Module 3 Buttarro Ch 171-184

Question 1

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

a. Lower motor neurons (LMN)
b. Upper motor neurons (UMN)
c. Corticospinal tracts
d. Corticobulbar tracts

Answer 1

a. Lower motor neurons (LMN)

Lower motor neuron involvement and early LMN cell death leads to an insidious onset of asymmetric weakness that is evident initially in the limbs, usually in the arms.

Upper motor neuron cell death may result in hyperreflexia, spasticity, incoordination, and weakness.

Bulbar signs include dysarthria, dysphagia, and tongue fasciculations.

The corticospinal tracts are part of the UMN cells.

Question 2

The spouse of a patient newly diagnosed with amyotrophic lateral sclerosis (ALS) asks about long-term care. What will the provider include when teaching the family about this disease?

a. Bowel and bladder function will eventually be lost.
b. Positive-pressure ventilation can prolong life.
c. Preventing malnutrition is a key element in care.
d. The nerves affecting sensation will die initially.

Answer 2

c. Preventing malnutrition is a key element in care.

Prevention of malnutrition may improve both the quality and length of life.

Bowel and bladder function and sensation remain intact.

Positive-pressure ventilation helps to relieve sleep disturbance.

Question 3

A 35-year-old patient reports suddenly experiencing an asymmetric smile along with drooping and tearing in one eye. The patient has a history of a recent viral illness but is otherwise healthy. During the exam, the provider notes that there is unilateral full-face paralysis on the right side. What is the initial intervention for this patient?

a. Perform confirmatory diagnostic tests.
b. Prescribe oral corticosteroids.
c. Recommend wearing an eye patch.
d. Refer the patient to a neurologist.

Answer 3

b. Prescribe oral corticosteroids.

-Bell Palsy = Acute progressive UNILATERAL weakness of the facial nerve, caused by inflammatory proccess of unknown eitiology
-TREATED with CORTICOSTEROIDS within 72 hours of onset or IVIG
- a peripheral facial nerve condition
-self limiting
-typically occurs after recent viral infection (varicella, mono, flu, CMV)
-either side of the face can be affected.
-more common in last trimester of pregnancy
DIAGNOSED: based on history, don’t need MRI unless central lesion is suspected

central lesion sx = is asymmetrical weakness with numbness tingling and ABILITY o wrinkle for head

Bell palsy pt are UNABLE to wrinkle forehead, and UNABLE to close eyes

Patients may be instructed to tape the eye closed at night, but eye patches are not recommended.

Question 4

What is recommended to prevent ophthalmic complications in patients with Bell’s palsy?

a. Acupuncture
b. Lubricating eye drops
c. Patching of the eye

Answer 4

b. Lubricating eye drops

Bell palsy pt are UNABLE to wrinkle forehead, and UNABLE to close eyes

Patients may be instructed to tape the eye closed at night, but eye patches are not recommended.

Exposure keratitis from drying of the eye can result in blindness. Lubricating eye drops should be used every 2 hours. Protective eyewear to prevent moisture loss is recommended.

Question 5

Which symptoms may occur with Bell’s palsy? (Select all that apply.)

a. Alteration in taste
b. Decreased hearing
c. Drooling
d. Inability to open the eye
e. Tinnitus

Answer 5

a. Alteration in taste
c. Drooling
e. Tinnitus

Bell’s palsy may cause altered taste, drooling, and tinnitus. It causes increased sensitivity to noises and an inability to close the eye.

