Advanced Assessment Interpreting Findings 3rd Edition GoolsGrubbs Test Bank
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Chapter 15. Neurological System
Identify the choice that best completes the statement or answers the question.
____ 1. When carrying out a mental status exam on a non-English speaking patient, it is important to have a(n):
|A.||Patient’s family member, who is bilingual, interpret for the patient|
|B.||Objective interpreter ask the questions for the patient|
|C.||Friend of the patient interpret the questions for the patient|
|D.||Any of the above is acceptable|
____ 2. When examining the carotid arteries, the clinician should:
|A.||Ask the patient to hold his/her breath while auscultating the carotid arteries|
|B.||Use the bell of the stethoscope to listen over the carotid arteries|
|C.||Palpate one carotid artery at a time|
|D.||All of the above|
____ 3. A 44-year-old male presents to the emergency room with the “worst headache of his life.” He is holding his head and appears severely distressed. This is a patient symptom that should prompt a clinician to look for signs of a:
____ 4. An 8-year-old child presents to the emergency room with a severe unilateral, throbbing headache. She is lying on the gurney with her eyes closed while holding her head. She denies ever having this kind of headache in the past. She complains of sensitivity to light and noise. An appropriate history question to ask the parent would be:
|A.||What do you think triggered the headache?|
|B.||Have you had a fever?|
|C.||Does anyone in your family suffer from migraine headache?|
|D.||B and C|
____ 5. A 41-year-old male patient presents to the emergency department complaining of severe headache pain. He describes it as a piercing, right sided head pain that occurred earlier in day for about 1 hour and now is recurring. You note lacrimation and rhinorrhea on the right side of the face. Which of the following types of headache is the patient describing?
____ 6. An 85-year-old female patient arrives ambulance to the emergency department accompanied her husband. He reports that his wife had been ill with pneumonia and, 2 days ago, went to the family physician who prescribed azithromycin twice a day. The husband reports that he is making sure she gets the medicine. His wife has been staying in bed and resting. She awoke from sleep last night and was extremely agitated, left the house, and was walking outside. She did not recognize her husband and wanted to call the police. Which of the following is an appropriate question for the history?
|A.||Does your wife have dementia or frequent episodes of confusion?|
|B.||Has your wife been running a fever?|
|C.||Is your wife allergic to any medication?|
|D.||Has your wife ever had a mental status exam?|
____ 7. A 60-year-old female complains of several episodes of dizziness and nausea that started this morning. She denies trauma, falling, or loss of consciousness. She has a 5-year history of hypertension and takes a beta blocker daily. On physical examination, there are no neurologic deficits or any abnormal findings and ECG is normal. Which of the following tests should be performed?
|A.||Test the patient for Kernig’s sign|
|B.||Test the patient for Brudzinski sign|
|C.||Perform the Hallpike maneuver|
|D.||Assess for Babinski’s sign|
____ 8. Ménière’s ’disease presents with the following triad of symptoms:
|A.||Vertigo, nystagmus, hearing loss|
|B.||Vertigo, tinnitus, hearing loss|
|C.||Vertigo, syncope, hearing loss|
|D.||None of the above|
____ 9. A 77-year-old male is brought into the emergency department accompanied his daughter. She reports that her father has been complaining of right-handed weakness for 2 to 3 hours and that she has noticed him slurring his speech. On physical examination, the right hand grip strength is 1/ 5 compared to the left hand grip of 5/5. A facial droop is noted on the right side of the face. Cranial nerve dysfunction is noted in the right-sided CNVII, CN V, CNIX, CNX, CNXI, and CNXII. The clinician should request the following diagnostic test immediately:
|A.||MRI of head|
|B.||CT of the head|
____ 10. A female patient presents to the clinic with complaints of a severe, throbbing, unilateral headache. She complains of seeing flashes of light prior to the headache. She complains of sound and light sensitivity as well as nausea. The clinician should recognize these as symptoms of:
|A.||Epilepsy with aura|
|D.||Normal pressure hydrocephalus|
____ 11. On a history and physical examination of a 34-year-old patient, during the review of systems, he reports occasional episodes of headache. He describes the headache pain as a “band is around his head” and tightness in the neck and shoulders. The clinician should recognize these symptoms as:
____ 12. An 81-year-old patient with heart failure comes into the emergency room accompanied his daughter. The daughter reports that her father “banged his head” as he was getting out of the car 4 days ago. He did not complain of headache pain, so she did not obtain medical advice. She reports that she noticed a mild facial droop, slurring of speech, and gait disturbance in her father today. She reports that her father takes Coumadin, digoxin, and an ACE inhibitor. On physical examination, there is decreased right hand grip 2/5 strength and decreased right quadriceps strength 2/ 5 compared to the left side 5/5. CT scan shows an intracranial bleed. Which of the following is the most probable diagnosis?
