A 76-year-old patient arrives at the office with his wife with complaints of episodes of slurred speech, word-finding difficulties, and numbness in his arm. The first priority in management is:
- Tell him to take an aspirin right away.
- Order a CT scan.
- Send him to the ER.
- Perform an EKG.
3. Send him to the ER.
An aspirin is incorrect if you are concerned of stroke and you are not sure if it is hemorrhagic or ischemic in origin. A CT is reasonable, but should be done emergently upon admission to the ER. An EKG would be applicable for chest pain or hospital admission.
Which one of these patients are most at risk for ischemic stroke?
- A patient with atrial fibrillation on Coumadin with INR of 1.2
- A patient with 2ppd tobacco history of 40 years who quit 5 years ago
- A patient on anticoagulation therapy with INR of 4.0
- A hypertensive patient currently being treated with Losartan
1. A patient with atrial fibrillation on Coumadin with INR of 1.2
The patient who is out of his therapeutic window and at risk for a thromboembolic event (INR range 2–3). Smokers who quit are at greater risk than non-smokers, but at 5 years their risk drops to half that of smokers.
Initial urgent treatment for dizziness is associated with which of the following?
- Nausea and vomiting
This is the only correct answer because it could be associated with stroke or TIA. The others are all non-urgent symptoms or associations.
Which of the following situations is NOT considered a "Red Flag" for referral for a patient the FNP is seeing in his/her practice?
- A patient who presents with an abnormal perception of movement (sensation of spinning)
- A patient with peripheral nerve compression
- A patient with no response to treatment or improvement from standard therapy
- Acute or sudden onset of symptoms—change in LOC, visual change
1. A patient who presents with an abnormal perception of movement (sensation of spinning)
All of the answers are red flags for referral except vertigo.
What is the first symptom seen in the majority of Parkinson’s patients?
- Intention tremor
- Rest tremor
3. Rest tremor
Asymmetric tremor at rest is usually seen in one hand as a presenting symptom for PD. Intention tremor is also known as essential tremor and presents symmetrically in a different population. The other symptoms are seen later in the disease.
A 73-year-old female patient presents with limb paralysis nystagmus, vertigo, nausea, slurred speech, and cerebellar ataxia. An occlusion of which part of the brain is suspected?
- Occipital and temporal lobes, dorsal surface of thalamus, upper part of cerebellum, midbrain
- Anterior cerebral surfaces
- Posterior cerebral surfaces
- Parts of the medulla
1. Occipital and temporal lobes, dorsal surface of thalamus, upper part of cerebellum, midbrain
The most common areas of occlusion are the ICA or MCA. The midbrain, upper part of the cerebellum and dorsal surface of the thalamus receive blood from the basilar artery, which also supplies the temporal and occipital lobes. Thus, the patient exhibits symptoms in the regions of the brain that have been affected with slurred speech, cerebellar ataxia, nausea and vertigo, and limb paralysis, nystagmus. The posterior cerebral surface would result in bilateral motor sensory, visual complaints, and contralateral hemiplegia. Answer D would result in pain, temperature, and sensation impairment, as well as vertigo and dysphagia—in a contralateral fashion.
Dysarthria, dysphagia, and diplophia are signs of which of the following?
- Peripheral vertigo
- Central vertigo
- Presyncopal causes of vertigo
- Psychogenic causes of vertigo
2. Central vertigo
These are all signs of stroke, therefore they are not consistent with Peripheral vertigo, Presyncopal causes of vertigo, or Psychogenic causes of vertigo.
What diagnostic maneuver reproduces the characteristics of vertigo?
- Epley maneuver
- Dix–Hallpike maneuver
- Lying prone on the exam table
- VNG (video nystagnography)
2. Dix–Hallpike maneuver
The Epley maneuver is the repositioning maneuver used to treat BPPV, while the Dix–Hallpike will elicit nystagmus and vertigo.
A patient presents with dizziness, delayed clockwise rotational clockwise nystagmus, and spinning for less than a minute after position change and denial of hearing loss and headache. The appropriate diagnostic evaluation to use would be what?
- CT with contrast
- No studies are necessary.
3. No studies are necessary.
Vertigo without neurologic deficits requires no imaging. It is a clinical diagnosis.
An 82-year-old patient presents with a history of TIA and confusion. A sensitive neurologic test for stroke would be what?
- The pronator drift
- Epley maneuver
- Visual field exam
- Get-up-and-go test
1. The pronator drift
The pronator drift will show upper motor neuron weakness if the patients arm drifts, as well as confusion if they are unable to follow instructions. The Epley maneuver is done for vertigo. Visual fields should be assessed as part of a neuro exam, and the get-up-and-go test is a timed mobility test for the elderly.
