APEA 3P EXAM Prep Neuro
A patient who is 82 years old is brought into the clinic. His wife states that he was working in his garden today and became
... [Show More] disoriented and had slurred speech. She helped him back into the house, gave him cool fluids, and within 15 minutes his symptoms resolved. He appears in his usual state of health when he is examined. He states that although he was scared by the event, he feels fine now. How should the nurse practitioner proceed? - Answer Prescribe an aspirin daily.
Re-examine him tomorrow.
Send him to the emergency department.
Order an EKG.
This patient likely suffered a transient ischemic attack. He needs urgent evaluation with head CT and/or MRI, ECG, lab work (CBC, PTT, lytes, creatinine, glucose, lipids and sedimentation rate); possible magnetic resonance angiography, carotid ultrasound, and/or transcranial Doppler ultrasonography. He is at increased risk of stroke within the first 48 hours after an event like this one. On initial evaluation, the most important determination to be made is whether the etiology of the stroke or TIA is ischemic or hemorrhagic. After this determination, treatment can begin. Unfortunately, this determination cannot be made in the clinic. The patient needs urgent referral to a center where this evaluation and possible treatment can be performed.
The most common presenting sign of Parkinson's disease is: - Answer muscular rigidity.
tremor.
falling.
bradykinesia.
Approximately 70% of patients with Parkinson's disease have tremor as the presenting symptom. The tremor typically involves the hand but can involve the legs, jaw, lips, tongue. It seldom involves the head. Muscular rigidity and bradykinesia are two less common presenting signs.
When should medications be initiated in a patient who is diagnosed with Parkinson's disease? - Answer As soon as the disease is diagnosed
When symptoms interfere with life's activities
When nonpharmacologic measures have been exhausted
After MRI and CT have ruled out stroke or tumor
The medications used to treat patients who have Parkinson's disease do not prevent the progression of the disease. Therefore, it is not necessary to start medications until symptoms interfere with the patient's quality of life. Levodopa is often used initially at the lowest dose that helps a patient manage symptoms. It can be titrated upward as needed. Orthostatic hypotension is a common side effect of levodopa, so blood pressure should be monitored closely.
A 72-year-old patient with history of polymyalgia rheumatica complains of new onset, unilateral headache and visual changes. Her neurologic exam is otherwise normal. Her CT results are WNL. ESR is 75 (Normal: 0-29). VS: BP 140/82, HR 67, RR 18, T 100. What is the most likely reason for her symptoms? - Answer Transient ischemic attack
Temporal arteritis
Meningitis
CVA
Polymyalgia rheumatica (PMR) is a chronic inflammatory condition that produces morning stiffness in the neck, shoulders, and hips. Its peak incidence is 70-80 years old. PMR is commonly associated with temporal arteritis, also known as giant cell arteritis. Temporal arteritis is a chronic vasculitis of the medium and large vessels. Temporal arteritis is characterized by new onset unilateral temporal headache, abrupt onset of visual disturbances, elevated sedimentation rate, jaw claudication, and unexplained fever. This is best diagnosed by temporal artery biopsy. She should be referred to neurology for evaluation today.
What recommendation should be made to an older adult who is diagnosed with mild dementia? - Answer Driving will probably not increase your risk of an accident.
The healthcare provider should recommend that the patient stop driving today.
The healthcare provider should recommend assessment of driving to determine risk of an accident.
The patient may continue to drive as long as he feels comfortable.
Dementia independently increases the risk of motor vehicle accidents if the patient drives. The healthcare provider should discuss this with the patient and a family member if a family member is present during the older adult's evaluation. Depending on the degree of impairment, the healthcare provider could recommend stopping driving, or recommend that an assessment be done. The assessment is usually completed by either an occupational or physical therapist or someone trained to assess this.
A person with 20/60 vision: - Answer is legally blind.
will have difficulty reading a newspaper.
will be unable to see the big "E" on the eye chart.
has better vision than someone with 20/80 vision.
Using the Snellen nomenclature for describing visual acuity (example 20/80), the first number represents the test distance. In most cases this is 20 feet. The second number represents the distance at which the average eye can see the letters on a specific line of the chart. In other words, the examinee can see at 20 feet what an average eye (20/20) can see at 80 feet. 20/80 is a measure of distant vision, not near vision such as reading a newspaper. The big "E" represents 20/200 vision. 20/200 is considered legally blind by most standards.
