of lumbar disc

B

Rationale: The degeneration of the vertebral body includes increased bone formation of the subchondral bone adjacent to endplate and is called sclerosis. It is less able to absorb loads and causes formation of osteophytes, bony projections also known as spurs. These may compress on neurological structures and cause symptoms. Synovitis is inflammation of synovial joints. Foraminal stenosis causes the compression of exiting nerve roots. Lumbar disc compression can cause symptoms but is not an osteophyte.

Anticholinesterase agents are used to improve myasthenia gravis muscle function through which of the following actions?

A.

Increase secretion of acetylcholine.

B.

Prevent breakdown of acetylcholine.

C.

Increase sensitization postsynaptic receptors.

D.

Increase number of postsynaptic muscle receptors.

B

Rationale: Anticholinesterase agents prevent the breakdown of acetylcholine by acetylcholinesterase. The effect of the anticholinesterase agents is to prolong the effect of the neurotransmitter acetylcholine. The agents do not increase secretion of the neurotransmitter acetylcholine or sensitize the receptors of acetylcholine. The postsynaptic muscle receptors are destroyed and cannot be regenerated.

Which of the following diagnostic studies is considered the most reliable to identify spinal cord and soft-tissue injuries?

A.

Lateral cervical spine radiographs

B.

CT scan

C.

MRI

D.

Flexion/extension radiographs

C

Rationale: The benefits of MRI in evaluating acute spinal cord injury (SCI) are its ability to identify cord compression, soft-tissue injuries such as herniated disc and epidural hematoma, ligament instability, and intramedullary hematomas. Lateral C-spine radiographic studies can identify vertebral fractures and can assess for misalignment of the cervical spine but cannot identify cord or soft-tissue injuries. CT scans are not considered as beneficial as MRI in identifying injury to the spinal cord, soft tissue, or ligaments. Flexion/extension radiographs are used in certain patients to identify misalignment of the spine (ligament injury) but are not able to identify actual injury to the cord, soft tissues, or ligaments.

A patient reports he or she experiences irritability and mood changes days prior to a seizure. What is this period called?

A.

Preictal

B.

Aura

C.

Intraictal

D.

Postictal

A

Rationale: The preictal state is the “warning” sign of an impending seizure that may occur days prior to the seizure. This may include feelings of general irritability or depression, mood changes, anxiety, headaches, lethargy, change in appetite, and light-headedness. An aura is the actual start of the seizure. Intraictal is the period of time during the seizure. Postictal is after the seizure.

Which of the following secondary injuries would be the most important determinants of outcomes in patients following traumatic brain injuries?

A.

Hyponatremia and tachycardia

B.

Hypoxia and hypotension

C.

Hyperglycemia and hypothermia

D.

Hyperthermia and metabolic acidosis

B

Rationale: Current research has found the two most important determinants of outcome following a traumatic brain injury are hypoxia and hypotension. They both are considered secondary injuries and determine cerebral perfusion. Hyperglycemia, hyperthermia, hyponatremia, and metabolic acidosis are secondary injuries and can affect outcomes but are not as severe as secondary injuries affecting cerebral perfusion.

Which of the following would be a contraindication for administering a thrombolytic?

A.

Patient’s home medications include Eliquis

B.

National Institutes of Health Stroke Scale score of 10

C.

Patient on a daily aspirin

D.

Negative CT scan

a. Rationale: Eliquis is classified as a novel anticoagulant. An NIHSS score of 10 is not a contraindication for alteplase. Depending upon other criteria, it would be an indication. Antiplatelet agents, such as aspirin, are not a contraindication to alteplase in acute stroke. An acute ischemic stroke will have a negative CT scan initially.

Your patient has a sudden loss of consciousness. An emergency CT is obtained and an intracerebral hemorrhage (ICH) is seen. Which of the following would be the LEAST common cause of an ICH?

A.

Anticoagulation therapy

B.

Hypertensive crisis

C.

Aneurysm rupture

D.

Vascular tumor

C

Rationale: Aneurysm rupture results in subarachnoid hemorrhages (SAH) and intraventricular hemorrhage (IVH), not primarily intracerebral bleeds. Anticoagulated patients, hypertensive crisis, and vascular tumors will typically cause bleeding into the parenchyma and are called intracerebral hemorrhage (ICH).

Which of the following statements is a true regarding cerebral palsy (CP)?