Question 6

A patient exhibits visual field defect, ataxia, and dysarthria and complains of a mild headache. A family member reports that the symptoms began several hours prior. An examination reveals normal range of motion of the neck. What type of cerebrovascular event is most likely?

a. Hemorrhagic stroke
b. Hypertensive intracerebral hemorrhage
c. Ischemic stroke
d. Transient ischemic attack (TIA)

Answer 6

c. Ischemic stroke

NUCHAL rigidity is more common with hemorrhagic stroke

Ischemic stroke

• interruption of blood flow in the CNS
• occurs in one SINGLE event that resolves in a few hours
• DONOT typically have HA
• THROMBOLIC therapy (TPA) is given to patients with ischemic stroke.
• Sx depend on Location Middle artery=most common
  1. LEFT Middle SX
• RIGHT side face, right arm, right leg weakness, hemianopia = Losing sight in HALF of your visual field, (confrontation) with expressive (brocas) aphasia= difficulty speaking, but can understand

2. Right: middle
   - LEFT side face, arm, leg weakness with possible Henianopia

Question 7

An elderly patient is brought to the emergency department after being found on the floor after a fall. The patient has unilateral sagging of the face, marked slurring of the speech, and paralysis on one side of the body. The patient’s blood pressure is 220/190 mm Hg. What is the likely treatment for this patient?

a. Carotid endarterectomy
b. Close observation until symptoms resolve
c. Neurosurgical consultation
d. Thrombolytic therapy

Answer 7

c. Neurosurgical consultation

This patient has signs consistent with hemorrhagic stroke and will need consultation with a neurosurgeon to determine whether surgical intervention will be beneficial.

Carotid endarterectomy is performed in patients with carotid stenosis and is used in patients with hemispheric ACVS (TIA).

Patients with TIA may be observed to monitor symptoms.

Hemorrhagic Stroke:

• sudden onset severe headache “thunderclamp”
• pain may radiate
• n/v
• NUCHAL RIGIDITY
• LOC
• typically caused by an aneurysm rupture or vascular malformations

Question 8

A previously healthy 30-year-old patient is brought to the emergency department with signs of stroke. Diagnostic testing determines an ongoing ischemic cause. The patient’s spouse reports that symptoms began approximately 2 hours prior to transport. What is the recommended treatment?

a. Administration of low-molecular-weight heparin
b. Neurosurgical consultation for possible surgery
c. Observation for complications prior to initiating tPA
d. Tissue plasminogen activator (tPA) administration

Answer 8

d. Tissue plasminogen activator (tPA) administration

This patient meets the criteria for tPA administration and it should be begun within 4.5 hours after onset of symptoms. This patient has had symptoms for over 2 hours, so tPA should begin immediately.
LMW heparin is not indicated.

Neurosurgical intervention is recommended for patients with hemorrhagic stroke.

Question 9

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

a. Hyperactive delirium
b. Hypoactive delirium
c. Sundowner syndrome
d. Worsening dementia

Answer 9

c. Sundowner syndrome

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

Question 10

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

Answer 10

b. Delirium

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

Question 11

An elderly patient has symptoms of depression and the patient’s daughter asks about possible Alzheimer’s disease (AD) since there is a family history of this disease. A screening evaluation shows no memory loss. What is the initial step in managing this patient?

a. Order brain imaging studies such as CT or MRI.
b. Perform genetic testing to identify true risk.
c. Prescribe a trial of an antidepressant medication.
d. Recommend a trial of a cholinesterase inhibitor drug.

Answer 11

c. Prescribe a trial of an antidepressant medication.

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

Question 12

A patient reports a recurrent sensation of spinning associated with nausea and vomiting. Which test will the provider order to confirm a diagnosis for this patient?

a. Electroencephalogram (ECG)
b. Holter monitoring and electrocardiogram
c. Neuroimaging with computerized tomography (CT)
d. The Hallpike-Dix positioning maneuver

Answer 12

d. The Hallpike-Dix positioning maneuver

Dizziness can be wither associated with Cardiac issue, eye issue of ear (vestibular issue= Vertigo) or brain (cerebellum)

Must determine if vestibular lesion done by performing Hallpike-Dix position maneuver to evaluate vestibular function

If seizure activity is suspected, an electroencephalogram will be ordered.

Holter monitoring and ECG are used if patients report syncope or lightheadedness.

