A pt is asked to stand with feet together and arms at their sides and to close their eyes for 30 seconds without support. The clinician notices that the pt loses their balance. The clinician then whispers a few numbers and asks the pt to repeat what they’ve heard. Which cranial nerve is being tested?
A. VIII
B. X
C. V
D. VII
A. VIII
- AKA = vestibulocochlear nerve- responsible for hearing and vestibular function (balance).
- X = vagus nerve = ask the pt to say “ah” monitor for bilateral/symmetrical palate movement.
- V = trigeminal nerve = injury here would be indicated by dysfunction in facial sensation or facial strength.
- VII = facial nerve = assess for facial symmetry by asking the pt to perform facial movements.
The knee-jerk reflex is affected by which of the following nerve roots?
A. C5-6
B. C6-7
C. L2-4
D. S1
C. L2-4
- Biceps and brachioradials reflexes = C5-6
- Triceps reflex = C6-7
- Patellar reflex = L2-4
- Achilles reflex = S1
A pt presents with a temperature of 100.94F, nuchal rigidity, and a change in mental status. The pt has a decreased level of consciousness and a hx of a recent seizure within a week of initiation of symptoms. Blood glucose level is 101. A CBC and serum electrolytes are pending, but blood cultures have not yet been obtained. Which of the following is the next PRIORITY intervention?
A. Lumbar puncture
B. Head CT scan
C. Administration of acetaminophen for the fever
D. Initiation of antimicrobial therapy
B. Head CT scan
- This pt is presenting with the classic triad of bacterial meningitis = fever, nuchal rigidity, and a change in mental status.
- Head CT is performed before a lumbar puncture if the following risk factors are present: papilledema, focal neurologic deficit, abnormal level of consciousness, new-onset seizure (within one week of presentation), hx of central nervous system disease (stroke, mass), or immunocompromise (HIV, immunosuppressive therapy, solid organ or bone marrow transplant).
A pt presents following a focal motor seizure. The family is concerned that the pt may be experiencing another seizure because the pt is still confused. Physical assessment findings are significant for weakness of the right arm and an altered level of consciousness. These findings likely represent which of the following?
A. Generalized status epilepticus
B. Aura
C. Postictal period
D. Myoclonic seizure
C. Postictal period
- This is the period of transition from the ictal state back to the pt’s baseline level.
- It is not uncommon for pts to remain confused and have suppressed alertness.
- Focal neurologic deficits may be present = weakness of hand/arm/leg that appears on one side of the body.
- May only last seconds, but could also last up to a few hours depending on the part of the brain that is affected.
- Aura = often described as a warning symptom that the pt experiences at the beginning of a seizure. They do not cause symptoms or change the level of consciousness.
- Generalized status epilepticus = consists of generalized bilateral tonic-clonic movements.
- Myoclonic seizure = a type of generalized seizure, characterized by sudden, brief muscle contractions that may occur singularly or in clusters; impaired consciousness is not common.
Which of the following disease states has been found to be associated with giant cell arteritis?
A. Polymyalgia rheumatica
B. Trigeminal neuralgia
C. Bell’s palsy
D. Multiple sclerosis
A. Polymyalgia rheumatica
- Occurs in 50% of pts with giant cell arteritis.
- It can precede, accompany, or occur after giant cell arteritis.
Which of the following is a risk factor for a recurrent ischemic stroke after a transient ischemic attack (TIA)?
A. Age 50 yrs
B. PMH of Hyperlipidemia
C. Initial blood pressure of 160/90mmHg after TIA
D. Duration of TIA symptoms >8 minutes
C. Initial blood pressure of 160/90mmHg after TIA
- Risk factors for ischemic stroke after TIA = 60+ yrs, hx of TIA or ischemic stroke within 30 days of index event, hx of diabetes, systolic BP >140 or diastolic BP >90, unilateral weakness, isolated speech disturbance, TIA duration >10 minutes, presence of vascular pathologies (large artery atherosclerosis, small vessel disease), and presence of acute infarction on MRI or acute/chronic ischemic lesions on CT.
A pt presents with a throbbing headache with visual disturbances. The pt reports seeing a bright spot with an area of visual loss. Which of the following precipitating factors may have exacerbated this type of headache?
A. Drinking wine
B. Overeating
C. Consuming monosodium glutamate
D. Chewing
A. Drinking wine
- This pt is presenting with a migraine with an aura, which often involves vision disturbances.
- Trigger factors = stress, menstruation, visual stimuli, weather changes, consuming nitrates, fasting, drinking wine, sleep disturbances, and consuming aspartame.
