Neuro Disorders: MODULE II Buttaro

Which diagnostic test helps confirm a diagnosis of Guillain-Barré syndrome (GBS) in a patient who is developing muscle weakness and paresthesias? Lumbar puncture MRI imaging Nerve conduction studies Screening for systemic infection

ANS: A A lumbar puncture is the most important confirmatory test showing albuminocytologic disassociation. MRI imaging typically is not necessary unless there is concern for spine pathology but does not diagnose GBS. Nerve conduction studies are not necessary for the diagnosis. Screening for systemic infection is based on history and does not diagnose GBS.

A patient diagnosed with Parkinson's disease (PD) has been prescribed carbidopa-levodopa with good results but develops increased dyskinesia. Which drug will be added to this patient's regimen to help control this symptom?a. Amantadine b. Benztropine c. Ropinirole d. Tolcapone

ANS: A Amantadine is an antiviral agent that has antiparkinsonian activity. It is useful for controlling dyskinesia as adjunctive therapy to levodopa and is more effective than anticholinergic drugs. Benztropine is an anticholinergic drug that may be used for this purpose but is less effective and is more commonly used to treat antipsychotic-induced parkinsonism. Ropinirole is used as a first-line agent in patients with young-onset PD. Tolcapone is a COMT agent to prolong and potentiate the effects of levodopa to help prevent "wearing off" periods.

Which drug is used to treat patients with focal epilepsy and complex partial seizures? a. Carbamazepine b. Ethosuximide c. Lamotrigine d. Topiramate

ANS: A Carbamazepine is used for focal and complex partial seizures. Ethosuximide is useful for petit mal seizures in children. Lamotrigine has a wide range of effectiveness but has an increased risk for Stevens-Johnson syndrome. Topiramate is not a first-line drug because of cognitive side effects.

A patient with a family history of amyotrophic lateral sclerosis (ALS) begins to have symptoms that include asymmetric weakness in the arms and difficulty walking. The neurologist recognizes these symptoms as characteristic of involvement of which portion of the nervous system? Lower motor neurons (LMN) Upper motor neurons (UMN) Corticospinal tracts Corticobulbar tracts

ANS: A Lower motor neuron involvement and early LMN cell death leads to an insidious onset of asymmetric weakness that is evident initially in the limbs, usually in the arms. Upper motor neuron cell death may result in hyperreflexia, spasticity, incoordination, and weakness. Bulbar signs include dysarthria, dysphagia, and tongue fasciculations. The corticospinal tracts are part of the UMN cells.

A patient with Alzheimer's disease (AD) is taking donepezil to treat cognitive symptoms. The patient's son reports noting increased social withdrawal and sleep impairment. What is the initial step to manage these symptoms? Encourage activity and exercise. Prescribe a selective serotonin reuptake inhibitor (SSRI). Recommend risperidone. Referral to a neurologist for evaluation.

ANS: A Patients with AD may have improvement in depression with nonpharmacologic management, including exercise and increased activity. If this is not effective, an SSRI may be prescribed. Risperidone and other antipsychotics should not be prescribed.

What are common symptoms noted in patients diagnosed with Parkinson's disease? (Select all that apply.) Bradykinesia Festination Hyperphonia Rigidity Symmetric tremor

ANS: A, B, D Symptoms of Parkinson's disease include bradykinesia, or loss of automatic movement, festination, or an impulse to take much quicker and shorter steps, and rigidity. Hypophonia, not hyperphonia occurs. Tremors are unilateral or asymmetric.

Which monitoring parameters are necessary when caring for a patient with Guillain-Barré syndrome (GBS)? (Select all that apply.) Bladder scans Cardiac telemetry Imaging studies Fever Vital capacity measures

ANS: A, B, D, E Urinary retention can cause discomfort and infection, so assessment of urinary retention is necessary. Cardiac telemetry is essential, as are measures of pulmonary function. Imaging studies are not essential.

Which are common hyperkinetic movement disorders? (Select all that apply.) a. Dystonia Essential tremor Parkinson's disease Progressive supranuclear palsy Tourette's syndrome

ANS: A, B, E Dystonia, essential tremor, and Tourette's are hyperkinetic disorders. Parkinson's disease and progressive supranuclear palsy are hypokinetic disorders.

An 80-year-old patient becomes apathetic, with decreased alertness and a slowing of speech several days after hip replacement surgery alternating with long periods of lucidity. What is the most likely cause of these symptoms? a. Anesthesia effects Delirium Pain medications Stroke

ANS: B An acute presentation of these symptoms is most likely delirium since they alternate with lucid periods. The other causes may contribute to delirium by intensifying it.

