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Rehab > Rehab Midterm 2 > Flashcards

Rehab Midterm 2 Flashcards

1
Q

define TBI

A

an alteration in brain function function or other evidence of brain pathology caused by an external force

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2
Q

define head injury

A

a blow to the head or laceration that may occur without causing unjury to the brain

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3
Q

define open TBI

A

occurs when the head is hit by an object that breaks the skull and enters the brain

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4
Q

define closed TBI

A

occurs when the brain is injured but the skull remains intact

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5
Q

What GCS score for TBI is mild

A

. 13 - 15

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6
Q

what GCS score for TBI is moderate

A

.9 - 12

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7
Q

What GCS score for TBI is severe

A

. 3 - 8

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8
Q

Common causes of TBI from most common to least

A 
. Falls -35
. Traffic related accidents - 17
. Sports -16
. Assults - 10
. Other - 21
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9
Q

Which age group is the most at risk for sustaining TBI

A

0-4 and 15-19 yo

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10
Q

Which age group has the highest rates of hospitalization and death after TBI

A

greater than 75 yo

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11
Q

what is the most common cause of TBI in adults over 65 yo

A

fall-related injuries

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12
Q

what is the most common cause of TBI in 15-19 yo

A

motor vehicle accidents

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13
Q

what are the leading causes of death after TBI from violence

A

. Self-inflicted - 60
. Intentional assult - 32
. Unintentional - 4

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14
Q

Shaken baby syndrome is also known as

A

inflicted childhood neurotrauma

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15
Q

risk factors for SBS

A 
. Mothers less than 19 yo
. Education less than 12 years
. Single
. African american or native american
. Limited parental care
. Newborns less than 28 weeks old
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16
Q

what is sbs

A

shaken baby syndrome

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17
Q

how many individuals with tbi test positive for drugs and alcohol

A

50 percent

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18
Q

define primary injury tbi

A

damage that occurs directly and immediately as a result of trauma to the brain

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19
Q

true or false

cerebral contusions are responsible for loss of consciousness

A

. False (DAI is responsible)

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20
Q

cortical contusion causes 2 deficits and is a risk factor for

A

. Focal cognitive and sensory motor deficits

. Risk for seizures

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21
Q

what is the name of cortical contusions that occurs under the impact site

A

coup injury

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22
Q

what is the name of cortical contusions that occurs remots and opposite site of impact

A

countercoup injury

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23
Q

what is the distinguishing feature of tbi

A

diffuse axonal injurty (DAI)

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24
Q

what is DAI

A

diffuse axonal injurty (DAI)

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25
Q

what is DAI

A

produced by acceleration-deceleration and rotational forces that common results from motor accidents

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26
Q

true or false

lateral impact leads to poorer outcome in DAI than head-on

A

. True

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27
Q

true or false

DAI are responsible for loss of consciousness

A

. True

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28
Q

what is the mechanism for DAI

A

. Direct axonal shearing

. Disruption of the intra-axonal cytoskeleton

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29
Q

deficits due to DAI tend to recover (gradually/quickly)

A

grandually

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30
Q

what is diaschisis. What causes it

A

. Neuronal disconnection remote from a site of injury but anatomically connected to the damaged area becoming functionally depressed
. Caused by DAI or focal contusions

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31
Q

diaschisis occurs (remote/local) to the site of injury

A

diaschisis occurs remote to the site of injury

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32
Q

what is EDH and SDH

A

epidural hematoma and subdural hematoma

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33
Q

between skull and dura mater

EDH
SDH

A

EDH

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34
Q

laceration of underlying dural veins and arteries

EDH
SDH

A

EDH

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35
Q

meningeal artery is common cause

EDH
SDH

A

EDH

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36
Q

damage to dural sinuses

EDH
SDH

A

EDH

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37
Q

lenticular shape

EDH
SDH

A

EDH

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38
Q

why is EDH a neurologic emergency

A

EDH quickly expands and rapidly causes neurologic deterioration

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39
Q

these are susceptible to shear and rupture from brief high-velocity angular accelerations

A

bridging veins

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40
Q

tearing of bridging veins

EDH
SDH

A

SDH

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41
Q

angular acceleration shears vessels located in the subarachnoid

EDH
SDH

A

SDH

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42
Q

between dura mater and aracchnoid mater

EDH
SDH

A

SDH

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43
Q

crescent shape

EDH
SDH

A

SDH

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44
Q

what is secondary injury in TBI

A

any damage to brain tissue that takes place after the initial injury. Develops over hours and days later

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45
Q

secondary injury is associated with

A 
. Disruption of cerebral blood flow and metabolism
. Massive release of neurochemicals
. Cerebral edema
. Disruption of ion homeostasi
. Brain swelling
. Increased levels of EAA
. Increase lactate levels
. Mitochondrial dysfunction
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46
Q

response to the initial injury and early events involved with secondary injury

A

Brain swelling which causes

. Increase ICP
. Decrease cerebral perfusion pressure (CPP)

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47
Q

chronic period after injury is characterised by

A

multiple neurotransmitter deficits and cellular dysfunction

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48
Q

mechanisms by which TBI recovery occurs

A

. Reversal of diaschisis

. Resolution of cerebral edema and blood flow

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49
Q

GCS of eye open spontaneously

A

. 4

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50
Q

GCS of eye open to verbal command

A

. 3

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51
Q

GCS of eye open to painful stimuli

A

. 2

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52
Q

GCS of eye has no opening

A

. 1

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53
Q

GCS of verbal oriented and converse

A

. 5

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54
Q

GCS of verbal disoriented and converses

A

. 4

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55
Q

GCS of verbal inappropriate words

A

. 3

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56
Q

GCS of verbal incomprehensible sounds

A

. 2

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57
Q

GCS of verbal has no response

A

. 1

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58
Q

GCS of motor obeys verbal commands

A

. 6

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59
Q

GCS of motor purposeful localization

A

. 5

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60
Q

GCS of motor withdrawl

A

. 4

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61
Q

GCS of motor flexor posturing

A

. 3

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62
Q

GCS of motor extensor posturing

A

. 2

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63
Q

GCS of motor no response

A

. 1

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64
Q

what is criteria for mild TBI

A

. Confusion, disorientation, loss of consciousness for less than 30 minutes, PTA for less than 24 hours, or other abnormalities

. GCS score of 13 to 15 after 30 minutes

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65
Q

common symptoms of concussion

A

memory loss, poor concentration, impaired emotional control, posttraumatic headaches, sleep disorders, fatigue, irritability, dizziness

