Neuro
Assessing vision and visual fields involves testing
CN: II
You perform extraocular movement (EOM) testing on a middle-aged patient. He is unable to move his eyes upward and inward. This indicates a possibility of paralysis of CN:
III
Loss of corneal reflex is in part seen in dysfunction of CN:
V
4 to 6. Match the CN with the appropriate function or test.
CN I - Sense of smell
CN VII - Facial symmetry, drooping mouth (Bell’s palsy)
CN IX - Tongue and throat, swallowing
You examine a 29-year-old woman, Cecilia, who reports a sudden onset of right-sided facial asymmetry. She is unable to close her right eyelid tightly, frown, or smile on the affected side. She states, “I was fine last night when I went to bed and woke up like this.” Her health history and physical examination are otherwise unremarkable. Her medications include a multivitamin daily and a progestin implant for contraception. She is not a smoker. This presentation likely represents paralysis of CN:
VII
Which represents the most appropriate diagnostic test for Cecilia, the patient in question 7?
Lyme disease testing
In prescribing a systemic corticosteroid for a patient with Bell's palsy, the nurse practitioner (NP) considers that its use:
should be initiated as soon as possible after the onset of facial paralysis
Bell's palsy is also known as:
C. idiopathic facial paralysis.
A 46-year-old man diagnosed with Bell's palsy and being treated with a systemic corticosteroid asks the NP about the use of an antiviral medication as he read online that an antiviral can help to "cure the disease." The NP correctly responds:
an antiviral can be considered though the benefit has not been established in clinical studies.
A 35-year-old normotensive woman with a history of bilateral tubal ligation presents with a 6-month history of gradual bilateral facial nerve paralysis, difficulty swallowing, altered EOMs, and diminished deep tendon reflexes (DTRs) in all four extremities. The NP considers:
making a prompt referral to neurology.
A 27-year-old man presents with a 5-week history of recurrent headaches that awaken him during the night. The pain is severe, lasts about 1 hour, and is located behind his left eye. Additional symptoms include lacrimation and nasal discharge. His physical examination is within normal limits, and he is currently headache-free. This clinical presentation is most consistent with:
cluster headache
A 22-year-old woman presents with a 3-year history of recurrent, unilateral, pulsating headaches with vomiting and photophobia. The headaches, which generally last 3 hours, can be minimized by resting in a dark room. She can usually tell that she is going to get a headache. She explains, "I see little 'squiggles' before my eyes for about 15 minutes before the headache starts." Her physical examination is unremarkable. This presentation is most consistent with:
migraine with aura
Indicators that a headache can be the presenting symptom of a serious underlying illness and consideration for neuroimaging include all of the following except:
similar headaches that occur periodically in clusters
Prophylactic treatment for migraine headaches in a 28-year-old woman with no chronic health problems who uses a levonorgestrel-releasing intrauterine device (LNG-IUD) for contraception includes the use of:
nortryptiline
Among the following beta blockers which is the preferred agent to e in preventing migraine headaches in a 40 year old woman with a history of bilateral tubal ligation and no history of airway disease?
propranolol
Antiepileptic drugs useful for preventing migraine headaches include all of the following except:
C. lamotrigine.
Evidence supports the use of all of the following vitamins and supplements for migraine prevention except:
D. ginkgo biloba.
You are examining a 65-year-old man who has a history of acute coronary syndrome (ACS) and migraine. Which of the following agents represents the best choice of acute headache (abortive) therapy for this patient?
C. acetaminophen
A 45-year-old man experiences rapidly progressing migraine headaches that are accompanied by significant GI upset. Appropriate acute headache (abortive) treatment includes all of the following except:
C. oral naproxen sodium.
With migraine, which of the following statements is true?
D. The pain is typically described as pulsating.
In tension-type headache, which of the following is true?
B. The pain is typically described as "pressing" in quality.
24 to 28. Indicate if each of the following is a risk factor for cluster headaches (yes or no).