A patient is diagnosed with trigeminal neuralgia and reports having paroxysms several times each day. What is the initial treatment for this patient? A combination of baclofen, lamotrigine, and phenytoin A high dose of carbamazepine with subsequent titration downward Botox injections or intranasal lidocaine as needed Low doses of anticonvulsants with gradual increase as needed

ANS: B Anticonvulsants are first-line treatments for trigeminal neuralgia - carbamazepine is started at the maximum therapeutic dose and titrated down to the lowest effective dose. Combination drug therapy is begun if the initial treatment is not effective or if the single drug regimen has intolerable side effects. Botox injections and intranasal lidocaine are used as adjuncts to anticonvulsants for acute pain relief.

A patient with dementia experiences agitation and visual hallucinations and is given haloperidol with a subsequent worsening of symptoms. Based on this response, what is the likely cause of this patient's symptoms? Alzheimer's disease Lewy body dementia Pseudodementia Vascular neurocognitive disorder

ANS: B Patients with Lewy body dementia may present with these symptoms and will have an increased sensitivity to neuroleptics; when given haloperidol for agitation, will actually worsen. The other causes do not have these characteristic symptoms and are not sensitive to neuroleptics in this manner.

A patient who has a seizure disorder and takes levetiracetam is brought to an emergency department as two consecutive 15-minute seizures occur. What is the priority action for this patient? Administer a dose of levetiracetam now and repeat in 10 minutes. Administer lorazepam and monitor cardiorespiratory status. Administer phenytoin and phenobarbital along with oxygen. Admit the patient to the hospital for a diagnostic work up.

ANS: B This patient has status epilepticus, which should be treated with benzodiazepines and close monitoring of airway, breathing, and circulation. The other interventions are not appropriate for acute seizure management.

A patient reports trembling of both hands causing difficulty performing tasks with the hands. The provider notes symmetric, rhythmic movements which are present at rest and no other neurological findings. A history reveals that the trembling decreases when the patient has a glass of wine with dinner. What is the initial action? Evaluation in an emergency department (ED) Prescribing a beta blocker medication Reassurance that these will subside Referral to a neurologist

ANS: B This patient has symptoms consistent with essential tremors. Reassurance may be the first action, but the symptoms will not subside. Beta blockers are used when the tremor is functionally or socially problematic. It is not necessary to refer to an ED or a specialist.

A patient reports two episodes of visual disturbances and eye pain that lasted 1 to 2 days each about 2 months apart. Which diagnostic testing will the provider order initially? Lumbar puncture Magnetic resonance imaging (MRI) Optical Coherence Tomography (OCT) Visual evoked potential

ANS: B Visual disturbances and eye pain may be the only presenting symptoms and should be investigated. The MRI is the gold standard for diagnosis of multiple sclerosis (MS). The other tests may be performed if the diagnosis is unclear or if MRI is not readily available.

An elderly patient has symptoms of depression and the patient's daughter asks about possible Alzheimer's disease (AD) since there is a family history of this disease. A screening evaluation shows no memory loss. What is the initial step in managing this patient? Order brain imaging studies such as CT or MRI. Perform genetic testing to identify true risk. Prescribe a trial of an antidepressant medication. Recommend a trial of a cholinesterase inhibitor drug.

ANS: C Elderly patients with depression who do not have other signs of AD may be given a trial of antidepressant medications initially in order to evaluate these symptoms. Brain imaging studies are not indicated initially. Genetic testing is not indicated. Once the degree of depression is determined and if other symptoms appear, an anticholinesterase inhibitor may be ordered.

A previously lucid patient with early-stage Alzheimer's disease is hospitalized after a surgical procedure and exhibits distractibility and perceptual disturbances that occur only in the late afternoon. The patient has difficulty sleeping at night and instead sleeps much of the morning. What is the likely cause of these symptoms? Hyperactive delirium Hypoactive delirium Sundowner syndrome Worsening dementia

ANS: C Patients with dementia are at increased risk of sundowner syndrome, characterized by the symptoms above and which typically appear in late afternoon and early evening. Hyperactive delirium is manifested by agitation and restlessness. Hypoactive delirium includes patients with decreased alertness, lethargy, and slowed speech. Delirium and worsening of dementia would cause symptoms around the clock, not just in the late afternoon or evening.

A patient exhibits visual field defect, ataxia, and dysarthria and complains of a mild headache. A family member reports that the symptoms began several hours prior. An examination reveals normal range of motion of the neck. What type of cerebrovascular event is most likely? Hemorrhagic stroke Hypertensive intracerebral hemorrhage Ischemic stroke Transient ischemic attack (TIA)

ANS: C Patients with ischemic stroke typically do not have headache; if they do, it is milder than with hemorrhagic stroke. A TIA resolves within minutes.

The spouse of a patient newly diagnosed with amyotrophic lateral sclerosis (ALS) asks about long-term care. What will the provider include when teaching the family about this disease? Bowel and bladder function will eventually be lost. Positive-pressure ventilation can prolong life. c. Preventing malnutrition is a key element in care. d. The nerves affecting sensation will die initially.

ANS: C Prevention of malnutrition may improve both the quality and length of life. Bowel and bladder function and sensation remain intact. Positive-pressure ventilation helps to relieve sleep disturbance.