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66
Q

what is post concussion syndrom

A

concussion symptoms persisting between 3 and 12 months

DSM: cognitive deficits and 3 or more subjective symptoms for at least 3 months

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67
Q

mainstay of monitoring after TBI

A

ICP using ventriculostomy

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68
Q

why is ventriculostomy precedure of choice

A

allows for therapeutic CSF drainage

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69
Q

ICP monitoring is appropriate for

A

GCS score of 8 or less and head CT showing contusion or edema OR systolic 90

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70
Q

define elevated ICP

A

20 - 25 mmHg

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71
Q

maneuvers to decrease ICP

A 
. Elevating the head of the bed 30 degrees
. Treatment of hyperthermia
. Mannitol administration
. Sedation
. Brief hyperventilation
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72
Q

define CPP

A

CPP = MAP - ICP

pressure gradient driving cerebral blood flow

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73
Q

desired CPP in adults

A

60 mmHg

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74
Q

how to directly measure ischemia

A

cerebral oxygen tension

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75
Q

secondary complications of TBI

A

. Elevated glucose levels: increased mortality, increase lactic acid, impair phosphorus metabolism

. Sodium imbalance: risks for seizure, volume status, hyponatremia

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76
Q

physiologic measurements during acute care of TBI and why

A

. Pupillary reflexes: determining lesion location, mortality, and global outcome

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77
Q

what are the neuroimaging techniques for TBI. Which is standard

A

CT scan: standard with suspected moderate to severe TBI

MRI: less able to detect skull fracture and acute blood

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78
Q

pathologic unconsciousness

Coma
Vegetative State
Minimally conscious state

A

Coma

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79
Q

evidence of wakefulness without sustained or reproducible responses to environment

Coma
Vegetative State
Minimally conscious state

A

Vegetative State

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80
Q

reproducible evidence of self-awareness or environmental awareness

Coma
Vegetative State
Minimally conscious state

A

Minimally conscious state

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81
Q

how to evaluate pt with depressed levels of consciousness

A

. Pupillary response
. Brain stem reflexes
. Ocular movements

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82
Q

what are the brain stem reflexes

A

corneal reflexes
gag reflex
oculocephalic reflexes (Doll’s eyes)

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83
Q

used to evaluate post traumatic amnesia

A

GOAT: Galveston Orientation and Amnesia Test

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84
Q

LCFS: Ranchos Levels of Cognitive Functioning Scale is used for

A

describe the process of cognition recovery as individual emerges from coma

also for method of assesing pt functioning for purposes of rehabilitation

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85
Q

TBI complications

A 
. Posttraumatic seizures (PTS)
. Heterotrophic ossification (HO)
. Deep venous thrombosis
. Swallowing and nutrition
. Bowel and bladder dysfunction
. Airway and pulmonary management
. Spacticity and contractures
. Normal pressure hydrocephalus
. endocrine dysfunction
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86
Q

PTS accounts for how many symptomatic seizures? Seizures in general population?

A

symptomatic - 20

general - 5

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87
Q

Define PTS

immediate
early period
late

A

immediate - less than 24 hours
early period - 24 hours to 7 days
late - more than 7 days

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88
Q

common treatment and prophylaxis for PTS

A

Phenytoin (Dilantin)

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89
Q

what is HO

A

ectopic bone formation

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90
Q

common prophylactic methods of HO

A

indomethacin, irradiation, Ca binding chelating agents: etidronate

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91
Q

What is spasticity? Is it upper or lower motor neuron

A

velocity dependent increase in tonic stretch reflexes with exaggerated tendon jerk responses

upper motor neuron

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92
Q

other than spacticity, what are other symptoms of upper motor neuron injury

A

. Loss of autonomic control
. Decreased dexterity
. Limb weakness

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93
Q

how is limb weakness assesed

A

Modified Ashworth Scale - based on the amount of resistance

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94
Q

define clinidal agitation

A

agitationi occuring during altered state of consciousness

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95
Q

what classes of treatment are used for PTS

A

. Atypical antipsychotic (AAP)
. B blockers
. Benzodiazepines

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96
Q

Atypical antipsychotic (AAP) used for PTS

A

quetiapine

D2 receptor agonist

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97
Q

. B blockers used for PTS

A

propranolol

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98
Q

. Benzodiazepines used for PTS

A

GABA-A receptor antagonist that can reduce agitation symptoms

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99
Q

definitions of stroke

A

non-traumatic brain injury caused by occlusion or rupture of cerebral blood vessels - results in sudden focal neurological deficit

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100
Q

what rank is stroke for cause of death

A

3rd

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101
Q

What are the modifiable risk factors of stoke

A 
. Hypertension
. Heart disease
. Hypercholesterolemia
. DM
. Elevated hematocrit
. Elevated homocyseine
. Elevated fibronogen
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102
Q

. Hypertension increases risk of stroke by

. And treatment

A

. Systolic pressure >165 mmHg and diastolic > 95
. Farmingham study and RCT metaanalysis
. 35 percent reduce with reduction 10-15 systolic and 5-6 diastolic

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103
Q

. Heart disease increases risk of stroke by

. And treatment

A

LVH, CHF, non-vascular AF increase by 2-6x
. AF increase risk of cerebral infarction 5x
. Warfarin and aspirin

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104
Q

. Hypercholesterolemia increases risk of stroke by

. And treatment

A 
. Development of atherosclerosis
. LDL < 100
. HDL > 60
. Total < 200
. HMG-CoA reductase or statins
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105
Q

. DM increases risk of stroke by

. And treatment

A

doubles risk of stroke

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106
Q

. Elevated hematocrit increases risk of stroke by

. And treatment

A

no treatment

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107
Q

. Elevated homocyseine increases risk of stroke by

. And treatment

A

enhance atherogenesis and hyper coagulabiity

. Vitamin B6 and folic acid

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108
Q

Treatment of heart disease to prevent stroke

A

with AF: anticoagulation, warfarin

without AF: aspirin 325 mg OD

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109
Q

Chances of surving next 5 years after stroke

stroke plus hypertension and heart disease
stroke plus hypertension or heart disease
stroke with heart disease

A

stroke plus hypertension and heart disease - 25stroke plus hypertension or heart disease - 50
stroke with heart disease - 75

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110
Q

what are the ischemic etiologies of stroke

A

thrombosis
emboli
lacunar

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111
Q

what are the hemorrhagic etiologies of stroke

A

intracerebral hemorrhage

subarachnoid hemorrhage

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112
Q

thrombosis stroke etiology

A

. large extracracial and intracranial vessels

. Occurs at night

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113
Q

emboli stroke etiology

A 
. Arise from heart
. From Large extracranial arteries: aorta and carotid
. Paradoxical
. Lodge in small cortical vessels
. Abrupt
. Commonly MCA
. Lysis and reperfusion
. Hemorrhagic transformation
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114
Q

lacunar etiology

A

. Small lesions: 1.5 cm
. Occlusion in the deep branches of cortical structures
. Disrupts pure motor, pure sensory, and motor-sensory