A.

CP is not preventable.

B.

CP is a disease found in children but can be cured.

C.

Most children with CP will die by the age of 10 years.

D.

CP has no cure.

D

Rationale: There is no cure for cerebral palsy (CP). It is preventable in some cases such as those due to maternal infections (vaccinations) or Rh incompatibility (use of Rhogam). CP can be at birth or acquired at a very young age. CP may shorten life expectancy, but many children with CP live into adult ages.

Plasmapheresis is treatment commonly used in managing Guillain–Barré. It involves the:

A.

Complete exchange of red blood cells

B.

Removal of antibodies with plasma exchange

C.

Washing of the white blood cells to clear allergens

D.

Filtering of the immunoglobulins

B

Rationale: Guillain–Barré is an autoimmune disorder. Plasmapheresis involves the exchange of serum plasma to remove the antibodies. Plasmapheresis does not exchange red blood cells, wash white blood cells, or filter immunoglobulins.

Which of the following best describes Moyamoya disease?

A.

Small, multiple aneurysms in the microcirculation

B.

Arteriovenous malformations

C.

Hyperlipidemia deposits of fat in the cerebral vessel wall

D.

Progressive occlusion of the intracranial internal carotid artery with collateral flow

D

Rationale: Moyamoya disease is the progressive narrowing or occlusion of the internal carotid artery with the development of collateral circulation called Moyamoya vessels. Presence of multiple, small aneurysms in the microcirculation is called Charcot-Bouchard. Hyperlipidemia results in the formation of plaque and the narrowing of the vessel but is not called Moyamoya vessels. Arteriovenous malformations (AVMs) are congenital vascular anomalies in which the arteries feed directly into draining veins.

When clearing a cervical spine injury in the acute period following a traumatic event, which of the following is NOT required?

A.

Maintain cervical immobilization until cleared of ligament injury

B.

Flexion/extension evaluation in an awake, asymptomatic patient

C.

Visualization of C1 through T1 on lateral cervical radiographs

D.

MRI of cervical spine

D

Rationale: MRI of cervical spine can be used to clear a cervical spine injury (C-spine) in certain circumstances but is not required. Maintaining cervical immobilization until ligament injuries can be cleared is required to prevent subluxation and cord compression if an injury is present. Awake, asymptomatic patients require evaluation (radiographs or physical assessment) of flexion and extension capability to determine if potential ligament injury since plain radiographs cannot identify ligament unless some degree of subluxation is noted. Lateral C-spines require visualization of C1–C7 and the tip of T1 to clear the C-spine of bony fractures.

Which of the following is a known risk factor for a brain tumor?

A.

Use of cellular phones

B.

Exposure to ionized radiation

C.

Consumption of fish with high mercury levels

D.

Use of microwaves

B

Rationale: Overall, causes of brain tumors are unknown. Exposure to ionized radiation is a known risk factor, which can be modified. Cell phones produce a very low magnetic radiation and have not been found to increase the risk of brain tumor. Environmental risks such as ingestion of high mercury and food cooked in microwave have not been found to increase risk of brain tumors.

Lobar intracerebral hemorrhage frequently presents with which neurological symptom?

A.

Cranial nerve deficits

B.

Decreased level of consciousness

C.

Pinpoint pupils

D.

Horner’s syndrome

B

Rationale: A decrease in level of consciousness is frequently associated with lobar intracerebral hemorrhage. A bleed within the brainstem frequently presents with cranial nerve deficits, pinpoint pupils, and Horner’s syndrome.

Patients with Mèniére’s disease often complain of feelings of aural fullness accompanied by which of the following other symptoms?

A.

Worst headache of their lives

B.

Urinary incontinence

C.

Roaring sound in ears

D.

Frequent ear infections

C

Rationale: A common complaint by patients is a “roaring” sound in their ears as well as aural fullness. Urinary incontinence is associated with normal-pressure hydrocephalus (NPH). Subarachnoid hemorrhage (SAH) presents with the “worst headache of their life.” M`eniére’s disease is not associated with frequent ear infections but can have hearing losses

Which of the following is NOT considered a cholinergic side effect of anticholinesterase medications used in managing myasthenia gravis?

A.

Diarrhea

B.

Nausea and vomiting

C.

Increased salivation

D.

