APEA 3P EXAM Prep Neuro Questions With Answers and Explanation
A patient who is 82 years old is brought into the clinic. His wife states that he was
... [Show More] working in his garden today and became 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?
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: 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?
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?
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?
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:
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?
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?
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:
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:
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?
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:
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?
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?
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:
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? 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? 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:
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:
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:
primary prevention. secondary prevention.
tertiary prevention.
primary or secondary prevention.
Primary prevention refers to an action that has the potential to prevent an event prior to its occurrence. Secondary prevention refers to an intervention demonstrated to help prevent a second occurrence of a deleterious event or may refer to an intervention designed for early detection. Tertiary prevention is an action designed to prevent additional deleterious events from occurring.
Mini mental status exam helps to identify patients who have symptoms of: cognitive impairment.
depression. behavioral changes. stroke.
The mini mental status exam (MMSE) is the most widely used screening tool in primary care to evaluate cognitive impairment. The exam helps healthcare providers evaluate six areas: orientation, short-term memory-retention/recall, language, attention, calculation, and constructional praxis. It does not diagnose Alzheimer’s disease but is used to assess cognition as described above.
A patient diagnosed with cluster headaches:
usually has scotomas.
can be diagnosed with an imaging study.
should eliminate triggers like nicotine and alcohol. may exhibit nuchal rigidity.
Lifestyle measures like avoiding alcohol, nicotine, and high altitudes may help prevent cluster headaches. Avoiding afternoon naps, bright lights, and glare during a headache cycle may prevent a subsequent headache from occurring. Cluster headaches are extremely painful headaches but are not as common as migraine or tension headaches. The headaches occur in cyclical patterns, hence the name “cluster.” The cycle lasts about 2-12 weeks. A single attack may last 30-90 minutes, but it could last up to 3 hours. Scotoma refers to an area of diminished vision in the visual field. In patients who have cluster headaches, neuroimaging, like CT or MRI, typically demonstrates no abnormalities. Patients who have meningitis may exhibit fever or nuchal rigidity.
Mrs. Johnson is an 89-year-old resident at a long-term care facility. Her state of health has declined rapidly over the past 2 months, and she can no longer make her
own decisions. Her daughter requests a family conference with the nurse practitioner. Some important principles that need discussion currently, if not previously documented, are:
bereavement support for the family, quality of life for the resident, and living will. health care proxy, living will, and hospice referral.
withdrawing therapy, hospice referral, and managing symptoms. end of life decisions, quality of life, and advance directives.
American Geriatrics Society stresses not only care of the patient but the care of the family as well. This includes meeting the current and future needs of the patient, family needs, and end-of-life issues with the living will. The living will is recognized as a valid advanced directive. Care includes developmental landmarks for the patient and family.
A young male patient with a herniated disk reports bilateral sciatica and leg weakness. If he calls the NP with complaints of urinary incontinence, what should be suspected?
Opioid overuse
Medial or lateral herniation Rupture of the disc
Cauda equina syndrome
Cauda equina syndrome is a medical emergency. It is characterized by compression of the spinal cord. A common manifestation of this is bowel or bladder dysfunction. This may include incontinence or the inability to urinate or have a bowel movement. This patient needs immediate neurosurgical or orthopedic referral.
The Snellen chart is used to assess:
near vision. distant vision. color vision. peripheral vision.
The Snellen eye chart was named after Dr. Hermann Snellen. The Snellen fractions, 20/20, 20/30, etc. are measures of sharpness of distant vision. Actually, 20/20 is not normal vision; it is a reference standard. Average acuity in a population is 20/15 or 20/10 (hence the reason there are two lines beneath the 20/20 vision line). When
visual acuity is assessed, each eye is covered and assessed independently; this is termed monocular.
The Mini-Cog is helpful in screening patients who have suspected: delirium.
dementia. Parkinson’s disease stroke.
The Mini-Cog is a screening tool for dementia. It is performed by telling the patient the names of three unrelated but familiar items. The patient is distracted by being asked to draw the face of a clock, and to indicate two specific times by drawing the hands on the clock. Then, the patient is asked to repeat the names of the three objects. Scores are received for correct naming of the items and clock drawings.
Which of the following would NOT be part of the differential diagnosis for an 84- year-old patient with dementia symptoms?
Tumor Cerebral hemorrhage Cerebral infarct
Normal aging process
Changes in cognition are not associated with the aging process, though 50% of adults over age 90 have some form of dementia. All patients should have some type of imaging to rule out tumor, infection, hemorrhage, infarct, etc. Experts have not agreed on which neuroimaging studies are most valuable.