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115
Q

lacunar stroke syndrome that is pure motor

A

dysarthria-clumsy hand

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116
Q

lacunar stroke syndrome that is pure sensory

A

ataxic hemiparises

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117
Q

lacunar stroke syndrome that is sensory motor

A

hemiballismus

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118
Q

what type of stroke occurs at night

A

cerebral thrombosis

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119
Q

what type of stroke has sudden onset

A

cerebral embolism

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120
Q

intracerebral stroke etiology

A 
. Small, deep, penetration arteries
. Charcot-Bouchard aneurysm
. Onset is dramatic
. High mortality 
. High rate of recovery
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121
Q

what type of stroke is the most dramatic

A

intracerebral hemorrhage

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122
Q

subarachnoid hemorrhave stroke etiology

A

. Saccular aneurysm - small defect in the wall of arteries
. Coma
. Dramatically abrupt

. AV malformation - web dilated vessels
. Seizure or chronic headache

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123
Q

which stroke is described as worst headache of life

A

subarachnoid hemorrhage

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124
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

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125
Q 
In a patient with symptoms of a stroke, which of the following is the fi rst-line diagnostic
radiological test?
A) MRI of the brain
B) Carotid Dopplers
C) MRA of the head
D) CT brain without contrast
A

D) Noncontrast CT of the brain is the fi rst-line diagnostic radiological test done in a patient
with symptoms of stroke. This is done to rule out an intracranial bleed

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126
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.

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127
Q 
Wernicke’s aphasia is characterized by intact:
A) Naming
B) Comprehension
C) Repetition
D) Fluency
A

D) Wernicke’s aphasia is a fl uent aphasia and is characterized by impaired naming, comprehension,
and repetition.

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128
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 infar

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129
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

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130
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.

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131
Q

The gold standard for assessment of swallowing function is:
A) Bedside swallow evaluation
B) Video fl uoroscopic 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 fl exible 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.

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132
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

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133
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 refl ex, and wet vocal quality after
swallow.

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134
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.

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135
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.

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136
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.

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137
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

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138
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 fi t and compliance, and decreased pain due to nighttime
spasms

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139
Q

Shoulder subluxation after stroke:
A) Occurs late in the recovery phase
B) Is always associated with pain
C) Is associated with fl accid hemiplegia
D) Will need radiological studies for diagnosis

A

C) Shoulder subluxation tends to occur early after a stroke in patients with fl accid 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.

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140
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

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141
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
fi nding, but is not reported as a common complication.

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142
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 defi cits
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

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143
Q

All of the following are features of lateral medullary syndrome except:
A) Hemiplegia
B) Dysphagia
C) Ipsilateral facial hemisensory defi cit
D) Palate and vocal cord paralysis

A

A) As the corticospinal tract is a medial structure, lateral medullary syndrome, also known
as Wallenberg syndrome, does not cause motor paralysis

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144
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

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145
Q

Which of the following is a contraindication for administration of tissue plasminogen activator (tPA)?
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 tPA. The other answers are
requirements for giving tPA in the setting of an acute stroke

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146
Q

Which of the following statements regarding National Institute of Health (NIH) stroke
scale is incorrect?
A) It requires training and certifi cation
B) It is valuable in quantifying defi cits 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 refl ected, palatal weakness is not scored, it does not assess distal weakness,
and it does not screen for neurocognitive dysfunction

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147
Q 
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

A) The physiological factors that account for stroke recovery include resolution of poststroke
edema, reperfusion of ischemic penumbra, resolution of diaschisis, and cortical
reorganization

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148
Q 
What is the most important modifi able risk factor for ischemic and hemorrhagic stroke?
A) Hypertension (HTN)
B) Gender
C) Race
D) Age
A

A) HTN is the most important modifi able 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 nonmodifi able.

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149
Q 
In a transient ischemic attack (TIA), the symptoms last for:
A) > 24 hours
B) < 24 hours
C) > 48 hours
D) > 1 week
A

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.

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150
Q 
A patient diagnosed with alexia is unable to:
A) Read
B) Write
C) Recognize
D) Calculate
A

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

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151
Q 
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
A

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

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152
Q 
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
A

C) A subarachnoid hemorrhage is usually caused by the rupture of an aneurysm. The
blood irritates the meninges, causing a severe headac

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153
Q 
On a computed tomography (CT) scan, a hemorrhage would appear:
A) Black
B) White
C) Grey
D) None of the above
A

B) On a CT scan, blood appears hyperdense (radiopaque) and will show up white

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154
Q 
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
A

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 diffi cult.

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155
Q 
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
A

C) ICP ≤ 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.

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156
Q

The inclusion criterion for tissue plasminogen activator (tPA) 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

A

D) All of the above are required before tPA is administered to a patient with acute
stroke.

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157
Q 
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
A

C) In a patient with transcortical mixed aphasia, the speech is nonfl uent and the patient is
unable to comprehend, but repetition is still intact

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158
Q

Good prognosis of recovery after stroke is associated with:
A) Complete arm paralysis
B) Prolonged fl accidity
C) Severe proximal spasticity
D) Some motor recovery of the hand by 4 weeks

A

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.

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159
Q 
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
A

C) MVA accounts for approximately 50% of all TBI cases. Assault is the second most common
cause

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160
Q 
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
A

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

161
Q 
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
A

C) The prognosis for recovery is better in a younger individual

162
Q 
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

A) In the elderly population, gait and visual disturbances lead to falls, which cause most
of the TBIs in the elderly.

163
Q

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

A) Epidural hematoma usually results from a skull fracture in the temporal bone crossing
the vascular territory of the middle meningeal arte

164
Q 
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
A

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.

165
Q

In decerebrate posturing, there is:
A) Flexion of the upper and lower extremities
B) Extension of the upper and fl exion of the lower extremities
C) Flexion of the upper and extension of the lower extremities
D) Extension of the upper and lower extremities

A

D) In decerebrate posturing, the limbs will be stiff and extended with internal rotation
of arms and ankles in plantar fl exion. In patients with decorticate posturing, the legs are
extended and the arms are fl exed and adducted

166
Q 
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
A

B) A GCS score 3 to 8 = severe TBI (coma). A GCS score of 9 to 12 = moderate TBI. A GCS
score of 13 to 15 = mild TBI.

167
Q 
Uncal herniation would cause compression of:
A) Cranial nerve (CN) III
B) CN I
C) CN VII
D) CN X
A

A) Uncal herniation causes compression of the CN III, which may lead to complete ipsilateral
CN III palsy (fi xed pupil dilation, ptosis, and ophthalmoplegia).

168
Q

A fi rst-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

A) The fi rst step would be to create a low-stimulus environment for the patient.

