Rehab Midterm 2

Question 1

define TBI

Answer 1

an alteration in brain function function or other evidence of brain pathology caused by an external force

Question 2

define head injury

Answer 2

a blow to the head or laceration that may occur without causing unjury to the brain

Question 3

define open TBI

Answer 3

occurs when the head is hit by an object that breaks the skull and enters the brain

Question 4

define closed TBI

Answer 4

occurs when the brain is injured but the skull remains intact

Question 5

What GCS score for TBI is mild

Answer 5

. 13 - 15

Question 6

what GCS score for TBI is moderate

Answer 6

.9 - 12

Question 7

What GCS score for TBI is severe

Answer 7

. 3 - 8

Question 8

Common causes of TBI from most common to least

Answer 8

. Falls -35
. Traffic related accidents - 17
. Sports -16
. Assults - 10
. Other - 21

Question 9

Which age group is the most at risk for sustaining TBI

Answer 9

0-4 and 15-19 yo

Question 10

Which age group has the highest rates of hospitalization and death after TBI

Answer 10

greater than 75 yo

Question 11

what is the most common cause of TBI in adults over 65 yo

Answer 11

fall-related injuries

Question 12

what is the most common cause of TBI in 15-19 yo

Answer 12

motor vehicle accidents

Question 13

what are the leading causes of death after TBI from violence

Answer 13

. Self-inflicted - 60
. Intentional assult - 32
. Unintentional - 4

Question 14

Shaken baby syndrome is also known as

Answer 14

inflicted childhood neurotrauma

Question 15

risk factors for SBS

Answer 15

. Mothers less than 19 yo
. Education less than 12 years
. Single
. African american or native american
. Limited parental care
. Newborns less than 28 weeks old

Question 16

what is sbs

Answer 16

shaken baby syndrome

Question 17

how many individuals with tbi test positive for drugs and alcohol

Answer 17

50 percent

Question 18

define primary injury tbi

Answer 18

damage that occurs directly and immediately as a result of trauma to the brain

Question 19

true or false

cerebral contusions are responsible for loss of consciousness

Answer 19

. False (DAI is responsible)

Question 20

cortical contusion causes 2 deficits and is a risk factor for

Answer 20

. Focal cognitive and sensory motor deficits

. Risk for seizures

Question 21

what is the name of cortical contusions that occurs under the impact site

Answer 21

coup injury

Question 22

what is the name of cortical contusions that occurs remots and opposite site of impact

Answer 22

countercoup injury

Question 23

what is the distinguishing feature of tbi

Answer 23

diffuse axonal injurty (DAI)

Question 24

what is DAI

Answer 24

diffuse axonal injurty (DAI)

Question 25

what is DAI

Answer 25

produced by acceleration-deceleration and rotational forces that common results from motor accidents

Question 26

true or false lateral impact leads to poorer outcome in DAI than head-on

Answer 26

. True

Question 27

true or false DAI are responsible for loss of consciousness

Answer 27

. True

Question 28

what is the mechanism for DAI

Answer 28

. Direct axonal shearing | . Disruption of the intra-axonal cytoskeleton

Question 29

deficits due to DAI tend to recover (gradually/quickly)

Answer 29

grandually

Question 30

what is diaschisis. What causes it

Answer 30

. Neuronal disconnection remote from a site of injury but anatomically connected to the damaged area becoming functionally depressed . Caused by DAI or focal contusions

Question 31

diaschisis occurs (remote/local) to the site of injury

Answer 31

diaschisis occurs remote to the site of injury

Question 32

what is EDH and SDH

Answer 32

epidural hematoma and subdural hematoma

Question 33

between skull and dura mater EDH SDH

Answer 33

EDH

Question 34

laceration of underlying dural veins and arteries EDH SDH

Answer 34

EDH

Question 35

meningeal artery is common cause EDH SDH

Answer 35

EDH

Question 36

damage to dural sinuses EDH SDH

Answer 36

EDH

Question 37

lenticular shape EDH SDH

Answer 37

EDH

Question 38

why is EDH a neurologic emergency

Answer 38

EDH quickly expands and rapidly causes neurologic deterioration

Question 39

these are susceptible to shear and rupture from brief high-velocity angular accelerations

Answer 39

bridging veins

Question 40

tearing of bridging veins EDH SDH

Answer 40

SDH

Question 41

angular acceleration shears vessels located in the subarachnoid EDH SDH

Answer 41

SDH

Question 42

between dura mater and aracchnoid mater EDH SDH

Answer 42

SDH

Question 43

crescent shape EDH SDH

Answer 43

SDH

Question 44

what is secondary injury in TBI

Answer 44

any damage to brain tissue that takes place after the initial injury. Develops over hours and days later

Question 45

secondary injury is associated with

Answer 45

``` . Disruption of cerebral blood flow and metabolism . Massive release of neurochemicals . Cerebral edema . Disruption of ion homeostasi . Brain swelling . Increased levels of EAA . Increase lactate levels . Mitochondrial dysfunction ```

Question 46

response to the initial injury and early events involved with secondary injury

Answer 46

Brain swelling which causes . Increase ICP . Decrease cerebral perfusion pressure (CPP)

Question 47

chronic period after injury is characterised by

Answer 47

multiple neurotransmitter deficits and cellular dysfunction

Question 48

mechanisms by which TBI recovery occurs

Answer 48

. Reversal of diaschisis | . Resolution of cerebral edema and blood flow

Question 49

GCS of eye open spontaneously

Answer 49

. 4

Question 50

GCS of eye open to verbal command

Answer 50

. 3

Question 51

GCS of eye open to painful stimuli

Answer 51

. 2

Question 52

GCS of eye has no opening

Answer 52

. 1

Question 53

GCS of verbal oriented and converse

Answer 53

. 5

Question 54

GCS of verbal disoriented and converses

Answer 54

. 4

Question 55

GCS of verbal inappropriate words

Answer 55

. 3

Question 56

GCS of verbal incomprehensible sounds

Answer 56

. 2

Question 57

GCS of verbal has no response

Answer 57

. 1

Question 58

GCS of motor obeys verbal commands

Answer 58

. 6

Question 59

GCS of motor purposeful localization

Answer 59

. 5

Question 60

GCS of motor withdrawl

Answer 60

. 4

Question 61

GCS of motor flexor posturing

Answer 61

. 3

Question 62

GCS of motor extensor posturing

Answer 62

. 2

Question 63

GCS of motor no response

Answer 63

. 1

Question 64

what is criteria for mild TBI

Answer 64

. Confusion, disorientation, loss of consciousness for less than 30 minutes, PTA for less than 24 hours, or other abnormalities . GCS score of 13 to 15 after 30 minutes

Question 65

common symptoms of concussion

Answer 65

memory loss, poor concentration, impaired emotional control, posttraumatic headaches, sleep disorders, fatigue, irritability, dizziness

Question 66

what is post concussion syndrom

Answer 66

concussion symptoms persisting between 3 and 12 months DSM: cognitive deficits and 3 or more subjective symptoms for at least 3 months

Question 67

mainstay of monitoring after TBI

Answer 67

ICP using ventriculostomy

Question 68

why is ventriculostomy precedure of choice

Answer 68

allows for therapeutic CSF drainage

Question 69

ICP monitoring is appropriate for

Answer 69

GCS score of 8 or less and head CT showing contusion or edema OR systolic 90

Question 70

define elevated ICP

Answer 70

20 - 25 mmHg

Question 71

maneuvers to decrease ICP

Answer 71

``` . Elevating the head of the bed 30 degrees . Treatment of hyperthermia . Mannitol administration . Sedation . Brief hyperventilation ```

Question 72

define CPP

Answer 72

CPP = MAP - ICP pressure gradient driving cerebral blood flow

Question 73

desired CPP in adults

Answer 73

60 mmHg

Question 74

how to directly measure ischemia

Answer 74

cerebral oxygen tension

Question 75

secondary complications of TBI

Answer 75

. Elevated glucose levels: increased mortality, increase lactic acid, impair phosphorus metabolism . Sodium imbalance: risks for seizure, volume status, hyponatremia

Question 76

physiologic measurements during acute care of TBI and why

Answer 76

. Pupillary reflexes: determining lesion location, mortality, and global outcome

Question 77

what are the neuroimaging techniques for TBI. Which is standard

Answer 77

CT scan: standard with suspected moderate to severe TBI MRI: less able to detect skull fracture and acute blood

Question 78

pathologic unconsciousness Coma Vegetative State Minimally conscious state

Answer 78

Coma

Question 79

evidence of wakefulness without sustained or reproducible responses to environment Coma Vegetative State Minimally conscious state

Answer 79

Vegetative State

Question 80

reproducible evidence of self-awareness or environmental awareness Coma Vegetative State Minimally conscious state

Answer 80

Minimally conscious state

Question 81

how to evaluate pt with depressed levels of consciousness

Answer 81

. Pupillary response . Brain stem reflexes . Ocular movements

Question 82

what are the brain stem reflexes

Answer 82

corneal reflexes gag reflex oculocephalic reflexes (Doll's eyes)

Question 83

used to evaluate post traumatic amnesia

Answer 83

GOAT: Galveston Orientation and Amnesia Test

Question 84

LCFS: Ranchos Levels of Cognitive Functioning Scale is used for

Answer 84

describe the process of cognition recovery as individual emerges from coma also for method of assesing pt functioning for purposes of rehabilitation

Question 85

TBI complications

Answer 85

``` . Posttraumatic seizures (PTS) . Heterotrophic ossification (HO) . Deep venous thrombosis . Swallowing and nutrition . Bowel and bladder dysfunction . Airway and pulmonary management . Spacticity and contractures . Normal pressure hydrocephalus . endocrine dysfunction ```

Question 86

PTS accounts for how many symptomatic seizures? Seizures in general population?

Answer 86

symptomatic - 20 general - 5

Question 87

# Define PTS immediate early period late

Answer 87

immediate - less than 24 hours early period - 24 hours to 7 days late - more than 7 days

Question 88

common treatment and prophylaxis for PTS

Answer 88

Phenytoin (Dilantin)

Question 89

what is HO

Answer 89

ectopic bone formation

Question 90

common prophylactic methods of HO

Answer 90

indomethacin, irradiation, Ca binding chelating agents: etidronate

Question 91

What is spasticity? Is it upper or lower motor neuron

Answer 91

velocity dependent increase in tonic stretch reflexes with exaggerated tendon jerk responses upper motor neuron

Question 92

other than spacticity, what are other symptoms of upper motor neuron injury

Answer 92

. Loss of autonomic control . Decreased dexterity . Limb weakness

Question 93

how is limb weakness assesed

Answer 93

Modified Ashworth Scale - based on the amount of resistance

Question 94

define clinidal agitation

Answer 94

agitationi occuring during altered state of consciousness

Question 95

what classes of treatment are used for PTS

Answer 95

. Atypical antipsychotic (AAP) . B blockers . Benzodiazepines

Question 96

Atypical antipsychotic (AAP) used for PTS

Answer 96

quetiapine | D2 receptor agonist

Question 97

. B blockers used for PTS

Answer 97

propranolol

Question 98

. Benzodiazepines used for PTS

Answer 98

GABA-A receptor antagonist that can reduce agitation symptoms

Question 99

definitions of stroke

Answer 99

non-traumatic brain injury caused by occlusion or rupture of cerebral blood vessels - results in sudden focal neurological deficit

Question 100

what rank is stroke for cause of death

Answer 100

3rd

Question 101

What are the modifiable risk factors of stoke

Answer 101

``` . Hypertension . Heart disease . Hypercholesterolemia . DM . Elevated hematocrit . Elevated homocyseine . Elevated fibronogen ```

Question 102

. Hypertension increases risk of stroke by | . And treatment

Answer 102

. Systolic pressure >165 mmHg and diastolic > 95 . Farmingham study and RCT metaanalysis . 35 percent reduce with reduction 10-15 systolic and 5-6 diastolic

Question 103

. Heart disease increases risk of stroke by | . And treatment

Answer 103

LVH, CHF, non-vascular AF increase by 2-6x . AF increase risk of cerebral infarction 5x . Warfarin and aspirin

Question 104

. Hypercholesterolemia increases risk of stroke by | . And treatment

Answer 104

``` . Development of atherosclerosis . LDL < 100 . HDL > 60 . Total < 200 . HMG-CoA reductase or statins ```

Question 105

. DM increases risk of stroke by | . And treatment

Answer 105

doubles risk of stroke

Question 106

. Elevated hematocrit increases risk of stroke by | . And treatment

Answer 106

no treatment

Question 107

. Elevated homocyseine increases risk of stroke by | . And treatment

Answer 107

enhance atherogenesis and hyper coagulabiity | . Vitamin B6 and folic acid

Question 108

Treatment of heart disease to prevent stroke

Answer 108

with AF: anticoagulation, warfarin without AF: aspirin 325 mg OD

Question 109

Chances of surving next 5 years after stroke stroke plus hypertension and heart disease stroke plus hypertension or heart disease stroke with heart disease

Answer 109

stroke plus hypertension and heart disease - 25stroke plus hypertension or heart disease - 50 stroke with heart disease - 75

Question 110

what are the ischemic etiologies of stroke

Answer 110

thrombosis emboli lacunar

Question 111

what are the hemorrhagic etiologies of stroke

Answer 111

intracerebral hemorrhage | subarachnoid hemorrhage

Question 112

thrombosis stroke etiology

Answer 112

. large extracracial and intracranial vessels | . Occurs at night

Question 113

emboli stroke etiology

Answer 113

``` . Arise from heart . From Large extracranial arteries: aorta and carotid . Paradoxical . Lodge in small cortical vessels . Abrupt . Commonly MCA . Lysis and reperfusion . Hemorrhagic transformation ```

Question 114

lacunar etiology

Answer 114

. Small lesions: 1.5 cm . Occlusion in the deep branches of cortical structures . Disrupts pure motor, pure sensory, and motor-sensory

Question 115

lacunar stroke syndrome that is pure motor

Answer 115

dysarthria-clumsy hand

Question 116

lacunar stroke syndrome that is pure sensory

Answer 116

ataxic hemiparises

Question 117

lacunar stroke syndrome that is sensory motor

Answer 117

hemiballismus

Question 118

what type of stroke occurs at night

Answer 118

cerebral thrombosis

Question 119

what type of stroke has sudden onset

Answer 119

cerebral embolism

Question 120

intracerebral stroke etiology

Answer 120

``` . Small, deep, penetration arteries . Charcot-Bouchard aneurysm . Onset is dramatic . High mortality . High rate of recovery ```

Question 121

what type of stroke is the most dramatic

Answer 121

intracerebral hemorrhage

Question 122

subarachnoid hemorrhave stroke etiology

Answer 122

. Saccular aneurysm - small defect in the wall of arteries . Coma . Dramatically abrupt . AV malformation - web dilated vessels . Seizure or chronic headache

Question 123

which stroke is described as worst headache of life

Answer 123

subarachnoid hemorrhage

Question 124

``` The most common cause of hemorrhagic stroke is: A) Ruptured aneurysm B) Arteriovenous malformation C) Hypertension D) Amyloid angiopathy ```

Answer 124

C) The most common cause of hemorrhagic stroke is uncontrolled hypertension

Question 125

``` In a patient with symptoms of a stroke, which of the following is the fi rst-line diagnostic radiological test? A) MRI of the brain B) Carotid Dopplers C) MRA of the head D) CT brain without contrast ```

Answer 125

D) Noncontrast CT of the brain is the fi rst-line diagnostic radiological test done in a patient with symptoms of stroke. This is done to rule out an intracranial bleed

Question 126

``` Aphasia is an impairment in: A) Language B) Speech C) Phonation D) Swallowing ```

Answer 126

A) Aphasia is an impairment in language. Dysarthria is a motor speech disorder characterized by slow, weak, or uncoordinated movements of speech musculature. Impairment in swallowing is called dysphagia. Impairment in the ability to produce sounds is dysphonia.