The CHA2DS2–VASc Index is used for categorizing patients according to risk. These risk factors include all of the following EXCEPT:
- Age 65–74.
All of the answers are variables used to assess the risk to start anticoagulation except for drugs. Additional variables include sex, vascular disease, LVEF, thromboembolism, PAD, CHF.
A patient with multiple sclerosis presents with concerns of exacerbation. The nurse practitioner knows the examination will likely present with the following:
- Tremor at rest
- Hyperreflexia + Babiniski, upper motor neuron signs, ataxic gait
- Hyporeflexia, decreased reflexes, hypotonia, sensory disturbance
- Sensory deficit that follows a single dermatomal distribution
2. Hyperreflexia + Babiniski, upper motor neuron signs, ataxic gait
Would be a Parkinson’s patient, Hyporeflexia, decreased reflexes, hypotonia, sensory disturbance is incorrect. Sensory deficit does not follow single dermatomal distributions.
A child presents with febrile seizures. Which statement offers the BEST information for the education of the family by the NP?
- These types usually present as absence or simple partial seizures.
- The child will usually need anticonvulsant therapy for 6 months.
- There is a higher risk of developing epilepsy later in life (greater than the general population).
- Most occur on the first day of fever; > 75% > 102 degrees.
4. Most occur on the first day of fever; > 75% > 102 degrees.
Febrile seizures occur with fever > 100, 75% > 102, and in the absence of an identifiable cause. They do not require treatment and usually occur on the first day the fever does. They are typically generalized, less than 15 minutes in duration, and may have tonic clinic activity. The risk for developing epilepsy later in life is slightly increased from that of the general population (1%).
Ménière’s disease is an idiopathic disorder that is characterized by which of the following?
- Episodic attacks of vertigo lasting less than a minute and hearing loss
- Dizziness, double vision, hearing loss, tinnitus, vertigo
- Episodic attacks of vertigo, tinnitus, aural fullness, and hearing loss
- Disabling attacks of vertigo, diplopia, hearing loss, tinnitus, and aural fullness
3. Episodic attacks of vertigo, tinnitus, aural fullness, and hearing loss
By definition, Ménière’s has the classic symptoms of vertigo tinnitus and hearing loss accompanied by aural fullness. The condition can be chronic or can resolve. There is an extensive differential for dizziness and double vision, including stroke; MS is not associated with Ménière’s.
A primary headache differs from a secondary headache in what way?
- A primary headache is the first headache of someone’s life.
- A secondary headache presents with an aura.
- A secondary headache is a result of abnormal anatomic pathology.
- A primary headache is due to systemic disease.
3. A secondary headache is a result of abnormal anatomic pathology.
It is also due to systemic disease. A migraine presents with an aura 20% of the time.
First-line treatment for essential tremor is which of the following?
- Propranolol (Inderal)
- Alprazalam (Xanax)
- Amitryptylline (Elavil)
1. Propranolol (Inderal)
Though many patients will self-medicate with alcohol, and it will suppress the symptoms, beta-blockers are the first-line treatment.
A 62-year-old woman complains of severe lancinating pain in her right cheek that worsens with cold drinks or teeth brushing. She is afraid to chew or eat because it seems to initiate the attack. The most likely diagnosis is which of the following?
- Sinus infection
- Abscessed tooth
- Trigeminal neuralgia
- Bell’s palsy
3. Trigeminal neuralgia
Classic symptoms of trigeminal neuralgia is shock-like severe lancinating unilateral pain in the sensory distribution of the trigeminal nerve (CN V), often initiated by cold, chewing, or a sensory stimulus. The etiology is often unknown. Bell’s palsy does not present this way or with the same distribution.
What test for carpal tunnel syndrome reports a positive finding for tingling after passive flexion of the wrist for 1 minute?
- Tinel’s sign
- C-T-S test
- Radial test
- Phalen’s Sign
4. Phalen’s Sign
Phalen’s sign—numbness and tingling in the median nerve distribution of the fingers.
A 35-year-old male c/o (complaints of) the abrupt onset of recurrent "ice pick" headaches behind one eye. He presents to the NP’s office with an acute episode. On physical exam, the patient is noted to have tearing in one eye, ptosis, and nasal discharge/congestion. The NP's plan for therapeutic management would be which of the following?
- High-dose NSAIDs
- High-dose oxygen 7–10 L
- Send to the ER for CT scan
2. High-dose oxygen 7–10 L
This patient meets the classic presentation for cluster headache. He does not need to go to the ER, especially with a "recurrent" history. The presentation of a Horner’s-like syndrome is normal. He will respond to high-dose oxygen for acute treatment. Verapamil should also be titrated or adjusted for prevention.
