Pathophysiology Ch 17: Alterations in Cognitive Systems, Cerebral Hemodynamics, and Motor Function

Question 1

Cognitive operations cannot occur without the effective functioning of the brain’s:

a. Pons
b. Medulla oblongata
c. Reticular activating system
d. Cingulate gyrus

Answer 1

ANS: C
Cognitive cerebral functions require a functioning reticular activating system (RAS).
Cognitive operations are not managed by any of the other options.

Question 2

Which intracerebral disease process is capable of producing diffuse dysfunction?

a. Closed head trauma with bleeding
b. Subdural pus collections
c. Neoplasm
d. Infarct emboli

Answer 2

ANS: D
Disorders within the brain substance (intracerebral)—bleeding, infarcts emboli, and
tumors—primarily functioning as masses may cause diffuse dysfunction. Such localized
destructive processes directly impair functioning of the thalamic or hypothalamic
activating systems. Disorders outside the brain but within the cranial vault (extracerebral),
including neoplasms, closed-head trauma with subsequent bleeding, and subdural
empyema (accumulation of pus), can cause similar dysfunction.

Question 3

What is the most common infratentorial brain disease process that results in the direct
destruction of the reticulating activation system (RAS)?
a. Cerebrovascular disease
b. Demyelinating disease
c. Neoplasms
d. Abscesses

Answer 3

ANS: A
Infratentorial disorders produce a decline in arousal through a direct destruction of the
RAS and its pathways. The most common cause of direct destruction is cerebrovascular
disease, but demyelinating diseases, neoplasms, granulomas, abscesses, and head injury
also may cause brainstem destruction by tissue compression.

Question 4

What stimulus causes posthyperventilation apnea (PHVA)?

a. Changes in PCO2 levels
b. Changes in PaCO2 levels
c. Damage to the forebrain
d. Any arrhythmic breathing pattern

Answer 4

ANS: B
With normal breathing, a neural center in the forebrain (cerebrum) produces a rhythmic
breathing pattern. When consciousness decreases, lower brainstem centers regulate the
breathing pattern by responding only to changes in PaCO2 levels. This irregular breathing
pattern is called PHVA. The other options are not responsible for PHVA.

Question 5

Posthyperventilation apnea (PHVA) ceases and rhythmic breathing is resumed when levels
of arterial:
a. Carbon dioxide increase 
b. Carbon dioxide become normal
c. Oxygen increase 
d. Oxygen decrease

Answer 5

ANS: B
Rhythmic breathing returns when the PCO2 level returns to normal. None of the remaining
options would affect normal rhythmic breathing after PHVA.

Question 6

Cheyne-Stokes respirations are described as a:
a. Sustained deep rapid but regular pattern of breathing
b. Crescendo-decrescendo pattern of breathing, followed by a period of apnea
c. Prolonged inspiratory period, gradually followed by a short expiratory period
d. Completely irregular breathing pattern with random shallow, deep breaths and
irregular pauses

Answer 6

ANS: B
Cheyne-Stokes respiration is an abnormal rhythm of breathing (periodic breathing) that
alternates between hyperventilation and apnea. Cheyne-Stokes respirations do not include
a sustained deep respiratory rate. Altered inspiratory and expiratory periods are not
characteristic of Cheyne-Stokes respirations. Random, irregular breathing patterns are not
observed during Cheyne-Stokes respirations.

Question 7

Vomiting is associated with central nervous system (CNS) injuries that compress which of
the brain’s anatomic locations?
a. Vestibular nuclei in the lower brainstem
b. Floor of the third ventricle
c. Any area in the midbrain
d. Diencephalon

Answer 7

ANS: A
Vomiting, yawning, and hiccups are complex reflexlike motor responses that are
integrated by neural mechanisms in the lower brainstem. Vomiting often accompanies
CNS injuries that involve the vestibular nuclei. The remaining options will not trigger
vomiting when compressed.

Question 8

Which midbrain dysfunction causes pupils to be pinpoint size and fixed in position?

a. Diencephalon dysfunction
b. Oculomotor cranial nerve dysfunction
c. Dysfunction of the tectum
d. Pontine dysfunction

Answer 8

ANS: D
Pinpoint fixed pupils are a result of pontine dysfunction. The diencephalon, oculomotor
cranial nerve, and tectum are not involved in such a pupil reaction.

