PMR 6 - brain injury Flashcards
1
Q
Which of the following is a non -modifiable risk factor for stroke?
a. Hypertension
b. Atrial fibrillation
c. Age
d. Smoking
A
C) Of the factors listed above, age is the non-modifiable risk factor for a stroke.
2
Q
The most common cause of hemorrhagic stroke is:
a. Ruptured aneurysm
b. Arteriovenous malformation
c. Hypertension
d. Amyloid angiopathy
A
C) The most common cause of hemorrhagic stroke is uncontrolled hypertension.
3
Q
In a patient with symptoms of a stroke, which of the following is the first-line diagnostic radiological test?
a. MRI of the brain
b. Carotid Dopplers
c. MRA of the head
d. CT brain without contrast
A
D) Non-contrast CT of the brain is the first-line diagnostic radiological test done in a patient with symptoms of stroke. This is done to rule out an intracranial bleed.
4
Q
Aphasia is an impairment in:
a. Language
b. Speech
c. Phonation
d. Swallowing
A
A) Aphasia is an impairment in language.
Dysarthria is a motor speech disorder characterized by slow, weak, or uncoordinated movements of speech musculature. Impairment in swallowing is called dysphagia. Impairment in the ability to produce sounds is dysphonia.
5
Q
Wernicke’s aphasia is characterized by intact:
a. Naming
b. Comprehension
c. Repetition
d. Fluency
A
D) Wernicke’s aphasia is a fluent aphasia and is characterized by impaired naming, comprehension, and repetition.
6
Q
Spatial neglect is more commonly seen in:
a. Dominant hemisphere infarcts
b. Nondominant hemisphere infarcts
c. Brainstem strokes
d. Cerebellar strokes
A
B) Spatial neglect is more often seen with nondominant middle cerebral artery infarcts.
7
Q
Unawareness of illness in patients with spatial neglect is called:
a. Asomatognosia
b. Anosodiaphoria
c. Anosognosia
d. Apraxia
A
C) Unawareness of illness in patients with spatial neglect is called anosognosia.
Asomatognosia is a condition where patients do not recognize that parts of their body belong to them. When patients with spatial neglect appear unconcerned or joke about their disability, it is called anosodiaphoria.
Apraxia is a disorder of motor planning when strength, sensation, and coordination are intact.
8
Q
Which of the following cranial nerves is not involved in the swallowing function?
a. Trigeminal nerve
b. Spinal accessory nerve
c. Glossopharyngeal nerve
d. Hypoglossal nerve
A
B) The spinal accessory nerve does not have a role in the swallowing mechanism. The trigeminal, facial, glossophary ngeal, vagus, and hypoglossal nerves all have a role in the swallowing function.
9
Q
The gold standard for assessment of swallowing function is:
a. Bedside swallow evaluation
b. Video fluoroscopic swallowing study (VFSS)
C. Fiberoptic endoscopic evaluation of swallowing (FEES)
d. Esophagoscopy
A
B) The VFSS is the gold standard in swallowing assessment. FEES is a bedside procedure in which a nasally inserted flexible endoscope is used to directly view the nasopharynx and larynx during swallowing. A bedside swallow examination may miss silent aspiration. Esophagoscopy is useful in assessing anatomical abnormalities of esophagus.
10
Q
The following is not a phase of swallowing:
a. Oral phase
b. Lingual phase
c. Esophageal phase
d. Pharyngeal phase
A
B) The three phases of swallowing include the oral, pharyngeal, and esophageal phases.
11
Q
Predictors of aspiration on a bedside swallow exam include all of the following except:
a. Tachycardia
b. Cough
c. Voice change after swallow
d. Dysphonia
A
A) Predictors of aspiration on bedside swallow exam include abnormal cough, cough after swallow, dysphonia, dysarthria, abnormal gag reflex, and wet vocal quality after swallow.
12
Q
Factors increasing the risk of urinary incontinence after a stroke include all of the following except:
a. Male sex
b. Advanced age
c. Greater stroke severity
d. Diabetes mellitus
A
A) Factors increasing the risk of urinary incontinence include advanced age, greater stroke severity, and diabetes.
13
Q
What is the greatest predictor of community ambulation after a stroke?
a. Use of an assistive device
b. Walking speed
c. Degree of lower extremity motor strength
d. Type of stroke
A
B) The greatest predictor of community ambulation after a stroke is walking speed according to a study conducted by Perry et al.
14
Q
Baclofen is an antispasticity agent that is:
a. A structural analogue of gamma amino butyric acid (GABA)
b. An alpha-2 adrenergic agonist
c. A hydantoin derivative
d. An imidazoline derivative
A
A) Baclofen is a structural analogue of
GABA, which is one of the main inhibitory neurotransmitters in the central nervous system.
15
Q
Which of the following is a side effect of tizanidine, a medication used in spasticity?
a. Abnormal renal function tests
b. Somnolence
c. Cardiac toxicity
d. Electrolyte abnormalities
A
B) One of the common side effects of tizanidine is drowsiness or somnolence.
Other side effects may include hypotension, dizziness, weakness, dry mouth, and elevated liver functions.
16
Q
The goals of intrathecal baclofen therapy in patients with poststroke spastic hypertonia include all of the following except:
a. Improved positioning and hygiene
b. Prevention of complications
c. Ease caregiver burden and time
d. Initiate ambulation
A
D) The goals of intrathecal baclofen therapy in patients with poststroke hypertonia include improved positioning, facilitation of hygiene, prevention of complications, ease caregiver burden, orthotic fit and compliance, and decreased pain due to nighttime spasms.
17
Q
Shoulder subluxation after stroke:
a. Occurs late in the recovery phase
b. Is always associated with pain
c. Is associated with flaccid hemiplegia
d. Will need radiological studies for diagnosis
A
C) Shoulder subluxation tends to occur early after a stroke in patients with flaccid hemiplegia. Although shoulder subluxation is listed as a common cause of shoulder pain, the relationship between the two remains controversial. The clinical diagnosis of shoulder subluxation can be made without imaging studies.
18
Q
Malnutrition and hypoalbuminemia have been associated with which of the following in acute rehabilitation stroke patients?
a. Better functional outcome
b. Higher complication rate
c. Shorter length stay
d. Improved functional improvement rate
A
B) Malnutrition and hypoalbuminemia have been associated with poorer functional outcomes, higher complication rates, longer length of stay, and reduced functional improvement rates in acute rehabilitation stroke patients.