Question 127

``` Wernicke’s aphasia is characterized by intact: A) Naming B) Comprehension C) Repetition D) Fluency ```

Answer 127

D) Wernicke’s aphasia is a fl uent aphasia and is characterized by impaired naming, comprehension, and repetition.

Question 128

``` Spatial neglect is more commonly seen in: A) Dominant hemisphere infarcts B) Nondominant hemisphere infarcts C) Brainstem strokes D) Cerebellar strokes ```

Answer 128

B) Spatial neglect is more often seen with nondominant middle cerebral artery infar

Question 129

``` Unawareness of illness in patients with spatial neglect is called: A) Asomatognosia B) Anosodiaphoria C) Anosognosia D) Apraxia ```

Answer 129

C) Unawareness of illness in patients with spatial neglect is called anosognosia. Asomatognosia is a condition where patients do not recognize that parts of their body belong to them. When patients with spatial neglect appear unconcerned or joke about their disability, it is called anosodiaphoria. Apraxia is a disorder of motor planning when strength, sensation, and coordination are intact

Question 130

``` Which of the following cranial nerves is not involved in the swallowing function? A) Trigeminal nerve B) Spinal accessory nerve C) Glossopharyngeal nerve D) Hypoglossal nerve ```

Answer 130

B) The spinal accessory nerve does not have a role in the swallowing mechanism.

Question 131

The gold standard for assessment of swallowing function is: A) Bedside swallow evaluation B) Video fl uoroscopic swallowing study (VFSS) C) Fiberoptic endoscopic evaluation of swallowing (FEES) D) Esophagoscopy

Answer 131

B) The VFSS is the gold standard in swallowing assessment. FEES is a bedside procedure in which a nasally inserted fl exible endoscope is used to directly view the nasopharynx and larynx during swallowing. A bedside swallow examination may miss silent aspiration. Esophagoscopy is useful in assessing anatomical abnormalities of esophagus.

Question 132

``` The following is not a phase of swallowing: A) Oral phase B) Lingual phase C) Esophageal phase D) Pharyngeal phase ```

Answer 132

B) The three phases of swallowing include the oral, pharyngeal, and esophageal phases

Question 133

``` Predictors of aspiration on a bedside swallow exam include all of the following except: A) Tachycardia B) Cough C) Voice change after swallow D) Dysphonia ```

Answer 133

A) Predictors of aspiration on bedside swallow exam include abnormal cough, cough after swallow, dysphonia, dysarthria, abnormal gag refl ex, and wet vocal quality after swallow.

Question 134

``` Factors increasing the risk of urinary incontinence after a stroke include all of the following except: A) Male sex B) Advanced age C) Greater stroke severity D) Diabetes mellitus ```

Answer 134

A) Factors increasing the risk of urinary incontinence include advanced age, greater stroke severity, and diabetes.

Question 135

What is the greatest predictor of community ambulation after a stroke? A) Use of an assistive device B) Walking speed C) Degree of lower extremity motor strength D) Type of stroke

Answer 135

B) The greatest predictor of community ambulation after a stroke is walking speed according to a study conducted by Perry et al.

Question 136

Baclofen is an antispasticity agent that is: A) A structural analogue of gamma amino butyric acid (GABA) B) An alpha-2 adrenergic agonist C) A hydantoin derivative D) An imidazoline derivative

Answer 136

A) Baclofen is a structural analogue of GABA, which is one of the main inhibitory neurotransmitters in the central nervous system.

Question 137

``` Which of the following is a side effect of tizanidine, a medication used in spasticity? A) Abnormal renal function tests B) Somnolence C) Cardiac toxicity D) Electrolyte abnormalities ```

Answer 137

B) One of the common side effects of tizanidine is drowsiness or somnolence. Other side effects may include hypotension, dizziness, weakness, dry mouth, and elevated liver functions

Question 138

``` The goals of intrathecal baclofen therapy in patients with poststroke spastic hypertonia include all of the following except: A) Improved positioning and hygiene B) Prevention of complications C) Ease caregiver burden and time D) Initiate ambulation ```

Answer 138

D) The goals of intrathecal baclofen therapy in patients with poststroke hypertonia include improved positioning, facilitation of hygiene, prevention of complications, ease caregiver burden, orthotic fi t and compliance, and decreased pain due to nighttime spasms

Question 139

Shoulder subluxation after stroke: A) Occurs late in the recovery phase B) Is always associated with pain C) Is associated with fl accid hemiplegia D) Will need radiological studies for diagnosis

Answer 139

C) Shoulder subluxation tends to occur early after a stroke in patients with fl accid hemiplegia. Although shoulder subluxation is listed as a common cause of shoulder pain, the relationship between the two remains controversial. The clinical diagnosis of shoulder subluxation can be made without imaging studies.

Question 140

``` Malnutrition and hypoalbuminemia have been associated with which of the following in acute rehabilitation stroke patients? A) Better functional outcome B) Higher complication rate C) Shorter length stay D) Improved functional improvement rate ```

Answer 140

B) Malnutrition and hypoalbuminemia have been associated with poorer functional outcomes, higher complication rates, longer length of stay, and reduced functional improvement rates in acute rehabilitation stroke patients

Question 141

``` Common medical complications after stroke include all of the following except: A) Infections B) Falls C) Thrombosis D) Anemia ```

Answer 141

D) The common medical complications after a stroke include both urinary and chest infections, falls, deep vein thrombosis, decubitus ulcers, and pain. Anemia may be an associated fi nding, but is not reported as a common complication.

Question 142

``` All of the following are associated with poor performance behind the wheel for driving evaluation after a stroke except: A) Right hemisphere location of stroke B) Visual perceptual defi cits C) Aphasia D) Poor judgment or impulsivity ```

Answer 142

C) Aphasia may affect performance on written and road tests, but does not always interfere with self-directed driving

Question 143

All of the following are features of lateral medullary syndrome except: A) Hemiplegia B) Dysphagia C) Ipsilateral facial hemisensory defi cit D) Palate and vocal cord paralysis

Answer 143

A) As the corticospinal tract is a medial structure, lateral medullary syndrome, also known as Wallenberg syndrome, does not cause motor paralysis

Question 144

All of the following are accepted options for initial therapy for patients with noncardioembolic ischemic stroke except: A) Coumadin B) Aspirin C) Clopidogrel D) Combination of aspirin and extended release dipyridamole

Answer 144

A) Aspirin, clopidogrel, and combination of aspirin and extended release dipyridamole are accepted options for initial therapy for patients with noncardioembolic ischemic stroke. Anticoagulant therapy with Coumadin is recommended in the setting of embolic stroke unless there are contraindications

Question 145

Which of the following is a contraindication for administration of tissue plasminogen activator (tPA)? A) Stroke symptom onset less than 3 hours B) Platelet count greater than 100,000 C) INR less than 1.7 D) History of recent myocardial infarction (MI) within 3 months

Answer 145

D) A history of MI within 3 months is a contraindication for tPA. The other answers are requirements for giving tPA in the setting of an acute stroke

Question 146

Which of the following statements regarding National Institute of Health (NIH) stroke scale is incorrect? A) It requires training and certifi cation B) It is valuable in quantifying defi cits after a stroke C) It may help in predicting posthospital disposition D) Elements of brainstem function are well reflected

Answer 146

D) Some of the limitations of the NIH stroke scale are that elements of brainstem function are not well refl ected, palatal weakness is not scored, it does not assess distal weakness, and it does not screen for neurocognitive dysfunction

Question 147

``` Physiological factors that account for stroke recovery include all the following except: A) Side of stroke B) Resolution of poststroke edema C) Reperfusion of ischemic penumbra D) Cortical reorganization ```

Answer 147

A) The physiological factors that account for stroke recovery include resolution of poststroke edema, reperfusion of ischemic penumbra, resolution of diaschisis, and cortical reorganization

Question 148

``` What is the most important modifi able risk factor for ischemic and hemorrhagic stroke? A) Hypertension (HTN) B) Gender C) Race D) Age ```

Answer 148

A) HTN is the most important modifi able risk factor in both ischemic and hemorrhagic stroke. In fact, studies have shown that patients with blood pressure less than 120/80 have about half the lifetime risk of stroke as compared with those with high blood pressure. The other risk factors listed are nonmodifi able.

Question 149

``` In a transient ischemic attack (TIA), the symptoms last for: A) > 24 hours B) < 24 hours C) > 48 hours D) > 1 week ```

Answer 149

B) In a patient with TIA, the symptoms will resolve in less than 24 hours. On the other hand, in a stroke, the symptoms persist for over 24 hours and may never fully resolve.

Question 150

``` A patient diagnosed with alexia is unable to: A) Read B) Write C) Recognize D) Calculate ```

Answer 150

A) Alexia is an inability to read. Agraphia is an inability to write. Agnosia is an inability to recognize objects, people, sounds, smells, or shapes. Acalculia is an inability to perform mathematical tasks

Question 151

``` A stroke affecting the right hemisphere of the brain will usually cause weakness on the: A) Ipsilateral side B) Contralateral side C) Bilaterally D) None of the above ```

Answer 151

B) The right hemisphere of the brain controls the left side of the body, and the left brain hemisphere controls the right side of the body

Question 152

``` Patients complaining of having “the worst headache” of their life should raise suspicions of a/an: A) Migraine headache B) Subdural hematoma C) Subarachnoid hemorrhage D) Epidural hematoma ```

Answer 152

C) A subarachnoid hemorrhage is usually caused by the rupture of an aneurysm. The blood irritates the meninges, causing a severe headac

Question 153

``` On a computed tomography (CT) scan, a hemorrhage would appear: A) Black B) White C) Grey D) None of the above ```

Answer 153

B) On a CT scan, blood appears hyperdense (radiopaque) and will show up white

Question 154

``` A suspected intracranial hemorrhage would require a computed tomography (CT) of the head: A) With contrast B) Without contrast C) With and without contrast D) Would not require a CT of the head ```

Answer 154

B) The head CT would usually be done without contrast since both contrast and blood would appear as white on the scan, making diagnosis more diffi cult.

Question 155

``` In a patient with a stroke, the intracranial pressure (ICP) should be kept at: A) > 20 mm Hg B) > 40 mm Hg C) < 20 mm Hg D) > 80 mm Hg ```

Answer 155

C) ICP ≤ 15 is considered normal. In a patient with a stroke, you want to keep the ICP as close to normal as possible. Increased ICP reduces cerebral blood perfusion. Central perfusion pressure (CPP) should remain > 60 mm Hg.

Question 156

The inclusion criterion for tissue plasminogen activator (tPA) is: A) 18 years of age or older with informed consent B) Head computed tomography (CT) negative for blood C) Well-established time of onset less than 3 hours before treatment initiation with moderate to severe stroke symptoms D) All of the above

Answer 156

D) All of the above are required before tPA is administered to a patient with acute stroke.

Question 157

``` In a patient with transcortical mixed aphasia, the patient will have: A) Fluent speech B) Good comprehension C) Preserved repetition (echolalia) D) None of the above ```

Answer 157

C) In a patient with transcortical mixed aphasia, the speech is nonfl uent and the patient is unable to comprehend, but repetition is still intact

Question 158

Good prognosis of recovery after stroke is associated with: A) Complete arm paralysis B) Prolonged fl accidity C) Severe proximal spasticity D) Some motor recovery of the hand by 4 weeks

Answer 158

D) If there is some motor recovery of the hand by 4 weeks, there is up to a 70% chance of making a complete or almost complete recovery.

Question 159

``` Overall, the most common cause of severe traumatic brain injury (TBI) is: A) Alcohol (ETOH) intoxication B) Falls C) Motor vehicle accidents (MVA) D) Assault ```

Answer 159

C) MVA accounts for approximately 50% of all TBI cases. Assault is the second most common cause

Question 160

``` Techniques to prevent aspiration while eating in a patient with a stroke would include: A) Chin tuck B) Head rotation C) Mendelsohn maneuver D) All of the above ```

Answer 160

D) All of the above mentioned maneuvers prevent aspiration by providing airway protection. Tucking the chin helps prevent liquid from entering the larynx. Head rotation (turning the head toward the paretic side) helps force the bolus of food into the contralateral pharynx. The Mendelsohn maneuver involves having the patient voluntarily hold the larynx at its maximal height to increase the duration of the cricopharyngeal opening

Question 161

``` Risk factors for disability after a stroke would include all of the following except: A) Bilateral lesions B) Severe neglect C) Young age D) Delay in rehabilitation ```

Answer 161

C) The prognosis for recovery is better in a younger individual

Question 162

``` Traumatic brain injuries (TBI) in elderly patients are most frequently due to: A) Falls B) Motor vehicle accidents C) Alcohol (ETOH) abuse D) Assault ```

Answer 162

A) In the elderly population, gait and visual disturbances lead to falls, which cause most of the TBIs in the elderly.

Question 163

Epidural hematoma occurs most frequently from: A) Rupture of the middle meningeal artery B) Arteriovenous malformation C) Shearing of bridging veins between pia-arachnoid and the dura D) None of the above

Answer 163

A) Epidural hematoma usually results from a skull fracture in the temporal bone crossing the vascular territory of the middle meningeal arte

Question 164

``` Of the following disorders of consciousness, which would have the best prognosis? A) Coma B) Vegetative state C) Minimally conscious state D) None of the above ```

Answer 164

C) In a minimally conscious state, the patient will be able to show some evidence of self or environmental awareness and will show evidence of purposeful behaviors.

Question 165

In decerebrate posturing, there is: A) Flexion of the upper and lower extremities B) Extension of the upper and fl exion of the lower extremities C) Flexion of the upper and extension of the lower extremities D) Extension of the upper and lower extremities

Answer 165

D) In decerebrate posturing, the limbs will be stiff and extended with internal rotation of arms and ankles in plantar fl exion. In patients with decorticate posturing, the legs are extended and the arms are fl exed and adducted

Question 166

``` A Glasgow Coma Scale (GCS) score of 3 to 8 would indicate: A) Death B) Severe traumatic brain injury (TBI) C) Mild TBI D) Moderate TBI ```

Answer 166

B) A GCS score 3 to 8 = severe TBI (coma). A GCS score of 9 to 12 = moderate TBI. A GCS score of 13 to 15 = mild TBI.

