Chapter 18: Disorders of the Central and Peripheral Nervous Systems and the Neuromuscular Junction
MUL!PL" C#$!C"
1. Diffuse axonal injuries (DAIs) of the brain often result in: a. Reduced levels of consciousness c. Fine motor tremors b. Mild but ermanent d!sfunction d. "isual "isual disturbances A#$: A
Focal brain injuries account for more than t%o&thirds of head injur! deaths' DAIs accounts for less than one third. o%ever more severel! disabled survivors includin* those in an unresonsive state or reduced level of consciousness hav e DAIs. +he other otions do not aroriatel! comlete the stem. ,+$: 1
R-F: ,a*e /0
0. hat event is most li2el! to occur to the brain in a classic cerebral concussion3 a. 4rief eriod of vital si*n instabilit! b. 5erebral edema throu*hout the cerebral cortex c. 5erebral edema throu*hout the diencehalon d. Disrution of axons extendin* from the diencehalon and brainstem A#$: A
+ransient cessation of resiration can occur %ith brief eriods of brad!cardia and a decrease in blood ressure occurs oc curs lastin* 67 seconds or less. "ital "ital si*ns stabili8e %ithin a fe% seconds to %ithin normal limits. +he other otions do not accuratel! describe an event associated %ith a classic cerebral concussion. ,+$: 1
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6. hich disorder has clinical manifestations that include decreased consciousness for u to 9
hours as %ell as retro*rade and osttraumatic amnesia3 a. Mild concussion c. 5ortical contusion b. 5lassic concussion d. Acute subdural hematoma A#$: 4
-vidence of a classic concussion is the immediate loss of consciousness %hich lasts less than 9 hours. Retro*rade and antero*rade (osttraumatic) amnesia is also resent. +he other otions do not al!. ,+$: 1
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. hat *rou is most at ris2 of sinal cord injur! from minor trauma3 a. 5hildren c. Adults b. Adolescents d. ;lder adults A#$: D
4ecause of reexistin* de*enerative vertebral disorders older adults are articularl! at ris2 for minor trauma resultin* in serious sinal cord injur! eseciall! from falls. +he ris2 to the other a*e *rous is less than that of the older adult.
,+$: 1
R-F: ,a*e 96
. +he edema of the uer u er cervical cord after sinal cord injur! is considered life threatenin*
because of %hich ossible outcome3 a. !ovolemic shoc2 from blood lost durin* the injur! b. 4reathin* difficulties from an imairment to the diahra*m c. ead injur! that li2el! occurred durin* the injur! d. $inal shoc2 immediatel! after the injur! A#$: 4
In the cervical re*ion sinal cord s%ellin* ma! be life threatenin* because of the ossibilit! of resultin* imairment of the diahra*m function (hrenic nerves exit 56&5). +he other otions do not aroriatel! exlain the threat. ,+$: 1
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9. hat indicates that sinal shoc2 is terminatin*3 a. "oluntar! movement belo% the level of injur! b. Reflex emt!in* of the bladder c. ,aresthesia belo% the level of injur! d. Decreased dee tendon reflexes and flaccid aral!sis A#$: 4
Indications that sinal shoc2 is terminatin* include the reaearance of reflex activit! h!erreflexia sasticit! and reflex emt!in* of the bladd er. +ermination +ermination of a sinal cord injur! is not evidenced b! an! of the other otions. ,+$: 1
R-F: ,a*e <0
=. hat term is used to describe the comlication that can result from a sinal cord injur! above
+9 that is roducin* arox!smal h!ertension as %ell as iloerection and s%eatin* above the sinal cord lesion3 a. 5raniosacral d!sreflexia c. Autonomic h!erreflexia b. ,aras!mathetic d!sreflexia d. Retro*rade h!erreflexia A#$: 5
Individuals most li2el! to be affected have lesions at the +9 level or above. ,arox!smal h!ertension (u to 677 mm * s!stolic) a oundin* headache blurred vision s%eatin* above the level of the lesion %ith flushin* of the s2in nasal con*estion nausea iloerection caused b! ilomotor sasm and brad!cardia brad !cardia (67 to 7 beats>minute) characteri8e autonomic h!erreflexia. #o other otions aroriatel! describe this comlication. ,+$: 1
R-F: ,a*es <6&<
/. h! does a erson %ho has a sinal cord injur! exerience fault! control of s%eatin*3 a. +he h!othalamus is unable to re*ulate bod! heat as a result of dama*e to the
s!mathetic nervous s!stem. b. +he thalamus is unable to re*ulate bod! b od! heat as a result of dama*e to the s!mathetic nervous s!stem. c. +he h!othalamus is unable to re*ulate bod! heat as a result of dama*e to the aras!mathetic nervous s!stem.