169
Q

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

A

D) All of the above are appropriate interventions for a TBI patient with bowel and bladder
dysfunction.

170
Q

Dysarthria involves all of the following except:
A) Chewing and swallowing diffi culty
B) Hoarseness
C) Drooling
D) Complete movement of the lip, tongue, and jaw

A

D) In dysarthria, there are limited lip, tongue, and jaw movements.

171
Q 
Risk factors for developing poststroke depression include:
A) Lack of social support
B) Cognitive impairment
C) High severity of defi cits
D) All of the above
49
A

D) All of the above are risk factors for poststroke depression

172
Q

Seizures in stroke patients are associated with:
A) Large parietal or temporal hemorrhages
B) Older age
C) Confusion
D) All of the above

A
  1. D) All of the above are associated with seizures in stroke patients.
173
Q

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

A

B) Decreased patient mobility will lead to the development of decubitus ulcers. Stroke
patients require frequent turning and repositioning.

174
Q 
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
A

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

175
Q 
Syndrome of inappropriate antidiuretic hormone (SIADH) is found in:
A) Acute stroke
B) Chronic traumatic brain injury (TBI)
C) Acute TBI
D) Chronic stroke
A

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 fl uid restriction, loop diuretics, and monitoring
weight and serum sodium level. In patients with severe symptoms, intravenous hypertonic
saline can be used

176
Q 
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
A

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.

177
Q 
Aphasia classifi cation 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
A

C) Fluent versus nonfl uent 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

178
Q

A 63-year-old right-handed woman with hypertension suddenly had diffi culty 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

A

D) This aphasic syndrome resembles Broca’s aphasia, but because it involves the extrasylvian
region, repetition is intact.

179
Q

A 63-year-old right-handed woman with hypertension suddenly had diffi culty 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

A) This refl ects a lesion in the anterior cerebral artery territory (extrasylvian). Nonfl uent
(motor) aphasias affect anterior (pre-Rolandic) region

180
Q

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

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).

181
Q 
Which of the following is not a symptom of Gerstmann’s syndrome?
A) Agraphia
B) Acalculia
C) Alexia
D) Finger agnosia
A

C) The four components of Gerstmann’s syndrome are fi nger agnosia, acalculia, right-left
disorientation, and agraphia.

182
Q 
A 54-year-old woman experiences a left middle cerebral artery infarction. She presents with impaired comprehension, fl uent 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
A

D) Although both Wernicke’s aphasia and conduction aphasia are characterized by fl uent
speech, only Wernicke’s aphasia also includes impaired comprehen

183
Q

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

A

B) Neuropsychologists do not prescribe medication, but do conduct cognitive evaluations
and engage in cognitive remediation and psychotherapy.

184
Q 
Which of the following is not a common condition that a neuropsychologist would evaluate
or treat?
A) Dementia
B) Cerebrovascular accident (CVA)
C) Depression
D) Neuropathy
A

D) This would be the physiatrist or the neurologist; the neuropsychologist evaluates and
treats brain-behavior disorders, not disorders of peripheral nerves.

185
Q

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 6–8 hours or more
D) The evaluation includes an interview and mostly paper-and-pencil tests

A

A) Testing is paper-pencil, ranges from < 1 to 8+ hours, and is tailored to the individual
referral question

186
Q 
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
A

B) Frontotemporal dementia is actually a cortical dementia

187
Q

Which of the following dementias is characterized by fl uctuating course, extrapyramidal
features, and occasionally visual hallucinations and delusions?
A) Alzheimer’s disease
B) Frontotemporal dementia
C) Lewy body disease
D) Dementia pugilistica

A

C) Lewy body disease.

188
Q

A 55-year-old patient complains of some diffi culty 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

A

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.

189
Q 
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
A

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.

190
Q 
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

A) Alzheimer’s disease affects episodic memory.

191
Q

On testing, a 75-year-old former engineer currently has an IQ score that is 2.5 standard
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

A

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.

192
Q 
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
A

C) Driving is demanding on attention, memory, and executive functioning (sequencing,
planning, shifting, etc), but less so language

193
Q 
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
A

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

194
Q

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 specifi c job
D) Assessment of the patient’s family circumstances is necessary

A

B) Some aspects of IQ are very good predictors (e.g., mathematics and vocabulary); the
other answers are all true

195
Q

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 fi rst 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

A

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

196
Q

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
defi cits
D) Cognitive rehabilitation has a large education component

A

B) Cognitive rehabilitation strives for ecological validity. It is informed by theory,
focuses both on amelioration (through practice) and compensation, and involves much
psychoeducation

197
Q

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)

A

B) This is a primary effect; the others are secondary effects.

198
Q 
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

A) TBI commonly affects frontal, temporal, and limbic areas.

199
Q

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)

A

C) Actually, left frontal damage is typically associated with depression; the rest are true

200
Q

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

A

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.

201
Q 
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
A

D) Continually correcting patients may confuse or agitate them further; common recommendations
are to “go with” their confabulations while they are acutely agita

202
Q

Following a concussion, a player should:
A) Be evaluated the same day and not return to play
B) Return to play; he is fi ne
C) Be evaluated and, if he is fi ne, be allowed to return to play the same day
D) Be sent to the ER immediately for admission

A

A) The 2011 update of the American College of Sports Medicine’s consensus statement on
concussion explicitly states no return to play same day.

203
Q 
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
A

C) Specifi cally, sustained attention and concentrat

204
Q 
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
A

B) Visuospatial neglect is often due to right hemisphere damage

205
Q 
Which of the following syndromes means an inability to recognize or appreciate
stimuli?
A) Aphasia
B) Amnesia
C) Apraxia
D) Agnosia
A

D) Aphasia is a language disorder; amnesia is a disorder of memory; apraxia is an inability
to perform purposeful movements

206
Q

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)

A

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.

207
Q

Disorientation and transient attentional diffi culties due to infection, medications, electrolyte
imbalance, or dehydration is likely to be:
A) Delusional disorder
B) Dementia
C) Amnestic disorder
D) Delirium

A

D) By defi nition, delirium is a temporary state of mental confusion and fl uctuating consciousness,
with numerous causes; dementia requires signifi cant decrease in (usually
memory) at least two areas of cognitive functioning; amnestic disorder only involves
memory.

208
Q 
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
A

C) Simple seizures do not impair consciousness; partial seizures are isolated.

209
Q 
Generalized seizures that involve only involuntary muscle jerking are called:
A) Myoclonic
B) Tonic
C) Absence
D) Tonic–clonic
A

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

210
Q 
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
A

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.