____ 13. Which of the following microorganisms is a common cause of meningitis?
____ 14. A 43-year-old male presents to the emergency department in a stupor accompanied his wife. She called the ambulance because her husband was difficult to awaken this morning. She reports that for the last 3 days, he has had fever and upper respiratory infection. Yesterday he had a headache. He has had no medical treatment. On physical examination, the patient demonstrates 103 fever, sluggish pupil response, and nuchal rigidity. Which of the following should the clinician attempt to elicit next?
____ 15. Spina bifida is a disorder that is associated with a headache syndrome caused by:
|B.||Normal pressure hydrocephalus|
____ 16. Which of the following is a common trigger of migraine headache?
|D.||All of the above|
____ 17. Your patient with a cervical herniated disc presents with a weakened biceps reflex. The biceps reflex is a test of the following spinal nerves:
|A.||C3 to C4|
|B.||C4 to C5|
|C.||C5 to C6|
|D.||C7 to T1|
____ 18. In order to test abstract thought on the mental status exam, the clinician can ask:
|A.||Count serial 7’s backward|
|B.||Spell the word “world” backward|
|C.||Draw a clock that shows 2:30|
|D.||How is your brother-in-law related to you?|
____ 19. A 56-year-old woman brings her 78-year-old father to the emergency room. The patient complains that sometimes he can’t think straight. His daughter reports that her father has been “tripping over his own feet” and has become incontinent of urine in the last few days. The patient’s medications include an ACE inhibitor and beta blocker. On physical examination, vital signs are within normal limits, heart and lungs show no abnormalities, cranial nerves are intact, and sensation and muscle strength are normal. A mental status exam is normal. Imbalanced gait and a positive Romberg test are apparent. Which of the following are possible disorders?
|B.||Normal pressure hydrocephalus|
|D.||A & B|
____ 20. A 65-year-old woman is accompanied her daughter for a physical examination. She has mild heart failure and takes digitalis and an ACE inhibitor. As you examine the patient, you note flat affect, hand tremor, and slowed movements. The tremor is worsened at rest. There are no neurologic deficits. Hand grip, sensation of face and extremities, and lower extremity muscle strength are within normal limits and bilaterally equal. DTRs are equal bilaterally. CN II to XII are intact. The mental status exam is normal. These are key signs of:
|B.||Normal pressure hydrocephalus|
____ 21. A 65-year-old male complains of a headache that feels “like a knife is cutting into his head.” He also reports feeling right-sided scalp and facial pain and “seeing double” at times. He has a history of hypertension and hyperlipidemia. His medications include beta blocker, statin drug, and an ACE inhibitor. On physical examination, you note palpable tenderness over the right side of the forehead. There are no neurological deficits. Vision is 20/20 with lenses. No weakness of extremities. CN II to XII are intact. The history corresponds to which of the following disorders?
|B.||Giant cell arteritis|
____ 22. In dementia, which of the following cognitive functions is most commonly lost first?
|B.||Knowing the place|
|C.||Estimating the time|
____ 23. A 78-year-old female comes to the clinic for a physical examination. She is accompanied her daughter and looks to her daughter to answer questions during the interview. She was diagnosed with early Alzheimer’s disease 2 years ago, and her daughter would like her current mental status evaluated.
You ask the patient her daughter’s name, and she answers correctly. You ask her the date and time, and she answers incorrectly. You hand the patient a pencil and ask her if she knows what it is. She replies with, “Is it a stick?” You ask the patient to put on a patient gown, and she does not know how to perform the task. These are examples of disorientation to time and:
|A.||Agnosia and apraxia|
|B.||Anomia and aphasia|
|C.||Agnosia and ataxia|
|D.||Apathy and ataxia|
____ 24. You are an emergency room clinician that assisted with CPR on a 20-year-old trauma patient. The CPR was unsuccessful, the patient expired, and you need to explain this to the family in the waiting room. Upon telling the mother about the death of her son, she becomes dizzy and faints. What is the most likely cause for the woman fainting?
|C.||Syncope due to hypoxia|
|D.||Dizziness and vertigo|
____ 25. An 88-year-old female is accompanied her daughter to the emergency department. The daughter explains that her mother was having her hair washed at the beauty salon, then complained of dizziness and fainted. The 88-year-old patient has a history of hypertension for which she takes a beta blocker. Otherwise she was in her usual state of health until this incident. On examination, she has no neurological deficits. Which of the following conditions should be considered?
|A.||Benign positional vertigo|
Chapter 15. Neurological System
- ANS: B
Ask the family or significant other whether the patient’s behavior patterns have changed. If the patient does not speak or write English, have an interpreter available during the examination. It is important to have an objective interpreter ask the patient translated questions. The patient may not be truthful or forthcoming if he/she knows the interpreter. A friend or relative may slant the mental status exam questions or influence the patient regarding the answers. A good screening tool for use in the outpatient setting is the Mini-Mental Status Exam, described in detail in Chapter 20.