d. +he thalamus is unable to re*ulate bod! b od! heat as a result of dama*e to sinal nerve
roots. A#$: A
A sinal cord injur! results in disturbed thermal control because the h!othalamus is unable to re*ulate a dama*ed s!mathetic nervous s!stem. +his dama*e causes fault! control of s%eatin* and radiation throu*h caillar! dilation. +he other otions do not aroriatel! describe the rocess that causes fault! control of s%eatin*. ,+$: 1
R-F: ,a*e <0
<. Autonomic h!erreflexia?induced brad!cardia is a result of stimulation of the: a. $!mathetic nervous s!stem to @&adrener*ic recetors to the sinoatrial node b. 5arotid sinus to the va*us nerve to the sinoatrial node c. ,aras!mathetic nervous s!stem to the *lossohar!n*eal nerve to the
atrioventricular node d. 4undle branches to the α&adrener*ic recetors to the sinoatrial node A#$: 4
+he intact autonomic nervous s!stem reflexivel! resonds %ith an arteriolar sasm that increases blood ressure. 4arorecetors in the cerebral vessels the carotid sinus an d the aorta sense the h!ertension and stimulate the aras!mathetic s!stem. +he heart rate d ecreases but the visceral and eriheral vessels do not dilate d ilate because efferent imulses cannot ass throu*h the cord. +he rocess is not aroriatel! described b ! the other otions. ,+$: 1
R-F: ,a*es <6&< Fi*ure 1/&16
17. A herniation of %hich dis2 %ill li2el! result in motor and sensor! chan*es of the lateral lo%er
le*s and soles of the feet3 a. B0&B6 b. B6&B
c. B&$1 d. $0&$6
A#$: 5
5linical manifestations of osterolateral rotrusions include radicular ain exacerbated b! movement and strainin* (medial calf su**ests B' lateral calf su**ests $1 root comression). erniation of an! of the other vertebrae %ill not result in the described s!mtoms. ,+$: 1
R-F: ,a*es <&<9 Fi*ure 1/&1
11. hich condition oses the hi*hest ris2 for a cerebrovascular accident (5"A)3 (5"A)3 a. Insulin&resistant diabetes mellitus c. ,ol!c!themia b. !ertension d. $mo2in* A#$: 4
!ertension is the sin*le *reatest ris2 factor for stro2e. +he other otions are reco*ni8ed ris2 factors but do not carr! the intensit! of h!ertension. ,+$: 1
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10. A ri*ht hemishere embolic 5"A 5"A has resulted in left&sided aral!sis and reduced sensation of of
the left foot and le*. hich cerebral arter! is most li2el! affected b! the emboli3 a. Middle cerebral c. ,osterior cerebral
b. "ertebral
d. Anterior cerebral
A#$: D
$!mtoms of an embolic stro2e in onl! the ri*ht anterior cerebral arter! %ould include left& sided contralateral aral!sis or aresis (*reater in the foot and thi*h) and mild uer extremit! %ea2ness %ith mild contralateral lo%er extremit! sensor! deficienc! %ith loss of vibrator! and>or osition sense and loss of t%o&oint discrimination. ,+$: 1
R-F: ,a*e 977 +able 1/&
16. Atrial fibrillation rheumatic heart disease and valvular rosthetics are ris2 factors for %hich
t!e of stro2e3 a. emorrha*ic b. +hrombotic
c. -mbolic d. Bacunar
A#$: 5
i*h&ris2 sources for the onset of embolic stro2e are atrial fibrillation (1C to 0C of stro2es) left ventricular aneur!sm or thrombus left atrial thrombus recent m!ocardial infarction rheumatic valvular disease mechanical rosthetic valve nonbac terial thrombotic endocarditis bacterial endocarditis atent foramen ovale and rimar! intracardiac tumors. +hese are not ris2 factors for the other otions rovided. ,+$: 1