Neuroimaging with CT is used when patients possibly have a central lesion which would present with difficulty balancing.

Question 13

An older adult patient reports sensations of being off balance when walking but does not experience dizziness. The provider will refer this patient to which specialist for further evaluation?

a. Audiologist
b. Cardiologist
c. Neurologist
d. Otolaryngologist

Answer 13

c. Neurologist

This patient has problems of balance without dizziness, suggestive of a central neural lesion and should be referred to a neurologist.

Patients with vertigo are likely to have vestibular dysfunction and would be referred to an otolaryngologist and possibly an audiologist if hearing is affected.

Patients with syncope or lightheadedness are more likely to have an underlying cardiac disorder and would be referred to a cardiologist.

Question 14

Following an upper respiratory infection, a patient begins to develop ataxia and distal paresthesias, along with oculomotor symptoms and double vision. Based on these presenting symptoms which type of Guillain-Barré syndrome (GBS) does this patient have?

a. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)
b. Acute motor axonal neuropathy (AMAN)
c. Classic Guillain-Barré syndrome
d. Miller Fisher syndrome (MFS)

Answer 14

d. Miller Fisher syndrome (MFS)

GBS-symmetric paresthesias and/or lack of weakness, typically starting in lower extremities and evolving ocer days or hours typically Patients with have HISTORY of Recent infection. Can spread up and affect respiratory muscles
DX with LP lookin for increased protein

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

Question 15

Which diagnostic test helps confirm a diagnosis of Guillain-Barré syndrome (GBS) in a patient who is developing muscle weakness and paresthesias?

a. Lumbar puncture
b. MRI imaging
c. Nerve conduction studies
d. Screening for systemic infection

Answer 15

a. Lumbar puncture

A lumbar puncture is the most important confirmatory test showing albuminocytologic disassociation.

MRI imaging typically is not necessary unless there is concern for spine pathology but does not diagnose GBS.

Nerve conduction studies are not necessary for the diagnosis. Screening for systemic infection is based on history and does not diagnose GBS.

Question 16

Which monitoring parameters are necessary when caring for a patient with Guillain-Barré syndrome (GBS)? (Select all that apply.)

a. Bladder scans
b. Cardiac telemetry
c. Imaging studies
d. Fever
e. Vital capacity measures

Answer 16

a. Bladder scans
b. Cardiac telemetry
d. Fever
e. Vital capacity measures

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

Question 17

A patient reports recurrent headaches occurring 1 or 2 times per month that generally occur with weather changes or when sleep patterns are disrupted. They are described as severe, with throbbing on one side of the head and sometimes accompanied by nausea. What is the recommended abortive treatment for this type of headache?

a. Gabapentin
b. Propranolol
c. Ergotamine tartrate
d. Topiramate

Answer 17

c. Ergotamine tartrate

Migraines typically are severe, described as pounding or throbbing accompanied by n/v, phono, photophobia, can be associated with identified triggers,

tx: *must rule our Cardiovascular problems, medications to treat headache are vasoconstrictors
Severe attacks
1. Triptans = first line abortive-may cause flushing or tinging
2. ergotamine-may cause nausea

mild-mod
-analgesiacs with antiemetics

moderate- severe
-triptans with nsaids (naproxen)

Propholactice tx taken every day

• Beta-blockers
• TCAs (elavil at bedtime)
• SNRIs - effexor
• anticonvulsants- topamax, valporate

The other medications are preventive medications and are used for patients having more than 4 per mo

Question 18

A patient has recurrent cluster headaches and asks about abortive therapy. Which therapy is effective for most patients with cluster headaches?

a. Lithium
b. NSAIDs
c. Oxygen
d. Verapamil

Answer 18

c. Oxygen

Cluster headaches

• unilateral
• pts will wake up with it
• last 15-90 minutes
• can occur several times a day
• typically pts are restless and cannot sit still, moaning or crying

tx; Oxygen works as abortive therapy for cluster headaches in 75% of patients and should be inhaled at the start of an attack.