A 23-year-old female pt is seen in the office by the NP for c/o weakness, poor balance, and problems with walking. She states, “I’m so clumsy. Sometimes I fall when I walk”. She reports new-onset vision loss and bladder incontinence. Each episode lasts a few days; she has had several in the past 6 months. When she bends her head forward to tie her shoes, she reports a sharp shooting sensation from the upper to the lower back. She is anxious and crying. What is the MOST LIKELY diagnosis for this pt?
A. Vitamin B12 deficiency
B. Trigeminal neuralgia
C. Multiple sclerosis
D. Myasthenia gravis
C. Multiple Sclerosis
- this is an autoimmune disease that affects the spine and brain.
- peak incidence is 15-45yrs.
- MRI of spinal cord and brain is needed to confirm diagnosis.
- Lhermitte sign = a sharp, shooting, electric-shock sensation from the upper to lower spine with neck flexion is indicative of disease.
The NP is instructing the pt to flex both wrists at 90 degrees for 1 minute. A positive test suggests which of the following?
A. Median nerve inflammation
B. Meningeal irritation
C. Appropriate brachioradialis reflex
D. Scaphoid bone fracture
A. Median nerve inflammation
- This is the Phalen’s test for the assessment for carpal tunnel syndrome.
- Kernig’s sign = Pain with knee extension- assesses for meningitis.
- Brudzinski’s sign = pt bends hips and knees with neck flexion- assesses for meningitis.
Which of the following is a contraindication for prescribing the “triptan” drug class?
A. PUD
B. Ischemic heart disease
C. AKI
D. Hepatic impairment
B. Ischemic heart disease
- Triptans should not be used in the following conditions: hemiplegic or basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal’s angina, uncontrolled HTN, and pregnancy.
- They should also be limited to less than 10 days of use per month to avoid medication overuse headache.
Which cranial nerve(s) is(are) responsible for tongue movement?
A. VIII
B. IX and X
C. XI
D. XII
D. XII
- The pt is asked to stick out their tongue; it should be midline. Look for atrophy and fasciculations (small, involuntary, flicker-like movements).
The NP places a coin in the pt’s palm and asks the pt to identify the object with their eyes closed. This is an example of which test of cortical sensory function?
A. Graphesthesia
B. Two-point discrimination
C. Stereognosis
D. Light touch
C. Stereognosis
- Graphesthesia = writing a number or shape on the palm and asking them to identify it.
- Two- point discrimination = using two ends of a cotton swab and touching the pt’s skin in various locations. The pt should be able to identify if you touched them once or twice.
- Light touch = assesses for sensation.
When testing the patellar reflex, a brisker-than-average response is observed. This is indicated by which grade of DTR grading scale?
A. 0
B. 2+
C. 1+
D. 3+
D. 3+
- 2+ is normal.
- 4+ is hyperactive
The NP assesses for facial symmetry when asking the pt to raise their eyebrows, squeeze their eyes shut, frown, smile, and puff their cheeks out. Which cranial nerve is being evaluated?
A. II
B. VII
C. VI
D. VIII
B. VII
- Facial nerve
- II = optic nerve = assesses near and distant vision tests, ophthalmoscopic examination, and testing for visual fields by confrontation and extinction.
- VI = abducens = lateral eye movement.
- VIII = acoustic nerve = hearing.
A pt presents with a fever, nuchal rigidity, and altered mental status. During the assessment, the NP gently raises the pt’s head and notices the spontaneous flexion of the pt’s hips and knees. Based on this finding, which of the following tests should also be perfomed?
A. Brudzinki sign
B. Lachman test
C. Valgus stress test
D. Kernig sign
D. Kernig sign
- used for testing for meningeal irritation which can occur with meningitis or subarachnoid hemorrhage.
- This pt had already tested + for the Brudzinski sign (flexion of the hips and knees with neck flexion), the next step is to test for the Kernig sign (the inability to allow full extension of the knee when the hip is flexed at 90 degrees.
An older adult pt presents after a few days of generalized fatigue with a headache over the temple region. The pt reports a low-grade fever, jaw claudication, and transient monocular vision loss. Based on this clinical presentation, which of the following is indicated for diagnosis?
A. Temporal artery biopsy
B. Erythrocyte sedimentation rate
C. C-reactive protein
D. CT scan
A. Temporal artery biopsy
- This pt is presenting with symptoms suggestive of giant cell arteritis.
- S/s = age over 50 years, new headache, abrupt onset of visual changes, jaw claudication, unexplained fever, and vascular abnormalities.
- Diagnosis = temporal artery biopsy or temporal artery color doppler ultrasound.
Bell’s palsy is associated with dysfunction of which cranial nerve?
A. III
B. VII
C. VIII
D. XI
B. VII
- This is an isolation of peripheral facial paralysis.
- Inflammation of the facial nerve causes weakness of the upper and lower portions of the face.