- ANS: D
Auscultation of the carotid arteries is an important portion of the neurological examination, particularly for elderly patients. The patient should be asked to hold his or her breath during auscultation. The bell of the stethoscope is used to auscultate for bruits. One carotid artery at a time is palpated. A bruit in the carotid artery may be an indicator of potential stroke or carotid artery stenosis and should be followed further tests, such as carotid duplex and carotid ultrasound.
- ANS: C
The pain associated with subarachnoid hemorrhage is generally described as severe and acute in onset. The onset is often described as a thunderbolt or lightning. The severity is described as “the worst headache of my life.” It is generally made worse lying down. There is often associated nausea and/or vomiting and possible rapid deterioration in neurological function. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated movement, light, and noise. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The pain will gradually worsen over days to weeks. Headache due to a brain tumor is difficult to diagnose. A headache that awakens a patient from sleep is often a brain tumor. Headache with neurological deficits should also raise suspicion of brain tumor.
- ANS: D
A migraine is one of the most common types of vascular headache and accounts for a significant percentage of clinic and emergency department visits each year. They occur more frequently in women and the majority of patients report a family history of migraine. Onset of migraine is uncommon after the age of 40 years. They generally do not occur daily and are often associated with the menstrual cycle. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia.
- ANS: B
Cluster headaches have rapid crescendo patterns, peaking in approximately 10 to 15 minutes and often lasting 30 to 60 minutes per episode (rarely lasting over 2 hours each). Attacks occur as frequently as two to three times per day. The pain is generally in the area of the trigeminal nerve and is described as unilateral, penetrating, sharp, excruciating, and unrelenting in nature. There may be associated unilateral lacrimation, nasal congestion or rhinorrhea, pallor, flushing, conjunctival redness, ptosis—all on the same side as the pain.
- ANS: A
Delirium can be observed in both elderly and younger patients and is generally defined as an acute confusional state, affecting all aspects of cognition and mentation. The signs and symptoms of delirium generally have a more acute or rapidly progressive onset as opposed to the slow, gradual decline noted in the organic dementias. The acute mental status change is often associated with other signs or symptoms—such as hallucinations, illusions, incoherent speech, and constant aimless activity—that help to narrow the differential diagnosis. Electrolyte disturbances, infection, and polypharmacy are frequent causes of delirium in the elderly.
- ANS: C
Characterized sudden-onset dizziness lasting less than 30 seconds and following a head position change, benign positional vertigo (cupulolithiasis) may be accompanied nystagmus. It usually subsides but may recur at any time. In addition to the history, a provocative test for positional nystagmus can be performed (Hallpike maneuver), although it is not always positive. The provocative test involves moving the patient quickly from a sitting position to a lying position with the head turned to the side and the head dependent over the side of the examination table. After a few seconds, vertigo and nystagmus occur. This response fatigues with immediate repetition of the test.
- ANS: B
The exact cause of Ménière’s disease is unknown. However, the symptoms are associated with increased fluid and pressure in the labyrinth. Ménière’s disease commonly involves a triad of symptoms: severe vertigo, tinnitus, and hearing loss. The vertigo is transient but recurrent. The tinnitus and hearing loss may also be intermittent and/or recurrent but often become worse over time. A sensation of ear fullness may precede an episode. During the episode, vertigo is often debilitating and is associated with nausea and vomiting. The tinnitus and hearing loss are usually unilateral.
- ANS: B
Strokes are divided into two main categories: thrombotic and hemorrhagic; however, the two can be difficult to differentiate using clinical signs and symptoms. The onset is usually an abrupt altered level of consciousness accompanied hemiparesis or hemiplegia. Patients may experience confusion, memory impairment, and aphasia. Signs and symptoms vary with the location and severity of the stroke. Mentation and cognitive changes may be temporary or permanent depending on the extent of injury. Communication alterations stemming from fluent or receptive aphasia may be mistaken as dementia. A CT scan, without contrast, is the preferred imaging study in early stroke because hemorrhage may be difficult to determine on an MRI in the first 48 hours. In studies of ischemic stroke patients, researchers have shown the reversibility of abnormalities on CT or MRI through the use of thrombolytic therapy within a 3-hour window.