A patient is diagnosed with carpal tunnel syndrome. Which finger is not affected by carpal tunnel syndrome?
Thumb Second finger Fourth finger Fifth finger
Carpal tunnel syndrome is an entrapment neuropathy of the median nerve at the wrist due to inflammation of the wrist tendons, transverse carpal ligament, and/or surrounding soft tissue. Compression of the median nerve produces paresthesias in
the thumb, index finger, middle finger, and the radial side of the fourth finger. The fifth finger is not affected.
Which factor listed below does NOT contribute to the risk of falls in older adults? Decreased vision
Changes in cognition Decreased hearing Anticholinergic medications
Many factors contribute to falls in older patients. The annual incidence of falls in patients who are 80 years and older is near 50%. About 5% of falls result in serious consequences. The risk for falls should be assessed frequently in older adults.
What condition often causes a chief complaint of nocturnal paresthesias? De Quervain’s tenosynovitis
Carpal tunnel syndrome Ulnar radiculopathy Medial epicondylitis
Nocturnal paresthesias are typical in patients who have carpal tunnel syndrome. A patient will complain of nighttime numbness, tingling, or “sleeping” hands and arms. This is a result of compression of the median nerve that traverses through the carpal tunnel. If the nerve is compressed, the symptoms (nocturnal paresthesias) usually result. With surgical decompression, symptoms usually abate.
A 52-year-old patient presents with an acute drooping upper right eyelid. She states that the right side of her face feels numb. Stroke has been ruled out. Based on the most likely etiology, how should she be managed?
Steroids plus an antiviral agent
Immediate referral to the emergency department Antiviral agent only
Steroids only
This patient probably has Bell’s palsy. This is an acute unilateral event that affects the facial nerve (CN VII) and forehead muscles. Sometimes this results in smoothing of the forehead on the affected side. Stroke must always be considered in the differential in a patient who has these complaints. A stroke may spare the muscles
of the forehead. Early treatment with oral steroids like prednisone (60 mg/d and tapered over 10 days) should be started within 72 hours of the onset of symptoms. This has been found to decrease the risk of permanent facial paralysis. Oral antiviral agents may be of benefit because of the likely possibility of Bell’s palsy occurring secondary to infection with the herpes simplex virus.
A patient is examined and found to have a positive Kernig's and Brudzinski's signs. What is the most likely diagnosis?
Hepatitis Encephalitis Meningitis Pneumonitis
The findings of positive Kernig’s and Brudzinski’s signs are highly suggestive of meningitis. Kernig’s sign is elicited by leg extension, then observing for neck pain and flexion. Brudzinski’s sign is elicited by passively flexing the neck and observing for flexion of the legs.
The "get up and go" test in an older adult patient is used to evaluate: risk for falls.
lower extremity strength. mental acuity.
driving safety.
The “get up and go” test is used to evaluate musculoskeletal function. The patient is asked to rise from a seated position in an armchair, walk across the room, turn around, and return to the chair. This test evaluates the patient’s gait, balance, leg strength, and vestibular function. It should be assessed in patients who report a fall or who present after a fall but who appear without injury.
Sumatriptan (Imitrex) is a medication used to abort migraine headaches. It may also be used to treat:
tension headaches. cluster headaches. serotonin abnormalities. depression.
Sumatriptan is a member of the medication class used to abort migraine headaches. Sumatriptan is also used to treat patients who experience cluster headaches. Relief is usually realized in about 10 minutes or less after using sumatriptan. The triptans are not helpful for patients with tension headaches. Migraine prophylactic agents may be helpful in patients who have serotonin abnormalities or depression.
A 70-year-old male who is diabetic presents with gait difficulty, cognitive disturbance, and urinary incontinence. What is part of the nurse practitioner’s differential diagnosis?
Diabetic neuropathy
Normal pressure hydrocephalus Parkinson’s Disease
Multiple sclerosis
The classic triad of normal pressure hydrocephalus is described above. Diabetic neuropathy would not be typical because this involves three different areas of complaint. Parkinson’s disease presents with tremor, gait disturbance, and bradykinesia. Multiple sclerosis almost never presents beyond the age of 50 years and would be even less likely presentation in a 70-year-old. The incidence of normal pressure hydrocephalus varies from 2-20 million people per year. It is more common in elderly patients and affects both genders equally. This is diagnosed by the presence of enlarged ventricles on CT scan.