Urinary retention

D

Rationale: Cholinergic side effects of anticholinesterase medications include diarrhea, increased salivation, and nausea and vomiting. Urinary retention is not considered a side effect of anticholinesterase agents.

Intracellular swelling in the brain occurred following an anoxic brain injury. What is this called?

A.

“Steal” phenomenon

B.

Neurogenic cerebral edema

C.

Vasogenic cerebral edema

D.

Cytotoxic cerebral edema

D

Rationale: Cerebral edema is classified as vasogenic and cytotoxic. Cytotoxic cerebral edema involves intracellular swelling and is caused by hypoxic and/or anoxic brain injuries. Vasogenic cerebral edema is interstitial swelling and is usually caused direct trauma or injury to the brain tissue. The “steal” phenomenon involves inappropriate distribution of blood flow to areas of injury following traumatic brain injury. Neurogenic cerebral edema is not a classification of brain swelling.

Which of the following frequently presents with nausea, vomiting, and ataxia?

A.

Cerebellar hemorrhage

B.

Thalamic hemorrhage

C.

Pituitary hemorrhage

D.

Frontal lobe hemorrhage

A

Rationale: Cerebellar hemorrhage frequently presents with nausea, vomiting, and ataxia. Thalamic hemorrhage presents with loss motor and/or sensory. Headache and sudden loss of consciousness is sign of lobar (frontal lobe) hemorrhage. Pituitary hemorrhage causes sudden onset of headache and visual field deficits.

Which of the following radiographs is best used to identify spinal segmental instability in an awake, nontraumatic patient?

1. A.

   Cervical CT scan

2. B.

   Diffusion-weighted imagery

3. C.

   Myelogram

4. D.

   Flexion extension x-rays

D

Rationale: Cervical flexion extension radiographs are used to evaluate vertebral segmental stability. Diffusion weighted imagery is used to identify brain hypoperfusion in stroke patients. Myelogram is utilized to view central and lateral recesses and can visualize compression of individual nerve roots.

Which of the following is a TRUE statement about rehabilitation with spinal cord–injured (SCI) patients?

A.

Rehabilitation begins after the patient is stabilized in the acute period.

B.

The goal of rehabilitation in SCI patients is to return the patient to his or her prior level of functioning.

C.

Preventing secondary injuries in SCI patients is a component of rehabilitation.

D.

It provides long-term assistance to patients with SCI.

C

Rationale: Rehabilitation begins on admission into an acute care facility. A major component of rehabilitation is the prevention of secondary injuries that can adversely affect outcome. A goal of rehabilitation is to improve the patient’s independence in activities of daily living, but it is not realistic to have the goal of returning to their prior level of function in spinal cord–injured (SCI) patients. Rehabilitation is to assist with reintegration of the patient into society with good resources, but it is not to provide long-term care and assistance to the patient.

The cardinal feature of Guillain–Barré includes which of the following?

A.

Unilateral ascending paralysis

B.

Descending bilateral paresthesia

C.

Bilateral ascending paralysis

D.

Bilateral spasticity in upper extremities

C

Rationale: The primary characteristic of paralysis in Guillain–Barré (GB) is bilateral, ascending paralysis. It may or may not involve ventilatory muscles and requirement for mechanical ventilation. It is bilateral, not unilateral, paralysis. GB presents in an ascending manner, not in a descending manner.

Which of the following has been associated with a genetic increase in risk of brain tumor?

A.

Down syndrome

B.

Autoimmune disorders

C.

Glioblastoma gene

D.

Neurofibromatosis

D

Rationale: Genetic syndromes, such as neurofibromatosis types I and II, have been associated with brain tumor risk in families. Glioblastoma has a less than 1% with a genetic predisposition. Allergies and immune disorders may protect against brain tumors. Down syndrome has a very low association with brain tumors.

Which of the following is the priority of care of a patient following a seizure?

A.

Reorient the patient to place and time.

B.

Determine whether the patient has a recollection of the seizure.

C.

Maintain the patient’s airway and breathing.

D.

Assess for the presence of Todd’s paralysis.

C

Rationale: Airway and breathing are always the priorities. Following a seizure, patients may have altered mentation and are unable to maintain airway. All of the other answers are interventions following a seizure, but the priority is airway.

When assessing a patient with meningitis, you passively flex the patient’s neck and his or her knees automatically flex upward. What is this called?

A.

Brudzinski’s sign

B.

Romberg sign

C.

Kernig’s sign

D.