A patient reports a history of transient ischemic attack (TIA) 6 months ago. His daily medications are lisinopril, pravastatin, and metformin. After advising him to quit smoking, what intervention is most important in helping to prevent stroke in him? - Answer Auscultation of carotid arteries at each visit
Taking low dose aspirin daily
Assessing hemoglobin A1C every 3-6 months
Encouraging smoking cessation at each visit
Antiplatelet therapy, usually aspirin, inhibits the enzyme cyclooxygenase and reduces thromboxane A2 production, which stimulates platelet aggregation. Thus, risk of ischemic stroke is reduced. The dosage of aspirin needed to prevent an event is debatable. Most studies found that 75-150 mg daily was as effective in preventing stroke as was higher doses. Lower doses of aspirin are associated with less GI toxicity and fewer side effects.
A 75-year-old is diagnosed with essential tremor. What is the most commonly used medication to treat this? - Answer Carbidopa
Long-acting propanolol
Phenobarbital
Gabapentin
Tremor is the most common of all movement disorders and essential tremor is the most common cause of all tremors. It is characterized by rhythmic movement of a body part, commonly the hands or head. Beta blockers are the most commonly used medication class to treat essential tremor. Propanolol is the most commonly used medication, but other beta blocking agents are used as well. Both gabapentin and phenobarbital are used, but, not nearly as often. Carbidopa is used in patients with Parkinson's disease.
A patient who had an embolic stroke has recovered and is performing all of her activities of daily living. Taking aspirin for stroke prevention is an example of: - Answer primary prevention.
secondary prevention.
tertiary prevention.
quaternary prevention.
The patient is taking aspirin to prevent recurrent stroke. Research demonstrates that taking an aspirin daily can significantly reduce the risk of subsequent strokes and MI. Secondary prevention means that the intervention is performed to prevent another occurrence of the deleterious event. If she had never had a stroke but took aspirin daily for prevention of stroke, that would be primary prevention. Taking aspirin at home during the course of having an MI is an example of tertiary prevention. There is no reference in the literature to quaternary prevention.
An older adult patient with organic brain syndrome is at increased risk of abuse because she: - Answer lives in a nursing home.
has multiple caregivers.
is incontinent of stool and urine.
has declining cognitive function.
Older adults are at increased risk of abuse because of their decline in cognitive function. Caregiver strain, stress, and depression occur at higher rates than in the general population. According to the National Center of Elder Abuse, family members are likely to be abusers of infirm older adults. Healthcare providers should remain alert to signs of abuse and caregiver stress.
A patient with migraine headaches and hypertension should receive which medication class with caution? - Answer Beta blockers
Triptans
Pain medications
ACE inhibitors
The class of medications called "triptans" work to eradicate migraine headaches by producing vasoconstriction. This can produce a potentially serious drug-disease interaction in patients with hypertension. An episode of severe hypertension can result. Triptans may be used in patients with well-controlled hypertension, but a hypertensive episode is always possible.
A patient who is 60 years old complains of low back pain for the last 5-6 weeks. She states that the severity is about 4/10 and that she gets no relief from sitting, standing, or lying. The NP should consider: - Answer sciatica.
ankylosing spondylitis.
disk disease.
systemic illness.
Systemic illness, like cancer or infection, is a serious consideration when patients report no relief of pain with position change. Additionally, this patient is female, older, and has had pain longer than 4 weeks. These are three risk factors for systemic cause of low back pain. Sciatica presents with pain that radiates down the leg. Ankylosing spondylitis is typical in males in their 40s and produces pain at nighttime that is improved with being upright. Disk disease is a consideration, but, an absence of relief with lying down is unusual.
A patient complains of severe right-sided facial pain. She states that her symptoms have worsened over the past 48 hours. Which diagnosis below is NOT part of the differential diagnosis? - Answer Bell's palsy
Trigeminal neuralgia
Tooth abscess
Shingles
Bell's palsy does not produce pain. It usually produces symptoms over several hours. Common symptoms include sagging eyebrow, an impaired eye blink or the inability to blink the eye on the affected side, and mouth drawn up on the affected side. The facial nerve, Cranial Nerve VII, is affected in patients who present with Bell's palsy. Trigeminal neuralgia (TN) is a common cause of facial pain characterized by paroxysmal electric shock like pains. TN involves the Cranial Nerve V (trigeminal nerve).