NSAIDs are not useful.

Lithium and verapamil work well as preventive medications for cluster headaches but are not given for abortive treatment.

Question 19

Which medications may be useful in treating tension-type headache? (Select all that apply.)

a. Triptan drugs
b. Lithium
c. Muscle relaxants
d. NSAIDs
e. Oxygen

Answer 19

a. Triptan drugs
c. Muscle relaxants
d. NSAIDs

Tension HA:

• feeling like a tight band across head
• do not have n/v
• nagging
• common triggers are headache
• not exacerbated by activity

Triptan drugs, muscle relaxants, and NSAIDs may all be used to treat tension-type headaches.

Lithium and oxygen are not used.

Question 20

A patient is brought to the emergency department with fever, lethargy, and headache. No meningeal signs are noted. The examination reveals hypotension and lethargy and the examiner notes petechiae on the patient’s trunk. What do these findings indicate?

a. Progressing meningococcemia
b. Encephalitis
c. Increased intracranial pressure (ICP)
d. Probable viral infection

Answer 20

a. Progressing meningococcemia

Petechiae are an ominous sign, indicating a rapidly progressing meningococcemia.

Patients with encephalitis or other viral infection will not usually have petechiae and severe symptoms.

Increased ICP will present with hypertension.

Question 21

A provider suspects that a patient has bacterial meningitis. When should antibiotics be given?

a. If the serum C-reactive protein is greater than 10 mg/L
b. Immediately after blood and spinal cultures are obtained
c. Prior to obtaining a computed tomography (CT) scan or lumbar puncture (LP)
d. When initial spinal fluid gram stain results are available

Answer 21

c. Prior to obtaining a computed tomography (CT) scan or lumbar puncture (LP)

In all cases of suspected meningitis, the first dose of antimicrobials should be administered immediately after blood cultures are obtained and prior to the CT and LP to avoid critical delays in treatment.

The CSF culture will still yield bacteria for 1 to 2 hours after the first dose.

Waiting for any laboratory results may delay effective treatment.

Question 22

A patient reports trembling of both hands causing difficulty performing tasks with the hands. The provider notes symmetric, rhythmic movements which are present at rest and no other neurological findings. A history reveals that the trembling decreases when the patient has a glass of wine with dinner. What is the initial action?

a. Evaluation in an emergency department (ED)
b. Prescribing a beta blocker medication
c. Reassurance that these will subside
d. Referral to a neurologist

Answer 22

b. Prescribing a beta blocker medication

This patient has symptoms consistent with essential tremors.

Reassurance may be the first action, but the symptoms will not subside.

Beta blockers are used when the tremor is functionally or socially problematic. It is not necessary to refer to an ED or a specialist.

Question 23

Which are common hyperkinetic movement disorders? (Select all that apply.)

a. Dystonia
b. Essential tremor
c. Parkinson’s disease
d. Progressive supranuclear palsy
e. Tourette’s syndrome

Answer 23

a. Dystonia
b. Essential tremor
e. Tourette’s syndrome

Dystonia, essential tremor, and Tourette’s are hyperkinetic disorders.

Parkinson’s disease and progressive supranuclear palsy are hypokinetic disorders

Question 24

A patient reports two episodes of visual disturbances and eye pain that lasted 1 to 2 days each about 2 months apart. Which diagnostic testing will the provider order initially?

a. Lumbar puncture
b. Magnetic resonance imaging (MRI)
c. Optical Coherence Tomography (OCT)
d. Visual evoked potential

Answer 24

b. Magnetic resonance imaging (MRI) = Gold standard

clinical symptoms of MS: eye pain and visual disturbances = most common
associated with pain in back or neck, paresthesias or weakness of limbs

Visual disturbances and eye pain may be the only presenting symptoms and should be investigated. The MRI is the gold standard for diagnosis of multiple sclerosis (MS). T