Kehr’s sign

A

Rationale: Brudzinski’s and Kernig’s signs are both signs of meningeal irritation and can be present in patients with meningitis. The Brudzinski’s sign is seen when the flexion of the neck causes knees to passively flex. The Kernig’s sign is pain or hamstring spasm upon straightening the bent leg. Romberg’s sign is found in patients with vertigo. Kehr’s sign is found in splenic injuries.

A patient presents to your unit with the diagnosis of an intracerebral hemorrhage. Which of the following blood pressure (BP) parameters orders would be expected?

A.

Keep systolic BP >220 mmHg.

B.

Maintain systolic BP <100 mmHg.

C.

Maintain systolic BP between 130 and 150 mmHg.

D.

Treat BP only if patient rebleeds.

C

Rationale: The goal in a hemorrhagic stroke is to keep the systolic blood pressure (SBP) low to prevent a rebleed but high enough for perfusion of the brain tissue. Frequently, the BP will be ordered as a range such as between 130 and 150 mmHg. An SBP > 220 mmHg will increase incidence of rebleeding. Less than 100 mmHg will increase ischemic injury. The BP should be managed to prevent complications such as rebleeds, not to treat them only when they occur.

Postoperative management of carotid endarterectomy (CE) includes monitoring of neurological assessment. Which of the following physiological changes is NOT considered a common cause for the neurological deterioration following the CE?

A.

Reperfusion injury with cerebral edema

B.

Embolic showers

C.

Cerebral ischemia

D.

Subdural hematoma

D

Rationale: The procedure of carotid endarterectomy (CE) involves clamping of the carotid artery, which can lead to cerebral ischemia. Placing a catheter into the carotid artery to perform the CE can cause embolic showers. When the carotid artery is opened and perfusing, reperfusion hyperemia can predispose the patient to brain edema. Subdural hematoma is not a common complication of CE.

Which of the following patients is LEAST likely to experience a chronic subdural hematoma?

A.

An 85-year-old male patient

B.

A patient with severe dementia

C.

Patient on anticoagulation therapy

D.

An alcoholic patient

C

Rationale: The elderly, alcoholics, and dementia patients are prone to experiencing chronic subdural hematomas. These patient populations have atrophy of brain, resulting in a greater capacity to hold the volume of venous blood, delaying the onset of symptoms. Patients on anticoagulation are more likely to experience an intracerebral hemorrhage or an acute to subacute bleed.

Which of the following types of headache may be accompanied by an aura?

A.

Cluster headaches

B.

Migraine headaches

C.

Stress headaches

D.

Daily headaches

Rationale: An aura has been found to frequent migraine headaches. It is not associated with cluster, stress, or daily headaches.

Which of the following is LESS meaningful when talking to the patient about the brain tumor pathology and prognosis?

A.

Malignant or benign

B.

Tumor growth

C.

Location of tumor

D.

Patient’s comorbidities

A

Rationale: A benign tumor in the brain may be more life-threatening than a malignancy due to several factors. The location is very important because the tumor may be benign but is present in an eloquent area of the brain or a difficult location to reach with surgery or radiation. Tumor behavior or growth is important to the development of symptoms. Patient’s comorbidities, including health and age, play a significant role in outcomes with brain tumors.

Aneurysms can be classified based on the shape, size, and origin of the aneurysm. Which of the following terms best describes an aneurysm with a neck?

A.

Saccular aneurysm

B.

Fusiform aneurysm

C.

Giant aneurysm

D.

Mycotic aneurysm

A

Rationale: An aneurysm with a neck is called a saccular or berry aneurysm. A fusiform is more of an outpouching of the vessel wall. A giant aneurysm is based upon the size of the aneurysm, measuring greater than 2.5 cm in diameter. A mycotic aneurysm is classified based upon origin being an infectious source such as endocarditis.

A patient is diagnosed with disc protrusion (propulsion). Which of the following best describes disc herniation?

A.

Occurs when nucleus ruptures through innermost fibers of the annulus fibrosus with no disruption to outer annular fibers.

B.

Rupture of nucleus distorts the outermost fibers of the annulus and causes bulge outward.

C.

Complete split of annulus allows nuclear material to leak out of surrounding spaces.

D.

Extruded nuclear substance is no longer attached to material remaining within the disc and fragments may float around the spinal canal.