An older adult patient has an audible carotid bruit. He has a history of hypertension, hyperlipidemia, and a myocardial infarction 5 years ago. He has no complaints today. The finding of a bruit indicates that the patient:
probably will have a stroke.
has five times the risk of stroke compared to individuals who do not have a carotid bruit.
is more likely to die from cardiovascular disease than cerebrovascular disease. probably has a significant carotid artery lesion.
In asymptomatic patients, carotid bruits are a poor predictor of carotid artery stenosis or stroke risk. Even when a bruit is identified and the patient has a stroke, the majority of strokes will occur in an area other than the carotid artery. Patients with a carotid bruit have double the risk of stroke compared to patients without an audible bruit. In patients with significant carotid artery stenosis, only 50% have an audible carotid bruit. The value of a carotid bruit is that it is a good marker of generalized atherosclerosis. When it is identified, disease in other vessels should be evaluated. Statistically, patients with an audible carotid bruit are more likely to die of cardiovascular disease than cerebrovascular disease.
The “pill-rolling” tremor that is typical in patients with Parkinson’s disease is: an early manifestation of the disease.
present only with movement. usually bilateral.
worse when the patient sleeps.
The “pill-rolling” tremor is the earliest manifestation of the disease. It occurs at rest, but not with movement. The tremor is worse with emotional stress and gets better or ceases with sleep.
Which finding in a patient with migraine headache symptoms would compel the examiner to order an imaging study?
First occurrence with typical migraine symptoms Nausea and photophobia
Rapidly increasing intensity of headache Fully reversible speech disturbance
Fully reversible speech disturbance in conjunction with migraine-type symptoms likely represents a typical aura. Nausea and photophobia are typical of migraine headaches. A normal neurological exam in conjunction with typical migraine symptoms, even on the first occurrence, does not compel the examiner to order an imaging study. A headache with rapidly increasing intensity, a history of lack of coordination, localized neurologic symptoms, or a headache that awakens the patient from sleep all increase the likelihood that a neurologic abnormality exists.
Any of these findings should compel the examiner to order an imaging study. The study most likely to be ordered is a CT scan or MRI with and without contrast.
However, an MRA may be ordered depending on the suspected underlying abnormality.
A 70-year-old male patient is diagnosed with vertigo. Which choice below indicates that the vertigo is more likely to be of central etiology?
Brief duration Nystagmus present Nausea and vomiting Persistent symptoms
Central etiologies involve the brainstem or cerebellum; peripheral etiologies typically involve the vestibular system. Vertigo in a patient is a common complaint and can be due to multiple etiologies. Hyperventilation can produce dizziness. In an older adult, the etiology is more likely from multiple factors: taking 5 or more medications, orthostatic hypotension. Tinnitus (ringing in the ears) and hearing loss typically indicate a peripheral etiology. An audible carotid bruit would steer the healthcare provider to explore carotid stenosis and underlying cardiovascular disease.
A 60-year-old patient has anosmia. Which cranial nerve must be assessed? I
II V X
Anosmia refers to the inability to smell. Cranial nerve I is the olfactory nerve and is not usually tested. However, cranial nerve I lesions do occur. Anosmia would be a clinical manifestation of this. If CN I is assessed, the examiner uses a familiar smell like coffee or peppermint and asks the examinee to identify the smell. The inability to do this with a familiar smell is termed anosmia.
A typical description of sciatica is:
deep and aching. worse with lying down. burning and sharp.
precipitated by coughing.
Sciatica is irritation of the nerve root. Patients usually complain of sharp, burning pain that can be accompanied by numbness, tingling and radiating pain down the posterior, lateral, or anterior aspect of one leg. Disk herniation, which could cause sciatica, produces increased pain with coughing, sneezing, or the Valsalva maneuver.
A patient complains of right leg numbness and tingling following a back injury. He has a diminished right patellar reflex and his symptoms are progressing to both legs. What test should be performed?
Lumbar X-rays Lumbar CT scan Lumbar MRI Correct
Lumbar MRI with contrast
This patient has symptoms that could indicate an urgent neurological situation. Acute radiculopathy could indicate the need for intervention by a neurosurgeon. An MRI is a superior study because it provides excellent information about the soft tissues, like the lumbar disks. Contrast might be used in this patient if he had a history of previous back surgery. Then, contrast would be helpful to distinguish scar tissue from disks.
Which cranial nerve is assessed by administering the Snellen test? II
III IV VI
The Snellen chart is used to assess vision. Cranial nerve II, the optic nerve, must be intact for intact visual acuity. Cranial nerves III, IV, and VI are responsible for eye movement, not vision.
Which class of medications is NOT used for migraine prophylaxis?