Question 167

``` Uncal herniation would cause compression of: A) Cranial nerve (CN) III B) CN I C) CN VII D) CN X ```

Answer 167

A) Uncal herniation causes compression of the CN III, which may lead to complete ipsilateral CN III palsy (fi xed pupil dilation, ptosis, and ophthalmoplegia).

Question 168

A fi rst-line intervention for posttraumatic agitation would be: A) Placing patient in a quiet room and limiting the number of visitors B) Restraining the patient C) Medicating the patient D) Getting a psychiatric evaluation

Answer 168

A) The fi rst step would be to create a low-stimulus environment for the patient.

Question 169

Which of the following may be helpful for a traumatic brain injury (TBI) patient with bladder and bowel dysfunctions? A) Frequent toileting B) Anticholinergics C) Condom catheter for men and absorbent pads for women D) All of the above

Answer 169

D) All of the above are appropriate interventions for a TBI patient with bowel and bladder dysfunction.

Question 170

Dysarthria involves all of the following except: A) Chewing and swallowing diffi culty B) Hoarseness C) Drooling D) Complete movement of the lip, tongue, and jaw

Answer 170

D) In dysarthria, there are limited lip, tongue, and jaw movements.

Question 171

``` Risk factors for developing poststroke depression include: A) Lack of social support B) Cognitive impairment C) High severity of defi cits D) All of the above 49 ```

Answer 171

D) All of the above are risk factors for poststroke depression

Question 172

Seizures in stroke patients are associated with: A) Large parietal or temporal hemorrhages B) Older age C) Confusion D) All of the above

Answer 172

50. D) All of the above are associated with seizures in stroke patients.

Question 173

Skin integrity is maintained in stroke patients by all of the following measures except: A) Protection from moisture B) Decreasing patient mobility C) Maintenance of adequate nutrition and hydration D) Frequent position changes

Answer 173

B) Decreased patient mobility will lead to the development of decubitus ulcers. Stroke patients require frequent turning and repositioning.

Question 174

``` A traumatic brain injury (TBI) patient that is confused and inappropriate would be considered a Ranchos level: A) IV B) V C) VI D) None of the above ```

Answer 174

B) A Ranchos level IV patient would be confused and agitated. A level VI patient would be confused and appropriate. Ranchos level refers to the Ranchos Los Amigos scale, which is used in rating recovery from brain injury

Question 175

``` Syndrome of inappropriate antidiuretic hormone (SIADH) is found in: A) Acute stroke B) Chronic traumatic brain injury (TBI) C) Acute TBI D) Chronic stroke ```

Answer 175

C) SIADH is common in the acute TBI period and is characterized by hyponatremia, euvolemia, low blood urea nitrogen (BUN), and decreased blood and increased urine osmolality. Treatment for mild cases includes fl uid restriction, loop diuretics, and monitoring weight and serum sodium level. In patients with severe symptoms, intravenous hypertonic saline can be used

Question 176

``` In “locked-in” syndrome, the patient is: A) Paralyzed with possible preserved vertical gaze and blinking B) Unable to speak C) Awake and sensate D) All of the above ```

Answer 176

D) “Locked-in” syndrome is due to bilateral pontine infarcts or damage affecting the corticospinal and bulbar tracts and sparing the reticular activating system. The patient experiences all of the above mentioned phenomena.

Question 177

``` Aphasia classifi cation is based on which three parts of the language assessment? A) Fluency, repetition, prosody B) Fluency, comprehension, naming C) Fluency, comprehension, repetition D) Comprehension, reading, writing ```

Answer 177

C) Fluent versus nonfl uent speech localizes anterior from posterior aphasic syndromes; impairment in comprehension distinguishes Wernicke’s from conduction aphasia; and the ability to repeat implies that perisylvian language areas are intact

Question 178

A 63-year-old right-handed woman with hypertension suddenly had diffi culty getting words out. Speech was sparse, halting, and labored. She was able to follow three-step commands and repeated words and sentences with 100% accuracy. What kind of aphasia is present in this patient? A) Broca’s aphasia B) Wernicke’s aphasia C) Transcortical sensory aphasia D) Transcortical motor aphasia

Answer 178

D) This aphasic syndrome resembles Broca’s aphasia, but because it involves the extrasylvian region, repetition is intact.

Question 179

A 63-year-old right-handed woman with hypertension suddenly had diffi culty getting words out. Speech was sparse, halting, and labored. She was able to follow three-step commands and repeated words and sentences with 100% accuracy. Where is the most likely location of her lesion? A) Middle cerebral artery-anterior cerebral artery territory (extrasylvian, anterior) B) Middle cerebral artery-posterior cerebral artery territory (extrasylvian, posterior) C) Broca’s area D) Wernicke’s area

Answer 179

A) This refl ects a lesion in the anterior cerebral artery territory (extrasylvian). Nonfl uent (motor) aphasias affect anterior (pre-Rolandic) region

Question 180

You are most likely to see conduction aphasia following damage to: A) The arcuate fasciculus B) The angular gyrus C) Middle cerebral artery-posterior cerebral artery (MCA-PCA) watershed areas D) Middle cerebral artery-anterior cerebral artery (MCA-ACA) watershed areas

Answer 180

A) Conduction aphasia is considered a disconnection syndrome in which speech comprehension (Wernicke’s area) is disconnected via a lesion in the arcuate fasciculus from the speech production area (Broca’s area).

Question 181

``` Which of the following is not a symptom of Gerstmann’s syndrome? A) Agraphia B) Acalculia C) Alexia D) Finger agnosia ```

Answer 181

C) The four components of Gerstmann’s syndrome are fi nger agnosia, acalculia, right-left disorientation, and agraphia.

Question 182

``` A 54-year-old woman experiences a left middle cerebral artery infarction. She presents with impaired comprehension, fl uent speech, impaired naming, and the presence of a homonymous hemianopsia. The most likely diagnosis is: A) Broca’s aphasia B) Conduction aphasia C) Anomic aphasia D) Wernicke’s aphasia ```

Answer 182

D) Although both Wernicke’s aphasia and conduction aphasia are characterized by fl uent speech, only Wernicke’s aphasia also includes impaired comprehen

Question 183

All of the following are reasons to refer for a neuropsychological evaluation or consult except: A) When impairment of cognitive functioning or behavior is suspected B) When medication is being considered for a patient’s mood disorder or behavior C) When you want to track progress of rehabilitation after TBI or other neurological disorder D) To plan treatments that utilize cognitive strengths to compensate for weaknesses

Answer 183

B) Neuropsychologists do not prescribe medication, but do conduct cognitive evaluations and engage in cognitive remediation and psychotherapy.

Question 184

``` Which of the following is not a common condition that a neuropsychologist would evaluate or treat? A) Dementia B) Cerebrovascular accident (CVA) C) Depression D) Neuropathy ```

Answer 184

D) This would be the physiatrist or the neurologist; the neuropsychologist evaluates and treats brain-behavior disorders, not disorders of peripheral nerves.

Question 185

All of the following are true about a neuropsychological evaluation except: A) The same battery of tests is administered to everyone and is always determined in advance B) Testing is noninvasive C) Testing can last from < 1 hour to 6–8 hours or more D) The evaluation includes an interview and mostly paper-and-pencil tests

Answer 185

A) Testing is paper-pencil, ranges from < 1 to 8+ hours, and is tailored to the individual referral question

Question 186

``` All of the following are examples of frontal-subcortical dementia except: A) Normal pressure hydrocephalus B) Frontotemporal dementia C) Vascular dementia D) Parkinson’s dementia ```

Answer 186

B) Frontotemporal dementia is actually a cortical dementia

Question 187

Which of the following dementias is characterized by fl uctuating course, extrapyramidal features, and occasionally visual hallucinations and delusions? A) Alzheimer’s disease B) Frontotemporal dementia C) Lewy body disease D) Dementia pugilistica

Answer 187

C) Lewy body disease.

Question 188

A 55-year-old patient complains of some diffi culty paying attention and episodic memory problems (such as forgetting what she ate yesterday for dinner). She is not depressed. What is the most likely diagnosis (although, of course, you would want to evaluate further)? A) Delirium B) Alzheimer’s disease C) Amnestic disorder D) Normal aging

Answer 188

D) Normal aging is characterized by decreased processing speed and some decrease in attention and episodic memory. Her age would be more consistent with aging, as opposed to Alzheimer’s disease, but may warrant further evaluation.

Question 189

``` Which of the following is true? A) Dementia is necessarily progressive B) Dementia does not always impair memory C) Dementia cannot have acute onset D) Dementia is “global” impairment ```

Answer 189

B) Some like HIV dementia and some of the frontotemporal dementias actually may not impair memory. Dementias can be treatable (e.g., normal pressure hydrocephalus), can be acute (e.g., traumatic brain injury or stroke), and are not always global.

Question 190

``` Which type of memory would be most affected by Alzheimer’s disease? A) Episodic memory B) Remote memory C) Implicit memory D) Procedural memory ```

Answer 190

A) Alzheimer’s disease affects episodic memory.

Question 191

On testing, a 75-year-old former engineer currently has an IQ score that is 2.5 standard deviations below the mean. She is alert and not depressed. What is the most likely diagnosis? A) Delirium B) Dementia C) Amnestic disorder D) Mental retardation

Answer 191

B) This was an acquired (and not congenital) disorder, so dementia rather than mental retardation (MR) would be likely. Given that the patient had been an engineer, MR is unlikely, and since she is alert, delirium is unlikely. Given that other cognitive functions are involved in addition to memory, she does not meet criteria for an amnestic disorder.

Question 192

``` All of the following functions have been shown to be important cognitive predictors of driving ability except: A) Attention B) Memory C) Language D) Executive functioning ```

Answer 192

C) Driving is demanding on attention, memory, and executive functioning (sequencing, planning, shifting, etc), but less so language

Question 193

``` Which test would be most useful as a predictor of driving ability? A) Boston naming test (BNT) B) Clock drawing C) Trailmaking test D) Rorschach inkblot test ```

Answer 193

C) This is the best test of attention and set-shifting (executive functioning); BNT is a language test, clock drawing is a good screen for Alzheimer’s, and the Rorschach is a personality/ psychopathology test

Question 194

Which of the following is not true with regard to assessing a patient’s ability to return to work? A) Assessment of emotional and behavioral functioning is important B) Assessment of academic ability and IQ is not necessary C) Much depends on the demands of the individual’s specifi c job D) Assessment of the patient’s family circumstances is necessary

Answer 194

B) Some aspects of IQ are very good predictors (e.g., mathematics and vocabulary); the other answers are all true

Question 195

Which statement is correct about the Mini Mental Status Examination (MMSE)? A) The MMSE is unfortunately not available in many languages besides English B) The MMSE can be used with patients with at least a fi rst grade education C) The MMSE is a cognitive screening instrument, with a maximum of 20 points D) The MMSE is a cognitive screening instrument, but does not measure executive functioning

Answer 195

D) The MMSE is out of 30 points, requires at least an eighth grade education, and is translated into many languages. It measures executive function

Question 196

Which of the following is least true regarding cognitive rehabilitation? A) Cognitive rehabilitation is informed and guided by theoretical models B) Cognitive rehabilitation’s goal is to increase test scores C) Cognitive rehabilitation focuses on both amelioration of and compensation for defi cits D) Cognitive rehabilitation has a large education component

Answer 196

B) Cognitive rehabilitation strives for ecological validity. It is informed by theory, focuses both on amelioration (through practice) and compensation, and involves much psychoeducation

Question 197

All of the following are common secondary effects of closed head injury except: A) Hypoxia B) Meningeal/cerebral laceration C) Edema D) Intracranial bleeding (e.g., subdural hematoma)

Answer 197

B) This is a primary effect; the others are secondary effects.

Question 198

``` All of the following are common brain areas affected by traumatic brain injury (TBI) except: A) Parietal areas B) Orbitofrontal C) Anterior temporal D) Limbic areas ```

Answer 198

A) TBI commonly affects frontal, temporal, and limbic areas.

Question 199

Which of the following is not true with regard to frontal lobe damage and emotion/ behavior? A) Orbitofrontal damage has been associated with disinhibition B) Orbitofrontal damage has been associated with impulsivity C) Right frontal damage has been associated with depression D) Medial frontal damage has been associated with lack of initiation (abulia)

Answer 199

C) Actually, left frontal damage is typically associated with depression; the rest are true

Question 200

Children who sustain a brain injury early in life sometimes appear to have no residual sequelae. This is because: A) They are resilient and “bounce back” even after severe trauma B) The effects of brain injury sometimes take time to emerge C) Other parts of their brain immediately take over D) They do not really sustain true brain injury

Answer 200

B) Cognitive or behavioral issues may not be evident until that time, developmentally, that child would reach certain milestones; as the child grows and their brain develops, problems may emerge.

Question 201

``` Which of the following is not a recommendation to reduce agitation in traumatic brain injury patients? A) Reduce noise B) Stay calm C) Rest breaks D) Correct confabulations ```

Answer 201

D) Continually correcting patients may confuse or agitate them further; common recommendations are to “go with” their confabulations while they are acutely agita

Question 202

Following a concussion, a player should: A) Be evaluated the same day and not return to play B) Return to play; he is fi ne C) Be evaluated and, if he is fi ne, be allowed to return to play the same day D) Be sent to the ER immediately for admission

Answer 202

A) The 2011 update of the American College of Sports Medicine’s consensus statement on concussion explicitly states no return to play same day.

Question 203

``` Asking a patient to count backward from 100 by 7 (or spell WORLD backward) is a test of: A) Orientation B) Abstraction C) Attention D) Memory ```

Answer 203

C) Specifi cally, sustained attention and concentrat

Question 204

``` The inability to attend to a side of space, usually the left, is referred to as: A) Amnesia B) Neglect C) Disorientation D) Gerstmann’s syndrome ```

Answer 204

B) Visuospatial neglect is often due to right hemisphere damage

Question 205

``` Which of the following syndromes means an inability to recognize or appreciate stimuli? A) Aphasia B) Amnesia C) Apraxia D) Agnosia ```

Answer 205

D) Aphasia is a language disorder; amnesia is a disorder of memory; apraxia is an inability to perform purposeful movements

Question 206

Which of the following tests is most useful for evaluation of memory loss? A) Mini Mental Status Examination (MMSE) B) Galveston Orientation and Amnesia Test (GOAT) C) Ranchos Los Amigos Scale D) Glasgow Coma Scale (GCS)

Answer 206

B) The GOAT is out of 100 points and is useful for assessing severity of posttraumatic amnesia; the MMSE is a cognitive screener, the Ranchos Los Amigos Scale stages recovery from traumatic brain injury, and the GCS measures coma and severity of TBI.

Question 207

Disorientation and transient attentional diffi culties due to infection, medications, electrolyte imbalance, or dehydration is likely to be: A) Delusional disorder B) Dementia C) Amnestic disorder D) Delirium

Answer 207

D) By defi nition, delirium is a temporary state of mental confusion and fl uctuating consciousness, with numerous causes; dementia requires signifi cant decrease in (usually memory) at least two areas of cognitive functioning; amnestic disorder only involves memory.

Question 208

``` Seizures that involve only one region of the brain and do not impair consciousness are called: A) Generalized B) Complex partial C) Simple partial D) Simple generalized ```

Answer 208

C) Simple seizures do not impair consciousness; partial seizures are isolated.

Question 209

``` Generalized seizures that involve only involuntary muscle jerking are called: A) Myoclonic B) Tonic C) Absence D) Tonic–clonic ```

Answer 209

A) Tonic seizures involve “drop attacks” or abrupt falls; absence seizures involve staring or trance-like states; tonic–clonic seizures have both convulsions and stiffening of the body followed by involuntary muscle jerking

Question 210

``` According to the Glasgow Coma Scale (GCS), a severe brain injury would be: A) 13 to 15 B) 0 to 2 C) 8 to 12 D) 3 to 7 ```

Answer 210

D) The Glasgow Coma Scale is from 3 to 15. A score of < 8 indicates a severe brain injury. A score of 9 to 12 indicates moderate brain injury, and a score of 13 or over indicates mild injury.