- ANS: C
Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia. There may be tenderness to palpation of the temporal arteries. Auras, if experienced, may include blurred vision and scotoma and/or other prodromal symptoms, such as anorexia, irritability, restlessness, or paresthesias lasting from 30 minutes to 3 hours before the onset of migraine pain.
- ANS: A
Typical symptoms of tension headache include mild to moderate nonthrobbing pressure, or squeezing pain, that can occur anywhere in the head or neck. The pain often starts slowly as a dull and aching discomfort that progresses to holocranial pain and pressure. The pain can recur intermittently, lasting from minutes to hours, usually remitting with rest or removal of the stressful trigger. There is usually no associated nausea and vomiting. Although patients may report photophobia and phonophobia, it is less severe than those associated with migraines. Tension headaches are not aggravated movement or activity. The neck muscles are often tight to palpation.
- ANS: C
Subdural hematomas can be either acute or chronic. Acute subdural hematomas are usually associated with an acute head injury and can cause a range of symptoms, including headache and loss of consciousness. A chronic subdural hematoma in the elderly population may enlarge significantly before the patient begins to notice head pain. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The physical findings vary depending on the severity of the trauma but may include progressive neurological deterioration, which may advance to include coma. The elderly patient with head trauma and anticoagulants should raise suspicion of subdural hematoma.
- ANS: B
Meningitis involves inflammatory central nervous system (CNS) disease generally caused either viral or bacterial infection. The etiology of meningitis includes community-acquired, post-traumatic, aseptic, carcinomatous, or transferred from another bodily source. The most common organisms belong to such genera as Streptococcus, Neisseria (meningitides), Haemophilus (influenzae), Listeria, Staphylococcus (aureus) as well as gram-negative bacilli and gram-positive cocci. Meningitis can affect persons of all ages, including children.
- ANS: B
In meningitis fever, photophobia, phonophobia, nausea, vomiting, and nuchal rigidity occur. Patients can rapidly decline to delirium, seizures, and, if untreated, coma. On neurological examination, the patient may be lethargic and febrile and have altered mentation along with nuchal rigidity and/or guarding, contracted and sluggish pupils, and a generally “toxic” appearance. Brudzinski’s and Kernig’s signs are helpful in assessing potential meningeal conditions (see Box 15.6). Delirium or acute confusion necessitates immediate transfer to an emergency department for treatment, as the patient can rapidly deteriorate to coma.
- ANS: A
Chiari malformations are brainstem malformations. There are three types of Chiari malfunction. Chiari type I is most often associated with occipital headaches and generally seen in the adult population but can be diagnosed at any age. Type I symptoms may be very vague and transient, and it is often misdiagnosed as another neurological disease. Type II is generally diagnosed in infants or children and is associated with myelomeningocele or other open neural tube defects or in adults with undiagnosed spina bifida occulta or tethered cord. Type III malformation is rare, diagnosed in infants, associated with cervical myelomeningocele or pseudomeningocele, and carries a very poor prognosis.
- ANS: D
|Common Migraine Triggers:|
|• Altered sleep|
|• Specific foods, missed meals|
|• Hormone supplements|
- ANS: C
Box 15.3 Deep Tendon Reflexes
|Biceps: C5, C6
Brachioradialis: C5, C6
Triceps: C6, C7
Patellar: L3, L4
- ANS: D
Rationale: Box 15.1 Mental Status Components
|Orientation—The patient should normally be aware of person, date, and place. Ask the patient his or her full name, current date, and place in which the examination is being done.
Memory—Recent and remote memory should normally be intact. Ask what the patient had for lunch yesterday (recent) and where he or she graduated from elementary school (remote).
Fund of knowledge (take into consideration the patient’s level of education)—Ask about any recent news events or significant upcoming or past holiday.
Attention span—Ability to focus on the interviewer without being easily distracted. Ask the patient to repeat a short list of numbers (e.g., 7-8-9-3-0-2). Inability to repeat six or more numbers indicates attention deficit.
Concentration—Ability to concentrate on a question or task. Ask the patient to remember three unrelated words (red, happy, and five) and then to repeat them in 5 minutes, or ask the patient to count backward from 100 7.
Language—Use and understanding of language. Ask the patient to write a full sentence or to spell world backward. Distinguish between dysphonias and dysarthrias, as these indicate mechanical disturbances often due to CN dysfunction. Assess fluency of speech asking the patient to repeat “no ifs, ands, or buts about it.” Dysfluent speech is Broca’s aphasia. Speech that is devoid of content indicates Wernicke’s aphasia.