Question 9

What characteristic is a medical criterion of brain death?

a. Akinetic mutism
b. Coma
c. Apnea
d. Locked-in syndrome

Answer 9

ANS: C
Apnea is viewed as a criterion of brainstem death, whereas the remaining options reflect
cerebral death.

Question 10

A clinical manifestation caused by damage to the lower pons includes an abnormal:
a. Flexion with or without extensor response of the lower extremities

b. Extension response of the upper and lower extremities

c. Extension response of the upper extremities and flexion response of the lower
extremities

d. Flaccid response in the upper and lower extremities

Answer 10

ANS: B
A flaccid state with little or no motor response to stimuli is characteristic of damage to the
pons. None of the other responses are considered a clinical manifestation of damage to the
lower pons.

Question 11

Which person is at the greatest risk for developing delirium?

a. An individual with diabetes celebrating a 70th birthday
b. A depressed Hispanic woman
c. An individual on the second day after hip replacement
d. A man diagnosed with schizophrenia

Answer 11

ANS: C
Delirium is associated with autonomic nervous system overactivity and typically develops
in 2 to 3 days, most commonly in critical care units, postsurgically, or during withdrawal
from CNS depressants (e.g., alcohol, narcotic agents). Age, gender, and chronic illnesses
are not generally associated with delirium triggers.

Question 12

A sudden, explosive, disorderly discharge of cerebral neurons is termed:

a. Reflex
b. Seizure
c. Epilepsy
d. Convulsion

Answer 12

ANS: B
A sudden, explosive, disorderly discharge of cerebral neurons describes a seizure. This
description is not accurate for the other options.

Question 13

A complex partial seizure is described as:

a. Alternating of tonic and clonic movements
b. Impairment of both consciousness and the ability to react to exogenous stimuli
c. Focal motor movement without loss of consciousness
d. One seizure followed by another in less than 1 minute

Answer 13

ANS: B
A complex partial seizure results is impaired consciousness, as well as the inability to
respond to exogenous stimuli. None of the other options accurately describe a complex
partial seizure.

Question 14

Status epilepticus is considered a medical emergency because of the:

a. Loss of consciousness
b. Development of cerebral hypoxia
c. Possibility of a head injury during seizures
d. Decrease in brain metabolism

Answer 14

ANS: B
Status epilepticus is a true medical emergency because a single seizure can last longer than
30 minutes, resulting in hypoxia of the brain. The other options are not the criteria used to
consider status epilepticus.

Question 15

The most critical aspect in correctly diagnosing a seizure disorder and establishing its
cause is:
a. Computed tomographic (CT) scan
b. Cerebrospinal fluid analysis
c. Skull x-ray studies 
d. Health history

Answer 15

ANS: D
Although the history may be supplemented with the remaining options, it remains the
pivotal tool for establishing the cause of a seizure disorder.

Question 16

What type of seizure starts in the fingers and progressively spreads up the arm and extends
to the leg?
a. Complex-psychomotor seizure 
b. Focal (partial) Jacksonian seizure
c. Generalized seizures 
d. Atonic-drop seizure

Answer 16

ANS: B
Focal (partial) Jacksonian seizures most often begin in the face and fingers and then
progressively spread to other body parts. The other options do not begin and spread in the
fashion described.

Question 17

What area of the brain mediates the executive attention functions?

a. Limbic
b. Prefrontal
c. Parietal
d. Occipital

Answer 17

ANS: B
The prefrontal areas mediate several cognitive functions, called executive attention
functions (e.g., planning, problem solving, setting goals). The remaining options are not
areas involved with the mediation of executive attention functions.

Question 18

What term describes the loss of the comprehension or production of language?

a. Agnosia
b. Aphasia
c. Akinesia
d. Dysphasia

Answer 18

ANS: B
Aphasia is the loss of the comprehension or production of language. The remaining
options are not terms used to describe this loss of function.

Question 19

What is the normal intracranial pressure (in mm Hg)?

a. 5 to 15
b. 7 to 20
c. 12 to 14
d. 80 to 120

Answer 19

ANS: A
Intracranial pressure is normally 5 to 15 mm Hg or 60 to 180 cm water (H2O). The
remaining options reflect increased intracranial pressure.

Question 20

Cerebral edema is an increase in the fluid content of the brain’s:

a. Ventricles
b. Tissue
c. Neurons
d. Meninges

Answer 20

ANS: B
Cerebral edema is an increase in the fluid content of brain tissue; that is, a net
accumulation of water within the brain. Cerebral edema is not noted in the brain’s
ventricles, neurons, or meninges.