Question 211

``` A clinical feature of normal pressure hydrocephalus (NPH) is: A) Memory impairment B) Urinary incontinence C) Ataxic gait D) All of the above ```

Answer 211

D) Sometimes called the “3 Ws” for wet, wobbly, and wacky, NPH is characterized by ataxic gait, urinary incontinence, and dementia.

Question 212

``` Which of the following is not a clinical fi nding in Parkinson’s disease? A) Resting tremor B) Hallucinations C) Festinating gait D) Hypophonia ```

Answer 212

B) Hallucinations may be seen in Lewy body disease, which has extrapyramidal features; the rest are fi ndings in Parkinson’s disease

Question 213

``` “Pseudodementia” is best characterized as: A) Malingering B) Delirium C) Normal aging D) Depression ```

Answer 213

D) Pseudodementia, or dementia of depression, often involves impairments in attention, memory, and processing speed, which may resemble dementia

Question 214

``` 92. Which of the following is a benign tumor arising from dural or arachnoid cells? A) Glioma B) Astrocytoma C) Meningioma D) Glioblastoma multiforme ```

Answer 214

C) The dura and arachnoid (as well as the pia) are meninges; thus tumors arising from the meninges are called meningiomas. These are benign tumors, but can grow large and cause mass effect.

Question 215

``` Ischemic strokes are caused by: A) Aneurysm tear B) Intracranial bleeding C) Thrombi or emboli D) All of the above ```

Answer 215

C) Thrombi or emboli involve blockage of blood vessels; the others are hemorrhagic causes of stroke.

Question 216

Parkinson’s disease has been linked to: A) Loss of cholinergic neurons in the nucleus basalis of Meynert B) Loss of dopaminergic neurons in the substantia nigra C) Overproduction of GABA in the caudate nucleus D) Overproduction of dopamine in the basal ganglia

Answer 216

B) Loss of dopaminergic neurons in the substantia nigra.

Question 217

``` What part of the central nervous system (CNS) is affected in multiple sclerosis (MS)? A) Dendritic receptors B) Axon C) Terminal branches D) Myelin sheath ```

Answer 217

D) In MS, the fatty covering surrounding the axon (the myelin sheath) is attacked by the immune system. MS does not affect peripheral nerve myelin.

Question 218

``` Which cortical lobe contains the primary somatosensory cortex? A) Frontal lobe B) Temporal lobe C) Parietal lobe D) Occipital lobe ```

Answer 218

C) Specifi cally, the postcentral gyrus contains the primary somatosensory cortex

Question 219

``` Amnesia for events that occurred before the disturbance to the brain is called: A) Anterograde amnesia B) Retrograde amnesia C) Declarative amnesia D) Korsakoff’s amnesia ```

Answer 219

B) Retrograde amnesia.

Question 220

Which of the following is not characteristic of a grand mal seizure? A) The seizure involves motor convulsions B) The seizure is preceded by an aura C) The seizure has a clonic phase D) The seizure has a spell of absence

Answer 220

D) Grand mal, or tonic–clonic, seizures have both a tonic and clonic phase, involve convulsions, and are often preceeded by an aura; absence spells are characteristic of petit mal, or absence, seizures

Question 221

Damage to the right hemisphere of the brain can cause all of the following except: A) Anosognosia B) Inability to recognize prosody C) Diffi culty analyzing sequences of stimuli D) Diffi culty analyzing the gestalt of stimuli

Answer 221

C) The right hemisphere analyzes the gestalt and emotional prosody of speech and has to do with awareness; the left hemisphere is involved in speech and sequential or linear reasoning.

Question 222

``` Coup-contrecoup injuries in traumatic brain injuries (TBI) are typically concentrated in: A) Frontal and parietal lobes B) Frontal and temporal lobes C) Occipital and parietal lobes D) Subcortical structures ```

Answer 222

B) The frontal lobe is often affected directly in TBI, and the temporal lobes are affected due to the bony protuberances surrounding the temporal region; the coup is the contusion directly beneath the impact; the contre coup is the side opposite the impact.

Question 223

``` Which is the most common dementia accompanied by a peripheral neuropathy? A) Alzheimer’s disease B) Vascular dementia C) Traumatic brain injury dementia D) Wernicke–Korsakoff ```

Answer 223

D) Owing to long-term alcohol abuse and thiamine defi ciency, dementia and peripheral neuropathy often result.

Question 224

``` Which of the following dementias features spongiform cerebral cortex? A) Alzheimer’s dementia B) Creutzfeldt–Jakob disease C) AIDS dementia D) Wilson’s disease ```

Answer 224

B) Caused by a prion, Creutzfeldt-Jakob disease results in spongiform cortex (with an appearance of “Swiss cheese”), dementia, and rapid progression to death.

Question 225

``` Which is the most common cause of falls in the elderly? A) Neuropathy B) Normal pressure hydrocephalus C) Medications, especially sedatives D) TIA ```

Answer 225

C) Medications, especially sedatives

Question 226

``` Which disorder is least associated with a higher incidence of depression? A) Alzheimer’s disease (AD) B) Parkinson’s disease C) Huntington’s disease D) Stroke ```

Answer 226

A) Alzheimer’s disease typically results in apathy early on; the others characteristically (and due to subcortical involvement) involve depression

Question 227

``` Compared with epidural hematomas, subdural hematomas: A) Originate from arterial bleeding B) May develop slowly C) Cause severe headaches D) Are often fatal ```

Answer 227

B) Subdural hematomas are common in the elderly, may occur after a fall or even spontaneously, are due to tearing of weak venous blood vessels, and are often asymptomatic, sometimes resolving on their own or coming to attention only after several days.

Question 228

``` Severity of brain injury is most reliably indicated by: A) Presence of seizure B) Presence of vomiting C) Chronic neck pain D) Length of coma and amnesia ```

Answer 228

D) Seizures, vomiting, and neck pain may not be present and do not reliably indicate the severity of a brain injury.

Question 229

``` Which is the best study for locating white matter plaque in multiple sclerosis or vascular infarcts? A) Computed tomography (CT) B) Electroencephalogram (EEG) C) Magnetic resonance imaging (MRI) D) Lumbar puncture (LP) ```

Answer 229

C) MRI has better resolution of white matter and other soft tissue; CT is better for detecting blood, bone, or shrapnel; EEG measures brain waves, such as in seizure; an LP is used to assess for infectious material in cerebrospinal fl uid.

Question 230

``` Alzheimer’s disease patients are placed in nursing homes primarily because of: A) Wandering B) Memory impairment C) Incontinence D) Hallucinations ```

Answer 230

A) Wandering.

Question 231

``` Pseudobulbar palsy is characterized by: A) Emotional lability B) Dysphagia C) Frontal damage D) All of the above ```

Answer 231

D) From frontal damage, pseudobulbar palsy is due to damage to the upper motor neuron corticobulbar tract.

Question 232

Which of the following is not true with regard to the left hemisphere of the brain? A) Damage results in loss of details B) Damage results in left neglect C) It is the dominant hemisphere for language for right-handers D) It is the dominant hemisphere for language for most left-handers

Answer 232

B) 95% of right-handers and 70% of left-handers are left-dominant for language; the left hemisphere is involved in detail analysis, whereas the right hemisphere is involved in whole/gestalt analysis; left neglect occurs from right hemisphere damage.

Question 233

``` Which behavioral problem, common after brain injury, is frequently confused with depression? A) Impulsivity B) Disinhibition C) Abulia D) Agitation ```

Answer 233

C) Abulia, or lack of initiation, can look like depression and is more of a “negative” symptom, compared with the other “positive” symptoms, from frontal lobe inju

Question 234

Signifi cant amounts of pain are reported by 95% of ________ traumatic brain injury (TBI) patients, but by only 22% of _________ TBI patients. A) Severe; mild B) Mild; severe C) Moderate; mild D) All of the above

Answer 234

B) The most pain is actually reported by patients with mild brain injury; postconcussive syndrome is thought to involve psychiatric as well as cognitive symptoms.

Question 235

``` Repeated concussions may result in: A) Parkinson-like symptoms B) Alzheimer-like neuropathology C) Second impact syndrome D) All of the above ```

Answer 235

D) Chronic traumatic encephalopathy (CTE), or dementia pugilistica, results in extrapyramidal symptoms and Alzheimer pathology. Second impact syndrome results from inability to autoregulate blood pressure after repeat concussion; this hypertensive emergency has resulted in death (in those younger than 18)

Question 236

``` Which are the most commonly injured areas of the brain after a traumatic brain injury (TBI)? A) Occipital and frontal B) Frontal and temporal C) Parietal and frontal D) Occipital and temporal ```

Answer 236

B) Regardless of site of impact, the orbitofrontal and anterior temporal lobes are the most commonly injured sites of the brain because of the close relation of the lobes to the bones

Question 237

Which of the following is not true about diffuse axonal injury (DAI)? A) Primarily occurs at the grey matter B) Only seen in traumatic brain injury (TBI) C) Responsible for loss of conscience (LOC) D) Occurs from acceleration-deceleration and rotational forces

Answer 237

A) DAI is seen in the white matter, primarily in the corpus callosum, midbrain, pons, and central white matter

Question 238

Which best describes someone who is in a vegetative state? A) Eyes are open, eyes are tracking, he or she has sleep-wake cycles B) Eyes are closed, eyes are not tracking, he or she has no sleep-wake cycles C) Eyes are closed, eyes are not tracking, he or she has sleep-wake cycles D) Eyes are open, eyes are not tracking, he or she has sleep-wake cycles

Answer 238

D) A comatose patient has eyes opened and no sleep-wake cycles. A patient in a minimally conscious state (MCS) has eyes open, tracking, and reproducible behavior. Emergence from MCS occurs when there is consistent command following

Question 239

``` What is the Glasgow Coma Scale (GCS) for someone who withdraws from pain, is confused, and opens eyes to pain? A) 6 B) 8 C) 10 D) 12 ```

Answer 239

C) Scoring for withdrawing from pain (without localizing) is 4, confused is 4, and eyes opening to pain 2.

Question 240

``` What is the description of a Rancho Los Amigos level of IV? A) Localized response to stimuli B) Confused with inappropriate behavior C) Confused but appropriate behavior D) Confused and agitated behavior ```

Answer 240

D) Level III is answer choice A (localized response to stimuli), level V is answer choice B (confused with inappropriate behavior), level VI is answer choice C (confused but appropriate behavior).

Question 241

``` What type of bleeding does an injury to the medial meningeal artery cause? A) Subdural hematoma (SDH) B) Epidural hematoma (EDH) C) Subarachnoid hemorrhage (SAH) D) Intracranial hemorrhage (ICH) ```

Answer 241

B) The middle meningeal artery is responsible for causing an EDH. An EDH has a biconvex shape and is rapidly evolving

Question 242

Which of the following is not a description of a subdural hematoma (SDH)? A) Occurs primarily in younger patients B) Clinical fi ndings may sometimes be delayed for weeks C) Caused by an injury to the bridging veins D) Lentiform in shape on imaging

Answer 242

A) SDH occurs primarily in the elderly because of atrophy of the brain and stretching of the bridging veins. This stretching makes them vulnerable to mild trauma to the head. Because it is a vein and there is atrophy, the SDH expands slowly in the space, which can delay symptoms for weeks. Usually, history can reveal a previous fall.

Question 243

``` Which of the following is true about Glasgow Coma Scale (GCS) in traumatic brain injury (TBI)? A) A GCS of 2 is a severe injury B) A GCS of 8 is a moderate injury C) A GCS of 10 is a moderate injury D) A GCS of 12 is a mild injury ```

Answer 243

C) A mild injury is a GCS of 13 to 15, a moderate injury is a GCS of 9 to 12, and a severe injury is a GCS of 3 to 8. The lowest score is a 3 on the GCS.

Question 244

``` What is the most common location of heterotopic ossifi cation (HO) after traumatic brain injury (TBI)? A) Shoulder B) Knee C) Hip D) Elbow ```

Answer 244

C) HO occurs most frequently in the hips, followed by elbows, shoulders, and kne

Question 245

``` Which is the most sensitive test used to identify early heterotopic ossifi cation (HO)? A) X-ray B) Serum alkaline phosphatase C) Computed tomography (CT) scan D) Bone scan ```

Answer 245

D) Phase 1 and 2 of a bone scan can help detect HO within 2 to 4 weeks. To detect HO on x-ray requires bone maturation, which can take as long as 4 weeks. CT scan is not indicated for HO identifi cation, and serum alkaline phosphatase is a nonspecifi c/nonsensitive test.

Question 246

What is the best acute predictor of outcome after a traumatic brain injury (TBI)? A) Best motor response of the Glasgow Coma Scale (GCS) B) Best verbal response on the GCS C) Best eye opening response on the GCS D) Initial GCS score

Answer 246

A) The best motor GCS and the best overall GCS within the fi rst 24 hours is considered to be the best acute predictor of outcome in TBI

Question 247

What does not describe posttraumatic amnesia (PTA)? A) It is a predictor of recovery and outcome in traumatic brain injury (TBI) B) It measures retrograde amnesia C) It is an indication of sustaining ongoing new memories D) It can be assessed using the Galveston Orientation and Amnesia Test (GOAT)

Answer 247

B) PTA assesses anterograde amnesia, the ability to retain ongoing memories, from the time of the TBI to present. Retrograde amnesia is memory loss of events occurring prior to the injury. The GOAT is an objective assessment tool that tracks PTA, where a score of 75 or greater for 2 consecutive days is considered the end of PTA.

Question 248

``` Which is the most commonly injured cranial nerve (CN)? A) CN I B) CN II C) CN VII D) CN VIII ```

Answer 248

A) The olfactory nerve (CN I) is the most commonly injured cranial nerve. Injury to CN I can lead to anosmia and an altered, usually poor, appetite. The injury occurs because of the shearing forces that damage the small nerves on the cribriform plate.

Question 249

How is the severity of a concussion graded? A) Concussion grading scales, such as Cantu and Colorado Head Injury Scales B) Presence of loss of conscious (LOC) C) Presence of posttraumatic amnesia (PTA) D) Severity of ongoing symptoms

Answer 249

D) A concussion is a mild traumatic brain injury and should never be graded with grading scales. The majority of concussions do not have LOC and therefore should not be used as an indication of severity. Concussion severity is determined by the number, severity, and length of symptoms present.