19
Q
Common medical complications after stroke include all of the following except:
a. Infections
b. Falls
C. Thrombosis
d. Anemia
A
D) The common medical complications after a stroke include both urinary and chest infections, falls, deep vein thrombosis, decubitus ulcers, and pain. Anemia may be an associated finding, but is not reported as a common complication.
20
Q
All of the following are associated with poor performance behind the wheel for driving evaluation after a stroke except:
a. Right hemisphere location of stroke
b. Visual perceptual deficits
c. Aphasia
d. Poor judgment or impulsivity
A
C) Aphasia may affect performance on written and road tests, but does not always interfere with self-directed driving.
21
Q
All of the following are features of lateral medullary syndrome except:
a. Hemiplegia
b. Dysphagia
c. Ipsilateral facial hemisensory deficit
d. Palate and vocal cord paralvsis
A
A) As the corticos pinal tract is a medial structure, lateral medullary syndrome, also known as Wallenberg syndrome, does not cause motor paralysis.
22
Q
All of the following are accepted options for initial therapy for patients with noncardioembolic ischemic stroke except:
a. Coumadin
b. Aspirin
c. Clopidogrel
d. Combination of aspirin and extended release dipyridamole
A
A) Aspirin, clopidogrel, and combination of aspirin and extended release dipyridamole are accepted options for initial therapy for patients with noncardioembolic ischemic stroke. Anticoagulant therapy with Coumadin is recommended in the setting of embolic stroke unless there are contraindications.
23
Q
Which of the following is a contraindication for administration of tissue plasminogen activator (PA)?
a. Stroke symptom onset less than 3 hours
b. Platelet count greater than 100,000
C. INR less than 1.7
d. History of recent myocardial infarction (MI) within 3 months
A
D) A history of Mi within 3 months is a contraindication for PA. The other answers are requirements for giving PA in the setting of an acute stroke.
24
Q
Which of the following statements regarding National Institute of Health (NIH)
stroke scale is incorrect?
a. It requires training and certification
b. It is valuable in quantifying deficits after a stroke
c. It may help in predicting posthospital disposition
d. Elements of brainstem function are well reflected
A
D) Some of the limitations of the NIH stroke scale are that elements of brainstem function are not well reflected, palatal weakness is not scored, it does not assess distal weakness, and it does not screen for neurocognitive dysfunction.
25
Physiological factors that account for stroke recovery include all the following except:
a. Side of stroke
b. Resolution of poststroke edema
c. Reperfusion of ischemic penumbra
d. Cortical reorganization
A) The physiological factors that account for stroke recovery include resolution of poststroke edema, reperfusion of ischemic penumbra, resolution of diaschisis, and cortical reorganization.
26
What is the most important modifiable risk factor for ischemic and hemorrhagic stroke?
a. Hypertension (HTN)
b. Gender
c.Race
d. Age
A) HT is the most important modifiable risk factor in both ischemic and hemorrhagic stroke. In fact, studies have shown that patients with blood pressure less than 120/80 have about half the lifetime risk of stroke as compared with those with high blood pressure. The other risk factors listed are non-modifiable.
27
In a transient ischemic attack (TIA), the symptoms last for:
a. > 24 hours
b. < 24 hours
C. > 48 hours
d. > 1 week
B) In a patient with TIA, the symptoms will resolve in less than 24 hours. On the other hand, in a stroke, the symptoms persist for over 24 hours and may never fully resolve.
28
A patient diagnosed with alexia is unable to:
a. Read
b. Write
c. Recognize
d. Calculate
A) Alexia is an inability to read. Agraphia is an inability to write. Agnosia is an inability to recognize objects, people, sounds, smells, or shapes. Acalculia is an inability to perform mathematical tasks.
29
A stroke affecting the right hemisphere of the brain will usually cause weakness on the:
a. Ipsilateral side
b. Contralateral side
c. Bilaterally
d. None of the above
B) The right hemisphere of the brain controls the left side of the body, and the left brain hemisphere controls the right side of the body.
30
Patients complaining of having "the worst headache" of their life should raise suspicions of a/an:
a. Migraine headache
b. Subdural hematoma
c. Subarachnoid hemorrhage
d. Epidural hematoma
C) A subarachnoid hemorrhage is usually caused by the rupture of an aneurysm. The blood irritates the meninges, causing a severe headache.
31
On a computed tomography (CT) scan, a hemorrhage would appear:
a. Black
c. Grey
b. White
d. None of the above
B) On a CT scan, blood appears hyperdense (radiopaque) and will show up white.
32
A suspected intracranial hemorrhage would require a computed tomography
(CT) of the head:
a. With contrast
b. Without contrast
c. With and without contrast
d. Would not require a CT of the head
B) The head CT would usually be done without contrast since both contrast and blood would appear as white on the scan, making diagnosis more difficult.
33
In a patient with a stroke, the intracranial pressure (ICP) should be kept at:
a. > 20 mm Hg)
b. > 40 mm Hg
c. < 20 mm Hg
d. > 80 mm Hg
C) ICP 5 15 is considered normal. In a patient with a stroke, you want to keep the ICP as close to normal as possible. Increased ICP reduces cerebral blood perfusion. Central perfusion pressure (CPP) should remain > 60 mm Hg.
34
The inclusion criterion for tissue plasminogen activator (PA) is:
a. 18 years of age or older with informed consent
b. Head computed tomography (CT) negative for blood
c. Well-established time of onset less than 3 hours before treatment initiation with moderate to severe stroke symptoms
d. All of the above
D) All of the above are required before tPA is administered to a patient with acute stroke.
35
In a patient with transcortical mixed aphasia, the patient will have:
a. Fluent speech
b. Good comprehension
c. Preserved repetition (echolalia)
d. None of the above
C) In a patient with transcortical mixed aphasia, the speech is non-fluent and the patient is unable to comprehend, but repetition is still intact.
36
Good prognosis of recovery after stroke is associated with:
a. Complete arm paralysis
b. Prolonged flaccidity
c. Severe proximal spasticity
d. Some motor recovery of the hand by 4 weeks
D) If there is some motor recovery of the hand by 4 weeks, there is up to a 70% chance of making a complete or almost complete recovery.
37
Overall, the most common cause of severe traumatic brain injury (TBI) is:
a. Alcohol (ETOH) intoxication
b. Falls
C. Motor vehicle accidents (MVA)
d. Assault
C) MVA accounts for approximately 50% of all TBI cases. Assault is the second most common cause.