211
Q 
A clinical feature of normal pressure hydrocephalus (NPH) is:
A) Memory impairment
B) Urinary incontinence
C) Ataxic gait
D) All of the above
A

D) Sometimes called the “3 Ws” for wet, wobbly, and wacky, NPH is characterized by
ataxic gait, urinary incontinence, and dementia.

212
Q 
Which of the following is not a clinical fi nding in Parkinson’s disease?
A) Resting tremor
B) Hallucinations
C) Festinating gait
D) Hypophonia
A

B) Hallucinations may be seen in Lewy body disease, which has extrapyramidal features;
the rest are fi ndings in Parkinson’s disease

213
Q 
“Pseudodementia” is best characterized as:
A) Malingering
B) Delirium
C) Normal aging
D) Depression
A

D) Pseudodementia, or dementia of depression, often involves impairments in attention,
memory, and processing speed, which may resemble dementia

214
Q 
92. Which of the following is a benign tumor arising from dural or arachnoid cells?
A) Glioma
B) Astrocytoma
C) Meningioma
D) Glioblastoma multiforme
A

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.

215
Q 
Ischemic strokes are caused by:
A) Aneurysm tear
B) Intracranial bleeding
C) Thrombi or emboli
D) All of the above
A

C) Thrombi or emboli involve blockage of blood vessels; the others are hemorrhagic causes
of stroke.

216
Q

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

A

B) Loss of dopaminergic neurons in the substantia nigra.

217
Q 
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
A

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.

218
Q 
Which cortical lobe contains the primary somatosensory cortex?
A) Frontal lobe
B) Temporal lobe
C) Parietal lobe
D) Occipital lobe
A

C) Specifi cally, the postcentral gyrus contains the primary somatosensory cortex

219
Q 
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
A

B) Retrograde amnesia.

220
Q

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

A

D) Grand mal, or tonic–clonic, seizures have both a tonic and clonic phase, involve convulsions,
and are often preceeded by an aura; absence spells are characteristic of petit
mal, or absence, seizures

221
Q

Damage to the right hemisphere of the brain can cause all of the following except:
A) Anosognosia
B) Inability to recognize prosody
C) Diffi culty analyzing sequences of stimuli
D) Diffi culty analyzing the gestalt of stimuli

A

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.

222
Q 
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
A

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.

223
Q 
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
A

D) Owing to long-term alcohol abuse and thiamine defi ciency, dementia and peripheral
neuropathy often result.

224
Q 
Which of the following dementias features spongiform cerebral cortex?
A) Alzheimer’s dementia
B) Creutzfeldt–Jakob disease
C) AIDS dementia
D) Wilson’s disease
A

B) Caused by a prion, Creutzfeldt-Jakob disease results in spongiform cortex (with an
appearance of “Swiss cheese”), dementia, and rapid progression to death.

225
Q 
Which is the most common cause of falls in the elderly?
A) Neuropathy
B) Normal pressure hydrocephalus
C) Medications, especially sedatives
D) TIA
A

C) Medications, especially sedatives

226
Q 
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

A) Alzheimer’s disease typically results in apathy early on; the others characteristically
(and due to subcortical involvement) involve depression

227
Q 
Compared with epidural hematomas, subdural hematomas:
A) Originate from arterial bleeding
B) May develop slowly
C) Cause severe headaches
D) Are often fatal
A

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.

228
Q 
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
A

D) Seizures, vomiting, and neck pain may not be present and do not reliably indicate the
severity of a brain injury.

229
Q 
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)
A

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 fl uid.

230
Q 
Alzheimer’s disease patients are placed in nursing homes primarily because of:
A) Wandering
B) Memory impairment
C) Incontinence
D) Hallucinations
A

A) Wandering.

231
Q 
Pseudobulbar palsy is characterized by:
A) Emotional lability
B) Dysphagia
C) Frontal damage
D) All of the above
A

D) From frontal damage, pseudobulbar palsy is due to damage to the upper motor neuron
corticobulbar tract.

232
Q

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

A

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.

233
Q 
Which behavioral problem, common after brain injury, is frequently confused with
depression?
A) Impulsivity
B) Disinhibition
C) Abulia
D) Agitation
A

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 inju

234
Q

Signifi cant 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

A

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.

235
Q 
Repeated concussions may result in:
A) Parkinson-like symptoms
B) Alzheimer-like neuropathology
C) Second impact syndrome
D) All of the above
A

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)

236
Q 
Which are the most commonly injured 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
A

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

237
Q

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

A) DAI is seen in the white matter, primarily in the corpus callosum, midbrain, pons, and
central white matter

238
Q

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

A

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

239
Q 
What is the Glasgow Coma Scale (GCS) for someone who withdraws from pain, is confused,
and opens eyes to pain?
A) 6
B) 8
C) 10
D) 12
A

C) Scoring for withdrawing from pain (without localizing) is 4, confused is 4, and eyes
opening to pain 2.

240
Q 
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
A

D) Level III 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).

241
Q 
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)
A

B) The middle meningeal artery is responsible for causing an EDH. An EDH has a biconvex
shape and is rapidly evolving

242
Q

Which of the following is not a description of a subdural hematoma (SDH)?
A) Occurs primarily in younger patients
B) Clinical fi ndings may sometimes be delayed for weeks
C) Caused by an injury to the bridging veins
D) Lentiform in shape on imaging

A

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.

243
Q 
Which of the following is true about Glasgow Coma Scale (GCS) in traumatic brain injury
(TBI)?
A) A GCS of 2 is a severe injury
B) A GCS of 8 is a moderate injury
C) A GCS of 10 is a moderate injury
D) A GCS of 12 is a mild injury
A

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.

244
Q 
What is the most common location of heterotopic ossifi cation (HO) after traumatic brain
injury (TBI)?
A) Shoulder
B) Knee
C) Hip
D) Elbow
A

C) HO occurs most frequently in the hips, followed by elbows, shoulders, and kne

245
Q 
Which is the most sensitive test used to identify early heterotopic ossifi cation (HO)?
A) X-ray
B) Serum alkaline phosphatase
C) Computed tomography (CT) scan
D) Bone scan
A

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
indicated for HO identifi cation, and serum alkaline phosphatase is a nonspecifi c/nonsensitive
test.

246
Q

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

A) The best motor GCS and the best overall GCS within the fi rst 24 hours is considered
to be the best acute predictor of outcome in TBI

247
Q

What does not describe posttraumatic 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)

A

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.

248
Q 
Which is the most commonly injured cranial nerve (CN)?
A) CN I
B) CN II
C) CN VII
D) CN VIII
A

A) The olfactory nerve (CN 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.

249
Q

How is the severity of a concussion graded?
A) Concussion grading scales, such as Cantu and Colorado Head Injury Scales
B) Presence of loss of conscious (LOC)
C) Presence of posttraumatic amnesia (PTA)
D) Severity of ongoing symptoms

A

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.

