nuro/ pain mgmt

Question 1

A healthy 20-year-old patient reports having had 1 or 2 episodes of syncope without loss of

consciousness. Which is the most likely type of syncope in this patient?
a. Cardiac
b. Neurogenic
c. Orthostatic hypotensive
d. Reflex syncope

Answer 1

ANS: D
Neurally mediated or reflex syncope is the most common cause of syncope and is primarily
seen in young adults. Cardiac, neurogenic, and orthostatic syncope are generally seen in older
adults.

Question 2

An elderly patient reports experiencing syncope each morning when getting out of bed. Which
assessment will the health care provider perform first to evaluate this patient’s symptoms?
a. Cardiac enzyme levels
b. Electroencephalogram
c. Fasting blood glucose
d. Orthostatic blood pressures

Answer 2

ANS: D
Orthostatic blood pressures should be measured first since this patient reports problems
associated with rising from a supine position. The other tests are performed as part of the
diagnostic workup only if indicated by associated symptoms or suspected causes.

Question 3

Which tests are indicated as part of the initial evaluation for women of childbearing age who
report syncope? (Select all that apply.)
a. 12-lead electrocardiogram
b. Cardiac enzyme levels
c. Complete blood count
d. Electroencephalogram
e. Serum glucose testing

Answer 3

ANS: A, C, E
Initial evaluation for all patients reporting syncope should include a standard 12-lead ECG.
Women of childbearing age should have a CBC, serum pregnancy test, and serum glucose
testing. Cardiac enzyme levels are obtained if the patient has cardiac risk factors. EEG is
performed only if there is a concern for seizure disorder.

Question 4

A patient who has chronic lower back pain reports increased difficulty sleeping unrelated to
discomfort, along with a desire to quit working. What will the provider do?
a. Ask the patient about addiction issues.
b. Consult with a social worker.
c. Increase the dosage of prescribed pain medications.
d. Order radiographic studies of the lower spine.

Answer 4

ANS: B
Patients who exhibit poor sleep and poor coping may be developing mental defeat as a result
of chronic pain and should be evaluated and treated early for this to prevent further disability
and improve functionality. Substance abuse may be a part of mental defeat and should be
evaluated based on assessment findings. Unless the symptoms are related to pain, increasing
the dose of analgesics and ordering diagnostic studies are not indicated

Question 5

A patient with chronic leg pain describes the pain as “stabbing” and “throbbing.” This is
characteristic of which type of pain?
a. Neuropathic pain
b. Referred pain
c. Somatic pain
d. Visceral pain

Answer 5

ANS: C
Somatic pain is caused by the activation of nociceptors in the peripheral tissues, including
skin, bones, muscles, and soft tissue and is usually well-localized and characterized as
stabbing, aching, or throbbing. Neuropathic pain occurs from injury to or disease of the
nervous system and is described as burning, shooting, or tingling. Referred pain is a kind of
visceral pain that is localized, but not attributable to the involved organ. Visceral pain is
related to an organ and is often referred and poorly localized.

Question 6

A patient is beginning treatment for chronic pain and is unable to tolerate nonsteroidal
anti-inflammatory drugs. What will the provider prescribe for this patient?
a. A mixed opiate product
b. A pure opioid compound
c. A referral for a nerve block procedure
d. A selective serotonin reuptake inhibitor (SSRI)

Answer 6

ANS: D
Using the three-step analgesic ladder, the provider should use step 1 medications that include
NSAIDs, tricyclic antidepressants, selective serotonin reuptake inhibitors, or anticonvulsants.
Since the patient cannot tolerate NSAIDs, an SSRI is an appropriate choice. The next step if
these fail is a mixed opioid product. The third step is a pure opioid product. If medication
therapy fails, a referral for nerve block may be necessary

Question 7

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 7

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

Question 8

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 8

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

Question 9

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 9

ANS: D
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 10

A 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 10

ANS: A
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 11

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 11

ANS: D
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 12

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 12

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

Question 13

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 13

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

Question 14

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 14

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

Question 15

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 15

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

Question 16

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 16

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

Question 17

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 17

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

Question 18

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 18

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

Question 19

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 19

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

Question 20

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 20

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

Question 21

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 21

ANS: C
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 22

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 22

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

Question 23

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 23

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

Question 24

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 24

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

Question 25

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 25

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

Question 26

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 26

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

Question 27

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

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

Answer 27

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

Question 28

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 28

ANS: C
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 29

Which is the preferred treatment for primary brain tumors?