Beta-blockers
Calcium channel blockers Triptans
Tricyclic antidepressants
The class of medications known as triptans, which includes sumatriptan, is used as abortive agents, not for prophylaxis. The other classes mentioned can be used for prophylaxis. Other prophylactic agents commonly used include lithium, SSRIs, anticonvulsants, and fever.
The most common polyneuropathy in older adults is associated with: Charcot-Marie-Tooth disease.
diabetes mellitus. urinary incontinence. Guillain-Barre syndrome.
A polyneuropathy is a term that refers to a process that affects multiple nerves, usually peripheral. The distal nerves are more commonly affected. Symptoms described by patients are burning, weakness, or loss of sensation. Charcot-Marie- Tooth disease is a rare, hereditary primary motor sensory neuropathy. Guillain-Barre is an acute autoimmune neuropathy that is primarily demyelinating. Urinary incontinence does not represent a common polyneuropathy in older adults.
Which symptom below is true of cluster headaches but not migraine headaches? It is more common in females.
The length of the headache duration is about 30-90 minutes. The most common characteristic is family history.
Sunlight is a common trigger.
The typical cluster headache lasts less than 3 hours; usually less than 90 minutes. Migraine headaches usually last 4-72 hours, and are more common in females.
Cluster headaches are more common in males and can be triggered by alcohol or
nicotine intake. Migraines may be triggered by diet, skipping meals, sunlight, red wine, aged cheeses, or menses. Family history is a common finding in patients who have migraine headaches.
Which headache listed below is more likely to be triggered by food? Cluster
Migraine Tension Vascular
Migraine headaches are more likely to be triggered by food than tension headaches or others. Common food triggers are alcohol, chocolate, aged cheeses, nuts, nitrates, nitrites, and caffeine.
Restless legs syndrome is part of the differential diagnosis for Mr. Wheaton. What should be part of the laboratory workup?
BUN/Cr Serum ferritin ALT/AST
Urinalysis
Restless legs syndrome (RLS) is the unrelenting urge to move the legs. This rarely affects the upper extremities. The symptoms are relieved by movement of the affected limbs and only occur if the affected limbs are at rest. Iron deficiency has been considered as a cause of RLS. The exact mechanism of iron deficiency is not known, but many patients who exhibit symptoms of restless legs syndrome have low serum ferritin levels and have relief of symptoms when supplemented with iron. Even in patients with normal serum levels, a month long trial of iron may be helpful.
Which of the following are diagnostic criteria for migraine headache without aura? Pain is episodic during the headache
Pain lasts 4-72 hours
There are underlying neurologic abnormalities Photophobia must be present
There are no specific tests that diagnose migraine headaches. The diagnosis must be made based on the clinical presentation of the patient and elimination of other
etiologies for the headache. In order to meet International Headache Society criteria for a migraine headache without aura, 5 criteria must be met. They include: 1) headache lasts 4-72 hours, 2) has 2 of these characteristics (unilateral pulsating quality, moderate to severe intensity, aggravated by routine activity), 3) at least one of the following occurs during headache (nausea and/or vomiting, photophobia, OR phonophobia), 4) 5 or more attacks have occurred with these characteristics, 5) there is no other reason for the headache's occurrence.
A 72-year-old patient with a history of coronary artery disease and hypertension reports an episode of slurred speech and right-sided facial droop that started yesterday while at home. It lasted for about an hour. She denies pain or headache. She presents to the clinic today and no longer has any of these symptoms. What is the most likely explanation for these symptoms?
Stroke Bell's palsy
Trigeminal neuralgia Transient ischemic attack
Transient ischemia attack (TIA) is defined as an episode of transient neurologic dysfunction without acute infarction. Stroke is defined as an infarction of the central nervous system tissue. It is considered the end point. Facial drooping and slurred speech are examples of neurologic dysfunction. Bell's palsy can produce facial drooping, but this condition would not have resolved in an hour. Trigeminal neuralgia is a neuralgia involving the 5th cranial nerve. It is characterized by intermittent electric painful sensations in the face.
A 70-year-old patient exhibits a unilateral resting tremor. This likely indicates: intention tremor.
alcohol withdrawal. Parkinson’s disease. benign essential tremor.
Parkinson’s disease is an idiopathic neurodegenerative movement disorder characterized by 4 prominent features: bradykinesia, muscular rigidity, resting tremor, and postural instability. The "pill-rolling" tremor is the presenting sign in 50- 80% of patients with Parkinson’s disease. Approximately 30% of patients do not present with tremors of any type.
A 62-year-old female patient presents to the clinic with very recent onset of intermittent but severe facial pain over the right cheek. She is diagnosed with trigeminal neuralgia. What assessment finding is typical of this?