B

Rationale: Disc protrusion or propulsion involves the rupture of the outermost fibers of the annulus. This results in bulging outward of the disc. Disc nuclear herniation without protrusion involves injury to the inner annulus without disruption of the outer. Nuclear extension is the complete split of the annulus allowing nuclear material to leak into surrounding spaces, but protruded material remains attached. Extruded nuclear substances, which are not attached and float around the spinal cord, are called sequestered nuclei.

A paraplegic patient is being taught in rehabilitation to prevent pressure ulcers while sitting in the wheelchair. Which of the following strategies is the MOST important to preventi pressure ulcers?

A.

Use air cushion pad at all times.

B.

Perform frequent shifts in the chair.

C.

Use a Hoyer lift to move in the chair.

D.

Massage skin frequently to improve skin circulation.

B

Rationale: Paraplegic patients are taught to perform frequent chair shifting to prevent prolonged pressure and pressure ulcers (redistribution techniques). Cushions can be used in chair to lower the risk, but shifting frequently is more important. Hoyer lifts can be used, but paraplegic patients can usually shift themselves with their upper extremities. Massaging can improve circulation to skin but is not a technique to prevent pressure ulcers while sitting in the wheelchair.

Hydrocephalus present in Chiari type II malformations is classified as which of the following?

A.

Communicating hydrocephalus

B.

Noncommunicating hydrocephalus

C.

Degenerative hydrocephalus

D.

Productive hydrocephalus

B

Rationale: When there is an obstruction to cerebrospinal fluid (CSF) flow resulting in hydrocephalus, it is called noncommunicating hydrocephalus. Communicating hydrocephalus is a result of overproduction or decreased reabsorption of the CSF. Degenerative and productive hydrocephalus is not a classification of hydrocephalus.

Which of the following autoimmune disorders is most commonly associated with trigeminal neuralgia?

A.

Lupus

B.

Multiple sclerosis

C.

Myasthenia gravis

D.

CREST syndrome

B

Rationale: When trigeminal neuralgia (TN) is found in the younger population without other risk factors, they will frequently test for multiple sclerosis (MS). TN and MS are associated disorders, which frequently occur together. Lupus, crest syndrome, and myasthenia gravis are autoimmune disorders but are not frequently associated with TN.

Which of the following aneurysms is caused by septic emboli associated with bacterial endocarditis?

A.

Charcot–Bouchard

B.

Giant aneurysm

C.

Ehler’s aneurysm

D.

Mycotic aneurysm

Rationale: Mycotic aneurysms are a result of a septic source such as endocarditis showering septic emboli. Charcot–Bouchard is the presence of multiple tiny aneurysms within the deep structures of the brain. A giant aneurysm measures greater than 2.5 cm in diameter. Ehlers–Danlos syndrome is a connective tissue disease resulting in formation of aneurysms throughout the vasculature.

Hyperventilation with the lowering of PaCO2 causes which of the following physiological effects in the cerebral circulation?

A.

Cerebral vasodilation

B.

Cerebral vasoconstriction

C.

Increased intracranial pressure

D.

Cerebral edema

B

Rationale: Carbon dioxide (CO₂) is a potent vasodilator in the cerebral circulation. A decrease in PaCO₂ causes cerebral vasoconstriction, thus lowering ICP. An increase in PaCO₂ causes cerebral vasodilation resulting in an increase in the intracranial pressure (ICP). The lowering of the PaCO₂ does not increase cerebral edema.

Which of the following best describes the pain syndrome associated with trigeminal neuralgia?

A.

Dull, constant aching pain along the jaw line

B.

Constant, severe, knifelike facial pain occurs bilaterally

C.

Muscle spasms along the V1 and V2 branches, which result in cramping-like pain

D.

Shock-like sensations, intermittent or episodic facial pain that occurs unilaterally

D

Rationale: The pain of trigeminal neuralgia (TN) is neuropathic pain. It is frequently described as shock-like or electrical pain, which comes in volleys, or episodes of pain. It usually occurs unilateral. It is not described as dull, constant, or a cramping-like pain.

Which of the following is the most common result of an intracranial aneurysm rupture?

A.

Subarachnoid hemorrhage

B.

Epidural hematoma

C.

Subdural hematoma

D.