24. onset at age 65 years or older - no
25. heavy alcohol use - yes
26. tobacco user- yes
27. male gender - yes
28. recent increase in life stressors- no
29. C Which of the following is most specific for abortive therapy of cluster headaches?
B. supplemental oxygen
30. Which of the following oral agents has the most rapid analgesic onset?
B. liquid ibuprofen (Motrin", Advil®)
31. Triptans should be used with caution with the concomitant use of:
A. high-dose SSRI.
32. Limitations associated with the use of butalbital with acetaminophen and caffeine (Fioricet®) include its:
C. high rate of rebound headache if used frequently.
33. The use of neuroleptics such as prochlorperazine (Compazine) and promethazine (Phenergan®)
in headache therapy should be limited to less than three times per week because of their:
B. EPM risk.
34. Which of the following statements about ergotamines is false?
A. This drug class is effective in the treatment of tension-type headaches.
35. With appropriately prescribed headache prophylactic therapy, the patient should be informed to expect:
C. an approximately 50% reduction in the number of headaches.
36, A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers prescribing all of the following except:
D. triptan prophylaxis.
37. A first-line prophylactic treatment option for the prevention of tension-type headache is:
A. nortriptyline.
prescribing the addition of which of the following to help improve her overall migraine symptoms?
C. naproxen sodium
39. A 68-year-old man presents with new-onset headaches. He describes the pain as bilateral frontal to occipital and most severe when he arises in the morning and when coughing. He feels much better by mid-afternoon. The history is most consistent with headache caused by:
B. increased ICP.
40. Short-term systemic corticosteroid therapy would be most appropriate in treating:
C. acute intractable or severe migraines and cluster headaches.
41. When evaluating a patient with acute headache, all of the following observations would indicate the absence of a more serious underlying condition except:
A. onset of headache with exertion, coughing, or sneezing.
42. The more common secondary headache etiology includes all of the following except:
C. cluster cephalalgia
43 to 45. Match the female-to-male ratio for each type of primary headache listed:
43. Tension-type headache - C. 5:4
44. Migraine without aura - B. 2:1
45. Cluster headache - A. 1:3 to 1:8
46 to 48. Match each patient with the most appropriate triptan formulation.
46. A 34-year-old man with rapid-onset migraine headache that typically lasts 3 to 4 hours with nausea but no vomiting - oral sumatriptan
47. A 44-year-old woman with a slowly developing migraine that typically lasts 6 to 8 hours with little GI upset - A. oral naratriptan
48. A 38-year-old woman with rapid-onset migraine that is often accompanied with significant nausea and vomiting - C. intranasal zolmitriptan
49 to 54. Indicate the appropriate course of action (head CT scan, head MRI, or neither) for each of the following patients:
49. A 45-year-old man who presents with a sudden, abrupt headache. Upon questioning, he appears somewhat confused with decreased alertness to his surroundings. - head CT scan
50. A 48-year-old woman with a history of breast cancer who presents with a 3-month history of progressively severe headache and bulging optic disk. - head MRI
51. A 24-year-old man who presents in the emergency department (ED) following a motor vehicle accident. He exhibits confusion and falls in and out of consciousness. - head CT scan
52. A 57-year-old woman with a prior history of a brain tumor that was removed 8 years ago.
She complains of headaches that have been increasing in frequency and intensity over the past month. - head MRI
53. A 37-year-old man diagnosed with cluster-type headache 10 years ago that is consistently alleviated with high-dose oral NSAID and injectable triptan - neither
54. A 27-year-old woman with migraines occurring consistently for the past 10 years around 2 to 3 days prior to onset of menses, accompanied by photo-/phonophobia, nausea, and vomiting, with partial relief with ibuprofen; normal neurological examination - neither
55. In counseling a patient who experiences migraines, you recommend all of the following lifestyle changes to minimize the risk of triggering a headache except:
A. avoiding eating within 1 to 2 hours of morning awakening.
56. A 37-year-old woman complains of migraine headaches that typically occur within hours after ear-ing in a restaurant. Potential triggers that can influence the onset and severity of migraine symptoms include all of the following except:
D. baked whitefish.
57. Which of the following is incorrect regarding the CGRP inhibitor class?
D. nearly eliminates migraines for over 50% of individual
58. Which of the following is likely a candidate for the use of CGRP inhibitor?
B. A 45 year old woman who experiences about 15 migraine days per month despite propranolol therapy
59. Which of the following is most closely linked to migraines?
D. motion sickness
60. An 18-year-old college freshman is brought to the student health center with a chief complaint of a 3-day history of progressive headache and intermittent fever. On physical examination, he has positive Kernig and Brudzinski signs. The most likely diagnosis is:
B. bacterial meningitis.
61. Of the following, which is the least likely bacterial source to cause meningitis?
A. colonization of the skin
62. Risk factors for bacterial meningitis include all of the following except:
A. being over 25 years of age.
63. The average incubation period for the organism N meningitidis is:
B. 3 to 4 days.
64. A 19-year-old college sophomore was diagnosed with meningococcal meningitis today. You speak to the school health officers about the risk to the other students on campus. You inform them that:
D. individuals with household-type or more intimate contact are considered to be at risk.
65. When evaluating the person who has bacterial meningitis, the NP expects to find CSF results of:
C. glucose at about 30% of serum levels.
66. When evaluating a patient who has aseptic or viral meningitis, the NP expects to find CS results of:
B. a predominance of lymphocytes.
67. Which of the following describes the Kernig sign?
C. Elicited with the patient lying supine and the hip flexed 90°, it is present when extension of the knee from this position elicits resistance or pain in the lower back or posterior thigh.
68. Physical examination findings in papilledema include:
C. optic disk bulging.
69. Which of the following vaccines is not typically recommended for individuals over 5 years of age?
B. Hib
70. Which of the following signs and symptoms most likely suggests meningitis caused by N meningitidis?
A. a purpura or petechial rash
71. All of the following persons should receive a dose of the MCV4 meningococcal vaccine except:
D. a 14-year-old who received a first dose of the same vaccine at 11 years of age.
72. Chemoprophylaxis for household contacts of an individual diagnosed with meningitis can include all of the following except:
C. multiple doses of amoxicillin.
73 to 75. Indicate (Yes or No) whether postexposure prophylaxis is needed for adult household contacts of an individual with the following conditions.
73. Viral meningitis - no
74. Bacterial meningitis associated with acute bacterial rhinosinusitis - no
75. Bacterial meningitis with bacterial pneumonia -no
76. The cause of MS is best described as:
A. a destructive process of the nerve fiber protecting myelin.
77. Common symptoms of MS, especially in earlier disease, include all of the following except:
D. symptoms improving in a warmer environment.
78. Risk factors for MS include all of the following except:
A. being older than 50 years of age.
79 to 81. Match each diagnostic test with the expected finding for a patient with multiple sclerosis.
79. MRI - B. presence of demyelinating plaques
80. Analysis of CSF - A. presence of oligoclonal bands
81. Evoked potential test - C. delays in timing of CNS response
82. Treatment options in MS to attenuate disease progression include:
A. interferon beta-1b.
83. PD is primarily caused by:
B. loss of the pigmented dopaminergic neurons.
84. Which of the following is most consistent with findings in patients with PD?
C. tremor at rest and bradykinesia
85. The diagnosis of PD relies on findings of:
A, clinical evaluation of its cardinal clinical features.
86. When considering treatment for PD, levodopa is typically used:
B. as a first-line treatment in early disease.
87. Other conditions to consider in the differential diagnosis of PD can include all of the following except:
D. multiple sclerosis.
88 to 90. Match each type of procedure with its description in the treatment of PD.
88. Subthalamotomy - B. destruction of part of the subthalamic nucleus
89. Pallidotomy - A. ablation of part of the globus pallidus interna
90. Deep brain stimulation - C. high-frequency electrostimulation of the brain
91. Which of the following statements regarding "on" and "off" periods of PD is false?
B. An "off" period typically occurs at the maximum serum concentration (Cmax) following levodopa dosing.
92 to 94. Match each type of medication with the condition it can treat for patients with PD.
92. SNRI (e,g., venlafaxine) - B. depression
93. Pimavanserin (Nuplazid®) - C. hallucinations
94. Cholinesterase inhibitors (e.g., rivastigmine (Exelon*]) - A. dementia
95. A 64-year-old man recently diagnosed with PD asks about exercising. He states, "I usually like to walk briskly around my neighborhood for 30 minutes at least four to five times a week." The NP responds:
C. Exercise is encouraged and likely has a neuroprotective effect.
96 to 99. Match each type of seizure with its most appropriate description.
96. Myoclonic - D. brief, jerking contractions of arms, legs, trunk, or all of these
97. Absence (petit mal) - A. blank staring lasting 3 to 50 seconds, accompanied by impaired level of consciousness
98. Tonic-clonic (grand mal) - C. rigid extension of arms and legs, followed by sudden jerking movements with loss of consciousness
99. Simple partial or focal - B. awake state with abnormal motor and psychic behavior lasting seconds
100. Which of the following antiepileptic medications is least likely to cause a significant drug-drug interaction?
C. gabapentin
101. Which of the following medications requires ongoing therapeutic monitoring of drug levels?
B. phenytoin
102. Which of the following statements about potential drug interactions with phenytoin is false?
D. When phenytoin and theophylline are given together, the result is a higher concentration of both drugs than when given separately.