Pain is much worse with sticking her tongue out Pain is better with light touch over the affected area Pain is relieved with NSAIDs
Pain may be triggered with light touch of the right cheek
Trigeminal neuralgia is a common cause of severe facial pain. It is described by patients as electric or shocking pain. Triggers for pain are light touch to the affected area, chewing, cool breeze on the cheek, and smiling or grimacing. It is more common in older adults.
In a patient with end-of-life physical pain, constipation commonly occurs. What is the most common cause of this?
Decreased activity Decreased fluids Opioid use
General slowing of body processes
Opioids can cause severe constipation. At end of life, this can be a significant cause of discomfort for the patient. Measures for relief of constipation should be instituted.
A 26-year-old HIV-positive patient presents with photophobia and temperature of 103.2° F. He complains of a headache. On exam, he is unable to demonstrate full extension of the knee when his hip is flexed. Which choice below is the most likely diagnosis?
Pneumocystis infection Meningitis
Septic bursitis Septic arthritis
The inability to demonstrate full extension of the knee when the hip is flexed is a positive Brudzinski's sign. This is present in patients who have meningitis. It is not present in patients who have septic bursitis or septic arthritis. HIV-positive patients are more likely to exhibit pneumonia secondary to pneumocystis infection, but he has no respiratory symptoms.
A patient cannot stick his tongue out of his mouth and move it from side to side. What cranial nerve is responsible for movement of the tongue?
Cranial Nerve III Cranial Nerve VII Cranial Nerve X Cranial Nerve XII
Cranial nerve (CN) XII enables a patient to stick his tongue out and to move it from side to side in his mouth. CN III is partly responsible for eye movement. CN VII is responsible for the ability to close the eyes tightly, wrinkle the forehead, smile, and the sensation of taste to the anterior 2/3 of the tongue. CN X is partly responsible for speaking and some tongue movement
What cranial nerve is responsible for hearing? II
III V VIII
Cranial nerve VIII is responsible for hearing. Cranial nerve II is the optic nerve and is responsible for vision. Cranial nerve III is partly responsible for eye movement.
Cranial nerve V is the facial nerve and is responsible for sensation of the face. It is tested by a light touch on the patient’s forehead.
An 80-year-old patient comes into the clinic with an ataxic gait, complaints of new- onset headache and slurred speech that began about 2 hours ago. What is the likely etiology of this event?
Adverse drug event Alcohol intoxication Stroke or TIA
Bell’s palsy
A new onset headache in an 80-year-old is not likely to be due to an adverse drug event. Stroke risk increases as age increases. Transient ischemia attack (TIA) is defined as an episode of transient neurologic dysfunction without acute infarction. Bell’s palsy is accompanied by facial numbness and sometimes slurred speech occurs if the upper lip is affected, but headache and an ataxic gait do not
accompany Bell’s palsy. Alcohol intoxication might be considered, but a stroke must be ruled out. When headache accompanies stroke, it is often hemorrhagic stroke, but ischemic stroke can cause headache too.
60- Mrs. Jopson is unable to name a familiar object. How is this described? Anomia
Anosmia Acanthosis Incompetent
Anomia is difficulty in the naming of familiar objects. This is an example of mild impairment. Other evidence of mild impairment is recent recall problems, decreased insight, and difficulty managing finances. Many mildly impaired adults are not able to state today’s date.
All the following characteristics may be found in an older adult with dementia. Which one is common in a patient with Alzheimer’s disease, but uncommon in a patient with another type of dementia?
Visual hallucinations Personality change Abrupt onset Indifference
The most common characteristics in a patient with Alzheimer’s disease (AD) are memory impairment, visual-spatial disturbances, indifference, occasional delusions, and agitation. Personality change can be seen in patients with fronto-temporal dementia. Abrupt onset can be seen in patients with delirium and vascular dementia. Visual hallucinations can be seen in patients with Lewy-body dementia.
A family member of a newly diagnosed Alzheimer’s disease patient asks how long the patient should take donepezil (Aricept), an acetylcholinesterase inhibitor, before learning whether it is beneficial or not. You reply:
4 - 8 weeks.
about 12 weeks.
6 - 12 months. at least 1 year.
The ideal time to evaluate the efficacy of an acetylcholinesterase inhibitor (Ach-I) is 6-12 months of continuous use. The evaluation should include caregiver feedback, repeat mental status assessments, ability to perform activities of daily living, healthcare provider’s assessment, side effects, and cost. If the Ach-I is stopped, it can be restarted at a later date. [Show Less]