Intracerebral hemorrhage

A

Rationale: Intracranial aneurysm rupture causes bleeding into the subarachnoid and intraventricular spaces. Epidural and subdural hematomas can be caused by trauma to the vascular but are not related to aneurysm rupture. Intracerebral hemorrhage (ICH) is bleeding into the brain parenchyma and is more likely caused by hypertension or anticoagulation.

A vaccine has been developed for which of the following types of meningitis?

A.

Tuberculosis meningitis

B.

Meningococcal meningitis

C.

Haemophilus influenzae meningitis

D.

Listeria

B

Rationale: Meningococcal meningitis is spread through an airborne route and can become an epidemic in close quarters. A vaccination has been developed against one strain of meningococcal meningitis and is recommended in people living in close quarters such as military barracks or college dorms.

Which of the following neurotransmitters will inhibit seizure activity?

A.

Glutamine

B.

Dopamine

C.

Acetylcholine

D.

Gamma-aminobutyric acid

D

Rationale: Gamma-aminobutyric acid is an inhibitory neurotransmitter in the brain and has been found to inhibit seizures. Glutamine is an excitatory neurotransmitter and has been found to stimulate seizures. Dopamine inhibits motor tone and is found to be diminished in Parkinson’s disease. Acetylcholine is a neurotransmitter at the level of the neuromuscular junction and is required for muscular contraction.

Which of the following types of tremor occur due to a fixed posture against gravity?

A.

Kinetic intentional tremor

B.

Postural tremor

C.

Magnetic gait tremor

D.

Ataxic tremor

B

Rationale: A postural tremor occurs due to a fixed posture against gravity. Kinetic intentional tremor occurs during goal directed movement. Magnetic gait occurs with normal-pressure hydrocephalus (NPH). Ataxia is an abnormal balance or coordination and is not considered a tremor.

When administering an osmotic diuretic, such as mannitol, which of the following laboratory values should be closely monitored?

A.

Calcium

B.

Creatinine

C.

Potassium

D.

Serum osmolality

D

Rationale: Osmotic diuretics increase serum osmolality, resulting in hemoconcentration. As the serum osmolality increases greater than 320 mmol, neurological injury can occur. As the serum becomes hemoconcentrated, serum Na⁺ levels increase. Thus, monitoring of both serum osmolality and Na⁺ levels is recommended. Hgb, hct, Ca⁺, PO4⁺, creatinine, and blood urea nitrogen (BUN) may also be ordered but are not as greatly affected.

Which of the following is the least severe or mildest form of spina bifida (SB)?

A.

Myelomeningocele

B.

SB occulta

C.

Syrinx

D.

Meningocele

B

Rationale: Spina bifida occulta is just the identifiable gap between vertebral bodies found on radiographic studies. It does not involve injury to the spinal cord or spinal nerve roots. Meningocele and myelomeningocele are also forms of spina bifida and are more severe due to the involvement of the spinal cord and spinal nerve roots. Syrinx is the fluid accumulation within the central portion of the spinal cord and is not considered a form of spina bifida.

Cerebral aneurysms can occur throughout the cerebral circulation. Which of the following is the most common location of a cerebral aneurysm?

A.

Anterior circulation

B.

Extracranial internal carotid artery

C.

Basilar artery

D.

Vertebral artery

A

Rationale: About 80% of cerebral aneurysms occur within the anterior circulation, including the intracranial portion of the internal carotid artery (ICA), middle cerebral artery (MCA), and anterior cerebral artery (ACA). Of the vessels in the anterior circulation, the intracranial internal carotid artery (ICA) has the highest frequency. Injury to extracranial portion of the ICA is more commonly caused by a traumatic dissection versus an aneurysm formation. The basilar artery and vertebral arteries make up the posterior circulation and account for about 20% of the cerebral aneurysms.

Which of the following brain tumors is classified as an extraaxial tumor?

A.

Oligodendrioglioma

B.

Astrocytoma

C.

Pituitary adenoma

D.

Ependymoma

C

Rationale: An oligodendrioglioma, astrocytoma, and ependymoma all gliomas arise from glial cells. They are classified as intraaxial tumors because they are actually located in brain tissue. A pituitary adenoma is a tumor involving the pituitary gland in the brain but is not composed of brain tissue cells. This is classified as an extraaxial tumor.

Trigeminal neuralgia is a type of neuropathic pain. The best treatment for neuropathic pain includes which of the following?

A.

An antiepileptic

B.

Opioid

C.