250
Q 
What is the most common symptom described after a concussion?
A) Dizziness
B) Poor sleep
C) Headache
D) Fatigue
A

C) Headaches are the most common symptom experienced after a concussion. The others
can also occur, but are not as frequent as headaches

251
Q

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

A

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 diffi culty with attention, memory,
headaches, poor mood, and overall poor general health.

252
Q

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

A

D) Agitation from a TBI is caused by confusion and inability to retain memory (posttraumatic
amnesia

253
Q

What is considered the most effective method for the prevention of heterotopic ossifi cation
(HO)?
A) Radiation of bone tissue
B) Range of motion
C) Nonsteroidal anti-infl ammatory drugs (NSAIDs)
D) Diphosphonates

A

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 signifi cantly in prevention

254
Q 
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) Indefi nitely
A

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

255
Q

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 NaCl tablets
D) Restrict oral (PO) fl uids

A

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

256
Q

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 day

A

C) RTP is a very important decision to maintain safety of athletes. RTP 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

257
Q

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

A

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 signifi cant neurological defi cits related to the expansion of
the epidural hematoma, such as midline shift and brain stem herniation

258
Q

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

A) An injury to CN III would cause ipsilateral dilation of the pupil. Normally, CN III
constricts the ipsilateral pupil with light exposure.

259
Q

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

A

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.

260
Q 
What neurotransmitter should be enhanced to improve cognitive recovery in patients
with a traumatic brain injury (TBI)?
A) Norepinephrine
B) Dopamine
C) Histamine
D) Acetylcholine
A

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.

261
Q 
The key features of cerebral palsy include all of the following except:
A) Abnormal movement and posture
B) Onset in fi rst 3 years of life
C) Nonprogressive
D) Mental retardation
A

D) Cerebral palsy is a disorder of movement and posture that occurs in fi rst 2 to 3 years of
life, usually from a single event that is nonprogressive. Mental retardation can occur as a
result of insult to the brain, but is not a key feature

262
Q 
The most likely cause of quadriplegic cerebral palsy (CP) is:
A) Prematurity (< 32 weeks)
B) Perinatal stroke
C) Hyperbilirubinemia
D) Birth asphyxia
A

D) Prematurity usually causes diplegic CP, as white matter adjacent to the ventricles is
affected. Stroke and congenital malformations more frequently cause hemiplegic CP.
Hyperbilirubinemia causes athetoid or dystonic CP. Severe anoxia causes diffuse brain
injury and hence quadriplegic CP.

263
Q

Good prognostic indications for ambulation in children with cerebral palsy (CP) include
all of the following except:
A) Independent sitting by 2 years of age
B) Fewer than three primitive refl exes by 18 months of age
C) Hemiplegic CP
D) Term birth

A

D) Term birth does not signify any specifi c insult or abnormality of movement or posture

264
Q

The American Academy of Neurology suggests screening children with cerebral palsy
(CP) for all of the following comorbidities except:
A) Mental retardation
B) Hearing and vision impairment
C) Speech and language delay
D) Oromotor dysfunction
E) Seizures

A

E) Children with CP have an increased incidence of seizures, sleep problems, and hydrocephalus,
but screening for these conditions is not recommended.

265
Q

Children with cerebral palsy (CP) are at risk for fractures and osteoporosis because of all
of the following except:
A) Malnutrition with calcium and vitamin D defi ciency
B) Immobility
C) Antiepileptic medication
D) Chronic respiratory infection

A

D) In children with cerebral palsy, immobility, malnutrition secondary to oromotor dysfunction,
and antiepileptic medications (particularly older generation medications) are
associated with decreased bone mineral density.

266
Q 
All of the oral antispasticity medications are likely to cause sedation except:
A) Baclofen
B) Diazepam
C) Dantrolene
D) Tizanidine
A

C) All of the other medications exact their effect through the central nervous system (CNS)
except for dantrolene, which works at the skeletal muscle level. Dantrolene inhibits the
release of calcium from the sarcoplasmic reticulum during excitation-contraction coupling
and suppresses the uncontrolled calcium release

267
Q 
Treatment of spasticity in cerebral palsy (CP) includes all of the following except:
A) Botulism toxin and phenol
B) Oral or intrathecal baclofen
C) Selective dorsal rhizotomy
D) Hyperbaric oxygen therapy (HBOT)
A

D) HBOT is considered an alternative therapy in patients with CP. Its primary use is in
wound care.

268
Q 
Ingestion of which of the following vitamins helps reduce the incidence of neural tube
defects?
A) Thiamine
B) Pyridoxine
C) Folic acid
D) Vitamin B12
A

C) Folic acid.

269
Q 
Neural tube defects occur between \_\_\_\_\_\_ days of gestation:
A) 7 and 18
B) 18 and 30
C) 31 and 46
D) 47 and 65
A

B) The nervous system is derived from ectoderm. The anterior neuropore closes around
23rd day of intrauterine life. The posterior neuropore closes at 26 and 27 days of intrauterine
life.

270
Q 
Environmental factors that are implicated in the development of neural tube defects
(NTDs) include:
A) Maternal diabetes mellitus
B) Folate defi ciency
C) Use of valproic acid
D) Maternal hyperthermia
E) All of the above
A

E) In addition to the above, maternal obesity, use of carbamazepine, antihistamines, and
sulfonamide medication increase the risk of NTD in women of child bearing age.

271
Q 
Prenatal tests for neural tube defects performed at 16 to 18 weeks of gestation include all
of the following except:
A) Measure serum alpha-fetoprotein
B) Acetylcholinesterase levels
C) Ultrasound of abdomen
D) Chromosomal assay
A

D) Chromosomal assay is not specifi c for the diagnosis of neural tube defects.

272
Q 
Children with meningomyelocele (MMC) have a higher incidence of:
A) Environmental allergies
B) Milk intolerance
C) Latex allergy
D) Medication allergies
A

C) Compared with the general population, children with MMC have a 20% or higher rate
of latex allergy.

273
Q 
Which of the following is often seen in children with meningomyelocele (MMC)?
A) Hydrocephalus
B) Chiari malformation
C) Neurogenic bladder
D) Precocious puberty
E) All of the above
A

E) Hydrocephalus can be seen with MMC or after closure of the defect. Leakage of cerebrospinal
fl uid stops and therefore requires shunting. Chiari malformation is a caudal
displacement of brain stem and ventricles, which can cause apnea, stridor, nystagmus,
opisthotonus, and dysphagia. Neurogenic bladder is commonly seen in patients with
MMC. Precocious puberty occurs more commonly in girls secondary to activation of the
hypothalamic–pituitary axis, probably due to hydrocephalus.