Question 25

A patient diagnosed with multiple sclerosis and begins disease modulating therapy (DMT) drugs. As part of the counseling about this therapy, the provider will tell the patient that this regimen will likely result in what outcome?

a. A decreased need for other medications
b. An induced long-term remission
c. A reduction in the exacerbation rate
d. A permanent stop of the disability

Answer 25

c. A reduction in the exacerbation rate

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

Question 26

A primary care provider suspects Parkinson’s disease (PD) in a patient. Which tests may be performed to diagnose this disorder?

a. Neuroimaging to identify specific midbrain lesion
b. Neuromuscular studies to identify reflex function
c. Presence of 2 cardinal signs which improve with levodopa
d. Serum creatine phosphokinase levels

Answer 26

c. Presence of 2 cardinal signs which improve with levodopa

PD is caused by a deficiency of DOPAMINE

Cardinal signs most suggestive of PD

1. asymmetrical/unilateral tremor AT REST aka rest tremor
   * PIn rolling tremors in hands*
2. posture instability
3. bradykinesia (slow movements, shuffle gain)

The diagnosis of idiopathic PD is made based on clinical presentation and examination findings with 2 of 3 cardinal manifestations present which respond to dopaminergic therapy

Neuroimaging that identifies Lewy bodies is the gold standard but is performed POST-MORTUM

Neuromuscular studies and serum laboratory studies are not useful unless excluding other causes of symptoms.

Question 27

A patient diagnosed with Parkinson’s disease (PD) has been prescribed carbidopa-levodopa with good results but develops increased dyskinesia. Which drug will be added to this patient’s regimen to help control this symptom?

a. Amantadine
b. Benztropine
c. Ropinirole
d. Tolcapone

Answer 27

a. Amantadine

Amantadine is an antiviral agent that has antiparkinsonian activity. It is useful for controlling dyskinesia as adjunctive therapy to levodopa and is more effective than anticholinergic drugs.

Benztropine is an anticholinergic drug that may be used for this purpose but is less effective and is more commonly used to treat antipsychotic-induced parkinsonism.

Ropinirole is used as a first-line agent in patients with young-onset PD.

Tolcapone is a COMT agent to prolong and potentiate the effects of levodopa to help prevent “wearing off” periods.

Question 28

What are common symptoms noted in patients diagnosed with Parkinson’s disease? (Select all that apply.)

a. Bradykinesia
b. Festination
c. Hyperphonia
d. Rigidity
e. Symmetric tremor

Answer 28

a. Bradykinesia
b. Festination
d. Rigidity

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

Question 29

A patient with a seizure disorder has seizures which begin with a gastric sensation and a feeling of déjà vu. Which site in the brain is the seizure focus?

a. Frontal
b. Occipital
c. Parietal
d. Temporal

Answer 29

d. Temporal

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

Question 30

A patient who has a seizure disorder and takes levetiracetam is brought to an emergency department as two consecutive 15-minute seizures occur. What is the priority action for this patient?

a. Administer a dose of levetiracetam now and repeat in 10 minutes.
b. Administer lorazepam and monitor cardiorespiratory status.
c. Administer phenytoin and phenobarbital along with oxygen.
d. Admit the patient to the hospital for a diagnostic work up

Answer 30

b. Administer lorazepam and monitor cardiorespiratory status.

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

Question 31

Which drug is used to treat patients with focal epilepsy and complex partial seizures?

a. Carbamazepine
b. Ethosuximide
c. Lamotrigine
d. Topiramate

Answer 31

a. Carbamazepine

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

Question 32

A patient reports paroxysms of burning, shock-like pain on both sides of the face usually triggered by chewing or talking. The provider suspects trigeminal neuralgia. Based on these presenting symptoms, what testing is indicated?

a. Autoimmune laboratory panel
b. Inflammatory markers
c. Magnetic resonance imaging (MRI)
d. Plain radiographs