A patient has developed loss of hearing over the past several weeks. His otoscopic exam is normal. What cranial nerve should be assessed? - Answer Cranial Nerve III
Cranial Nerve V
Cranial Nerve VIII
Cranial Nerve X
Cranial Nerve (CN) VIII is the CN responsible for hearing. When assessing CN VIII, each ear should be assessed individually. The Weber and Rinne tests can be used to distinguish between conductive and sensorineural hearing loss.
A 68-year-old smoker with a history of well-controlled hypertension describes an event that occurred yesterday while mowing his lawn. He felt very dizzy and "passed out" for less than 1 minute. He awakened spontaneously. Today, he has no complaints and states that he feels fine. Initially, the NP should: - Answer perform a complete neurological and cardiac exam with auscultation of the carotid arteries.
order a 12-lead ECG and carotid ultrasound, and perform a physical exam.
order a CT of the brain, blood clotting studies, and cardiac enzymes.
check blood pressure in three positions, order a 12-lead ECG, and schedule an exercise stress test.
The event described is syncope. Syncope is a brief and sudden loss of consciousness that occurs with spontaneous recovery. This is a significant event but it is especially so in a smoker with hypertension. The assessment of this patient must start with an examination of the cardiac and neurological systems. Based on the findings and tentative diagnosis of syncope, coupled with the patient's history of the event, other tests might be ordered to evaluate arrhythmias, stroke, transient ischemic attack, myocardial infarct, carotid stenosis, other vascular etiologies. A referral to specialty care is indicated after initial workup by the nurse practitioner.
Which characteristic is true of tension headaches, but not of cluster headaches? - Answer Cluster headaches are always bilateral.
Tension headaches are always bilateral.
Cluster headaches always cause nausea.
Tension headaches cause photosensitivity.
Cluster headaches are always unilateral. The affected side produces a red, teary eye with nasal congestion on the affected side. Nausea and photosensitivity are common. Tension headaches are always bilateral with no nausea or photosensitivity associated with them.
Which condition listed below does NOT impact an elder's ability to eat? - Answer Stroke
Parkinson's disease
Dysphagia
Hyperlipidemia
Many, many diseases impact an elder patient's ability to eat. About 50% of patients who have had stroke have impaired ability to eat. This can include difficulty feeding self as well as difficulty swallowing. Parkinson's disease and many other neurological diseases have great impact on eating, since coordinated muscle movement is needed for swallowing and feeding. Hyperlipidemia has no significant impact on a patient's ability to eat.
Mr. Williams has moderate cognitive deficits attributed to Alzheimer's disease and has been started on a cholinesterase inhibitor. The purpose of this drug is to: - Answer decrease agitation.
increase anticholinergic stimulation of the brain.
improve depression.
slow progression of his cognitive deficits.
This drug is a cholinesterase inhibitor. It will cause more acetylcholine to be available to neurons. Many patients show a slowing of cognitive decline when these medications are used for at least 1 year. A small percentage of patients, 10-25%, show significant improvement in symptoms. An anticholinergic medication would be contraindicated in these patients. There is no direct benefit on agitation or depression in patients who take this class of medications.
A neurologic disease that produces demyelination of the nerve cells in the brain and spinal cord is: - Answer Parkinson's disease.
late stage Lyme disease.
multiple sclerosis.
amyotrophic lateral sclerosis.
Multiple sclerosis (MS) is a disease of the central nervous system characterized by demyelination of the nerve cells. This produces varied neurological symptoms and deficits. This disease is typical in women between the ages of 16 and 40 years. It is rarely diagnosed after age 50 years. MS can be diagnosed in an adult who has one or more clinically distinct episodes of CNS dysfunction followed by at least partial remission.
An older adult patient is at increased risk of stroke and takes an aspirin daily. Aspirin use in this patient is an example of: - Answer primary prevention.
secondary prevention.
tertiary prevention.
primary or secondary prevention. [Show Less]