274
Q 
Children with meningomyelocele (MMC) are likely to be nonambulatory at which spinal
cord level?
A) Thoracic
B) Lumbar
C) Sacral
A

A) Generally, children with sacral level MMC are able to ambulate with or without crutches
or canes. Involvement of peroneal and foot muscles in patients with lumbar lesions will
result in limited but some ambulation with an assistive device (depending on quadriceps,
hamstrings, and hip fl exors involvement). Thoracic MMC lesions may cause total paralysis
of the lower limbs

275
Q 
Common presentations of myopathy in infants and children include all of the following
except:
A) Hypotonia
B) Delayed motor milestones
C) Feeding problem
D) Language problem
E) Abnormality of gait
A

D) Speech may be affected in patients with myopathy if the facial muscles are involved,
but language is not affected

276
Q 
Teenagers with complaints of diffi culty climbing stairs, falls, decreased endurance, and
episodic weakness are suggestive of:
A) Neuropathic etiology
B) Myopathic etiology
C) Cerebral etiology
D) Cerebellar etiology
A

B) All of the symptoms described above are common in muscle dise

277
Q

Gower’s sign is diagnostic of Duchenne muscular dystrophy.
A) True
B) False

A

B) Gower’s sign is suggestive of proximal muscle weakness, which can occur in any myopathic
process

278
Q 
Creatine kinase (CK) values in excess of 10,000 are usually seen in all of the following
except:
A) Duchenne muscular dystrophy
B) Dermatomyositis
C) Acute rhabdomyolysis
D) Congenital myopathies
A

D) Dystrophic and infl ammatory myopathies cause highly elevated CK levels. Congenital
myopathies cause mild to moderate elevations of CK

279
Q

Clinical features of peripheral vertigo include all of the following except:
A) Hearing loss
B) Post pointing and falling in the direction of disease
C) Vestibular and positional nystagmus
D) Cranial nerve dysfunction

A

D) Cranial nerve dysfunction, intact hearing, and loss of consciousness are suggestive of
central vertigo

280
Q

A Glasgow Coma Scale of 8 is suggestive of:
A) Mild injury
B) Moderate injury
C) Severe injury

A

C) The Glasgow Coma Scale examines three variables: eye opening, verbal response, and
motor abilities. Scores can range from 3 to 15. Score of 8 or less indicates a severe injury, 9
to 12 a moderate injury, and 13 to 15 a mild injury

281
Q

A 16-year-old sustains a head injury while playing football, and his amnesia resolves on
day 5 of rehabilitation. You consider this amnesia to be:
A) Mild
B) Moderate
C) Severe

A

B) Posttraumatic amnesia is considered mild if it persists less than 24 hours after the
injury. It is considered moderate if it persists between 1 and 7 days and severe if it lasts 8
days or longer

282
Q 
During neurorehabilitation, all of the following are common focuses of rehabilitation
except:
A) Tone abnormalities and spasticity
B) Deep vein thrombosis
C) Heterotopic ossifi cation
D) Chronic subdural hematoma
A

D) Chronic subdural hematomas and hydrocephalus can develop during the rehabilitation
phase, but are not focuses of therapy.

283
Q

A 9-year-old sustained C6-C7 spinal cord injury. Three months after the injury, the parents
report that his appetite is lacking and he has apathy, nausea, vomiting, and weakness. The
most likely reason for these symptoms is:
A) Hydrocephalus
B) Hypercalcemia
C) Decreased sodium
D) Depression

A

B) Hypercalcemia occurs in 25% of such patients 1 to 12 weeks after the injury and is
due to bone resorption. Calcium levels above 12 mg/dL can cause the above symptoms.
Although depression can cause apathy and loss of appetite, this combination of symptoms
including nausea and vomiting is most consistent with hypercalcemia

284
Q

Battle sign in head trauma is suggestive of:
A) Intracranial bleed
B) Diffuse axonal injury
C) Basilar skull fracture involving the temporal bone
D) Basilar skull fracture involving the orbits

A

C) Battle sign is retroauricular ecchymosis. In addition, hemotympanum and otorrhea are
suggestive of temporal bone fracture. Raccoon eyes are periorbital ecchymoses and suggest
an anterior skull base fracture.

285
Q

You are monitoring an 8-month-old (who was born preterm at 33 weeks) for developmental
delays. You are suspicious of child abuse. One of the physical signs that may confi rm
your suspicion is:
A) Bulging fontanels
B) Enlarged head circumference
C) Bruising in an unusual location such as the legs or the back
D) Retinal hemorrhage
E) All of the above

A

E) Infants with nonaccidental trauma (shaken baby syndrome) may have all of the above
signs, which should make you suspicious. CT of the head usually reveals subdural hematomas
of varying chronicity. Contusions and intracerebral hemorrhage can be seen

286
Q

Of the following types of brain injuries, which has a better prognosis for motor
recovery?
A) Diffuse axonal injury (DAI)
B) Bilateral hematomas
C) Focal contusion
D) Diffuse hypoxia secondary to head injury

A

C) In general, focal defi cits recover better than diffuse defi cits. Younger age also predicts
a better recovery

287
Q 
Which of the following can occur after moderate to severe head injury in children?
A) Executive function impairment
B) Visuomotor integration impairment
C) Memory impairment
D) All of the above
A

D) Following moderate to severe brain injuries, all of the above, including language
impairment, have been reported in various studies.

288
Q

Retinal hemorrhages are pathognomonic of child abuse.
A) True
B) False

A

B) Retinal hemorrhages can occur after hypoxic or ischemic injury, vaginal birth, side
impact car accidents, or child abuse. The sequelae can be visual impairment

289
Q

The most common type of skull fracture after a head injury is:
A) Depressed
B) Linear
C) Comminuted

A

B) Linear fracture is most common after a head injury and usually does not require neurosurgical
intervention. If the fracture crosses the suture line in infants, leptomeningeal
cyst can occur later in life

290
Q 
The most common site of spinal cord injury (SCI) in children is:
A) Thoracic
B) Lumbar
C) Cervical
D) Sacral
A

C) The most mobile portion of the spinal column is the cervical region (hence the most
vulnerable). Approximately 55% of SCI in children involve the cervical spine, 30% the
thoracic spine, and 15% the lumbar spi

291
Q 
Which condition can predispose children to cervical spinal cord injury because of atlantoaxial
dislocation?
A) Down syndrome
B) Klippel–Feil syndrome
C) Morquios syndrome
D) Achondroplasia
E) All of the above
A

E) The odontoid process helps to prevent dislocation of C1 onto C2. Aplasia of the odontoid
process can occur in mucopolysaccharidosis (Morquios syndrome) or Klippel–Feil
syndrome. In Down syndrome, congenital hypoplasia of the articulation of C1 and C2
can occur.