Question 250

``` What is the most common symptom described after a concussion? A) Dizziness B) Poor sleep C) Headache D) Fatigue ```

Answer 250

C) Headaches are the most common symptom experienced after a concussion. The others can also occur, but are not as frequent as headaches

Question 251

What should be initially prescribed to a patient with a traumatic brain injury (TBI) who suffers from insomnia, poor attention, poor memory, depressed mood, and headaches? A) A stimulant to help with the attention B) A sleeping medication and sleep hygiene C) A headache medication D) An antidepressant

Answer 251

B) For a patient with a TBI, sleep is one of the most important aspects of medication management. If it is not addressed, lack of sleep may cause diffi culty with attention, memory, headaches, poor mood, and overall poor general health.

Question 252

How should a behaviorally agitated traumatic brain injury (TBI) patient be managed? A) Restrain them even if not a risk to self or others B) Administer lorazepam or haloperidol to calm them C) Call hospital security to restrain them D) Identify cause of agitation and reorient the patient

Answer 252

D) Agitation from a TBI is caused by confusion and inability to retain memory (posttraumatic amnesia

Question 253

What is considered the most effective method for the prevention of heterotopic ossifi cation (HO)? A) Radiation of bone tissue B) Range of motion C) Nonsteroidal anti-infl ammatory drugs (NSAIDs) D) Diphosphonates

Answer 253

B) Range of motion is the best prophylaxis and treatment of HO. Radiation would have to be given to the whole body because HO development cannot be predicted. NSAIDs and diphosphonates have a role in treatment, but not signifi cantly in prevention

Question 254

``` How long should phenytoin be administered for seizure prophylaxis after a traumatic brain injury (TBI)? A) 1 week B) 6 months C) 1 year D) Indefi nitely ```

Answer 254

A) A study by Temkin et al. determined that phenytoin has been shown to be effective for prophylaxis of seizures when administered for 1 week

Question 255

What is the initial management for a traumatic brain injury (TBI) patient who has a sodium (Na+) of 132, is asymptomatic, and has no signs of dehydration? A) Administer hypertonic saline B) Prescribe demeclocycline C) Give NaCl tablets D) Restrict oral (PO) fl uids

Answer 255

D) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is hyponatremia in the setting of normal hydration, whereas cerebral salt wasting (CSW) is hyponatremia with physical signs of dehydration

Question 256

What is the best recommendation for return to play (RTP) in an adolescent who has sustained a concussion? A) If the athlete has no symptoms after 24 hours, can RTP the next day B) If the athlete has had loss of consciousness (LOC), RTP is delayed for a week C) If the athlete has no symptoms at rest for 24 hours, can begin light aerobic activities D) If the athlete has no symptoms at rest for 7 days, can RTP the next day

Answer 256

C) RTP is a very important decision to maintain safety of athletes. RTP should be based on the graduated RTP protocol. There are six stages, and to progress through each stage, the athlete must be asymptomatic for 24 hours

Question 257

Which of the following statements is correct regarding epidural hematomas (EDH)? A) Bleeding occurs between the dura and the arachnoid mater B) Symptoms develop slowly, over hours or days after injury C) Most commonly associated with venous bleeding D) Patients typically have a lucid interval before the development of neurological symptoms

Answer 257

D) An epidural hematoma occurs between the skull and the dura. It often develops quickly because it is usually secondary to an arterial bleed, such as the middle meningeal artery. Often, patients may have an initial headache with no other complaints. Within hours, patients may develop signifi cant neurological defi cits related to the expansion of the epidural hematoma, such as midline shift and brain stem herniation

Question 258

A 28-year-old woman after motor vehicle accident sustained a traumatic brain injury (TBI). The impact of injury was to the right side of her head, and she now has visual changes consistent with an oculomotor cranial nerve (CN) dysfunction. What would the ocular exam demonstrate? A) Dilation of the ipsilateral pupil B) Constriction of the ipsilateral pupil C) Dilation of the contralateral pupil D) Constriction of the contralateral pupil

Answer 258

A) An injury to CN III would cause ipsilateral dilation of the pupil. Normally, CN III constricts the ipsilateral pupil with light exposure.

Question 259

Which antiseizure medication is associated with disorders of the vestibular and cerebellar systems, such as nystagmus, ataxia, and vertigo as well as gingival hyperplasia? A) Phenobarbital B) Valproic acid C) Phenytoin D) Gabapentin

Answer 259

C) Phenobarbital is often associated with dizziness, irritability, confusion, rash, and cerebellar signs. These side effects usually occur at very high doses. Phenobarbital is not recommended for treatment or prophylaxis of seizures as a result of traumatic brain injury, as it can contribute to poor recovery. Valproic acid commonly causes gastrointestinal dysfunction. Sedation, tremor, and ataxia can also occur. Gabapentin primarily causes fatigue, somnolence, ataxia, and dizziness.

Question 260

``` What neurotransmitter should be enhanced to improve cognitive recovery in patients with a traumatic brain injury (TBI)? A) Norepinephrine B) Dopamine C) Histamine D) Acetylcholine ```

Answer 260

B) Medications such as amantadine, bromocriptine, and methylphenidate are dopaminergic, which assist in improving attention and cognitive function. Histamine has no role in cognitive recovery, except that histamine-2 blockers should be avoided because they cause sedation. Norepinephrine also has a limited role in the treatment of cognition in TBI.

Question 261

``` The key features of cerebral palsy include all of the following except: A) Abnormal movement and posture B) Onset in fi rst 3 years of life C) Nonprogressive D) Mental retardation ```

Answer 261

D) Cerebral palsy is a disorder of movement and posture that occurs in fi rst 2 to 3 years of life, usually from a single event that is nonprogressive. Mental retardation can occur as a result of insult to the brain, but is not a key feature

Question 262

``` The most likely cause of quadriplegic cerebral palsy (CP) is: A) Prematurity (< 32 weeks) B) Perinatal stroke C) Hyperbilirubinemia D) Birth asphyxia ```

Answer 262

D) Prematurity usually causes diplegic CP, as white matter adjacent to the ventricles is affected. Stroke and congenital malformations more frequently cause hemiplegic CP. Hyperbilirubinemia causes athetoid or dystonic CP. Severe anoxia causes diffuse brain injury and hence quadriplegic CP.

Question 263

Good prognostic indications for ambulation in children with cerebral palsy (CP) include all of the following except: A) Independent sitting by 2 years of age B) Fewer than three primitive refl exes by 18 months of age C) Hemiplegic CP D) Term birth

Answer 263

D) Term birth does not signify any specifi c insult or abnormality of movement or posture

Question 264

The American Academy of Neurology suggests screening children with cerebral palsy (CP) for all of the following comorbidities except: A) Mental retardation B) Hearing and vision impairment C) Speech and language delay D) Oromotor dysfunction E) Seizures

Answer 264

E) Children with CP have an increased incidence of seizures, sleep problems, and hydrocephalus, but screening for these conditions is not recommended.

Question 265

Children with cerebral palsy (CP) are at risk for fractures and osteoporosis because of all of the following except: A) Malnutrition with calcium and vitamin D defi ciency B) Immobility C) Antiepileptic medication D) Chronic respiratory infection

Answer 265

D) In children with cerebral palsy, immobility, malnutrition secondary to oromotor dysfunction, and antiepileptic medications (particularly older generation medications) are associated with decreased bone mineral density.

Question 266

``` All of the oral antispasticity medications are likely to cause sedation except: A) Baclofen B) Diazepam C) Dantrolene D) Tizanidine ```

Answer 266

C) All of the other medications exact their effect through the central nervous system (CNS) except for dantrolene, which works at the skeletal muscle level. Dantrolene inhibits the release of calcium from the sarcoplasmic reticulum during excitation-contraction coupling and suppresses the uncontrolled calcium release

Question 267

``` Treatment of spasticity in cerebral palsy (CP) includes all of the following except: A) Botulism toxin and phenol B) Oral or intrathecal baclofen C) Selective dorsal rhizotomy D) Hyperbaric oxygen therapy (HBOT) ```

Answer 267

D) HBOT is considered an alternative therapy in patients with CP. Its primary use is in wound care.

Question 268

``` Ingestion of which of the following vitamins helps reduce the incidence of neural tube defects? A) Thiamine B) Pyridoxine C) Folic acid D) Vitamin B12 ```

Answer 268

C) Folic acid.

Question 269

``` Neural tube defects occur between ______ days of gestation: A) 7 and 18 B) 18 and 30 C) 31 and 46 D) 47 and 65 ```

Answer 269

B) The nervous system is derived from ectoderm. The anterior neuropore closes around 23rd day of intrauterine life. The posterior neuropore closes at 26 and 27 days of intrauterine life.

Question 270

``` Environmental factors that are implicated in the development of neural tube defects (NTDs) include: A) Maternal diabetes mellitus B) Folate defi ciency C) Use of valproic acid D) Maternal hyperthermia E) All of the above ```

Answer 270

E) In addition to the above, maternal obesity, use of carbamazepine, antihistamines, and sulfonamide medication increase the risk of NTD in women of child bearing age.

Question 271

``` Prenatal tests for neural tube defects performed at 16 to 18 weeks of gestation include all of the following except: A) Measure serum alpha-fetoprotein B) Acetylcholinesterase levels C) Ultrasound of abdomen D) Chromosomal assay ```

Answer 271

D) Chromosomal assay is not specifi c for the diagnosis of neural tube defects.

Question 272

``` Children with meningomyelocele (MMC) have a higher incidence of: A) Environmental allergies B) Milk intolerance C) Latex allergy D) Medication allergies ```

Answer 272

C) Compared with the general population, children with MMC have a 20% or higher rate of latex allergy.

Question 273

``` Which of the following is often seen in children with meningomyelocele (MMC)? A) Hydrocephalus B) Chiari malformation C) Neurogenic bladder D) Precocious puberty E) All of the above ```

Answer 273

E) Hydrocephalus can be seen with MMC or after closure of the defect. Leakage of cerebrospinal fl uid stops and therefore requires shunting. Chiari malformation is a caudal displacement of brain stem and ventricles, which can cause apnea, stridor, nystagmus, opisthotonus, and dysphagia. Neurogenic bladder is commonly seen in patients with MMC. Precocious puberty occurs more commonly in girls secondary to activation of the hypothalamic–pituitary axis, probably due to hydrocephalus.

Question 274

``` Children with meningomyelocele (MMC) are likely to be nonambulatory at which spinal cord level? A) Thoracic B) Lumbar C) Sacral ```

Answer 274

A) Generally, children with sacral level MMC are able to ambulate with or without crutches or canes. Involvement of peroneal and foot muscles in patients with lumbar lesions will result in limited but some ambulation with an assistive device (depending on quadriceps, hamstrings, and hip fl exors involvement). Thoracic MMC lesions may cause total paralysis of the lower limbs

Question 275

``` Common presentations of myopathy in infants and children include all of the following except: A) Hypotonia B) Delayed motor milestones C) Feeding problem D) Language problem E) Abnormality of gait ```

Answer 275

D) Speech may be affected in patients with myopathy if the facial muscles are involved, but language is not affected

Question 276

``` Teenagers with complaints of diffi culty climbing stairs, falls, decreased endurance, and episodic weakness are suggestive of: A) Neuropathic etiology B) Myopathic etiology C) Cerebral etiology D) Cerebellar etiology ```

Answer 276

B) All of the symptoms described above are common in muscle dise

Question 277

Gower’s sign is diagnostic of Duchenne muscular dystrophy. A) True B) False

Answer 277

B) Gower’s sign is suggestive of proximal muscle weakness, which can occur in any myopathic process

Question 278

``` Creatine kinase (CK) values in excess of 10,000 are usually seen in all of the following except: A) Duchenne muscular dystrophy B) Dermatomyositis C) Acute rhabdomyolysis D) Congenital myopathies ```

Answer 278

D) Dystrophic and infl ammatory myopathies cause highly elevated CK levels. Congenital myopathies cause mild to moderate elevations of CK

Question 279

Clinical features of peripheral vertigo include all of the following except: A) Hearing loss B) Post pointing and falling in the direction of disease C) Vestibular and positional nystagmus D) Cranial nerve dysfunction

Answer 279

D) Cranial nerve dysfunction, intact hearing, and loss of consciousness are suggestive of central vertigo

Question 280

A Glasgow Coma Scale of 8 is suggestive of: A) Mild injury B) Moderate injury C) Severe injury

Answer 280

C) The Glasgow Coma Scale examines three variables: eye opening, verbal response, and motor abilities. Scores can range from 3 to 15. Score of 8 or less indicates a severe injury, 9 to 12 a moderate injury, and 13 to 15 a mild injury

Question 281

A 16-year-old sustains a head injury while playing football, and his amnesia resolves on day 5 of rehabilitation. You consider this amnesia to be: A) Mild B) Moderate C) Severe

Answer 281

B) Posttraumatic amnesia is considered mild if it persists less than 24 hours after the injury. It is considered moderate if it persists between 1 and 7 days and severe if it lasts 8 days or longer

Question 282

``` During neurorehabilitation, all of the following are common focuses of rehabilitation except: A) Tone abnormalities and spasticity B) Deep vein thrombosis C) Heterotopic ossifi cation D) Chronic subdural hematoma ```

Answer 282

D) Chronic subdural hematomas and hydrocephalus can develop during the rehabilitation phase, but are not focuses of therapy.

Question 283

A 9-year-old sustained C6-C7 spinal cord injury. Three months after the injury, the parents report that his appetite is lacking and he has apathy, nausea, vomiting, and weakness. The most likely reason for these symptoms is: A) Hydrocephalus B) Hypercalcemia C) Decreased sodium D) Depression

Answer 283

B) Hypercalcemia occurs in 25% of such patients 1 to 12 weeks after the injury and is due to bone resorption. Calcium levels above 12 mg/dL can cause the above symptoms. Although depression can cause apathy and loss of appetite, this combination of symptoms including nausea and vomiting is most consistent with hypercalcemia

Question 284

Battle sign in head trauma is suggestive of: A) Intracranial bleed B) Diffuse axonal injury C) Basilar skull fracture involving the temporal bone D) Basilar skull fracture involving the orbits

Answer 284

C) Battle sign is retroauricular ecchymosis. In addition, hemotympanum and otorrhea are suggestive of temporal bone fracture. Raccoon eyes are periorbital ecchymoses and suggest an anterior skull base fracture.