Abstract thoughts—Ask the patient to interpret a common proverb (e.g., a stitch in time saves nine), or ask the patient to answer an abstract question (e.g., “Is my sister’s brother a man or a woman?”).
- ANS: D
Normal pressure hydrocephalus is not fully understood. It is seen primarily in persons over 60 years of age and involves enlargement of the ventricles, often without increased CSF pressure; intraventricular pressures may be high or normal. One of the theorized causes includes intermittent pressure increases. It is slightly more common in men than in women. The patient often first notices some degree of gait disorder, followed the onset of a “clouding” of thought processes, which gradually progress. The typical picture is a patient who has a triad of gait disturbance, altered thought processes, and urinary incontinence. Strength and sensation are usually within normal limits. However, focal neurological findings are present and include increased deep tendon reflexes, the inability to tandem walk, positive Babinski, and/or positive Romberg.
- ANS: C
Parkinson’s disease occurs with approximately equal sex distribution, and usually begins between 45 and 65 years of age. Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. There is a flattened affect and blank stare. There is bradykinesia of gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal. Although Alzheimer’s disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer’s.
- ANS: B
Temporal arteritis is also referred to as giant cell arteritis or cranial arteritis. It is characterized chronic inflammation and the presence of giant cells in large arteries, usually the temporal artery, but can occur in the cranial arteries, the aorta, and coronary and peripheral arteries. It affects the arteries containing elastic tissue, resulting in narrowing and eventual occlusion of the lumen. It occurs more among persons over 50 years of age and is slightly more common in females than in males. The cause is unknown, but there seems to be a genetic predisposition. If left untreated, arteritis can rapidly lead to blindness that is often irreversible. The most common chief complaint is head pain that is lancinating, sharp, or “ice pick” in nature. Patients often complain of visual changes, including amaurosis, diplopia, blurred vision, visual field cuts, eye pain, periorbital edema, and intermittent unilateral blindness. Other common presenting symptoms include scalp and/or jaw tenderness, facial pain, and tenderness to palpation over the affected artery. The pain is generally hemicranial but can be bilateral or diffuse. There may be eye pain, which is usually bilateral; periorbital edema may be present. Other potential associated symptoms include an intermittent fever (generally low grade), nausea, and/or weight loss.
- ANS: C
When evaluating a patient’s mental status, assess orientation asking the patient to recite his or her full name, current location/place (clinic, hospital, home, etc.), and the date (day of the week, month, or year). Knowledge of time is generally impaired first, followed place. The inability to recite or recognize one’s name implies a significant deficit in mental status.
- ANS: A
Most organic dementias develop over months to years. There are typically no physical motor or sensory alterations until the condition is advanced. Memory impairment is the predominant symptom. There may be impairment in another area of cognitive functioning, such as with aphasia (producing language as well as understanding it), agnosia (perceptual impairment of environment), apraxia (inability to perform complex motor acts), and impairment in executive functioning (inability to plan, organize, sequence, and think abstractly). Ataxia is not a symptom of dementia—it is a problem with gait usually due to cerebellar dysfunction.
- ANS: B
Neurocardiogenic syncope, also called vasovagal syncope, is a common cause of dizziness and fainting. It is due to a sudden decrease in blood pressure and heart rate after prolonged standing, with stress, or from dehydration. It is a result of sympathetic sensitivity, causing a reflexive response that suddenly causes bradycardia and venous dilation. Hypotension and dizziness result.
- ANS: B
Vertebrobasilar insufficiency is seen mostly in the elderly and is exacerbated extension of the neck or changes in head position. There is temporary interruption of circulation in the posterior brain due to vertebral artery occlusion. Benign paroxysmal positional vertigo, or cupulolithiasis, is the most common vestibular disorder, resulting from otolithic crystals/particles detaching from the utricle membrane and migrating to the semicircular canal. It can occur spontaneously with motion or position change or as a result of vascular or labyrinth trauma. Characterized sudden-onset dizziness lasting less than 30 seconds and following a head position change, cupulolithiasis may be accompanied nystagmus. It usually subsides but may recur at any time. Labyrinthitis is caused the invasion of the ear bacteria or a virus. The bacterial version is more serious because it may lead to meningitis. Prompt treatment with antibiotics is necessary. Labyrinthitis is characterized severe vertigo, nystagmus, and hearing loss. Suppurative labyrinthitis may be secondary to bacterial otitis media or other bacterial infection. Serous labyrinthitis can be secondary to a variety of viral illnesses, including measles, mumps, chickenpox, influenza, mononucleosis, and adenovirus.