Question 21

What type of cerebral edema occurs when permeability of the capillary endothelium
increases after injury to the vascular structure?
a. Cytotoxic
b. Interstitial
c. Vasogenic
d. Ischemic

Answer 21

ANS: C
Increased permeability of the capillary endothelium of the brain after injury to the vascular
structure causes vasogenic edema. The remaining options are not consistent with this
description.

Question 22

A communicating hydrocephalus is caused by an impairment of the:

a. Cerebrospinal fluid flow between the ventricles
b. Cerebrospinal fluid flow into the subarachnoid space
c. Blood flow to the arachnoid villi
d. Absorption of cerebrospinal fluid

Answer 22

ANS: D
Hydrocephalus from impaired absorption outside the ventricles is called communicating
(extraventricular) hydrocephalus. The other options do not accurately describe the cause
of a communicating hydrocephalus.

Question 23

Which edema is most often observed with noncommunicating hydrocephalus?

a. Metabolic
b. Interstitial
c. Vasogenic
d. Ischemic

Answer 23

ANS: B
Interstitial edema is observed most often with noncommunicating hydrocephalus.
Noncommunicating hydrocephalus is not the cause of any of the other options.

Question 24

Which dyskinesia involves involuntary movements of the face, trunk, and extremities?

a. Paroxysmal
b. Tardive
c. Hyperkinesia
d. Cardive

Answer 24

ANS: B
Tardive dyskinesia is the involuntary movement of the face, trunk, and extremities. The
other terms do not describe involuntary movements of the face, trunk, and extremities.

Question 25

Antipsychotic drugs cause tardive dyskinesia by mimicking the effects of increased:

a. Dopamine
b. Gamma-aminobutyric acid
c. Norepinephrine
d. Acetylcholine

Answer 25

ANS: A
The antipsychotic drugs cause denervation hypersensitivity, which mimics the effect of too
much dopamine. None of the other options produce such an affect.

Question 26

The existence of regular, deep, and rapid respirations after a severe closed head injury is
indicative of neurologic injury to the:
a. Lower midbrain 
b. Pontine area
c. Supratentorial 
d. Cerebral area

Answer 26

ANS: A
Central reflex hyperpnea, which is a sustained deep and rapid but regular respiratory
pattern that is the result of central nervous system (CNS) damage or disease, involves the
lower midbrain and upper pons. This neurologic injury is observed after increased
intracranial pressure and blunt head trauma. Damage to any of the other areas listed would
not produce this breathing pattern.

Question 27

What type of posturing exists when a person with a severe closed head injury has all four
extremities in rigid extension with the forearms in hyperpronation and the legs in plantar
extension?
a. Decorticate
b. Decerebrate
c. Spastic
d. Cerebellar

Answer 27

ANS: B
Decerebrate posturing includes opisthotonos (hyperextension of the vertebral column) with
clenching of the teeth; extension, abduction, and hyperpronation of the arms; and
extension of the lower extremities including plantar extension. The other options do not
describe such posturing.

Question 28

Since his cerebrovascular accident, a man has been denying his left hemiplegia. What term
is used to describe this finding?
a. Visual agnosia 
b. Anosognosia
c. Amusia agnosia 
d. Agraphia agnosia

Answer 28

ANS: B
Anosognosia is ignorance or denial of the existence of disease. None of the remaining
options describes such denial.

Question 29

After a cerebrovascular accident, a man is unable to either feel or identify a comb with his
eyes closed. This is an example of:
a. Agraphia 
b. Tactile agnosia
c. Anosognosia 
d. Prosopagnosia

Answer 29

ANS: B
Tactile agnosia is the inability to recognize objects by touch. None of the other options
define the inability to recognize objects by touch.

Question 30

Most dysphasias are associated with cerebrovascular accidents involving which artery?

a. Anterior communicating
b. Posterior communicating
c. Circle of Willis
d. Middle cerebral

Answer 30

ANS: D
Dysphasias are usually associated with a cerebrovascular accident involving the middle
cerebral artery or one of its many branches. Damage to or occlusion of any of the other
options does not cause dysphasias.

Question 31

Tactile agnosia is related to injury of which area of the brain?

a. Frontotemporal
b. Parietal
c. Temporal
d. Broca area

Answer 31

ANS: B
Tactile agnosia (astereognosis) is the inability to recognize objects by touch as a result of
damage to the parietal lobe. Tactile agnosia is not related to an injury to any of the other
options.