Question 285

You are monitoring an 8-month-old (who was born preterm at 33 weeks) for developmental delays. You are suspicious of child abuse. One of the physical signs that may confi rm your suspicion is: A) Bulging fontanels B) Enlarged head circumference C) Bruising in an unusual location such as the legs or the back D) Retinal hemorrhage E) All of the above

Answer 285

E) Infants with nonaccidental trauma (shaken baby syndrome) may have all of the above signs, which should make you suspicious. CT of the head usually reveals subdural hematomas of varying chronicity. Contusions and intracerebral hemorrhage can be seen

Question 286

Of the following types of brain injuries, which has a better prognosis for motor recovery? A) Diffuse axonal injury (DAI) B) Bilateral hematomas C) Focal contusion D) Diffuse hypoxia secondary to head injury

Answer 286

C) In general, focal defi cits recover better than diffuse defi cits. Younger age also predicts a better recovery

Question 287

``` Which of the following can occur after moderate to severe head injury in children? A) Executive function impairment B) Visuomotor integration impairment C) Memory impairment D) All of the above ```

Answer 287

D) Following moderate to severe brain injuries, all of the above, including language impairment, have been reported in various studies.

Question 288

Retinal hemorrhages are pathognomonic of child abuse. A) True B) False

Answer 288

B) Retinal hemorrhages can occur after hypoxic or ischemic injury, vaginal birth, side impact car accidents, or child abuse. The sequelae can be visual impairment

Question 289

The most common type of skull fracture after a head injury is: A) Depressed B) Linear C) Comminuted

Answer 289

B) Linear fracture is most common after a head injury and usually does not require neurosurgical intervention. If the fracture crosses the suture line in infants, leptomeningeal cyst can occur later in life

Question 290

``` The most common site of spinal cord injury (SCI) in children is: A) Thoracic B) Lumbar C) Cervical D) Sacral ```

Answer 290

C) The most mobile portion of the spinal column is the cervical region (hence the most vulnerable). Approximately 55% of SCI in children involve the cervical spine, 30% the thoracic spine, and 15% the lumbar spi

Question 291

``` Which condition can predispose children to cervical spinal cord injury because of atlantoaxial dislocation? A) Down syndrome B) Klippel–Feil syndrome C) Morquios syndrome D) Achondroplasia E) All of the above ```

Answer 291

E) The odontoid process helps to prevent dislocation of C1 onto C2. Aplasia of the odontoid process can occur in mucopolysaccharidosis (Morquios syndrome) or Klippel–Feil syndrome. In Down syndrome, congenital hypoplasia of the articulation of C1 and C2 can occur.

Question 292

``` Spinal cord injury without radiographic abnormalities (SCIWORA) is most common in: A) Infants and young children B) Adolescents C) Adults D) Old age geriatric population ```

Answer 292

A) SCIWORA is most common in children below 8 years of age. The vertebral column in this population has more elasticity, hence fracture and dislocation are less common. However, myelopathy or central cord injury can occur. MRI of the spine is more sensitive than CT or radiography to reveal SCIWORA injuries

Question 293

A 16-year-old football player suffers a T10 fracture. He is paraparetic and has no sensation below T10. However, his proprioception, light touch, and vibration are intact. These fi ndings are suggestive of: A) Anterior spinal cord syndrome B) Posterior spinal cord syndrome C) Brown-Séquard syndrome D) Conus medullaris syndrome

Answer 293

A) In anterior spinal cord syndrome, there is paresis and analgesia below the lesion, but vibration and position sense are preserved as these are mediated by the posterior columns. In Brown-Séquard syndrome, there is ipsilateral motor paralysis, loss of touch as well as proprioception, and contralateral loss of pain and temperature below the level of the lesion.

Question 294

``` In adults, at what level does the spinal cord terminate? A) L1 B) L3 C) L4 D) T10 ```

Answer 294

A) The spinal cord terminates at L1 in adults and L2 in infants

Question 295

Spinal cord injuries are classifi ed by which of the following scales? A) Glasgow Coma Scale B) American Spinal Injury Association/International Medical Society of Paraplegia (ASIA/IMSOP) spinal cord impairment scale C) The Wee Functional Independence Measure Scale D) Barthel index

Answer 295

B) ASIA/IMSOP (American Spinal Injury Association/International Medical Society of Paraplegia) utilizes documentation of motor, sensory, and sphincter functions. Ten key muscles are graded using the Medical Research Council (MRC) scale, and sensation is assessed over 28 dermatomes. The Glasgow Coma Scale is used in traumatic brain injury. The Wee functional independence score measures self-care, mobility, cognition, and communication in children. The Barthel index is used to measure performance in activities of daily living following conditions such as stroke.

Question 296

``` Phrenic nerve pacing may be required with spinal cord injury at which level? A) C3–5 B) T3–5 C) T7–8 D) T12–4 ```

Answer 296

A) The phrenic nerve is formed from nerve roots C3–5 and supplies the diaphragm. Patients who require permanent ventilatory support can be candidates for phrenic nerve pacing.

Question 297

``` The most common identifi able risk factor for childhood ischemic stroke is: A) Hematological disorders B) Congenital heart disease C) Central nervous system infection D) Vasculitis ```

Answer 297

B) All of the above are causes of stroke in children, but congenital heart disease is the most common.

Question 298

In which type of spinal muscular atrophy (SMA) can most of the patients sit but not walk? A) Type I B) Type II C) Type III

Answer 298

B) SMA type I (Werdnig–Hoffmann disease) has its onset before 6 months of age. Most patients cannot sit, and the condition has a mortality rate of more than 90% by 3 months of age.

Question 299

``` Most children with spinal muscular atrophy (SMA) have: A) Mental retardation B) A single crease across their palm C) Epilepsy D) High cognitive function ```

Answer 299

D) SMA is a disease affecting the anterior horn cells (motor neurons) that causes neurogenic atrophy of muscles. The brain is not affected. They have high cognitive abilities. Therefore, providing them with tools for ambulation and mobility are important. Patients with Down syndrome usually have a single crease across their palms instead of two creases.

Question 300

``` All of the following are anterior horn cell disease affecting the motor neuron except: A) Spinal muscular atrophy B) Botulism C) Amyotrophic lateral sclerosis D) Poliomyelitis ```

Answer 300

B) Botulism is due to toxins produced by Clostridium botulinum. These toxins block the release of acetylcholine at the neuromuscular junction

Question 301

Lesions of the facial nerve distal to the nucleus (lower motor neuron involvement) result in: A) Paralysis of the lower facial muscles B) Paralysis of the upper (forehead) and lower facial muscles C) Paralysis of the lower facial muscles with sparing of upper facial muscles (forehead) D) Paralysis of upper and lower facial muscles as well as the muscles of mastication

Answer 301

B) When forehead muscles are involved in facial nerve palsy, it is indicative of a lower motor neuron lesion distal to the nucleus. The muscles of mastication are supplied by cranial nerve V. Lower facial muscles are involved in both upper and lower motor neuron facial palsies. Bilateral upper motor neuron innervation of the upper facial muscles leads to sparing of these muscles in an upper motor neuron lesio

Question 302

``` In Erb’s palsy, all of the following muscles are paralyzed except: A) Deltoid B) Bicep brachialis C) Supinator D) Intrinsic muscles of hand ```

Answer 302

D) Erb’s palsy involves injury to the upper trunk of the brachial plexus. Intrinsic muscles of hand are supplied by the ulnar nerve, which is supplied by C8-T1. In Erb’s palsy, the arm is held in adduction and internal rotation at the shoulder, extension at the elbow, pronation of the forearm, and fl exion at the wrist.

Question 303

The predominant type of neuropathy in Guillain–Barré syndrome (acute infl ammatory demyelinating polyradiculoneuropathy) is: A) Motor B) Sensory C) Ataxia D) Autonomic

Answer 303

A) Although all of the above can be seen, motor involvement predominates. Campylobacter jejuni, Mycoplasma pneumoniae, cytomegalovirus, and Epstein–Barr virus are common known causes.

Question 304

A 9-year-old girl with a history of diffi culty writing and frequent tripping is referred to your offi ce for bracing. You notice stork legs, pes cavus, and hammer toes. The ankle tendon refl ex is lost. Her mother had similar problems as a child. The above fi ndings are suggestive of: A) Spinal muscular atrophy B) Charcot–Marie–Tooth disease (CMT) C) Friedreich’s ataxia D) Congenital myopathy

Answer 304

B) Hereditary sensory-motor neuropathy (HSMN) type I and II are also known as CMT. It is a progressive motor and sensory demyelinating neuropathy (mainly autosomal dominant). The distal muscles of the lower extremity are affected more than the upper extremities. Spinal muscular atrophy and Friedreich’s ataxia are autosomal recessive conditions.

Question 305

All of the following are true in cases of myasthenia gravis (MG) except: A) It is an autoimmune disease B) It affects presynaptic receptors on the neuromuscular junction C) On repetitive nerve stimulation tests, there is a decremental response D) It can be diagnosed by edrophonium (Tensilon) test

Answer 305

B) MG affects postsynaptic receptors of the myoneural junction. Transmission of acetylcholine is blocked. Predominant clinical fi ndings include fatigability of ocular, bulbar, and skeletal muscles. This can result in ptosis, diplopia, slurred speech, diffi culty with chewing, respiratory problems, and weakness (proximal more than distal).

Question 306

``` Botulism is caused by: A) Gram-positive streptococci B) Gram-positive Clostridium C) Gram-negative Escherichia coli D) Gram-negative Shigella ```

Answer 306

B) Botulism is due to toxins produced by Clostridium botulinum. These toxins block the release of acetylcholine at the neuromuscular junction

Question 307

Duchenne muscular dystrophy is a progressive hereditary disease with a predictable course. However, with corticosteroids and physical medicine and rehabilitation (PM&R) treatment, the disease course can be: A) Modifi ed B) Cured C) Unaffected D) Halted

Answer 307

A) Corticosteroids and PM&R can help prolong independence by several years, hence modifying the disease course. No defi nitive cure is available yet.

Question 308

``` Duchenne muscular dystrophy (DMD) can affect all of the following except: A) Pulmonary system B) Intelligence quotient (IQ) C) Gastrointestinal (GI) system D) Cardiac system E) All of the above may be affected ```

Answer 308

E) DMD is a multisystem disease affecting: 1) Musculoskeletal system causing weakness and scoliosis 2) Pulmonary system affecting respiratory function and sleep problem (due to weakness of intercostal and diaphragmatic muscles) 3) Cardiac system causing cardiomyopathy 4) IQ and causing mental retardation 5) GI system causing problems with megacolon and malabsorption

Question 309

A 4-year-old boy presents with a history of diffi culty climbing stairs, falling, waddling gait, and large calf muscles. You suspect Duchenne muscular dystrophy (DMD). Of the following, the easiest and best confi rmatory diagnosis test is: A) Serum level of creatine kinase (CK) B) Polymerase chain reaction (PCR) genetic test C) Muscle biopsy D) Family history

Answer 309

B) CK may be increased by 10,000 times, but not diagnostic of DMD. A muscle biopsy is diagnostic, but invasive. The PCR genetic test is a simple blood test that is confi rmatory.

Question 310

An 8-year-old with a diagnosis of Duchenne muscular dystrophy (DMD) is referred for exercise. All of the following are allowed except: A) Swimming B) Daily walking C) Weight lifting D) Playing Wii

Answer 310

C) Children with DMD should avoid high-resistance exercises such as weight lifting. Keeping an active life with sustained nonresistive activities such as swimming is best.

Question 311

A 9-year-old suffered a traumatic brain injury (TBI). He is noted to be fi dgety and have piano playing movements of the fi ngers, and has diffi culty maintaining tongue protrusion. These symptoms are not seen when he is sleeping. This describes what type of movements? A) Chorea B) Tics C) Dystonia D) Tremors

Answer 311

A) Chorea describes brief, random, repetitive, rapid, purposeless movements. Dystonia is a repetitive, sustained abnormal posture that typically has a twisting quality. Tics are stereotyped, repetitive nonrhythmic movements that mainly involve the head and upper body. Tremor is a rhythmic oscillation.

Question 312

You are providing rehabilitation to a 12-year-old spinal cord injured boy. He has been complaining of intermittent headaches with nasal congestion and nausea. He perspires profusely on his face and neck. His blood pressure is elevated intermittently. The most likely level of his spinal cord injury is: A) T6 B) T12 C) L4

Answer 312

A) This patient has an acute and potentially life-threatening syndrome called autonomic dysrefl exia. This can occur with complete spinal cord injuries at the T6 level or above and is due to imbalanced sympathetic discharges of the splanchnic outfl ow

Question 313

``` In the child’s early years, all of the following are important parameters to monitor except: A) Head circumference B) Weight C) Height D) Body Mass Index ```

Answer 313

D) Head circumference, height, and weight are all important parameters that must be closely monitored in a child’s early years. BMI is not routinely monitored.

Question 314

``` A child should be able to maintain its head in the midline position by what age? A) 2 months B) 3 months C) 4 months D) 5 months ```

Answer 314

A) A child should be able to maintain its head in the midline position at 2 months of age. By 3 months, it should be able to prone prop on extended elbows. At 4 months, it can roll prone to supine, while at 5 months, it should be able to roll supine to prone.

Question 315

``` A child should be able to maintain its head in the midline position by what age? A) 2 months B) 3 months C) 4 months D) 5 months ```

Answer 315

D) A child should be able to pivot circles in prone at 5 months of age. It can maintain their head in the midline position at 2 months of age. By 3 months, it should be able to prone prop on extended elbows. At 4 months, it can roll prone to supine

Question 316

``` You observe a child that is able to crawl on its hands and knees (“creeps”). At what age should this milestone be met? A) 6 months B) 9 months C) 10 months D) 12 months ```

Answer 316

B) A child “creeps” at 9 months. They can pull to stand through half-kneel at 10 months, while independently ambulating at 1 year of age. Sitting with a straight back occurs at 6 months.

Question 317

You observe a child that is able to independently ambulate as well as come to stand independently. However, you note they cannot go up and down stairs. Approximately how old would you expect this child to be? A) 12 months B) 15 months C) 18 months D) 24 months

Answer 317

C) This child is 18 months old. At this point, it is unlikely they would be able to navigate steps.

Question 318

A friend is telling you of his little girl who just celebrated her third birthday. Which of the following do you not expect her to be able to complete? A) Up and down stairs with hands on rail B) Jumps clearing ground and lands on feet together C) Walks down stairs alternating feet D) Pedals tricycle

Answer 318

C) She would be able to complete all of the following with the exception of walking down stairs alternating feet. This is typically accomplished by the age of 4

Question 319

You are caring for a child with a known central nervous system (CNS) lesion. His upper extremities are characteristically kept in which position? A) Shoulder adduction, fl exion, and internal rotation with elbow fl exion, wrist pronation and fl exion, and fi nger and thumb fl exion B) Shoulder abduction, fl exion, and external rotation with elbow fl exion, wrist pronation and fl exion, and fi nger and thumb fl exion C) Shoulder adduction, extension, and internal rotation with elbow fl exion, wrist supination and fl exion, and fi nger and thumb fl exion D) Shoulder abduction, fl exion, and internal rotation with elbow extension, wrist pronation and fl exion, and fi nger and thumb extension

Answer 319

A) Full fl exor pattern is commonly seen in the upper extremity of children with CNS lesions. Upper extremity fl exor patterns include shoulder adduction, fl exion, and internal rotation with elbow fl exion, wrist pronation and fl exion, and fi nger and thumb fl exion. Extensor patterns are typically seen in the lower extremities

Question 320

You are caring for a child with a known central nervous system (CNS) lesion. Her lower extremities are characteristically kept in which position? A) Hip abduction, extension, and internal rotation, along with knee fl exion, internal tibial rotation, and equinovarus foot posturing B) Hip adduction, extension, and internal rotation, along with knee extension, internal tibial rotation, and equinovarus foot posturing C) Hip adduction, fl exion, and internal rotation, along with knee fl exion, internal tibial rotation, and equinovarus foot posturing D) Hip adduction, extension, and external rotation, along with knee extension, external tibial rotation, and equinovarus foot posturing

Answer 320

B) Extensor patterns are usually seen in the lower extremity of children with CNS lesions. The extension posture of the lower limb includes hip adduction, extension, and internal rotation, along with knee extension, internal tibial rotation, and equinovarus foot posturing. Flexor patterns are seen in the upper extremities. This includes shoulder adduction, fl exion, and internal rotation with elbow fl exion, wrist pronation and fl exion, and fi nger and thumb fl exion.