Answer 32

c. Magnetic resonance imaging (MRI)

Trigeminal Neuralgia- common well defined orofacial pain disorder caused by compression of the trigeminal nerve. Pain is described as acute onset spasms that can radiate along nerve. CN located around nose and border of cheek bone. can occur in both sides of the face

described as piercing and knife like

Pain is worsened by chewing, eating cold things or cold air

Treated with High dose anticonvulsant like Carbamazipine (tegretol) and muscle relaxers

Pain in both sides of face is similar to MS and MRI is done to confirm and r/o MS

Question 33

A patient is diagnosed with trigeminal neuralgia and reports having paroxysms several times each day. What is the initial treatment for this patient?

a. A combination of baclofen, lamotrigine, and phenytoin
b. A high dose of carbamazepine with subsequent titration downward
c. Botox injections or intranasal lidocaine as needed
d. Low doses of anticonvulsants with gradual increase as needed

Answer 33

b. A high dose of carbamazepine with subsequent titration downward

Anticonvulsants are first-line treatments for trigeminal neuralgia – carbamazepine is started at the maximum therapeutic dose and titrated down to the lowest effective dose.

Combination drug therapy is begun if the initial treatment is not effective or if the single drug regimen has intolerable side effects. Botox injections and intranasal lidocaine are used as adjuncts to anticonvulsants for acute pain relief.

Question 34

A patient diagnosed with trigeminal neuralgia has tried several medication regimens to control pain without success. What is the next step in management for this condition?

a. Consultation with a psychiatrist
b. Education about alternative treatments
c. Recommending a pain center
d. Referral to a neurosurgeon

Answer 34

d. Referral to a neurosurgeon

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

Question 35

A patient develops a gait disorder and the patient’s spouse reports noticing recent personality changes. The provider suspects a brain lesion. Which evaluation is especially important in the initial physical examination?

a. Assessment of peripheral reflexes
b. Evaluation of speech
c. Examination of the optic fundi
d. Testing for memory loss

Answer 35

c. Examination of the optic fundi

Gait disorders and personality changes are more typical presentations with nonfocal lesions. Examination of the optic fundi for papilledema may be the only finding to indicate increased intracranial pressure. The other assessments help determine focal involvement.

Question 36

Which is the preferred treatment for primary brain tumors?

a. Chemotherapy
b. Palliative care
c. Radiation therapy
d. Surgical resection

Answer 36

d. Surgical resection

surgical resection is the most effective treatment for brain tumors. Chemotherapy is limited in
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effectiveness because of difficulty crossing the blood-brain barrier. Radiation therapy is used as a primary, adjuvant, or palliative therapy. Palliative care is not the preferred treatment; many patients with brain tumors live for many years.

Question 37

What disorder is characterized by bilateral joint stiffness that is worse in the morning. located primarily to posterior neck, shoulders and pelvic girdle (groin pain that radiates to lateral aspects of thight and hips. Patient have difficulty in putting on clothes or moving from chair.

a. rheumatoid arthritis
b. osteo arthritis
c. Polymyalgia Rheumatica
d. rheumatoid arthritis

Answer 37

c. Polymyalgia Rheumatica

treated with oral steroids (prednisone)

Question 38

A patient reports symptoms of restlessness, fatigue, and difficulty concentrating. The provider
determines that these symptoms occur in relation to many events and concerns. What other
things will the provider question this patient about?
a. Ability to manage social situations
b. Body image and eating habits
c. Headaches and bowel habits
d. Occupational performance

Answer 38

c. Headaches and bowel habits

This patient has symptoms consistent with generalized anxiety disorder (GAD) in which
feelings occur in relation to many events.

Patients with GAD often have headaches and
irritable bowel syndrome. Restlessness and fatigue, also excessive worry

Tx with SSRI or SNRI d/t least side effects, however can have increased anxiety fatigue, headaches the first 2 weeks an then will go away

Phobias are linked to particular events and often include social
situations. Patients with obsessive-compulsive disorder (OCD tend to have eating disorders
and difficulty with occupational and academic performance.