A primary care provider suspects Parkinson's disease (PD) in a patient. Which tests may be performed to diagnose this disorder? Neuroimaging to identify specific midbrain lesion Neuromuscular studies to identify reflex function Presence of 2 cardinal signs which improve with levodopa Serum creatine phosphokinase levels

ANS: C The diagnosis of idiopathic PD is made based on clinical presentation and examination findings with 2 of 3 cardinal manifestations present which respond to dopaminergic therapy. Neuroimaging that identifies Lewy bodies is the gold standard but is performed post-mortem. Neuromuscular studies and serum laboratory studies are not useful unless excluding other causes of symptoms.

An elderly patient is brought to the emergency department after being found on the floor after a fall. The patient has unilateral sagging of the face, marked slurring of the speech, and paralysis on one side of the body. The patient's blood pressure is 220/190 mm Hg. What is the likely treatment for this patient? Carotid endarterectomy Close observation until symptoms resolve Neurosurgical consultation Thrombolytic therapy

ANS: C This patient has signs consistent with hemorrhagic stroke and will need consultation with a neurosurgeon to determine whether surgical intervention will be beneficial. Carotid endarterectomy is performed in patients with carotid stenosis and is used in patients with hemispheric ACVS (TIA). Patients with TIA may be observed to monitor symptoms. Thrombolytic therapy is given to patients with ischemic stroke.

A patient reports paroxysms of burning, shock-like pain on both sides of the face usually triggered by chewing or talking. The provider suspects trigeminal neuralgia. Based on these presenting symptoms, what testing is indicated? Autoimmune laboratory panel Inflammatory markers Magnetic resonance imaging (MRI) Plain radiographs

ANS: C Trigeminal neuralgia is a clinical diagnosis. Pain on both sides of the face raises a suspicion for multiple sclerosis and MRI is done to corroborate the presence of MS. Autoimmune laboratory pane is performed if alternative diagnoses are suspected. Inflammatory markers are not diagnostic. Plain radiographs are not indicated.

What are initial approaches when managing delirium in a hospitalized patient who is agitated and confused? (Select all that apply.) Administer medications for sleep. Apply physical restraints. Attend to hydration and toileting needs. Decrease stimulation. Discontinue any non-essential medications.

ANS: C, D, E Patients with delirium should be assisted with hydration and toileting needs. Stimulation should be decreased. Any non-essential medications should be discontinued. Giving medications for sleep may exacerbate the delirium. Physical restraints should be avoided unless necessary for safety.

A patient diagnosed with multiple sclerosis and begins disease modulating therapy (DMT) drugs. As part of the counseling about this therapy, the provider will tell the patient that this regimen will likely result in what outcome? A decreased need for other medications An induced long-term remission A reduction in the exacerbation rate A permanent stop of the disability

ANS: CDisease modulating therapy will reduce the rate of exacerbations of symptoms. It does not decrease the need for other medications, induce long-term remission, or stop the progression of the disease.

Following an upper respiratory infection, a patient begins to develop ataxia and distal paresthesias, along with oculomotor symptoms and double vision. Based on these presenting symptoms which type of Guillain-Barré syndrome (GBS) does this patient have? Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) Acute motor axonal neuropathy (AMAN) Classic Guillain-Barré syndrome Miller Fisher syndrome (MFS)

ANS: D Miller Fisher syndrome has oculomotor symptoms. Patients with this type tend to peak sooner and recover more completely and quickly.

A patient diagnosed with trigeminal neuralgia has tried several medication regimens to control pain without success. What is the next step in management for this condition? Consultation with a psychiatrist Education about alternative treatments Recommending a pain center Referral to a neurosurgeon

ANS: D Referral to a neurosurgeon is indicated after medical therapies have been exhausted. The other options may be included in long-term care, but a neurosurgery referral is warranted

A patient with a seizure disorder has seizures which begin with a gastric sensation and a feeling of déjà vu. Which site in the brain is the seizure focus? a. Fronta lb. Occipital c. Parietal d. Temporal

ANS: D Temporal sites cause epigastric and déjà vu sensations. Occipital sites causing complex partial seizures will have visual auras that may begin with eye twitching and visual hallucinations. Frontal sites cause dizziness or fear. Parietal sites cause sensory changes, such as numbness, tingling, or pain.

A previously healthy 30-year-old patient is brought to the emergency department with signs of stroke. Diagnostic testing determines an ongoing ischemic cause. The patient's spouse reports that symptoms began approximately 2 hours prior to transport. What is the recommended treatment? Administration of low-molecular-weight heparin Neurosurgical consultation for possible surgery Observation for complications prior to initiating tPA Tissue plasminogen activator (tPA) administration

ANS: DThis patient meets the criteria for tPA administration and it should be begun within 4.5 hours after onset of symptoms. This patient has had symptoms for over 2 hours, so tPA should begin immediately. LMW heparin is not indicated. Neurosurgical intervention is recommended for patients with hemorrhagic stroke.