R-F: ,a*e <<
1. Microinfarcts resultin* in ure motor or ure sensor! deficits are the result of %hich t!e of
stro2e3 a. -mbolic b. emorrha*ic
c. Bacunar d. +hrombotic
A#$: 5
A lacunar stro2e (lacunar infarct) is a microinfarct smaller than 1 cm in diameter. 4ecause of the subcortical location and small area of infarction these stro2es ma! have ure motor and sensor! deficits. +he other otions %ould not result in the comlications described. ,+$: 1
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1. hich vascular malformation is characteri8ed b! arteries that feed directl! into veins throu*h
vascular tan*les of abnormal vessels3 a. 5avernous an*ioma b. 5aillar! telan*iectasia
c. Arteriovenous an*ioma d. Arteriovenous malformation
A#$: D
In onl! an arteriovenous malformation (A" (A"M) do arteries feed directl! into veins throu*h a vascular tan*le of malformed vessels. ,+$: 1
R-F: ,a*es 97&97
19. hich clinical findin* is considered a dia*nostic indicator for an arteriovenous malformation
(A"M)3 a. $!stolic bruit over the carotid arter! b. Decreased level of consciousness c. !ertension %ith brad!cardia
d. Diastolic bruit over the temoral arter! A#$: A
A s!stolic s!stolic bruit over the carotid in the nec2 the mastoid rocess or (in a !oun* erson) the e!eball is almost al%a!s dia*nostic d ia*nostic of an A" A"M. +he other otions are not as indicative as the s!stolic bruit. ,+$: 1
R-F: ,a*e 97
1=. hich cerebral vascular hemorrha*e causes menin*eal irritation hotohobia and ositive
erni* and 4rud8ins2i si*ns3 a. Intracranial b. $ubarachnoid
c. -idural d. $ubdural
A#$: 4
Assessment findin*s related to onl! a subarachnoid hemorrha*e include menin*eal irritation and inflammation causin* nec2 stiffness (nuchal ri*idit!) hotohobia blurred vision irritabilit! irritabilit! restlessness and lo%&*rade fever. A ositive erni* si*n in %hich strai*htenin* the 2nee %ith the hi and 2nee in a flexed osition roduces ain in the bac2 and nec2 re*ions and a ositive 4rud8ins2i si*n in %hich assive flexion of the nec2 roduces nec2 ain and increased ri*idit! ma! aear. ,+$: 1
R-F: ,a*es 97&979
1/. In adults most intracranial tumors are located: a. Infratentoriall! c. Baterall! b. $uratentioriall! d. ,osterolaterall! A#$: A
Aroximatel! =7C to =C of all intracranial tumors dia*nosed in adults are located suratentoriall! (above the tentorium cerebella). +he other otions are not rimar! locations for intracranial tumors in adults. ,+$: 1
R-F: ,a*e 909
1<. In children most intracranial tumors are located: a. Infratentoriall! c. Baterall! b. $uratentioriall! d. ,osterolaterall! A#$: 4
Aroximatel! =7C of all intracranial tumors in children are located infratentoriall! (belo% the tentorium cerebelli) and not in the locations rovided b! the other otions. ,+$: 1
R-F: ,a*e 909
07. +he most common rimar! central nervous s!stem (5#$) tumor is the: a. Micro*lioma c. Astroc!toma b. #euroblastoma d. #euroma A#$: 5
Astroc!tomas are the most common rimar! 5#$ tumors (7C of all brain and sinal cord tumors). +he other otions do not occur as freEuentl!.