38
Techniques to prevent aspiration while eating in a patient with a stroke would include:
a. Chin tuck
b. Head rotation
c. Mendelsohn maneuver
d. All of the above
D) All of the above mentioned maneuvers prevent aspiration by providing airway protection. Tucking the chin helps prevent liquid from entering the larynx. Head rotation (turning the head toward the paretic side) helps force the bolus of food into the contralateral pharynx. The Mendelsohn maneuver involves having the patient voluntarily hold the larynx at its maximal height to increase the duration of the cricopharyngeal opening.
39
Risk factors for disability after a stroke would include all of the following except:
a. Bilateral lesions
b. Severe neglect
c. Young age
d. Delay in rehabilitation
C) The prognosis for recovery is better in a younger individual.
40
Traumatic brain injuries (TBI) in elderly patients are most frequently due to:
a. Falls
b. Motor vehicle accidents
C. Alcohol (ETOH) abuse
d. Assault
A) In the elderly population, gait and visual disturbances lead to falls, which cause most of the TBIs in the elderly.
41
Epidural hematoma occurs most frequently from:
a. Rupture of the middle meningeal artery
b. Arteriovenous malformation
C. Shearing of bridging veins between pia-arachnoid and the dura
d. None of the above
A) Epidural hematoma usually results from a skull fracture in the temporal bone crossing the vascular territory of the middle meningeal artery.
42
Of the following disorders of consciousness, which would have the best prognosis?
a. Coma
b. Vegetative state
C. Minimally conscious state
d. None of the above
C) In a minimally conscious state, the patient will be able to show some evidence of self or environmental awareness and will show evidence of purposeful behaviors.
43
In decerebrate posturing, there is:
a. Flexion of the upper and lower extremities
b. Extension of the upper and flexion of the lower extremities
c. Flexion of the upper and extension of the lower extremities
d. Extension of the upper and lower extremities
D) In decerebrate posturing, the limbs will be stiff and extended with internal rotation of arms and ankles in plantar flexion. In patients with decorticate posturing, the legs are extended and the arms are flexed and adducted.
44
A Glasgow Coma Scale (GCS) score of 3 to
8 would indicate:
a. Death
b. Severe traumatic brain injury (TBI)
c. Mild TBI
d. Moderate TBI
B) A GCS score 3 to 8 = severe TBI (coma).
A GCS score of 9 to 12 = moderate BI. A GCS
score of 13 to 15 = mild TBI.
45
Uncal heriation would cause compression of:
a. Cranial nerve (CN) III
b. CNI
c. CN VII
d. CNX
A) Uncal herniation causes compression of the CN IlI, which may lead to complete ipsilateral CN III palsy (fixed pupil dilation, ptosis, and ophthalmoplegia).
46
A first-line intervention for posttraumatic agitation would be:
a. Placing patient in a quiet room and limiting the number of visitors
b. Restraining the patient
c. Medicating the patient
d. Getting a psychiatric evaluation
A) The first step would be to create a low-stimulus environment for the patient.
47
Which of the following may be helpful for a traumatic brain injury (TBI) patient with bladder and bowel dysfunctions?
a. Frequent toileting
b. Anticholinergics
C. Condom catheter for men and absorbent pads for women
d. All of the above
D) All of the above are appropriate interventions for a TBI patient with bowel and bladder dysfunction.
48
Dysarthria involves all of the following except:
a. Chewing and swallowing difficulty
b. Hoarseness
C. Drooling
d. Complete movement of the lip, tongue, and jaw
D) In dysarthria, there are limited lip, tongue, and jaw movements.
49
Risk factors for developing post-stroke depression include:
a. Lack of social support
b. Cognitive impairment
c. High severity of deficits
d. All of the above
D All of the above are risk factors for post-stroke depression.
50
Seizures in stroke patients are associated with:
a. Large parietal or temporal hemorrhages
b. Older age
c. Confusion
d. All of the above
D) All of the above are associated with seizures in stroke patients.
51
Skin integrity is maintained in stroke patients by all of the following measures except:
a. Protection from moisture
b. Decreasing patient mobility
c. Maintenance of adequate nutrition and hydration
d. Frequent position changes
B) Decreased patient mobility will lead to the development of decubitus ulcers. Stroke patients require frequent turning and repositioning.
52
A traumatic brain injury (TBI) patient that is confused and inappropriate would be considered a Ranchos level:
a. IV
b. V
c. VI
d. None of the above
B) A Ranchos level IV patient would be confused and agitated. A level VI patient would be confused and appropriate. Ranchos level refers to the Ranchos Los Amigos scale, which is used in rating recovery from brain injury.
53
Syndrome of inappropriate antidiuretic hormone (SIADH) is found in:
a. Acute stroke
b. Chronic traumatic brain injury (TBI)
c. Acute TBI
d. Chronic stroke
C) SIADH is common in the acute TBI period and is characterized by hyponatremia, euvolemia, low blood urea nitrogen (BUN), and decreased blood and increased urine osmolality. Treatment for mild cases includes fluid restriction, loop diuretics, and monitoring weight and serum sodium level. In patients with severe symptoms, intravenous hypertonic saline can be used
54
In "locked-in" syndrome, the patient is:
a. Paralyzed with possible preserved vertical gaze and blinking
b. Unable to speak
c. Awake and sensate
d. All of the above
D) "Locked-in" syndrome is due to bilateral pontine infarcts or damage affecting the corticospinal and bulbar tracts and sparing the reticular activating system. The patient experiences all of the above mentioned phenomena.
55
Aphasia classification is based on which three parts of the language assessment?
a. Fluency, repetition, prosody
b. Fluency, comprehension, naming
c. Fluency, comprehension, repetition
d. Comprehension, reading, writing
C) Fluent versus nonfluent speech localizes anterior from posterior aphasic syndromes; impairment in comprehension distinguishes Wernicke's from conduction aphasia; and the ability to repeat implies that perisylvian language areas are intact.
56
A 63-year-old right-handed woman with hypertension suddenly had difficulty getting words out. Speech was sparse, halting, and labored. She was able to follow three-step commands and repeated words and sentences with 100% accuracy.
What kind of aphasia is present in this patient?
a. Broca's aphasia
b. Wernicke's aphasia
c. Transcortical sensory aphasia
d. Transcortical motor aphasia
D) This aphasic syndrome resembles
Broca's aphasia, but because it involves the extrasylvian region, repetition is intact.