A 72-year-old patient presents with c/o headache with unilateral marked scalp tenderness. You note induration of the temporal artery. Upon checking his labs, the FNP expect to find which of the following?
- Normal CRP
- ESR 100 mm or >
- WBC >15,000
- Positive western blot
2. ESR 100 mm or >
The ESR would be elevated with a diagnosis of temporal arteritis, which is what this patient most likely has. The CRP should be elevated. The other findings are not consistent with the condition.
When the FNP administers the Mini-mental status exam (MMSE) and asks what is the difference between a river and a lake? He/she is actually measuring which of the following?
- Education level
- Abstract thinking
3. Abstract thinking
Asking about similarities and differences is abstract thinking. Memory testing would be day, date, month, season etc. The test does not take into account the educational level or measure plasticity.
A 22-year-old patient with no cardiovascular history presents with a history of a unilateral headache accompanied by nausea, vomiting, photophobia, or phonobia. What further diagnostics are required to establish the diagnosis?
- No further laboratory investigation is needed
- CBC with differential
3. No further laboratory investigation is needed
The diagnosis is established on the basis of clinical findings. If there are clinical features that may suggest an alternative diagnosis, then additional laboratory investigations are necessary. If appropriate therapy is initiated and there is a lack of response, than an alternate diagnosis would also be considered.
Which of the following medications is the best choice for acute treatment of the patient who presents with unilateral headache accompanied by nausea, vomiting, photophobia or phonophobia?
Beta-blockers are preventative therapy. NSAIDs may be used for tension headache or episodic headache. Narcotics are not first-line. Triptans are first-line therapy for a patient without cardiovascular history.
Which CN is responsible for shoulder shrugging?
- CN X
- CN XI
- CN IX
- CN XII
2. CN XI
The vagus nerve is 10, the hypopharyngeal nerve is 9, and hypoglossal is 12; the nerve responsible for the shoulder shrug is CN 11.
Which CNs are being tested with EOM?
- A CN III, IV, VI
- CN III, IV, V
- CN II, III, IV
- CN II, IV, V
1. A CN III, IV, VI
CN 3—oculomotor medial deviation and all other directions, 4-trochlear (innervates superior oblique and downward gaze), 6 abducens (innervates lateral recturs and lateral gaze). Extraocular range of motion. CN V is the trigeminal nerve.
The next patient to be seen by the FNP is a 16-year-old old high school soccer player who suffered a Gr 1 concussion. The best advice at this time would be which of the following?
- Pupillary checks every hour, monitor vital signs
- You may return to play as soon as your symptoms have resolved
- Physical rest × 2 weeks, no contact sports with medical follow-up
- Physical and cognitive rest monitored by medical personnel. Monitor for emotional symptoms, headaches difficulty remembering, feeling foggy, trouble concentrating
2. You may return to play as soon as your symptoms have resolved
It needs to be monitored by medical personnel; some athletes will be inappropriately anxious to return to sport.
The classic presentation of carpal tunnel syndrome includes repetitive use and gradual onset of tingling (paresthesias) in which fingers?
- Thumb, index, and middle finger
- Index, middle, and fifth finger
- All the fingers of the hand
1. Thumb, index, and middle finger
Median nerve compression results in thumb, index finger, and middle finger symptoms.
During the neurologic exam, a patient has had a positive Romberg test. This highlights an issue in what part of the neurologic system?
- The sensory system and balance
- Mental status
- The motor system
- The reflex system
1. The sensory system and balance
The Romberg test helps assess proprioception—sensory and balance.
Which statement below best describes a positive Romberg test?
- The patient is unable to walk in a straight line with one foot in front of the other.
- The patient holds arms straight forward with eyes closed.
- The patient stands with feet together, eyes closed, arms at side with excessive swaying—begins to fall down and keeps feet far apart to maintain balance.
- Patient places outstretched arms with palms facing up and closed eyes. One arm goes downward after 5–10 seconds.
3. The patient stands with feet together, eyes closed, arms at side with excessive swaying—begins to fall down and keeps feet far apart to maintain balance.
Tandem gait test. The exam where the patient holds arms straight forward with their eyes closed is a negative test. The exam where the patient places their outstretched arms with palms facing up and closed eyes is a motor exam for pronator drift.
Serious causes of headache that require immediate urgent referral include which of the following?
- Cervical spondylosis
A careful history and physical would delineate the cause. Migraine can be diagnosed clinically and does not need further workup. Hypertension can be serious if not controlled, but is not usually the reason for immediate urgent referral. Patients with hypertensive crisis would require an urgent referral.