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

Answer 29

ANS: D
Surgical resection is the most effective treatment for brain tumors. Chemotherapy is limited in
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 30

A 14yearold child has a headache, unilateral weakness, and blurred vision
preceded by fever and nausea. The child’s parent reports a similar episode several months prior. The primary care pediatric nurse practitioner will consult with a pediatric neurologist to order
A. a lumbar puncture.
B. an electroencephalogram (EEG).
C. neuroimaging with magnetic resonance imaging (MRI).
D. positron emission tomography (PET) scan.

Answer 30

C. neuroimaging with magnetic resonance imaging (MRI).

Question 31

A child with a recent history of URI reports tingling and pain in one ear followed by
sagging of one side of the face. The primary care pediatric nurse practitioner observes that the child
cannot close the eye or mouth on the affected side but does not elicit limb weakness on that side.
What will the nurse practitioner do?
A. Initiate a short course of antibiotic therapy.
B. Perform diagnostic testing to rule out serious causes.
C. Prepare the parents for lifelong complications.
D. Prescribe oral prednisone 1 mg/kg/day initially.

Answer 31

D. Prescribe oral prednisone 1 mg/kg/day initially.

Question 32

The parents of an 18 monthold
child bring the child to the clinic after observing a .
brief seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of
103.1°F, and the primary care pediatric nurse practitioner notes a left otitis media. The child is alert and
responding normally. What will the nurse practitioner do?

A. Order a lumbar puncture, complete blood count, and urinalysis.
B. Prescribe an antibiotic for the ear infection and reassure the parents.
C. Refer to a pediatric neurologist for anticonvulsant and antipyretic prophylaxis.
D. Send the child to the emergency department for EEG and possible MRI.

Answer 32

B. Prescribe an antibiotic for the ear infection and reassure the parents.

Question 33

A 4yearold child who has previously met developmental milestones is not toilet
trained. The primary care pediatric nurse practitioner notes decreased reflexes in the lower extremities and observe a dimple above the gluteal cleft. Which diagnosis may be considered for
this child?
A. Arnold-Chiari malformation
B. Reye syndrome
C. Spina bifida cystica
D. Tethered cord

Answer 33

D. Tethered cord

Question 34

The primary care pediatric nurse practitioner is evaluating a 10yearold child
who is describing shooting pain in both legs associated with aching, tingling, and
burning. The child is unable to pinpoint specific locations for this pain. Which type of pain does the nurse practitioner suspect?

A. Chronic pain
B. Neuropathic pain
C. Somatic pain
D. Visceral pain

Answer 34

B. Neuropathic pain

Question 35

A 4yearold child has just been released from the hospital after orthopedic surgery on one leg following a bicycle accident. The child is sitting quietly on the exam table. When asked to rate pain, the child points to the “1” on a faces rating pain scale. What will the
primary care pediatric nurse practitioner do next?

A. Assess the child’s vital signs and ability to walk without pain.
B. Refill the prescription for narcotic analgesic medication. C. Suggest that the parents give acetaminophen for mild pain.
D. Teach the parent to give analgesics based on the child’s report of pain.

Answer 35

A. Assess the child’s vital signs and ability to walk without pain.

Question 36

The primary care pediatric nurse practitioner is preparing to perform a painful
procedure on a 4monthold
infant. Besides providing local anesthesia, what other pain control
method provides analgesic effects?
A. Providing toys
B. Singing or music
C. Sucrose solution
D. Swaddling or cuddling

Answer 36

C. Sucrose solution

Question 37

An adolescent female reports moderate dysmenorrhea with periods and tells the
primary care pediatric nurse practitioner that 400 mg ibuprofen every 6 to 8 completely control her pain. What will the nurse practitioner recommend?
A. Increasing the ibuprofen dose to 600 to 800 mg every 6 to 8 hours
B. Taking extra strength acetaminophen 1000 mg every 4 to 6 hours
C. Taking naproxen 500 mg initially and then 250 mg every 6 to 8 hours
D.Using extended-release naproxen 500 mg every 12 hours

Answer 37

A. Increasing the ibuprofen dose to 600 to 800 mg every 6 to 8 hours