57
A 63-year-old right-handed woman with hypertension suddenly had difficulty getting words out. Speech was sparse, halting, and labored. She was able to follow three-step commands and repeated words and sentences with 100% accuracy. Where is the most likely location of her lesion?
a. Middle cerebral artery-anterior cerebral artery territory (extrasylvian, anterior)
b. Middle cerebral artery-posterior cerebral artery territory (extrasylvian, posterior)
c. Broca's area
d. Wernicke's area
A) This reflects a lesion in the anterior cerebral artery territory (extrasylvian).
Nonfluent (motor) aphasias affect anterior (pre-Rolandic) regions
58
You are most likely to see conduction aphasia following damage to:
a. The arcuate fasciculus
b. The angular gyrus
c. Middle cerebral artery-posterior cerebral artery (MCA-PCA) watershed areas
d. Middle cerebral artery-anterior cerebral artery (MCA-ACA) watershed areas
A) Conduction aphasia is considered a disconnection syndrome in which speech comprehension (Wernicke's area) is disconnected via a lesion in the arcuate fasciculus from the speech production area
(Broca's area).
59
Which of the following is not a symptom of
Gerstmann's syndrome?
a. Agraphia
b. Acalculia
c. Alexia
d. Finger agnosia
C) The four components of Gerstmann's syndrome are finger agnosia, acalculia, right-left disorientation, and agraphia.
60
A 54-year-old woman experiences a left middle cerebral artery infarction. She presents with impaired comprehension, fluent speech, impaired naming, and the presence of a homonymous hemianopsia.
The most likely diagnosis is:
a. Broca's aphasia
b. Conduction aphasia
c. Anomic aphasia
d. Wernicke's aphasia
D) Although both Wernicke's aphasia and conduction aphasia are characterized by fluent speech, only Wernicke's aphasia also includes impaired comprehension.
61
All of the following are reasons to refer for a neuropsychological evaluation or consult except:
a. When impairment of cognitive functioning or behavior is suspected
b. When medication is being considered for a patient's mood disorder or behavior
C. When you want to track progress of rehabilitation after TBI or other neurological disorder
d. To plan treatments that utilize cognitive strengths to compensate for weaknesses
B) Neuropsychologists do not prescribe medication, but do conduct cognitive evaluations and engage in cognitive remediation and psychotherapy.
62
Which of the following is not a common condition that a neuropsychologist would evaluate or treat?
a. Dementia
b. Cerebrovascular accident (CA)
c. Depression
d. Neuropathy
D) This would be the physiatrist or the neurologist; the neuropsychologist evaluates and treats brain-behavior disorders, not disorders of peripheral nerves.
63
All of the following are true about a neuropsychological evaluation except:
a. The same battery of tests is administered to everyone and is always determined in advance
b. Testing is noninvasive
c. Testing can last from < 1 hour to 6-18 hours or more
d. The evaluation includes an interview and mostly paper-and-pencil tests
A) Testing is paper-pencil, ranges from < 1 to 8+ hours, and is tailored to the individual referral question.
64
All of the following are examples of frontal-subcortical dementia except:
a. Normal pressure hydrocephalus
b. Frontotemporal dementia
c. Vascular dementia
d. Parkinson's dementia
B) Frontotemporal dementia is actually a cortical dementia.
65
Which of the following dementias is characterized by fluctuating course, extrapyramidal features, and occasionally visual hallucinations and delusions?
a. Alzheimer's disease
b. Frontotemporal dementia
c. Lewy body disease
d. Dementia pugilistica
C) Lewy body disease.
66
A 55-year-old patient complains of some difficulty paying attention and episodic memory problems (such as forgetting what she ate yesterday for dinner). She is not depressed. What is the most likely diagnosis (although, of course, you would want to evaluate further)?
a. Delirium
b. Alzheimer's disease
c. Amnestic disorder
d. Normal aging
D) Normal aging is characterized by decreased processing speed and some decrease in attention and episodic memory.
Her age would be more consistent with aging, as opposed to Alzheimer's disease, but may warrant further evaluation.
67
Which of the following is true?
a. Dementia is necessarily progressive
b. Dementia does not always impair memory
c. Dementia cannot have acute onset
d. Dementia is "global" impairment
B) Some like HIV dementia and some of the frontotemporal dementias actually may not impair memory. Dementias can be treatable (e.g., normal pressure
hydrocephalus), can be acute (e.g., traumatic brain injury or stroke), and are not always global.
68
Which type of memory would be most affected by Alzheimer's disease?
a. Episodic memory
b. Remote memory
c. Implicit memory
d. Procedural memory
A) Alzheimer's disease affects episodic memory.
69
On testing, a 75-year-old former engineer currentlv has an IQ score that is 2.5 standard 69. deviations below the mean.
She is alert and not depressed. What is the most likely diagnosis?
a. Delirium
b. Dementia
c. Amnestic disorder
d. Mental retardation
B) This was an acquired (and not congenital) disorder, so dementia rather than mental retardation (MR) would be likely. Given that the patient had been an engineer, MR is unlikely, and since she is alert, delirium is unlikely. Given that other cognitive functions are involved in addition to memory, she does not meet criteria for an amnestic disorder.
70
All of the following functions have been shown to be important cognitive predictors of driving ability except:
a. Attention
b. Memory
c. Language
d. Executive functioning
C) Driving is demanding on attention, memory, and executive functioning (sequencing, planning, shifting, etc), but less so language.
71
Which test would be most useful as a predictor of driving ability?
a. Boston naming test (BNT)
b. Clock drawing
c. Trailmaking test
d. Rorschach inkblot test
C) This is the best test of attention and set-shifting (executive functioning); BNT is a language test, clock drawing is a good screen for Alzheimer's, and the Rorschach is a personality/psychopathology test.
72
Which of the following is not true with regard to assessing a patient's ability to return to work?
a. Assessment of emotional and behavioral functioning is important
b. Assessment of academic ability and
IQ is not necessary
c. Much depends on the demands of the individual's specific job
d. Assessment of the patient's family circumstances is necessary
B) Some aspects of IQ are very good predictors (e.g., mathematics and vocabulary); the other answers are all true.