103. The most common cause of new-onset unprovoked seizure is:
B. epilepsy.
104. A 34-year-old mother of two daughters is being evaluated following a new-onset seizure that caused a momentary loss of consciousness. Before being discharged, she asks if she can still drive her car. The NP responds that:
C. driving is restricted until a seizure-free period is achieved that is determined by state law.
105. When evaluating a patient with a new-onset unprovoked seizure, the most important aspect of the diagnostic evaluation is:
A. patient history.
106. Risk factors for TIA include all of the following except:
D. pernicious anemia.
107. A TIA is characterized as an episode of reversible neurological symptoms that can last
C. 24 hours.
108. When providing ongoing care for a patient with a recent TIA, you consider that:
A. long-term antiplatelet therapy is likely indicated.
109 to 111. Rank the following causes of stroke from most common (1) to least common (3):
109. Cerebral hemorrhage - 2
110. Cerebral ischemia - 1
111. Subarachnoid hemorrhage - 3
112 to 114. Match each type of stroke with its most common underlying cause.
112. Cerebral hemorrhage - hypertension
113. Cerebral ischemia - A. atherosclerosis
114. Subarachnoid hemorrhage (SAH) - B. ruptured cerebral aneurysm
115. Antiplatelet agents commonly used in secondary prevention of stroke include all of the following
except:
D. rivaroxaban.
116. Which of the following conditions is least likely to contribute to an increased risk of ischemic or hemorrhagic stroke?
C. Crohn's disease
117 to 123. When considering the diagnosis of acute stroke, which of the following can be part of the presentation? (Answer yes or no.)
117. partial loss of visual field - yes
118. unilateral hearing loss - yes
119. facial muscle paralysis - yes
120. Vertigo - yes
121. Diplopia - yes
122. Headache - yes
123. Ataxia - yes
124. Acute cerebral hemorrhage is best identified with which of the following imaging techniques?
B. CT scan
125. The use of a DOAC for secondary prevention of stroke is most useful for:
D. those with ischemic stroke and cardioembolic conditions.
126. You see a 25-year-old woman with a known factor V Leiden mutation who asks about contraceptives.
You suggest all of the following except:
A. combined oral contraceptive.
127. Which of the following patients would you consider neuroimaging with MRA to screen for the presence of a cerebral aneurysm?
D. a 46-year-old with four first-degree relatives with subarachnoid hemorrhage
128 to 132. You see a 54-year-old man who is a current smoker and has a history of hypertension, type 2 diabetes mellitus, and dyslipidemia. In considering stroke prevention, indicate if each of the following statements is true or false.
128. An acceptable blood pressure goal is less than 130/80 mm Hg. - true
129. An appropriate Alc target for this individual is less than 8.5%. - false
130. A statin is contraindicated for this patient. - false
131. Appropriate first-line antihypertensive medications can include thiazide diuretic, ACE inhibitor or ARB, or calcium channel blocker - true
132. He should be initiated on a DOAC. - false
133. Risk factors for GCA include all of the following except:
C. osteoarthritis.
134. In examining a 65-year-old woman who is undergoing evaluation for GCA, the NP considers the condition's clinical presentation is influenced by the diseases pathophysiology. Which of the following statements is false regarding GCA?
C. It primarily impacts smaller-sized vessels.
135. Mrs. Lewis is a 74-year-old woman with well-controlled hypertension. She is taking HCTZ and presents with a 3-day history of unilateral throbbing headache with difficulty chewing because of jaw pain. On physical examination, you find a tender, pulseless, noncompressible temporal artery. Blood pressure (BP) is 160/88 mm Hg, apical pulse is 98 bpm, and respiratory rate is 22/min; the patient is visibly uncomfortable. The optimal technique to confirm a diagnosis of GCA is:
B. biopsies of likely affected arteries.
136. Therapeutic intervention for Mrs. Lewis should include:
A. systemic corticosteroid therapy.
137. Headache associated with GCA is least likely to occur in the:
B. temporal area.
138. For a patient receiving standard therapy for GCA, the use of all of the following concomitant therapies should be considered except:
B. nitrate.
139. Concomitant disease often seen with GCA includes:
A. polymyalgia rheumatica.
140. One of the most serious complications of GCA is:
C. blindness.