Question 32

Neurofibrillary tangles characterize which neurologic disorder?

a. Dementia syndrome
b. Delirium
c. Alzheimer disease
d. Parkinson disease

Answer 32

ANS: C
Amyloid plaques, neurofibrillary tangles, as well as neuronal and synaptic losses in the
brain, characterize Alzheimer disease.

Question 33

The body compensates for a rise in intracranial pressure by first displacing the:

a. Cerebrospinal fluid
b. Arterial blood
c. Venous blood
d. Cerebral cells

Answer 33

ANS: A
A rise in intracranial pressure necessitates an equal reduction in the volume of the other
contents. The most readily displaced content of the cranial vault is cerebrospinal fluid
(CSF), not any of the other options.

Question 34

Stage 1 intracranial hypertension is caused by the:

a. Loss of autoregulation that normally maintains constant blood flow during changes
in cerebral perfusion pressure

b. Displacement of cerebrospinal fluid, followed by compression of the cerebral
venous system

c. Vasoconstriction of the cerebral arterial system with reciprocal increase in
systemic blood pressure

d. Compression of the medulla oblongata in the brainstem by herniation of the
cerebral cortex

Answer 34

ANS: B
If intracranial pressure remains high after cerebrospinal fluid (CSF) displacement out of
the cranial vault, then cerebral blood volume is altered, resulting in stage 1 intracranial
hypertension. Vasoconstriction and external compression of the venous system occur in an
attempt to further decrease the intracranial pressure. None of the remaining options
accurately describe the cause of stage 1 intracranial hypertension.

Question 35

Dilated and sluggish pupils, widening pulse pressure, and bradycardia are clinical findings
evident of which stage of intracranial hypertension?
a. 1
b. 2
c. 3
d. 4

Answer 35

ANS: C
Stage 3 intracranial hypertension exhibits clinical manifestations that include decreasing
levels of arousal, Cheyne-Stokes respiration or central neurogenic hyperventilation, pupils
that become sluggish and constricted, widened pulse pressure, and bradycardia. These
responses are not characteristic of any other stage.

Question 36

Dilation of the ipsilateral pupil, following uncal herniation, is the result of pressure on
which cranial nerve (CN)?
a. Optic (CN I) 
b. Abducens (CN VI)
c. Oculomotor (CN III) 
d. Trochlear (CN IV)

Answer 36

ANS: C
The oculomotor CN (III) is involved in this manifestation of pupil dilation. None of the
other options would result in pupil dilation when subjected to pressure.

Question 37

Which characteristic is the most critical index of nervous system dysfunction?

a. Size and reactivity of pupils
b. Pattern of breathing
c. Motor response
d. Level of consciousness

Answer 37

ANS: D
Level of consciousness is the most critical clinical index of nervous system function or
dysfunction. An alteration in consciousness indicates either improvement or deterioration
of a person’s condition. No other option is used as the critical index of nervous system.

Question 38

Diagnostic criteria for a persistent vegetative state include:

a. Absence of eye opening
b. Lack of subcortical responses to pain stimuli
c. Roving eye movements with visual tracking
d. Return of autonomic functions such as gastrointestinal function

Answer 38

ANS: D
Diagnostic criteria for vegetative state (VS) include the return of professed vegetative
(autonomic) functions, including sleep-wake cycles and normalization of respiratory and
digestive system functions. Only the correct option appropriately describes the diagnostic
criteria for a VS.

Question 39

Uncal herniation occurs when:

a. The hippocampal gyrus shifts from the middle fossa through the tentorial notch
into the posterior fossa.
b. The diencephalon shifts from the middle fossa straight downward through the
tentorial notch into the posterior fossa.
c. The cingulate gyrus shifts under the falx cerebri.
d. A cerebellar tonsil shifts through the foramen magnum.

Answer 39

ANS: A
Uncal herniation (i.e., hippocampal herniation, lateral mass herniation) occurs when the
uncus or hippocampal gyrus (or both) shifts from the middle fossa through the tentorial
notch into the posterior fossa. This shift results in the compression of the ipsilateral third
cranial nerve (CN), impairing parasympathetic function. This impairment is carried on in
the periphery of the nerve, then in the contralateral third CN, and finally in the
mesencephalon, inducing coma. The other options do not appropriately describe when
uncal herniation occurs.