73
Which statement is correct about the Mini
Mental Status Examination (MMSE)?
a. The MMSE is unfortunately not available in many languages besides English
b. The MMSE can be used with patients with at least a first grade education
c. The MMSE is a cognitive screening instrument, with a maximum of 20 points
d. The MMSE is a cognitive screening instrument, but does not measure executive functioning
D) The MMSE is out of 30 points, requires at least an eighth grade education, and is translated into many languages. It measures executive function.
74
Which of the following is least true regarding cognitive rehabilitation?
a. Cognitive rehabilitation is informed and guided by theoretical models
b. Cognitive rehabilitation's goal is to increase test scores
c. Cognitive rehabilitation focuses on both amelioration of and compensation for deficits
d. Cognitive rehabilitation has a large education component
B) Cognitive rehabilitation strives for ecological validity. It is informed by theory, focuses both on amelioration (through practice) and compensation, and involves much psychoeducation.
75
All of the following are common secondary effects of closed head injury except:
a. Hypoxia
b. Meningeal/cerebral laceration
c. Edema
d. Intracranial bleeding (e.g., subdural hematoma)
B) This is a primary effect; the others are secondary effects.
76
All of the following are common brain areas affected by traumatic brain injury
(TBI) except:
a. Parietal areas
b. Orbitofrontal
c. Anterior temporal
d. Limbic areas
A) TBI commonly affects frontal, temporal, and limbic areas.
77
Which of the following is not true with regard to frontal lobe damage and emotion/ behavior?
a. Orbitofrontal damage has been associated with disinhibition
b. Orbitofrontal damage has been associated with impulsivity
c. Right frontal damage has been associated with depression
d. Medial frontal damage has been associated with lack of initiation (abulia)
C) Actually, left frontal damage is typically associated with depression; the rest are true.
78
Children who sustain a brain injury early in life sometimes appear to have no residual sequelae. This is because:
a. They are resilient and "bounce back" even after severe trauma
b. The effects of brain injury sometimes take time to emerge
c. Other parts of their brain immediately take over
d. They do not really sustain true brain injury
B) Cognitive or behavioral issues may not be evident until that time,
developmentally, that child would reach certain milestones; as the child grows and their brain develops, problems may emerge.
79
Which of the following is not a recommendation to reduce agitation in traumatic brain injury patients?
a. Reduce noise
b. Stay calm
c. Rest breaks
d. Correct confabulations
D) Continually correcting patients may confuse or agitate them further; common recommendations are to "go with" their confabulations while they are acutely agitated.
80
Following a concussion, a player should:
a. Be evaluated the same day and not return to plav.
b. Return to play; he is fine
C. Be evaluated and, if he is fine, be allowed to return to play the same day
d. Be sent to the ER immediately for admission
A) The 2011 update of the American College of Sports Medicine's consensus statement on concussion explicitly states no return to play same day.
81
Asking a patient to count backward from
100 by 7 (or spell WORLD backward) is a test of:
a. Orientation
b. Abstraction
C. Attention
d. Memory
C) Specifically, sustained attention and concentration.
82
The inability to attend to a side of space, usually the left, is referred to as:
a. Amnesia
b. Neglect
c. Disorientation
d. Gerstmann's syndrome
B) Visuospatial neglect is often due to right hemisphere damage.
83
Which of the following syndromes means an inability to recognize or appreciate stimuli?
a. Aphasia
b. Amnesia
c. Apraxia
d. Agnosia
D) Aphasia is a language disorder; amnesia is a disorder of memory; apraxia is an inability to perform purposeful movements.
84
Which of the following tests is most useful for evaluation of memory loss?
a. Mini Mental Status Examination (MMSE)
b. Galveston Orientation and Amnesia Test (GOAT)
c. Ranchos Los Amigos Scale
d. Glasgow Coma Scale (GCS)
B) The GOAT is out of 100 points and is useful for assessing severity of posttraumatic amnesia; the MMSE is a cognitive screener, the Ranchos Los Amigos Scale stages recovery from traumatic brain injury, and the GCS measures coma and severity of TBI.
85
Disorientation and transient attentional difficulties due to infection, medications, electrolyte imbalance, or dehydration is likelv to be:
a. Delusional disorder
b. Dementia
C. Amnestic disorder
d. Delirium
D) By definition, delirium is a temporary state of mental confusion and fluctuating consciousness, with numerous causes; dementia requires significant decrease in (usually memory) at least two areas of cognitive functioning; amnestic disorder only involves memory.
86
Seizures that involve only one region of the brain and do not impair consciousness are called:
a. Generalized
b. Complex partial
c. Simple partial
d. Simple generalized
C) Simple seizures do not impair consciousness; partial seizures are isolated.
87
Generalized seizures that involve only involuntary muscle jerking are called:
a. Myoclonic
b. Tonic
c. Absence
d. Tonic-clonic
A) Tonic seizures involve "drop attacks" or abrupt falls; absence seizures involve staring or trance-like states; tonic-clonic seizures have both convulsions and stiffening of the body followed by involuntary muscle jerking.
88
According to the Glasgow Coma Scale
(GCS), a severe brain injury would be:
a. 13 to 15
b. 0 to 2
c. 8 to 12
d. 3 to 7
D) The Glasgow Coma Scale is from 3 to
15. A score of < 8 indicates a severe brain injury. A score of 9 to 12 indicates moderate brain injury, and a score of 13 or over indicates mild injury.
89
A clinical feature of normal pressure hydrocephalus (NPH) is:
a. Memory impairment
b. Urinary incontinence
c. Ataxic gait
d. All of the above
D) Sometimes called the "3 Ws" for wet, wobbly, and wacky, NPH is characterized by ataxic gait, urinary incontinence, and dementia.
90
Which of the following is not a clinical finding in Parkinson's disease?
a. Resting tremor
b. Hallucinations
c. Festinating gait
d. Hypophonia
B) Hallucinations may be seen in Lewy body disease, which has extrapyramidal features; the rest are findings in Parkinson's disease.
91
"Pseudodem entia" is best characterized as:
a. Malingering
b. Delirium
c. Normal aging
d. Depression
D) Pseudodementia, or dementia of depression, often involves impairments in attention, memory, and processing speed, which may resemble dementia.
92
Which of the following is a benign tumor arising from dural or arachnoid cells?
a. Glioma
b. Astrocytoma
c. Meningioma
d. Glioblastoma multiforme
C) The dura and arachnoid (as well as the pia) are meninges; thus tumors arising from the meninges are called meningiomas. These are benign tumors, but can grow large and cause mass effect.