Nonsteroidal anti-inflammatory drug

D.

Benzodiazepine

A

Rationale: Neuropathic pain is treated most effectively with antiepileptics (such as gabapentin) or tricyclic antidepressants. Nonsteroid anti-inflammatory drug (NSAID) can be a first-line treatment of neuropathic pain but is not as effective as antiepileptics. Neuropathic pain is not as responsive to opioids or anxiolytics in managing pain.

The most common presentation for a subarachnoid hemorrhage is which of the following?

A.

Sudden development of paralysis

B.

Ascending bilateral paralysis

C.

Complaints of “worst headache” of one’s life

D.

Expressive aphasia

C

Rationale: The most common sign of a subarachnoid hemorrhage (SAH) is “the worst headache” of their life. They may also experience some focal neurological deficits and nausea and vomiting. Paralysis is not a common presenting sign of an SAH. Aphasia is more commonly associated with an ischemic stroke.

Which of the following cranial nerves (CNs) is most commonly involved in long-term complications of bacterial meningitis?

A.

CN V (trigeminal nerve)

B.

CN I (olfactory nerve)

C.

CN IX (glossopharyngeal nerve)

D.

CN VIII (acoustic nerve)

D

Rationale: CN VIII (acoustic) is the most commonly damaged cranial nerve (CN) as a result of bacterial meningitis. Hearing loss is a long-term complication of bacterial meningitis. Other CNs frequently injured in meningitis include CN III (oculomotor), IV (trochlear), and VI (abducens), which are involved in extraocular eye movement and CN II (optic).

Which of the following would be the most appropriate method used to lower intracranial pressure?

A.

Elevate the head of the bed.

B.

Elevate the foot of the bed.

C.

Perform carotid massage.

D.

Place rolled towels on either side of the neck.

A

Rationale: Elevating the head of the bed facilitates venous drainage, thus lowering volume and pressure in the intracranium. Elevating the foot of the bed may actually increase the intracranial pressure (ICP). Carotid massage can cause bradycardia but is not used to lower the ICP. Maintaining head alignment is appropriate to facilitate venous drainage, but a rolled towel is not as effective as a soft cervical collar.

A patient has a seizure that is localized to the right upper extremity without impairment of consciousness. What is the classification of the seizure?

A.

Simple partial

B.

Complex partial

C.

Generalized seizure

D.

Nonepileptic seizure

A

Rationale: Simple partial seizures are localized seizures to one area of the brain in which the patient maintains consciousness. Complex partial seizures are also localized seizures but with the loss of consciousness. Generalized seizures occur across both hemispheres at once and are associated with a loss of consciousness. Nonepileptic seizures may be caused by subclinical or psychological seizures.

A patient is admitted with an acute ischemic stroke with a current history of sleep apnea. Which of the following would be the most appropriate intervention to improve outcomes?

A.

Continuous positive airway pressure

B.

Monitor end-tidal carbon dioxide levels

C.

Intubation and mechanical ventilation

D.

Place patient on ketogenic diet

A

Rationale: Treatment of sleep apnea improves the outcomes of stroke patients with sleep apnea. Treatment of sleep apnea includes the use of continuous positive airway pressure. Intubation and mechanical ventilation is invasive management of an airway but is not indicated to treat sleep apnea. Monitoring EtCO₂ can be used to assess for CO₂ retention but is not an intervention to improve outcomes. A ketogenic diet is not a known therapy for sleep apnea.

Neuroleptic agents are most commonly used to suppress symptoms of Tourette’s syndrome. Which of the following is the most common neurological side effect of neuroleptic agents?

A.

Dystonic movements

B.

Weight loss

C.

Acute renal failure

D.

Angioedema

A

Rationale: The most common neurological side effects of neuroleptic agents are dystonic movements (twisting or posturing), tremors, and involuntary movements. Weight loss is also a side effect of neuroleptic agents but it is not a neurological side effect. Acute renal failure and angioedema are not common side effects of neuroleptic agents.

Which of the following pituitary adenomas is most amendable to medical management?

A.

Adrenocorticotropic-secreting adenoma

B.

Nonsecreting adenoma

C.

Growth hormone-secreting adenoma

D.

Prolactinoma

D

Rationale: Prolactinoma is a pituitary adenoma, which secretes prolactin. Medical management is recommended to shrink the tumor. All of the other pituitary adenomas typically require surgical resection.