Question 39

A patient is diagnosed with panic disorder and begins taking a selective serotonin reuptake
inhibitor (SSRI) medication. Six weeks later, the patient reports little relief from symptoms.
What will the provider do next to manage this patient?
a. Change the medication to buspirone
b. Discontinue the medication
c. Increase the medication dose
d. Refer to a mental health provider

Answer 39

d. Refer to a mental health provider

Patients taking SSRIs for anxiety disorders should see effects within 2 to 4 weeks. If patients
have not had good results in 4 to 6 weeks, the provider should change the medication or refer
to a mental health provider.

Discontinuing an SSRI abruptly can cause withdrawal symptoms. Increasing the medication dose will not improve the effects.

Buspirone is somewhat useful
only for generalized anxiety disorder (GAD). because it may exaggerate depression symptoms

Question 40

Which medication is useful in treating both obsessive-compulsive disorder (OCD) and
post-traumatic stress disorder (PTSD)? (Select all that apply.)
a. Benzodiazepines
b. Buspirone
c. Selective serotonin reuptake inhibitors (SSRIs)
d. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
e. Tricyclic antidepressants (TCAs)

Answer 40

c. Selective serotonin reuptake inhibitors (SSRIs)
- fluoxetine (prozac)
- sertraline (zoloft)
- citalopram (celexa)
d. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- -venlafaxine (effexor)
- duloxetine (cymbalta)
e. Tricyclic antidepressants (TCAs)
- clomipramine (not first line d/t cardiac dysrhythmia, lethal in overdose)

Benzodiazepines and
buspirone are not indicated for either disorder.

Buspirone only for GAD
Benzo acute management not long term

Question 41

A patient is seen in clinic 2 weeks after the death of a parent. The patient reports feelings of
sadness and hopelessness and a feeling that the parent is still present, even to the point of
hearing the parent’s voice at times. What will the provider determine from these findings?
a. There is a concern for hypermania.
b. There is a possibility of manic episodes.
c. These are concerning for depression.
d. These are normal grief responses.

Answer 41

d. These are normal grief responses.

These are short-lived symptoms at this point, lasting less than 2 months.

Auditory and sensory hallucinations only in relation to the deceased are normal during intense grief.

Hypermania is an acute, short-lived manic episode.

Mania involves abnormal elevation of a person’s mood.

Depression is present when symptoms of grief are more severe and more prolonged.

Question 42

patient is seen frequently over a 9-month period with somatic complaints that are not
related to physical disease. The primary provider notes that the patient has had a 15% weight
loss in the previous 2 months and the patient reports difficulty sleeping. The spouse tells the
provider that the patient seems tired all the time and is irritable with other family members.
What will the provider do initially?
a. Perform a suicide risk assessment
b. Prescribe a selective serotonin reuptake inhibitor
c. Refer the patient for psychotherapy
d. Suggest cognitive-behavioral therapy

Answer 42

a. Perform a suicide risk assessment

For any patients with symptoms of depression, the initial action is to perform a thorough
assessment and evaluate potential suicide risk.

SSRIs can be prescribed once a diagnosis is
determined according to diagnostic criteria.

Psychotherapy and cognitive-behavioral therapy
may also be prescribed.

Question 43

A college student is brought to clinic by a parent who is concerned about increasingly bizarre
behavior and poor school performance. The provider notes difficulty engaging the patient in
an organized conversation. The patient denies any concerns about behavior. What will the
provider do initially to manage this patient’s symptoms?
a. Admit the patient for inpatient treatment
b. Begin treatment with lithium or lamotrigine
c. Counsel the parent to report any symptoms of depression
d. Schedule an appointment with a psychiatrist

Answer 43

b. Begin treatment with lithium or lamotrigine

Patients with symptoms of mania should begin treatment with a mood stabilizer and the
primary care provider should initiate treatment for an acute episode.