93
Ischemic strokes are caused by:
a. Aneurysm tear
b. Intracranial bleeding
c. Thrombi or emboli
d. All of the above
C) Thrombi or emboli involve blockage of blood vessels; the others are hemorrhagic causes of stroke.
94
Parkinson's disease has been linked to:
a. Loss of cholinergic neurons in the nucleus basalis of Meynert
b. Loss of dopaminergic neurons in the substantia nigra
c. Overproduction of GABA in the caudate nucleus
d. Overproduction of dopamine in the basal ganglia
B) Loss of dopaminergic neurons in the substantia nigra.
95
What part of the central nervous system
(CNS) is affected in multiple sclerosis (MS)?
a. Dendritic receptors
b. Axon
c. Terminal branches
d. Myelin sheath
D) In MS, the fatty covering surrounding the axon (the myelin sheath) is attacked by the immune system. MS does not affect peripheral nerve myelin.
96
Which cortical lobe contains the primary somatosensory cortex?
a. Frontal lobe
b. Temporal lobe
c. Parietal lobe
d. Occipital lobe
C) Specifically, the postcentral gyrus contains the primary somatosensory cortex.
97
Amnesia for events that occurred before the disturbance to the brain is called:
a. Anterograde amnesia
b. Retrograde amnesia
c. Declarative amnesia
d. Korsakoff's amnesia
B) Retrograde amnesia.
98
Which of the following is not characteristic of a grand mal seizure?
a. The seizure involves motor convulsions
b. The seizure is preceded by an aura
c. The seizure has a clonic phase
d. The seizure has a spell of absence
D) Grand mal, or tonic-clonic, seizures have both a tonic and clonic phase, involve convulsions, and are often preceded by an aura; absence spells are characteristic of petit mal, or absence, seizures.
99
Damage to the right hemisphere of the brain can cause all of the following except:
a. Anosognosia
b. Inability to recognize prosody
c. Difficulty analyzing sequences of
stimuli
d. Difficulty analyzing the gestalt of stimuli
C) The right hemisphere analyzes the gestalt and emotional prosody of speech and has to do with awareness; the left hemisphere is involved in speech and sequential or linear reasoning.
100
Coup-contrecoup injuries in traumatic brain injuries (TBI) are typically concentrated in:
a. Frontal and parietal lobes
b. Frontal and temporal lobes
c. Occipital and parietal lobes
d. Subcortical structures
B) The frontal lobe is often affected directly in TBI, and the temporal lobes are affected due to the bony protuberances surrounding the temporal region; the coup is the contusion directly beneath the impact; the contre coup is the side opposite the impact.
101
Which is the most common dementia accompanied by a peripheral neuropathy?
a. Alzheimer's disease
b. Vascular dementia
C. Traumatic brain injury dementia
d. Wernicke-Korsakoff
D) Owing to long-term alcohol abuse and thiamine deficiency, dementia and peripheral neuropathy often result.
102
Which of the following dementias _features spongiform cerebral cortex?
a. Alzheimer's dementia
b. Creutzfeldt-Jakob disease
c. AIDS dementia
d. Wilson's disease
B) Caused by a prion, Creutzfeldt-Jakob disease results in spongiform cortex (with an appearance of "Swiss cheese"), dementia, and rapid progression to death.
103
Which is the most common cause of falls in the elderly?
a. Neuropathy
b. Normal pressure hydrocephalus
c. Medications, especially sedatives
d. TIA
C) Medications, especially sedatives.
(Kaufman DM. Clinical Neurology for Psychiatrists. 5th ed. Philadelphia, PA:
Saunders; 2001.)
104
Which disorder is least associated with a higher incidence of depression?
a. Alzheimer's disease (AD)
b. Parkinson's disease
c. Huntington's disease
d. Stroke
A) Alzheimer's disease typically results in apathy early on; the others
characteristicall (and due to subcortical involvement) involve depression.
105
Compared with epidural hematomas, subdural hematomas:
a. Originate from arterial bleeding
b. May develop slowly
C. Cause severe headaches
d. Are often fatal
B) Subdural hematomas are common in the elderly, may occur after a fall or even spontaneously, are due to tearing of weak venous blood vessels, and are often asymptomatic, sometimes resolving on their own or coming to attention only after several days.
106
Severity of brain injury is most reliably indicated by:
a. Presence of seizure
b. Presence of vomiting
c. Chronic neck pain
d. Length of coma and amnesia
D) Seizures, vomiting, and neck pain may not be present and do not reliably indicate the severity of a brain injury.
107
Which is the best study for locating white matter plaque in multiple sclerosis or vascular infarcts?
a. Computed tomography (CT)
b. Electroencephalogram (EEG)
c. Magnetic resonance imaging (MRI)
d. Lumbar puncture (LP)
C) MRI has better resolution of white matter and other soft tissue; CT is better for detecting blood, bone, or shrapnel; EEG measures brain waves, such as in seizure; an LP is used to assess for infectious material in cerebrospinal fluid.
108
Alzheimer's disease patients are placed in nursing homes primarily because of:
a. Wandering
b. Memory impairment
c. Incontinence
d. Hallucinations
A) Wandering. (Kaufman DM. Clinical Neurology for Psychiatrists. 5th ed.
Philadelphia, PA: Saunders; 2001.)
109
Pseudobulbar palsy is characterized by:
a. Emotional lability
b. Dysphagia
c. Frontal damage
d. All of the above
D) From frontal damage, pseudobulbar palsy is due to damage to the upper motor neuron corticobulbar tract.
110
Which of the following is not true with regard to the left hemisphere of the brain?
a. Damage results in loss of details
b. Damage results in left neglect
c. It is the dominant hemisphere for language for right-handers
d. It is the dominant hemisphere for language for most left-handers
B) 95% of right-handers and 70% of left-handers are left-dominant for language; the left hemisphere is involved in detail analysis, whereas the right hemisphere is involved in whole/gestalt analysis; left neglect occurs from right hemisphere damage.
111
Which behavioral problem, common after brain injury, is frequently confused with depression?
a. Impulsivity
b. Disinhibition
c. Abulia
d. Agitation
C) Abulia, or lack of initiation, can look like depression and is more of a "negative" symptom, compared with the other "positive" symptoms, from frontal lobe injury.