,+$: 1
R-F: ,a*e 90<
01. Menin*iomas characteristicall! comress from: a. ithin c. ;utside the sinal cord ithin neural ne ural tissues b. ;utside sinal nerve roots d. ithin the subarachnoid sace A#$: 5
-xtramedullar! sinal cord tumors roduce d!sfunction b! comression of adjacent tissue not b! direct invasion. +he atholo*ic characteristic of menin*iomas is not aroriatel! described b! the other otions. ,+$: 1
R-F: ,a*e 966
00. hat is the central comonent of the atho*enic model of multile sclerosis3 a. M!elination of nerve fibers in the eriheral nervous s !stem (,#$) b. Dem!elination of nerve fibers in the 5#$ c. Develoment of neurofibrillar! tan*les in the 5#$ d. Inherited autosomal dominant trait %ith hi*h enetrance A#$: 4
Multile sclerosis (M$) is an autoimmune disorder diffusel! involvin* the de*eneration of 5#$ m!elin and loss of axons. +he other otions are not central comonents of the atho*enic model of M$. ,+$: 1
R-F: ,a*es 91/&91<
06. A blunt force injur! to the forehead %ould result in a coup injur! coup injur! to %hich re*ion of the brain3 a. Frontal c. ,arietal b. +emoral d. ;cciital A#$: A
Coup injuries Coup injuries occur directl! belo% the oint of imact. ;bjects stri2in* the front of the head usuall! roduce onl! cou injuries (contusions and fractures) because the inner s2ull in the occiital area is smooth. A cou injur! is not nearl! as li2el! %hen other ortions of the brain are affected. ,+$: 1
R-F: ,a*e /6
0. A blunt force injur! to the forehead %ould result in a contrecoup injur! contrecoup injur! to %hich re*ion of the
brain3 a. Frontal b. +emoral
c. ,arietal d. ;cciital
A#$: A
+he focal injur! roduces a contrecoup (on the ole oosite the site of imact) injur!. +he frontal ortion of the brain is oosite of the site o f imact. ;bjects stri2in* the bac2 of the head usuall! result in both cou and contrecou injuries because of the irre*ularit! of the inner surface of the frontal bones. A contrecou injur! is not nearl! as li2el! %hen other ortions of the brain are affected. ,+$: 1
R-F: ,a*e /6
0. $inal cord injuries most li2el! occur in %hich re*ion3 a. 5ervical and thoracic c. Bumbar and sacral b. +horacic and lumbar d. 5ervical and thoracic&lumbar A#$: D
"ertebral "ertebral injuries most often occur at vertebrae 51&50 (cervical) 5&5= and +1&B0 (thoracic lumbar). #one of the other otions are alicable. ,+$: 1
R-F: ,a*es <7&<1
09. +he most li2el! rationale for bod! temerature fluctuations after cervical sinal cord injur! is
that the erson has: a. Develoed bilateral neumonia or a urinar! tract infection. b. $ustain s!mathetic nervous s!stem dama*e resultin* in disturbed thermal control. c. $ustained a head injur! that dama*ed the h!othalamuss abilit! to re*ulate temerature. d. Develoed seticemia from osttrauma infection. A#$: 4
$inal cord injuries result in disturbed thermal control because the s!mathetic nervous s!stem is dama*ed. #one of the remainin* otions exlain this comlication. ,+$: 1
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0=. A man %ho sustained a cervical sinal cord injur! 0 da!s a*o suddenl! develos severe