Question 321

With the asymmetric tonic neck refl ex (ATNR), lateral rotation of the head on the trunk produces which of the following? A) Flexion in the upper and the lower limbs on the nasal side, and extension of both limbs on the occipital side B) Flexion in the upper and the lower limbs on the nasal side, and fl exion of both limbs on the occipital side C) Extension in the upper and the lower limbs on the nasal side, and fl exion of both limbs on the occipital side D) Extension in the upper and the lower limbs on the nasal side, and extension of both limbs on the occipital side

Answer 321

C) This is the classical fencer’s posture of extension in the upper and the lower limbs on the nasal side, and fl exion of both limbs on the occipital sid

Question 322

Which best describes the symmetric tonic neck refl ex (STNR)? A) Flexion of the neck facilitates extension in the upper limbs and extension of the lower limbs. Extension of the neck facilitates fl exion in the upper limbs and fl exion of the lower limbs B) Flexion of the neck facilitates extension in the upper limbs and fl exion of the lower limbs. Extension of the neck facilitates fl exion in the upper limbs and extension of the lower limbs C) Flexion of the neck facilitates fl exion in the upper limbs and extension of the lower limbs. Extension of the neck facilitates extension in the upper limbs and fl exion of the lower limbs D) Flexion of the neck facilitates fl exion in the upper limbs and extension of the lower limbs. Extension of the neck facilitates extension in the upper limbs and fl exion of the lower limbs

Answer 322

D) The STNR describes the effects of fl exing and extending the head. On fl exion of the neck, fl exion in the upper limbs and extension of the lower limbs is observed. On extension of the neck, the opposite pattern will be seen

Question 323

``` By what age should the palmar grasp refl ex disappear? A) 2 months B) 4 months C) 6 months D) 12 months ```

Answer 323

C) The palmar grasp refl ex is seen when an object is placed in the infant’s hand and strokes their palm. The fi ngers will close and they will grasp it. It is seen initially at birth and should disappear by 6 months of age.

Question 324

``` All of the following are proven teratogens except: A) Rubella virus B) Rubeolla virus C) Cytomegalovirus D) Toxoplasmosis ```

Answer 324

B) Exposure to potential teratogens increases the chances of malformations in the fetus. Of those listed, the only one not proven to be teratogenic is Rubeolla virus

Question 325

An infant with features of upward slant of palpebral fi ssures, low set ears, prominent occiput, hypoplastic fi nger nails, and short sternum is most consistent with which chromosomal syndrome? A) Trisomy 18 (Edwards syndrome) B) 45, X (Turner syndrome) C) Trisomy 13 (Patau syndrome) D) Trisomy 21 (Down syndrome)

Answer 325

D) The above clinical features all describe someone with Down syndrome or trisomy 21. Turner syndrome is characterized by being a female of short stature with a webbed neck, a broad “shield” chest, and wide-set nipples. In trisomy 18, the infant suffers from intrauterine growth retardation (IUGR), small mouth, and rocker-bottom feet.

Question 326

An infant with features of intrauterine growth retardation (IUGR), small mouth, low set abnormal ears, spasticity, and rocker-bottom feet is most consistent with which chromosomal syndrome? A) Trisomy 18 (Edwards syndrome) B) 45, X (Turner syndrome) C) Trisomy 13 (Patau syndrome) D) Trisomy 21 (Down syndrome)

Answer 326

A) The above clinical features all describe someone with Edwards syndrome or trisomy 18. Turner syndrome is characterized by being a female of short stature with a webbed neck, a broad “shield” chest, and wide-set nipples. In trisomy 21, the infant presents with the following features: upward slant of palpebral fi ssures, low set auricles, prominent occiput, hypoplastic fi nger nails, and short sternum. Patau syndrome, trisomy 13, is characterized by intrauterine growth retardation, coloboma (a gap in part of the structure) of the iris, cleft lip and palate, and urinary tract abnormalities.

Question 327

``` What is the most common congenital limb defi ciency? A) Left terminal transradial B) Left transhumeral C) Right terminal transradial D) Right transhumeral ```

Answer 327

A) The most common congenital limb defi ciency is a left terminal transradial defi ciency.

Question 328

Around what age should the fi rst prosthetic fi tting for a unilateral defi ciency occur? A) 3 to 4 months B) 6 to 7 months C) When the child begins to walk D) When the child is able to navigate stairs

Answer 328

B) At around 6 to 7 months, a normally developing child should achieve sitting balance. It is at this time they should undergo the fi rst fi tting for a unilateral device. A device with a more sophisticated terminal device is provided at around 11 to 13 months when the child begins to walk.

Question 329

``` What is the most common congenital lower limb defi ciency? A) Unilateral partial tibial defi ciency B) Fibular longitudinal defi ciency C) Partial proximal femoral defi ciency D) Bilateral partial tibial defi cienc ```

Answer 329

B) Fibula hemimelia is the most common congenital lower limb defi ciency. One-fourth of the time, this defi ciency occurs bilaterally

Question 330

Each of the following is true of tibia vara (Blount’s disease) except? A) Bowing of the proximal tibia is a result of abnormal function of the medial portion of the proximal tibial growth plate B) This disease is found most commonly in obese children who walk at 9 to 10 months C) It is more common in Caucasians than other racial groups D) Treatment is usually surgical, involving osteotomy of the proximal tibia and fi bula

Answer 330

C) Blount’s disease, or tibia vara, is most common in children of African American race. As such, it should be expected in all children in this population who suffer from persistent tibial bowing past the age of 2.

Question 331

``` The most common cause of congenital torticollis is fi brosis of which muscle? A) Trapezius B) Levator scapulae C) Sternocleidomastoid (SCM) D) Scalenes ```

Answer 331

C) The most common cause of congenital torticollis is fi brosis of the SCM

Question 332

A 5-year-old child is being lifted by the hand over a curb while crossing the street. Suddenly, the child experiences exquisite pain and refuses to move the affected arm. This child has most likely suffered a subluxation of which bone? A) Ulna B) Radius C) Humerus D) Scaphoid

Answer 332

B) In this situation described, the child is most at risk for subluxation of the radial head and neck distal to the annular ligament. This is referred to as nursemaid’s elbow.

Question 333

What is the most common cause of limping and pain in the hip of children? A) Slipped capital femoral epiphysis (SCFE) B) Trochanteric bursitis C) Legg–Calve–Perthes disease D) Transient toxic synovitis

Answer 333

D) Transient toxic synovitis is the most common cause of limping and hip pain in children. SCFE is commonly seen in preadolescent-adolescent obese boys and is a separation of the proximal femoral epiphysis through the growth plate. Trochanteric bursitis is not commonly seen in children. In Legg–Calve–Perthes disease, there is avascular necrosis at the femoral head. It is seen in children age 4 to 10 who have pain in the groin that radiates to the anterior/medial thigh toward the knee

Question 334

``` What is the most common connective tissue disease seen in children? A) Ankylosing spondylitis B) Juvenile rheumatoid arthritis (JRA) C) Reactive arthritis D) Systemic lupus erythematosus (SLE) ```

Answer 334

B) JRA is the most common connective tissue disease in children. A diagnosis of JRA is made in the presence of arthritis lasting greater than or equal to 6 weeks with an onset less than 16 years of age. The incidence is 13.9 per 100,000 per year, and the etiology remains unknown.

Question 335

``` There are three different types of hemophilia. Which of the following is the hallmark of this disease? A) Hemarthrosis B) Spondylosis C) Retinal hemorrhages D) Hematuria ```

Answer 335

A) Hemarthrosis is the hallmark of hemophilia. There are three different types of hemophilia (A, B, C), which are defi ciencies of factor VIII, factor IX, and factor XI, respectively. Hemarthrosis is defi ned as bleeding into the joints causing pain, swelling, and limited joint movement.

Question 336

``` The majority of cerebral palsy (CP) cases occur during which period? A) Prenatal B) Perinatal C) Infancy D) Childhood ```

Answer 336

A) Approximately 70% to 80% of cerebral palsy cases occur during the prenatal period. Some of the risk factors for CP include prenatal intracranial hemorrhage, placental complications, gestational toxins, or teratogenic agents

Question 337

``` Which is the most common type of cerebral palsy (CP)? A) Spastic quadriplegia B) Dyskinetic CP C) Spastic diplegia D) Mixed CP ```

Answer 337

C) Spastic diplegia is the most common type of CP. Approximately 75% of those with CP is of this type. There is greater involvement of the lower extremities in comparison with the upper extremities of those with spastic diplegia. Dyskinetic and mixed CP, which exhibits patterns of both spastic and dyskinetic CP, make up approximately 25% of those with CP.

Question 338

``` Which of the following is not a type of dyskinetic cerebral palsy (CP)? A) Dystonia B) Ataxia C) Athetosis D) Hemiballismus ```

Answer 338

D) Each is a characteristic type of CP except hemiballismus. Dystonia is characterized by slow rhythmic movements with tone changes generally found in the trunk and extremities, whereas ataxic-type involves uncoordinated movements associated with nystagmus, dysmetria, and a wide-based gait. Slow writhing involuntary movements, particularly in the distal extremities, describe athetosis

Question 339

``` In a child diagnosed with cerebral palsy (CP), independent sitting by what age is a good prognostic indicator for ambulation? A) 6 months B) 12 months C) 24 months D) 36 months ```

Answer 339

C) As described by Molnar, if independent sitting occurs by age two, prognosis for ambulation is good. “Will my child walk?” is usually the most frequent question asked by the parent of a newly diagnosed CP child.

Question 340

``` Arnold–Chiari malformation complicated by hydrocephalus occurs most commonly in which type of spina bifi da? A) Spina bifi da occulta B) Meningocele C) Myelomeningocele D) Myelocele ```

Answer 340

C) This malformation is seen in more than 90% of the cases with myelomeningocele. The protruding sac contains meninges, spinal cord, and spinal fl uid. Spina bifi da occulta results when there is failure of fusion of the posterior elements of the vertebrae. Meningocele is characterized by a protruding sac, which contains meninges and spinal fl uid, whereas myelocele is the presence of a cystic cavity in front of the anterior wall of the spinal cord.

Question 341

Which type of spinal muscular atrophy (SMA) is associated with good long-term survival? A) Type I (Werdnig–Hoffmann disease) B) Type II C) Type III (Kugelberg–Welander syndrome) D) Type IV

Answer 341

C) Type III, or Kugelberg–Welander syndrome, is associated with good long-term survival but dependent on respiratory function. It is an autosomal recessive disorder characterized by proximal weakness predominantly of the legs. Fasciculations are common, and scoliosis is frequent

Question 342

A 12-year-old boy presents with waddling gait and diffi culty in climbing stairs. On examination, he demonstrates signifi cant weakness in his proximal lower extremity muscles, especially the quadriceps, and some calf hypertrophy. What is the genetic inheritance of this disorder? A) Autosomal dominant B) X-linked recessive C) Autosomal recessive D) There is no genetic linkage

Answer 342

B) The abnormal gene for Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) is on the short arm of the X chromosome at position Xp21. Both DMD and BMD are inherited X-linked recessive diseases affecting primarily skeletal muscle and myocardium.

Question 343

``` The pathophysiology of Duchenne muscular dystrophy (DMD) involves: A) Merosin defi ciency B) Abnormally low levels of dysfertin C) Absence of dystrophin D) Mutations of sarcoglycan ```

Answer 343

C) The absence of dystrophin is the basis of the pathophysiology of DMD. Most of the genes in the affected area of the X chromosome encode for components of the dystrophinglycoprotein complex

Question 344

Which of the following complications is common in both Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD)? A) Cardiomyopathy B) Large bowel obstruction C) Ureteral refl ux D) Obstructive respiratory disease

Answer 344

A) Signifi cant cardiac involvement occurs in both DMD and BMD

Question 345

``` Which of the following muscular dystrophies is usually associated with a markedly reduced lifespan? A) Facioscapulohumeral dystrophy (FSHD) B) Becker muscular dystrophy (BMD) C) Limb girdle dystrophy D) Duchenne muscular dystrophy (DMD) ```

Answer 345

D) Although facioscapulohumeral dystrophy can be quite heterogeneous in its clinical presentation and course, it is typically only slowly progressive. The same is true of BMD and limb girdle dystrophy. Only DMD is usually associated with a markedly shortened life expectancy. DMD is a progressive myopathy that is universally fatal, with death usually occurring from respiratory or cardiac complications

Question 346

``` Which of the following is consistent with myopathy? A) Brisk muscle stretch refl exes B) Weakness and atrophy C) Sensory loss D) Urinary retention ```

Answer 346

B) Although the various forms of myopathy are clinically dissimilar, they all involve loss of muscle strength, causing loss of refl exes rather than hyperrefl exia, along with weakness and atrophy. Sensation remains intact, as only muscle fi bers are affected. Urinary retention is not part of these diseases, and the sensory nerves remain completely intact

Question 347

A 12-year-old girl with limb girdle muscular dystrophy is having trouble keeping up in school. She cannot ambulate fast enough to get to her next class on time. She is having diffi culty writing her examination papers and fi nishing on time. The ultimate cause of the majority of her clinical problems is: A) Skeletal muscle weakness B) Spasticity C) Cardiomyopathy D) Joint contracture

Answer 347

A) The vast majority of clinical problems encountered in neuromuscular disease can be directly linked to skeletal muscle weakness. Despite other comorbid conditions, studies have indicated that what causes most of the functional problems and impairs quality of life for people with neuromuscular disease is muscle weakness

Question 348

A physiatrist evaluating patients in a muscular dystrophy clinic wants to start the boys with Duchenne muscular dystrophy (DMD) on an exercise program. Knowing that dystrophin- defi cient muscle is very susceptible to exercise-induced muscle injury, the best way to begin the program would be: A) To allow the boys to play as hard and as long as they want, stopping only when they are too tired to play any more B) To have the boys exercise in a playful manner but with the supervision of a physical therapist C) To have the boys participate in the standard school physical program D) The exercise program is not a good idea, as it could make the disease progress faster stopping only when they are too tired to play anymore

Answer 348

B) Intervention with submaximal exercise training in neuromuscular disease has been shown to improve physical performance and increase muscle effi ciency while reducing fatigue and improving quality of life. However, in children, the exercise program must be worked into an enjoyable, playful setting. Supervision is necessary to make sure that the children do not play to exhaustion, which could produce muscle damage and overwork weakness.

Question 349

``` Which of the following is the major factor limiting ambulation in Duchenne muscular dystrophy (DMD)? A) Joint contracture B) Weakness C) Scoliosis D) Restrictive lung disease ```

Answer 349

C) Transition to a wheelchair, because it leads to prolonged static positioning of the limbs, is the largest contributor to the formation of joint contractures in DMD. Although poor nutrition and obesity might lead to wheelchair dependence sooner, they are not primary causes of joint contractures. Muscular atrophy is not directly related to contractures, although the pseudohypertrophy seen in the calf muscles of boys with DMD is associated with tightness in the heel cord and ankle plantar fl exion contractures.