- CN VII- accounts for facial expression movements, taste, lacrimation, salivation, and ear sensation.
- III = oculomotor nerve
-VIII = acoustic nerve - XI = spinal accessory nerve
A pt presents with a severe, unilateral, stabbing headache. The pt reports that the pain is localized in the periorbital region and also reports rhinorrhea. Upon physical assessment, ptosis and conjunctival injection are noted. Based on this clinical presentation, which of the following is indicated for initial acute therapy?
A. Ibuprofen (Motrin) 400mg
B. Acetaminophen (Tylenol) 1,000mg
C. Oxygen therapy at 12L/min for 15 mins
D. Propranolol (Inderal) 40mg daily
C. Oxygen therapy at 12L/min for 15 mins
- This pt is presenting with a cluster headache.
- s/s = severe, unilateral, sharp, stabbing pain, with autonomic symptoms ipsilateral to the headache, such as ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and/or nasal congestion.
- Tx = either oxygen inhalation or pharmacotherapy with triptans (subcutaneous Sumatriptan)
- Tx for tension headaches = Ibuprofen (Motrin) or Acetaminophen (Tylenol)
- Propranolol = tx for migraine prevention, not an acute attack.
Which of the following tests evaluates cerebellar function?
A. Pronator drift
B. Stereognosis
C. Vibration test
D. Finger-to-nose test
D. Finger-to-nose test
- This allows for the assessment of accuracy of movements, can also include the rapid alternating movements, finger tapping, or heel to shin movements.
- Pronator drift = assesses upper motor neuron pattern of weakness that causes the arm to pronate and drift downward when the pt is asked to hold the arm extended with palms up.
- Stereognosis = assesses cortical sensory function.
- Vibration test = assesses the sensory system by asking the pt to identify vibration when a tuning fork is held on or near them.
A pt presents with unilateral burning and stabbing facial pain. During assessment, the NP notices that the pain is localized to the cheek and chin area and worsens while the pt is talking and swallowing. The pain last for less than 2 minutes, and he reports an electric shock-like pain quality. Based on this clinical presentation, FIRST-LINE pharmacotherapy includes which of the following?
A. Gabapentin (Neurontin)
B. Carbamazepine (Tegretol)
C. Baclofen (Lioresal)
D. Lamotrigine (Lamictal)
B. Carbamazepine (Tegretol)
- This pt is presenting with Trigeminal neuralgia.
- Tx = carbamazepine (tegretol) or oxcarbazepine (trileptal).
- Alternatives include Gabapentin, Baclofen, and Lamotrigine if pt is not able to tolerate carbamazepine or oxcarbazepine.
A pt presents following a seizure. A family member reports that the pt suddenly lost control of their leg muscles and fell to the ground. This finding suggests which type of generalized seizure?
A. Atonic
B. Absence
C. Clonic
D. Tonic
A. Atonic
-AKA “drop seizures” = characterized by the sudden loss of control of the muscles (usually the legs), which causes the pt to fall to the ground.
-Absent = behavioral arrest along with staring and a blank facial expression.
- Clonic = rhythmic, jerking muscle contractions.
- Tonic = muscle stiffening along with impaired consciousness.
A ruptured intracranial aneurysm is often the cause of which type of stroke?
A. Embolic
B. Intracerebral hemorrhage
C. Subarachnoid hemorrhage
d. Thrombotic
C. Subarachnoid hemorrhage
- Embolic and Thrombotic = both are ischemic, often caused by an obstruction or blocked arterial access in a particular brain region.
- Intracerebral hemorrhage = often caused by HTN, amyloid angiopathy, and ruptured vascular malformation.
Which of the following is an indication for hospitalization for a pt with mild traumatic brain injury?
A. GCS score of 15
B. No intracranial abnormalities noted on the head CT
C. Headache
D. Recurrent vomiting
D. Recurrent vomiting
- Hospital criteria = GCS of <15, seizures or other neurologic deficits, recurring vomiting, abnormal head CT (midline shift, hemorrhage, ischemia, mass effect), and abnormal bleeding parameters or oral anticoagulation.
Which medication is indicated for acute treatment of a moderate-to-severe migraine attack?
A. Sumatriptan (Imitrex)
B. Metoprolol (Lopressor)
C. Amitriptyline (Elavil)
D. Topiramate (Topamax)
A. Sumatriptan (Imitrex)
- This is the only medication used for acute attacks.
- Prophylactic tx of migraines = Metoprolol, Amitriptyline, Propranolol, Venlafaxine, Valproate, and Topiramate = indicated for pts with frequent (4+ headaches a month) or long-lasting (12+hrs each episode) migraines or those that cause significant disability or reduced quality of life.
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