h!ertension and brad!cardia. e reorts severe h ead ain and blurred vision. +he most li2el! exlanation for these clinical manifestations is that he is: a. -xeriencin* acute anxiet! b. Develoin* sinal shoc2 c. Develoin* autonomic h!erreflexia d. -xeriencin* aras!mathetic areflexia A#$: 5
Autonomic h!erreflexia is the onl! otion that is char acteri8ed b! arox!smal h!ertension (u to 677 mm * s!stolic) a oundin* headache blurred vision s%eatin* above the level of the lesion %ith flushin* of the s2in nasal con*estion nausea iloerection caused b! ilomotor sasm and brad!cardia (67 to 7 beats er minute). ,+$: 1
R-F: ,a*es <6&<
0/. +he t!e of vascular malformation that most often results in hemorrha*e is: a. 5avernous an*ioma c. 5aillar! telan*iectasia b. "enous an*ioma d. Arteriovenous malformation A#$: D
In an arteriovenous malformation (A"M) (A"M) arteries feed directl! into veins throu*h a vascular tan*le of malformed vessels causin* venous hemorrha*in*. +he o ther otions are not as li2el! to result in a hemorrha*e. ,+$: 1
R-F: ,a*es 97&97
0<. Atheromatous laEues are most commonl! found:
a. In lar*er veins b. #ear caillar! shincters
c. At branches of arteries d. ;n the venous sinuses
A#$: 5
;ver 07 to 67 !ears atheromatous laEues (stenotic lesions) tend to form at branchin*s and curves in the cerebral circulation not at an! of the other otions rovided. ,+$: 1
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67. Multile sclerosis is best described as a(an): a. 5entral nervous s!stem dem!elination ossibl! from an immuno*enetic virus b. InadeEuate sul! of acet!lcholine at the neurotransmitter junction as a result of an
autoimmune disorder c. Deletion of doamine in the central nervous s!stem as a result of a virus d. De*enerative disorder of lo%er and uer motor neurons caused b! viral&immune factors A#$: A
Multile sclerosis (M$) is an autoimmune disorder diffusel! involvin* the de*eneration of central nervous s!stem (5#$) m!elin and loss of axons. M$ is described as occurrin* %hen a revious infectious insult to the 5#$ has occurred in a *eneticall! suscetible individual %ith %ith a subseEuent abnormal immune resonse in the 5#$. +he other otions do not adeEuatel! ad eEuatel! describe M$. ,+$: 1
R-F: ,a*es 91/&91<
61. hat is the most common oortunistic infection associated %ith acEuired immunodeficienc!
s!ndrome (AID$)3 a. #on&od*2in l!mhoma b. aosi sarcoma
c. +oxolasmosis d. 5!tome*alovirus
A#$: 5
+oxolasmosis +oxolasmosis is the most common oortunistic infection and occurs in a roximatel! one third of individuals %ith AID$. 5!tome*alovirus encehalitis is common in those %ith AID$ but is often not dia*nosed %hile the erson is alive. ;ther neolasms associated %ith human immunodeficienc! virus (I") include s!stemic non&od*2in l!mhoma and metastatic aosi sarcoma. ,+$: 1
R-F: ,a*e 91=
60. It is true that true that Guillain&4arrH s!ndrome (G4$): a. Is receded b! a viral illness. c. Results in as!mmetric aral!sis. b. Involves a deficit in acet!lcholine. d. Is an outcome of I". A#$: A
G4$ is considered to be an autoimmune disease tri**ered b! a recedin* bacterial or viral infection. #one of the other otions are true of G4$. ,+$: 1
R-F: ,a*es 900&906
66. It is true that true that m!asthenia *ravis: a. Is an acute autoimmune disease.
c.
Ma! result in adrener*ic crisis.
b. Affects the nerve roots.
d. 5auses muscle %ea2ness.