It is not necessary to
admit as an inpatient unless there is indication of harm to the self or others.

The primary
provider should refer for psychiatric evaluation but should begin medications as soon as
possible.

Question 44

patient is brought to the emergency department experiencing disorientation, confusion, and
fever. The patient describes visual and auditory hallucinations. The patient’s spouse states that
the patient had several drinks 12 hours prior to passing out. A blood alcohol level is 0.2%.
What is the recommended treatment?
a. Benzodiazepines
b. Intravenous fluids and rest
c. Naloxone
d. Phenobarbital

Answer 44

a. Benzodiazepines

This patient is showing symptoms of major alcohol withdrawal and should be treated with a
benzodiazepine, which is the safest, most effective drug to treat alcohol detoxification.

Without medications, the patient may develop seizures and delirium tremens or may die.

Naloxone is used for narcotics. Phenobarbital is used to treat seizures.

Question 45

A college student is brought to the emergency department by a roommate who is concerned
about symptoms of extreme restlessness, nausea, and vomiting. The provider notes elevations
of the pulse and blood pressure and pupillary dilation, along with hyperactive bowel sounds.
The provider suspects withdrawal from which substance?
a. Alcohol
b. Cocaine
c. LSD
d. Opioids

Answer 45

d. Opioids

This patient has symptoms consistent with opioid withdrawal, which causes restlessness,
hyperactive bowel sounds, pupillary dilation, and changes in vital signs.

Alcohol withdrawal
involves tremors, confusion, and hallucinations.

Cocaine withdrawal causes muscle tension,
teeth clenching, and blurred vision. LSD symptoms cause hallucinations.

Question 46

A 17-year-old male is brought to the clinic by a parent who is concerned that the patient has
become more isolated and withdrawn. The patient has expressed suspicions that his teachers
hate him and want him to fail. What will the provider tell this parent?
a. The adolescent should be evaluated by a psychiatrist.
b. The adolescent should be given a trial of antipsychotic medications.
c. These are common adolescent behaviors and will eventually go away.
d. These signs are diagnostic for schizophrenia.

Answer 46

a. The adolescent should be evaluated by a psychiatrist.

These signs, along with a family history of psychosis, can be predictive of schizophrenia, so
referral for psychiatric evaluation should be made.

Unless symptoms are present longer than a
month and the patient is diagnosed, antipsychotic medications are not indicated.

Without evaluation, these behaviors should not be dismissed as normal. While these signs may raise
concerns for schizophrenia, they are not diagnostic.

Question 47

A young male patient is reported to be more withdrawn from his peers than usual and has
dropped out of college and quit his job within the last 5 months. The parent is concerned that
the patient may have schizophrenia because a maternal uncle has the disease. What will the
provider do next?
a. Ask about the patient’s speech and thinking patterns
b. Consider treatment with antipsychotic medications
c. Reassure that classic symptoms of schizophrenia are not present
d. Refer the patient for inpatient psychiatric treatment

Answer 47

a. Ask about the patient’s speech and thinking patterns

In order to diagnose schizophrenia, one or more of the positive signs of delusions,
hallucinations, or disorganized speech must be present.

Unless there is a definitive diagnosis,
hospitalization and treatment are not indicated.

The patient has some signs of schizophrenia,
so further evaluation is necessary before reassurance can be made.

Question 48

Which are considered “negative” symptoms of schizophrenia? (Select all that apply.)

a. Auditory hallucinations
b. Delusions of persecution
c. Impaired self-care
d. Poor school performance
e. Withdrawing from peers

Answer 48

c. Impaired self-care
d. Poor school performance
e. Withdrawing from peers

Negative symptoms are those related to decrease or loss of normal functions and may include
social withdrawal, impaired self-care, and poor school performance.

Hallucinations and delusional beliefs are things added to normal behaviors and are considered positive symptoms
of schizophrenia.