112
Significant amounts of pain are reported by 95% of
traumatic brain injury (TBI) patients, but by only 22% of
TBI patients.
a. Severe; mild
b. Mild; severe
c. Moderate; mild
d. All of the above
B) The most pain is actually reported by patients with mild brain injury;
postconcussive syndrome is thought to involve psychiatric as well as cognitive symptoms.
113
Repeated concussions may result in:
a. Parkinson-like symptoms
b. Alzheimer-like neuropathology
c. Second impact syndrome
d. All of the above
D) Chronic traumatic encephalopathy
(CTE), or dementia pugilistica, results in extrapyramidal symptoms and Alzheimer pathology. Second impact syndrome results from inability to autoregulate blood pressure after repeat concussion; this hypertensive emergency has resulted in death (in those younger than 18).
114
Which are the most commonly inured areas of the brain after a traumatic brain injury (TBI)?
a. Occipital and frontal
b. Frontal and temporal
c. Parietal and frontal
d. Occipital and temporal
B) Regardless of site of impact, the orbitofrontal and anterior temporal lobes are the most commonly injured sites of the brain because of the close relation of the lobes to the bones.
115
Which of the following is not true about diffuse axonal injury (DAI)?
a. Primarily occurs at the grey matter
b. Only seen in traumatic brain injury (TBI)
C. Responsible for loss of conscience
(LOC)
d. Occurs from acceleration-deceleration and rotational forces
A) DAI is seen in the white matter, primarily in the corpus callosum, midbrain, pons, and central white matter.
116
Which best describes someone who is in a vegetative state?
a. Eyes are open, eyes are tracking, he or she has sleep-wake cycles
b. Eyes are closed, eyes are not tracking, he or she has no sleep-wake cycles
c. Eyes are closed, eyes are not tracking, he or she has sleep-wake cycles
d. Eyes are open, eyes are not tracking, he or she has sleep-wake cycles
D) A comatose patient has eyes opened and no sleep-wake cycles. A patient in a minimally conscious state (MCS) has eyes open, tracking, and reproducible behavior.
Emergence from MCS occurs when there is consistent command following.
117
What is the Glasgow Coma Scale
(GCS) for someone who withdraws from pain, is confused, and opens eyes to pain?
а. 6
b. 8
C. 10
d. 12
C) Scoring for withdrawing from pain (without localizing) is 4, confused is 4, and eyes opening to pain 2.
118
What is the description of a Rancho
Los Amigos level of IV?
a. Localized response to stimuli
b. Confused with inappropriate behavior
c. Confused but appropriate behavior
d. Confused and agitated behavior
D) Level Ill is answer choice A (localized response to stimuli), level V is answer choice
B (confused with inappropriate behavior), level VI is answer choice C (confused but appropriate behavior).
119
What type of bleeding does an injury to the medial meningeal artery cause?
a. Subdural hematoma (SDH)
b. Epidural hematoma (EDH)
c. Subarachnoid hemorrhage (SAH)
d. Intracranial hemorrhage (ICH)
B) The middle meningeal artery is responsible for causing an EDH. An EDH has a biconvex shape and is rapidly evolving.
120
Which of the following is not a description of a subdural hematoma (SDH)?
a. Occurs primarily in younger patients
b. Clinical findings may sometimes be delayed for weeks
c. Caused by an injury to the bridging veins
d. Lentiform in shape on imaging
A) SDH occurs primarily in the elderly because of atrophy of the brain and stretching of the bridging veins. This stretching makes them vulnerable to mild trauma to the head. Because it is a vein and there is atrophy, the SDH expands slowly in the space, which can delay symptoms for weeks. Usually, history can reveal a previous fall.
121
Which of the following is true about
Glasgow Coma Scale (GCS) in traumatic brain injury (TBI)?
a. AGCS of 2 is a severe injury
b. AGCS of 8 is a moderate injury
C. AGCS of 10 is a moderate injury
d. AGCS of 12 is a mild injury
C) A mild injury is a GCS of 13 to 15, a moderate injury is a GCS of 9 to 12, and a severe injury is a GCS of 3 to 8. The lowest score is a 3 on the GCS.
122
What is the most common location of heterotopic ossification (HO) after traumatic brain injury (TBI)?
a. Shoulder
b. Knee
с. Hip
d. Elbow
C) HO occurs most frequently in the hips, followed by elbows, shoulders, and knees.
123
Which is the most sensitive test used to identify early heterotopic ossification
(HO)?123.
a. X-ray
b. Serum alkaline phosphatase
c. Computed tomography (CT) scan
d. Bone scan
D) Phase 1 and 2 of a bone scan can help detect HO within 2 to 4 weeks. To detect HO on x-ray requires bone maturation, which can take as long as 4 weeks. CT scan is not g indicated for HO identification, and serum alkaline phosphatase is a nonspecific/non-sensitive test.
124
What is the best acute predictor of outcome after a traumatic brain injury (TBI)?
a. Best motor response of the Glasgow Coma Scale (GCS)
b. Best verbal response on the GCS
c. Best eye opening response on the
GCS
d. Initial GCS score
A) The best motor GCS and the best overall GCS within the first 24 hours is considered to be the best acute predictor of outcome in TBI.
125
What does not describe post traumatic amnesia (PTA)?
a. It is a predictor of recovery and outcome in traumatic brain injury (TBI)
b. It measures retrograde amnesia
c. It is an indication of sustaining ongoing new memories
d. It can be assessed using the Galveston Orientation and Amnesia Test (GOAT)
B) PTA assesses anterograde amnesia, the ability to retain ongoing memories, from the time of the TBI to present. Retrograde amnesia is memory loss of events occurring prior to the injury. The GOAT is an objective assessment tool that tracks PTA, where a score of 75 or greater for 2 consecutive days is considered the end of PTA.
126
Which is the most commonly injured cranial nerve (CN)?
a. CNI
b. CN II
c. CN VII
d. CN VIII
A) The olfactory nerve (CIN I) is the most commonly injured cranial nerve. Injury to CN I can lead to anosmia and an altered, usually poor, appetite. The injury occurs because of the shearing forces that damage the small nerves on the cribriform plate.
127
How is the severity of a concussion graded?
a. Concussion grading scales, such as Cantu and Colorado Head Injury Scales 7
b. Presence of loss of conscious LOC)
c. Presence of posttraumatic amnesia 36 (PTA)
d. Severity of ongoing symptoms
D) A concussion is a mild traumatic brain injury and should never be graded with grading scales. The majority of concussions do not have LOC and therefore should not be used as an indication of severity. Concussion severity is determined by the number, severity, and length of symptoms present.