A#$: D
-xertional fati*ue and %ea2ness that %orsens %ith activit! imroves %ith rest and recurs %ith resumtion of activit! characteri8es m!asthenia *ravis. #one of the other otions are true of m!asthenia *ravis. ,+$: 1
R-F: ,a*e 909
6. In %hich disorder are acet!lcholine recetor antibodies (I*G antibodies) roduced a*ainst
acet!lcholine recetors3 a. Guillain&4arrH s!ndrome b. Multile sclerosis
c. M!asthenia *ravis d. ,ar2inson disease
A#$: 5
+he main defect of m!asthenia *ravis is the formation of autoantibodies (an immuno*lobulin G I*GJ antibod!) a*ainst recetors at the Ach&bindin* site on the osts!natic membrane. +his defect is not found in an! an ! of the other otions. ,+$: 1
R-F: ,a*es 90&909
6. Multile sclerosis and Guillain&4arrH s!ndrome are similar in that the! both: a. Result from dem!elination b! an immune reaction. b. 5ause ermanent destruction of eriheral nerves. c. Result from inadeEuate roduction of neurotransmitters. d. 4loc2 acet!lcholine recetor sites at the m!oneuronal junction. A#$: A
Acute inflammator! dem!elinatin* ol!neuroath! (AID,) accounts for most occurrences of Guillain& 4arrH s!ndrome (G4$). Multile sclerosis (M$) is an autoimmune disorder diffusel! involvin* de*eneration of 5#$ m!elin and loss of axons. ;nl! the correct otion accuratel ! describes the similarit! bet%een M$ and G4$ ,+$: 1
R-F: ,a*e 91/ ,a*es 900&906
MUL!PL" %"SP$NS"
69. hich clinical manifestation is characteristic of cluster headaches3 (Select all that apply.) a. ,reheadache aura b. $evere unilateral tearin* c. Gradual onset of a ti*ht band around the head d. $i*nificant unilateral temoral ain e. ,ain lastin* from 67 to 107 minutes A#$: 4 5 5 -
+he cluster headache attac2 usuall! be*ins %ithout %arnin* and is characteri8ed b! severe unilateral tearin* burnin* eriorbital and retrobulbar or temoral ain lastin* 67 minutes to 0 hours. #either reheadache aura nor si*nificant unilateral temoral ain is clinical manifestation characteristic of cluster headaches. ,+$: 1
R-F: ,a*es 97/&97<
6=. hat are the initial clinical manifestations immediatel! noted after a sinal cord injur!3
(Select all that apply.) a. eadache b. 4ladder incontinence c. Boss of dee tendon reflexes d. !ertension e. Flaccid aral!sis A#$: 4 5 5 -
A comlete loss of reflex function in all se*ments belo% the level of the lesion characteri8es a sinal cord injur!. $evere imairment belo% the level of the lesion is obvious' it includes aral!sis and flaccidit! in muscles absence of sensation loss of bladder bladder and rectal control transient dro in blood ressure and oor venous circulation. #either headache nor h!ertension is an initial clinical manifestation related to a sinal cord injur!. ,+$: 1
R-F: ,a*e <0
M&C#!N'
Match the terms with the corresponding corresponding descriptions. KKKKKK A. 5omlication of mastoiditis mastoiditis KKKKKK 4. ;ortunistic infection KKKKKK 5. 5#$ manifestation of tuberculosis KKKKKK D. MosEuito&borne viral infection KKKKKK -. +ic2&borne bacterial infection infection 6/. 6<. 7. 1. 0.
Menin*itis -ncehalitis Cryptococcus neoformans 4rain abscess B!me B!me disease
6/. A#$: 5 ,+$: 1 R-F: ,a*es 911&910 M$5: +ubercular +ubercular menin*itis is is the most common common and serious serious form of central nervous s!stem (5#$) tuberculosis. 6<. A#$: D ,+$: 1 R-F: ,a*e 91 M$5: -ncehalitis is is an acute febrile febrile illness usuall! usuall! of viral viral ori*in %ith nervous s!stem involvement. Arthrood&borne Arthrood&borne (mosEuito&borne) (mosEuito&borne) viruses and heres simlex cause the most common encehalitides. 7. A#$: 4 ,+$: 1 R-F: ,a*e 91= M$5: ;ortunistic ;ortunistic infections ma! ma! be bacterial fun*al fun*al roto8oal or viral in ori*in ori*in and roduce nervous s!stem disease. 5r!tococcus neoformans is an examle of such an infection. 1. A#$: A ,+$: 1 R-F: ,a*e 916 M$5: Abscesses ma! occur in association association %ith a conti*uous sread sread of infection infection such as the the middle ear mastoid cells nasal cavit! and nasal sinuses. 0. A#$: ,+$: 1 R-F: ,a*e 91= M$5: B!me B!me disease a tic2&borne tic2&borne sirochete sirochete bacterial infection infection is a common arthrood&borne infection in the Lnited $tates.