Question 350

``` Restrictive lung disease is common in severe myopathies and is due primarily to: A) Recurrent pneumonia B) Obesity C) Respiratory muscle weakness D) Intrinsic lung damage ```

Answer 350

C) Respiratory impairment in the setting of a myopathy is due to weakness of the diaphragm, chest, and abdominal musculature. The other listed factors have not been shown to play a signifi cant role in restrictive lung dise

Question 351

Which gait characteristic is least likely to be associated with muscular dystrophy or myopathy? A) Toe walking in a child B) Ipsilateral foot drop C) Gluteus medius gait D) Increase in lumbar lordosis with standing or ambulation

Answer 351

B) The gait characteristic least likely to be associated with a myopathic process is an ipsilateral foot drop. In general, muscular dystrophy and the myopathic process typically affect the proximal more than the distal muscles. Because of hip abduction weakness, gluteus medius gait or a Trendelenburg gait can be noted with myopathic disorders. A child presenting with toe walking should be carefully evaluated for a neuromuscular disorder. In muscular dystrophy with hip extensor weakness, the stability of the hip can be maintained by lumbar lordosis, which places the center of gravity line posterior to the hip joint.

Question 352

The laboratory serum creatine kinase level would most likely be highest in which of the following? A) A 5-year-old boy with Becker muscular dystrophy (BMD) B) A 20-year-old man with BMD C) A 5-year-old boy with Duchenne muscular dystrophy (DMD) D) A 20-year-old man with DMD

Answer 352

C) A normal serum creatine kinase value essentially helps to exclude either BMD or DMD. Higher creatine kinase values are noted in the early disease stages and tend to decrease over time with loss of muscle fi bers. DMD children can present with a signifi - cantly elevated creatine kinase value, typically in the range of 20,000 international units/ liter or greater, and is usually higher than in BMD.

Question 353

Clinically, what criterion can be used to differentiate between Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD)? A) Utilization of Gower’s maneuver B) The ability to ambulate past the late teenage years C) Pseudohypertrophy of the calves D) Neck fl exor weakness

Answer 353

B) The most useful clinical criterion to distinguish BMD from DMD is the continued ability of the patient to walk into the late teenage years. Those with BMD will typically remain ambulatory beyond 16 years of age, whereas even the outlier DMD patients generally stop ambulating between 13 and 16 years of age. Gower’s maneuver, pseudohypertrophy of the calves, and neck fl exor weakness can be seen in both BMD and DMD and are not useful in distinguishing the two diagnose

Question 354

In a patient recently diagnosed with myotonic muscular dystrophy (MMD), all of the following are reasonable follow-up evaluations related to the diagnosis except: A) A check for insulin insensitivity and the presence of diabetes B) An electrocardiogram (ECG) evaluation for possible conduction abnormalities C) An ophthalmologic evaluation for cataracts D) An imaging study of the kidneys for stone

Answer 354

``` D) Myotonic muscular dystrophy affects skeletal muscle, smooth muscle, myocardium, brain, and ocular structures. Associated fi ndings include frontal pattern baldness, gonadal atrophy (in males), cataracts, insulin insensitivity, and cardiac dysrhythmias. ```

Question 355

``` The incidence of cerebral palsy is: A) 1 to 2.3 per 1,000 live births B) 10 to 23 per 1,000 live births C) 8 per 1,000 live births D) 0.1 to 0.23 per 1,000 live births ```

Answer 355

A) With improvements in obstetric care and the increased survival of premature infants, the incidence of cerebral palsy has remained the same over the past several decades (about 1–2.3 per 1,000 live births).

Question 356

Causes of cerebral palsy include all the following except: A) Toxoplasmosis, other agents, rubella, cytomegalovirus infection, herpes simplex (TORCH) infection during pregnancy B) Trauma to the child by age 2 C) Infection of the brain and/or meninges by age 2 D) Progressive lipid storage disease

Answer 356

D) Cerebral palsy is by defi nition due to a nonprogressive brain insult.

Question 357

Risk factors for cerebral palsy include all the following except: A) Extreme or very low birth weight, or prematurity B) Multiple gestation pregnancy C) Chorioamnionitis D) First delivery for mother

Answer 357

D) Obstetric care has improved, but other causes of cerebral palsy have increased, such as prematurity and the incidence of multiple gestation pregnancy. Chorioamnionitis is now recognized as a risk factor for cerebral p

Question 358

``` What percentage of cases of cerebral palsy are found to be due to complications of childbirth or birth asphyxia? A) 1% to 2% B) 5 % to 10% C) 30% to 50% D) 50% to 75% ```

Answer 358

B) About 5% to 10% of cases of cerebral palsy are due to complications of childbirth or birth asphyxia

Question 359

Gastrointestinal symptoms in patients with cerebral palsy include all the following except: A) Gastroesophageal refl ux B) Diffi culty coordinating swallow or dysphagia C) Constipation D) Poor pancreatic enzyme secretion

Answer 359

D) Motor function of the swallowing muscles and the bowel is affected by cerebral palsy. Pancreatic enzyme secretion is affected in children with cystic fi brosis.

Question 360

Which of the following statements is not true? A) Under nutrition is a goal in the management of cerebral palsy B) Triceps skin fold helps determine nutritional status in cerebral palsy C) Poor nutritional intake is associated with decreased community participation D) Poor swallow, refl ux, and constipation contribute to poor nutrition in cerebral pa

Answer 360

A) Appropriate nutrition is needed in children with cerebral palsy to maximize brain, muscle, and bone development. Undernourished children are at risk for multiple health problems, which may result in poor community participation

Question 361

``` Seizures occur in what percentage of children with cerebral palsy? A) 10% B) 30% C) 50% D) 90% ```

Answer 361

B) Seizures occur in about 30% of children with cerebral palsy.

Question 362

``` The most common type of abuse in children with disabilities is: A) Verbal abuse B) Neglect C) Physical abuse D) Financial abuse ```

Answer 362

B) Although any type of abuse can occur, neglect is the most common type of abuse in children with disabilities

Question 363

``` A child with cerebral palsy who is likely to walk in the future should have at least what skill by age 2? A) Smiling B) Rolling C) Sitting D) Cruising ```

Answer 363

C) Patients with cerebral palsy who are able to sit by age 2 have a good prognosis for future ambulation

Question 364

``` Which sport is not recommended for children with cerebral palsy? A) Swimming B) Adaptive horseback riding C) Weight lifting D) None of the above ```

Answer 364

D) Sports are a key component of a healthy lifestyle for children, including those with cerebral palsy. Damiano’s study refuted that weight lifting is contraindicated in cerebral palsy.

Question 365

``` In patients with cerebral palsy, precautions for therapeutic involvement: A) Are important for tracking severity B) Defi ne safe limits of treatment C) Determine location of therapy D) Reduce parent interactions ```

Answer 365

B) The American Academy of Pediatrics policy statement on prescribing therapies states that safety limits should be defi ned.

Question 366

Children with cerebral palsy should be referred to therapy: A) When they begin to show signs of walking B) When they display limitations in fi ne motor skills C) Only after the diagnosis is confi rmed D) Even if the diagnosis is not established and abnormal muscle tone exists

Answer 366

D) Early identifi cation of abnormal tone and motor development may precede diagnosis, but early intervention treatment should be instituted.

Question 367

When parental involvement in children with cerebral palsy is high: A) Children are more dependent B) Therapy is less important for function C) Compliance at home is improved D) Leisure time is reduced

Answer 367

C) When parents are involved in the care of children with cerebral palsy, the compliance for medications and exercise in the home is improved

Question 368

In patients with cerebral palsy, the use of augmentative communication: A) Enhances communication B) Creates diffi culty in classroom activities C) Decreases parent interaction by speech D) Meets all the communication needs of the child

Answer 368

A) Augmentative communication is important in patients with cerebral palsy who have diffi culty communicating. This has been shown to improve all communication efforts and has not been shown to create diffi culty in the classroom or decrease parent interaction. It may not, however, meet all of the communication needs of the child

Question 369

``` Indications for botulinum toxin in children with cerebral palsy include all of the following except: A) Thumb in palm deformity B) Dynamic equinus during swing phase C) Fixed knee fl exion contracture D) Focal dystonia ```

Answer 369

C) A fi xed contracture is not an indication for treatment with botulinum toxin A. All of the other choices relate to increased or abnormal muscle tone and may be relieved (at least partially) by botulinum toxin

Question 370

Comparing phenol with botulinum toxin in the treatment of spasticity for children with cerebral palsy, which of the following is true? A) Phenol is quicker and has fewer side effects B) Phenol is a less expensive option but more diffi cult technically to perform C) Botulinum toxin is longer lasting but less predictable D) Botulinum toxin has been subjected to fewer studies than phenol has

Answer 370

B) Although phenol injections may last longer than botulinum toxin injections, they are more diffi cult injections to perform and are associated with more side effects

Question 371

In patients with cerebral palsy, the ideal candidate for a selective posterior/dorsal rhizotomy is: A) An adolescent who is marginally ambulatory B) A child with mixed tone disorder C) A child with spasticity who has no orthopedic deformities D) A child with knee fl exion contractures but severe spasticity

Answer 371

C) Patients with spasticity but no orthopedic deformities have the best outcome after selective posterior/dorsal rhizotomy.

Question 372

Intrathecal baclofen is a treatment that is recommended for: A) A child with mixed tone abnormalities who has failed to respond adequately to oral medications B) A child with mild spastic diplegia C) A child with mental retardation, seizure disorder, and orthopedic deformity D) A child with severe spasticity and parents with a known history of noncompliance

Answer 372

A) Intrathecal baclofen should be considered for a child with signifi cant spasticity or dystonia interfering with function and who has had an adequate trial of oral medications

Question 373

Adductor myotomies should: A) Be considered for the older child with a dislocated hip and pain B) Be considered early in severe spasticity to prevent dislocation C) Be delayed until 6 years D) None of the above

Answer 373

B) Patients with severe spasticity are at risk for hip dislocation. Adductor myotomies have been shown to decrease that risk if performed early enough.

Question 374

When advising families with children with chronic illness and disability, practitioners should: A) Remain dogmatic on traditional therapies alone B) Allow for open discussion of benefi ts only C) Allow for a risk-benefi t discussion D) Understand that families are angry and need to act out with defi ance

Answer 374

C) According to the American Academy of Pediatrics policy statement on complementary and alternative medicine, families that request complementary treatments should engage in an open, risk-benefi t discussion

Question 375

``` What percentage of the population age 1 to 10 has spina bifi da occulta? A) 1% B) 8% C) 17% D) 30% ```

Answer 375

C) Studies show a 17% incidence of spina bifi da occulta in normal individuals age 1 to 10, with no neurologic involvement and incomplete closure of the posterior elements of the spine.

Question 376

``` What is the incidence of myelomeningocele (MMC) in the United States? A) 2 per 1,000 live births B) 20 per 1,000 live births C) 100 per 1,000 live births D) 10 per 1,000 live births ```

Answer 376

A) Rates have varied in the United States from 2.34 per 1,000 live births to as low as 0.51 per 1,000 live births. The declining rate could be related to awareness of the need for dietary supplements during pregnancy, especially folic acid.

Question 377

``` Which of the following interventions was found to reduce the frequency of myelomeningocele (MMC)? A) Vitamin B B) Vitamin E C) Folic acid D) Ascorbic acid ```

Answer 377

C) Folic acid supplementation was fi rst shown to decrease the rate of neural tube defi cits in the early 1980s in Wales

Question 378

``` What percentage of myelomeningoceles (MMCs) are associated with hydrocephalus at birth? A) 5% B) 15% C) 25% D) 50% ```

Answer 378

B) Approximately 15% of these babies have severe hydrocephalus and require immediate shunting

Question 379

``` Which is/are the most common shunt complication(s) when treating hydrocephalus in an infant with myelomeningocele? A) Infection and obstruction B) Lower limb weakness C) Pain and swelling D) Incontinence of bowel and bladder ```

Answer 379

A) The two most common shunt complications are infection and obstruction. Signs and symptoms vary with the age of the chil

Question 380

``` What is a leading cause of death for infants with myelomeningocele (MMC)? A) Symptomatic Chiari II malformation B) Infection C) Hydrocephalus D) Renal failure ```

Answer 380

A) Symptomatic Chiari II malformation remains the leading cause of death for infants with MMC

Question 381

``` What are frequent signs and symptoms of spinal cord “tethering”? A) Infection B) Increased weakness C) Cognition loss D) Gastrointestinal upset ```

Answer 381

B) Cord tethering may result in increasing weakness, scoliosis, pain, urologic dysfunction, or orthopedic deformities

Question 382

``` What percentage of those with myelomeningocele (MMC) will have normal urinary control? A) 50% B) 25% C) 10% D) 1% ```

Answer 382

C) Fewer than 10% of children with MMC have normal urinary control. Continence is an important issue and must be addressed.

Question 383

``` What is a frequent allergy in myelomeningocele (MMC)? A) Soap B) Poison ivy C) Latex D) Urine ```

Answer 383

C) Although the prevalence of latex allergy in the general population is estimated to be less than 1% to 2%, its prevalence in children with MMC ranges from 20% to 65% because of the repeated exposure

Question 384

``` What is the most common level of myelomeningocele (MMC)? A) Upper thoracic B) Cervical C) Lower thoracic D) Lumbar ```

Answer 384

D) The majority of children with MMC have lumbar lesions, with one-fourth having midlumbar lesions. Very few have cervical and upper thoracic levels

Question 385

Which is the major cause of calcaneal deformity in myelomeningocele (MMC)? A) Unopposed contraction of foot dorsifl exors B) Unopposed contraction of plantar fl exors C) Weakness of foot intrinsics D) Hip dislocation

Answer 385

A) Calcaneal deformities result from unopposed contraction of foot dorsifl exors and can be present at birth or develop later

Question 386

``` Which would best describe the ambulation potential for a patient with thoracic myelomeningocele (MMC)? A) Community ambulatory B) Household ambulatory C) Functional ambulatory D) Nonambulatory ```

Answer 386

C) Most patients with lumbar lesions will have some level of ambulation, but those with thoracic MMC can be functional ambulators.

Question 387

``` Which of the following affects IQ scores of children with myelomeningocele (MMC)? A) Central nervous system infections B) Recurrent shunt revisions C) Ability to ambulate D) Pressure ulcers ```

Answer 387

A) IQ scores are adversely affected by central nervous system infections but not by recurrent shunt revisions.

Question 388

Which best describes the development of female patients with myelomeningocele (MMC)? A) Normal B) Markedly reduced C) Increased likelihood of late puberty D) Increased likelihood of precocious puberty

Answer 388

D) Between 12% and 15% of girls with MMC show precocious puberty; 95% have menses

Question 389

``` Of those patients with myelomeningocele (MMC) who complete high school, about what percentage go on to further education? A) < 10% B) 20% C) 40% D) 50% ```

Answer 389

D) About one-half of those who fi nish high school go on to further education.

Question 390

What must accompany rehabilitation in those with myelomeningocele (MMC) as they move to adulthood? A) Anticipation and prevention of life-threatening events B) Rechecks as needed C) Avoidance of activity D) Insistence on employment

Answer 390

A) MMC presents lifelong challenges to affected patients, their families, and clinicians. Surveillance and education are required to prevent life-threatening events related to ventriculoperitoneal shunt malfunction, Chiari II malformation, renal failure, infection, and latex allergy-all in conjunction with maximizing function

Question 391

sole of foot stroked; fans out toes and twists foot in

Answer 391

babinski

Question 392

flash of light or puff of air; closes eyes

Answer 392

blinking

Question 393

palms touched, grasps tightly

Answer 393

grasping

Question 394

sudden move or loud noise; startles throws out arms and legs

Answer 394

moro

Question 395

cheek stroked or side of mouth touhed; turns towards source opens mouth and sucks

Answer 395

rooting

Question 396

infant held upright with feet touching ground; moves feet as if to walk

Answer 396

stepping

Question 397

mouth touched by object; suck on object

Answer 397

sucking

Question 398

placed face down in water; makes coordinated swimming movements

Answer 398

swimming

Question 399

place on back; makes fists and turns head to the right

Answer 399

tonic neck