128
What is the most common symptom described after a concussion?
a. Dizziness
b. Poor sleep
c. Headache
d. Fatigue
C) Headaches are the most common symptom experienced after a concussion. The others can also occur, but are not as frequent as headaches.
129
What should be initially prescribed to a patient with a traumatic brain injury (TBI) who suffers from insomnia, poor attention, poor memory, depressed mood, and headaches?
a. A stimulant to help with the attention
b. A sleeping medication and sleep hygiene
c. A headache medication
d. An antidepressant
B) For a patient with a TBI, sleep is one of the most important aspects of medication management. If it is not addressed, lack of sleep may cause difficulty with attention, memory, headaches, poor mood, and overall poor general health.
130
How should a behaviorally agitated traumatic brain injury (TBI) patient be managed?
a. Restrain them even if not a risk to self or others
b. Administer lorazepam or haloperidol to calm them
c. Call hospital security to restrain them
d. Identify cause of agitation and reorient the patient
D) Agitation from a TBI is caused by confusion and inability to retain memory (posttraumatic amnesia). First, the inciting factor should be identified. Then, one person should speak with the patient in a calm manner and redirect the patient as to where he or she is and why they are in the hospital.
The environment should be altered to minimize distractions, provide a structured program of therapies, and be safe. Restraints and medications such lorazepam should only be used if there is a risk for the patient to injure himself or herself or others. Haloperidol should never be used because it has been shown to negatively impact recovery.
131
What is considered the most effective method for the prevention of heterotopic ossification (HO)?
a. Radiation of bone tissue
b. Range of motion
c. Nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Diphosphonates
B) Range of motion is the best prophylaxis and treatment of HO. Radiation would have to be given to the whole body because HO development cannot be predicted. NSAIDs and diphosphonates have a role in treatment, but not significantly in prevention.
132
How long should phenytoin be administered for seizure prophylaxis after a traumatic brain injury (TBI)?
a. 1 week
b. 6 months
c. 1 year
d. Indefinitely
A) A study by Temkin et al. determined that phenytoin has been shown to be effective for prophylaxis of seizures when administered for 1 week. Beyond 1 week, treatment conferred no benefit to seizure prevention.
Long-term use of phenytoin has been associated with impaired neurologic recovery.
133
What is the initial management for a traumatic brain injury (TBI) patient who has a sodium (Na+) of 132, is asymptomatic, and has no signs of dehydration?
a. Administer hypertonic saline
b. Prescribe demeclocycline
c. Give NaCI tablets
d. Restrict oral (PO) fluids
D) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is hyponatremia in the setting of normal hydration, whereas cerebral salt wasting (CSW) is hyponatremia with physical signs of dehydration. Initial management for SIADH is fluid restriction, between 1 and 1.5 L/day. If fluid restriction does not improve Na+ and there is significant symptomatology, then hypertonic saline should be considered. However, the hypertonic saline should be administered slowly so as to prevent pontine myelinolysis or cardiac dysfunction. If chronic SIADH is diagnosed, demeclocycline should be prescribed for continued management.
134
What is the best recommendation for return to play (RTP) in an adolescent who has sustained a concussion?
a. If the athlete has no symptoms after 24 hours, can RTP the next day
b. If the athlete has had loss of consciousness (LOC), RTP is delayed for a week
c. If the athlete has no symptoms at rest for 24 hours, can begin light aerobic activities
d. If the athlete has no symptoms at rest for 7 days, can RTP the next dav
C) RTP is a very important decision to maintain safety of athletes. RT should be based on the graduated RTP protocol. There are six stages, and to progress through each stage, the athlete must be asymptomatic for 24 hours. If the athlete experiences any postconcussive symptoms at any stage, he or she must return to the previous stage of activity. Symptoms in relation to physical activity must be assessed, and no player should RTP if he or she has only been asymptomatic at rest LOC is not relevant for deciding whether a patient should RT.
135
Which of the following statements is correct regarding epidural hematomas
(EDH)?
a. Bleeding occurs between the dura and the arachnoid mater
b. Symptoms develop slowly, over hours or days after injury
c. Most commonly associated with venous bleeding
d. Patients typically have a lucid interval before the development of neurological symptoms
D) An epidural hematoma occurs between the skull and the dura. It often develops quickly because it is usually secondary to an arterial bleed, such as the middle meningeal artery. Often, patients may have an initial headache with no other complaints. Within hours, patients may develop significant neurological deficits related to the expansion of the epidural hematoma, such as midline shift and brain stem herniation.
136
A 28-year-old woman after motor vehicle accident sustained a traumatic brain injury (TBI). The impact of injury was to the right side of her head, and she now has visual changes consistent with an oculomotor cranial nerve (CN)
dysfunction. What would the ocular exam demonstrate?
a. Dilation of the ipsilateral pupil
b. Constriction of the ipsilateral pupil
c. Dilation of the contralateral pupil
d. Constriction of the contralateral pupil
A) An injury to CN Ill would cause
¡psilateral dilation of the pupil. Normally, CN III constricts the ipsilateral pupil with light exposure.
137
Which antiseizure medication is associated with disorders of the vestibular and cerebellar systems, such as nystagmus, ataxia, and vertigo as well as gingival hyperplasia?
a. Phenobarbital
b. Valproic acid
c. Phenytoin
d. Gabapentin
C) Phenobarbital is often associated with dizziness, irritability, confusion, rash, and cerebellar signs. These side effects usually occur at very high doses. Phenobarbital is not recommended for treatment or prophylaxis of seizures as a result of traumatic brain injury, as it can contribute to poor recovery. Valproic acid commonly causes gastrointestinal dysfunction. Sedation, tremor, and ataxia can also occur. Gabapentin primarily causes fatigue, somnolence, ataxia, and dizziness.
138
What neurotransmitter should be enhanced to improve cognitive recovery in patients with a traumatic brain injury (TBI)?
1a. Norepinephrine
b. Dopamine
c. Histamine
d. Acetylcholine
B) Medications such as amantadine, bromocriptine, and methylphenidate are dopaminergic, which assist in improving attention and cognitive function. Histamine has no role in cognitive recovery, except that histamine-2 blockers should be avoided because they cause sedation. Norepinephrine also has a limited role in the treatment of cognition in TBI.