Question 40

Which assessment finding marks the end of spinal shock?

a. Return of blood pressure and heart rate to normal
b. Gradual return of spinal reflexes
c. Return of bowel and bladder function
d. Evidence of diminished deep tendon reflexes and flaccid paralysis

Answer 40

ANS: B
A gradual return of spinal reflexes marks the end of spinal shock. The other options are not
an indication of the cessation of spinal shock.

Question 41

Characteristics of primary motor neuron atrophy include:

a. Loss of sensation in distal, proximal, or midline muscles
b. Fasciculations and muscle cramps
c. Flaccid paralysis with paresthesia
d. Spastic paralysis with increased deep tendon reflexes

Answer 41

ANS: B
Fasciculations are particularly associated with primary motor neuron injury, and muscle
cramps are common. The other options do not describe characteristics of primary motor
neuron atrophy.

Question 42

The weakness resulting from the segmental paresis and paralysis characteristic of anterior
horn cell injury is difficult to recognize because:
a. Upper motor neurons are involved.
b. The injury is microscopic.
c. Two or more nerve roots supply each muscle.
d. The person is unable to feel the involved muscles.

Answer 42

ANS: C
The paresis and paralysis associated with anterior horn cell injury are segmental; however,
because two or more roots supply each muscle, the segmental character of the weakness
may be difficult to recognize. The reason this pathophysiologic condition is difficult to
recognize is not appropriately explained by any of the other options.

Question 43

Parkinson disease is a degenerative disorder of the brain’s:

a. Hypothalamus
b. Anterior pituitary
c. Frontal lobe
d. Basal ganglia

Answer 43

ANS: D
Parkinson disease is a commonly occurring degenerative disorder of the basal ganglia and
not of any of the other brain structures.

Question 44

Clinical manifestations of Parkinson disease are caused by a deficit in which of the brain’s
neurotransmitters?
a. Gamma-aminobutyric acid
b. Dopamine
c. Norepinephrine 
d. Acetylcholine

Answer 44

ANS: B
Parkinson disease is a commonly occurring degenerative disorder involving deficits of
dopamine, not of any of the other options.

Question 45

Tremors at rest, rigidity, akinesia, and postural abnormalities are a result of the atrophy of
neurons in the brain’s:
a. Caudate that produces serotonin
b. Putamen that produces gamma-aminobutyric acid
c. Substantia nigra that produces dopamine
d. Hypothalamus that produces acetylcholine

Answer 45

ANS: C
The hallmark characteristics of Parkinson disease (PD) are a result of a loss of
dopaminergic-pigmented neurons in the substantia nigra pars compacta with dopaminergic
deficiency in the putamen portion of the striatum (the striatum includes the putamen and
caudate nucleus). The remaining options are not characteristics of PD.

Question 46

Dementia is commonly characterized by the deterioration in which abilities? (Select all
that apply.)
a. Sociability
b. Balance
c. Memory
d. Speech
e. Decision making

Answer 46

ANS: C, D, E

Dementia is the progressive failure (an acquired deterioration) of many cerebral functions
that include impairment of intellectual function with a decrease in orienting, memory,
language, executive attentional functions, and alterations in behavior. Loss of the need for
social contact and impaired balance are not associated with dementia, although a person
with such a diagnosis may exhibit these deficiencies.

Question 47

The clinical manifestations of Parkinson disease include: (Select all that apply.)

a. Fragmented sleep
b. Drooping eyelids
c. Depression
d. Muscle stiffness
e. Bradykinesia

Answer 47

ANS: A, C, D, E

The classic motor manifestations of Parkinson disease (PD) are bradykinesia, tremor at
rest (resting tremor), rigidity (muscle stiffness), and postural abnormalities. Nonmotor
symptoms associated with PD include hyponosmia, fatigue, pain, autonomic dysfunction,
sleep fragmentation, depression, and dementia with or without psychosis. Drooping
eyelids are not characteristics of PD.

Question 48

In Parkinson disease the basal ganglia influence the hypothalamic function to produce
which clinical manifestations? (Select all that apply.)
a. Inappropriate diaphoresis
b. Gastric retention
c. Vomiting
d. Diarrhea
e. Urinary retention

Answer 48

ANS: A, B, E
The basal ganglia influence hypothalamic function (autonomic and neuroendocrine)
through pathways connecting the hypothalamus with the basal ganglia and cerebral cortex.
Common autonomic symptoms in Parkinson disease include inappropriate diaphoresis,
gastric retention, constipation, and urinary retention. Neither vomiting nor diarrhea would
be clinical manifestation observed under these circumstances.