292
Q 
Spinal cord injury without radiographic abnormalities (SCIWORA) is most common in:
A) Infants and young children
B) Adolescents
C) Adults
D) Old age geriatric population
A

A) SCIWORA is most common in children below 8 years of age. The vertebral column
in this population has more elasticity, hence fracture and dislocation are less common.
However, myelopathy or central cord injury can occur. MRI of the spine is more sensitive
than CT or radiography to reveal SCIWORA injuries

293
Q

A 16-year-old football player suffers a T10 fracture. He is paraparetic and has no sensation
below T10. However, his proprioception, light touch, and vibration are intact.
These fi ndings are suggestive of:
A) Anterior spinal cord syndrome
B) Posterior spinal cord syndrome
C) Brown-Séquard syndrome
D) Conus medullaris syndrome

A

A) In anterior spinal cord syndrome, there is paresis and analgesia below the lesion, but
vibration and position sense are preserved as these are mediated by the posterior columns.
In Brown-Séquard syndrome, there is ipsilateral motor paralysis, loss of touch as
well as proprioception, and contralateral loss of pain and temperature below the level of
the lesion.

294
Q 
In adults, at what level does the spinal cord terminate?
A) L1
B) L3
C) L4
D) T10
A

A) The spinal cord terminates at L1 in adults and L2 in infants

295
Q

Spinal cord injuries are classifi ed by which of the following scales?
A) Glasgow Coma Scale
B) American Spinal Injury Association/International Medical Society of Paraplegia
(ASIA/IMSOP) spinal cord impairment scale
C) The Wee Functional Independence Measure Scale
D) Barthel index

A

B) ASIA/IMSOP (American Spinal Injury Association/International Medical Society of
Paraplegia) utilizes documentation of motor, sensory, and sphincter functions. Ten key
muscles are graded using the Medical Research Council (MRC) scale, and sensation is
assessed over 28 dermatomes.
The Glasgow Coma Scale is used in traumatic brain injury.
The Wee functional independence score measures self-care, mobility, cognition, and
communication in children.
The Barthel index is used to measure performance in activities of daily living following
conditions such as stroke.

296
Q 
Phrenic nerve pacing may be required with spinal cord injury at which level?
A) C3–5
B) T3–5
C) T7–8
D) T12–4
A

A) The phrenic nerve is formed from nerve roots C3–5 and supplies the diaphragm.
Patients who require permanent ventilatory support can be candidates for phrenic nerve
pacing.

297
Q 
The most common identifi able risk factor for childhood ischemic stroke is:
A) Hematological disorders
B) Congenital heart disease
C) Central nervous system infection
D) Vasculitis
A

B) All of the above are causes of stroke in children, but congenital heart disease is the most
common.

298
Q

In which type of spinal muscular atrophy (SMA) can most of the patients sit but not walk?
A) Type I
B) Type II
C) Type III

A

B) SMA type I (Werdnig–Hoffmann disease) has its onset before 6 months of age. Most
patients cannot sit, and the condition has a mortality rate of more than 90% by 3 months
of age.

299
Q 
Most children with spinal muscular atrophy (SMA) have:
A) Mental retardation
B) A single crease across their palm
C) Epilepsy
D) High cognitive function
A

D) SMA is a disease affecting the anterior horn cells (motor neurons) that causes neurogenic
atrophy of muscles. The brain is not affected. They have high cognitive abilities.
Therefore, providing them with tools for ambulation and mobility are important.
Patients with Down syndrome usually have a single crease across their palms instead of
two creases.

300
Q 
All of the following are anterior horn cell disease affecting the motor neuron except:
A) Spinal muscular atrophy
B) Botulism
C) Amyotrophic lateral sclerosis
D) Poliomyelitis
A

B) Botulism is due to toxins produced by Clostridium botulinum. These toxins block the
release of acetylcholine at the neuromuscular junction

301
Q

Lesions of the facial nerve distal to the nucleus (lower motor neuron involvement) result
in:
A) Paralysis of the lower facial muscles
B) Paralysis of the upper (forehead) and lower facial muscles
C) Paralysis of the lower facial muscles with sparing of upper facial muscles (forehead)
D) Paralysis of upper and lower facial muscles as well as the muscles of mastication

A

B) When forehead muscles are involved in facial nerve palsy, it is indicative of a lower
motor neuron lesion distal to the nucleus. The muscles of mastication are supplied by
cranial nerve V. Lower facial muscles are involved in both upper and lower motor neuron
facial palsies. Bilateral upper motor neuron innervation of the upper facial muscles leads
to sparing of these muscles in an upper motor neuron lesio

302
Q 
In Erb’s palsy, all of the following muscles are paralyzed except:
A) Deltoid
B) Bicep brachialis
C) Supinator
D) Intrinsic muscles of hand
A

D) Erb’s palsy involves injury to the upper trunk of the brachial plexus. Intrinsic muscles
of hand are supplied by the ulnar nerve, which is supplied by C8-T1. In Erb’s palsy, the
arm is held in adduction and internal rotation at the shoulder, extension at the elbow,
pronation of the forearm, and fl exion at the wrist.

303
Q

The predominant type of neuropathy in Guillain–Barré syndrome (acute infl ammatory
demyelinating polyradiculoneuropathy) is:
A) Motor
B) Sensory
C) Ataxia
D) Autonomic

A

A) Although all of the above can be seen, motor involvement predominates. Campylobacter
jejuni, Mycoplasma pneumoniae, cytomegalovirus, and Epstein–Barr virus are common
known causes.

304
Q

A 9-year-old girl with a history of diffi culty writing and frequent tripping is referred to
your offi ce for bracing. You notice stork legs, pes cavus, and hammer toes. The ankle
tendon refl ex is lost. Her mother had similar problems as a child. The above fi ndings are
suggestive of:
A) Spinal muscular atrophy
B) Charcot–Marie–Tooth disease (CMT)
C) Friedreich’s ataxia
D) Congenital myopathy

A

B) Hereditary sensory-motor neuropathy (HSMN) type I and II are also known as CMT.
It is a progressive motor and sensory demyelinating neuropathy (mainly autosomal
dominant). The distal muscles of the lower extremity are affected more than the upper
extremities.
Spinal muscular atrophy and Friedreich’s ataxia are autosomal recessive conditions.

305
Q

All of the following are true in cases of myasthenia gravis (MG) except:
A) It is an autoimmune disease
B) It affects presynaptic receptors on the neuromuscular junction
C) On repetitive nerve stimulation tests, there is a decremental response
D) It can be diagnosed by edrophonium (Tensilon) test

A

B) MG affects postsynaptic receptors of the myoneural junction. Transmission of acetylcholine
is blocked. Predominant clinical fi ndings include fatigability of ocular, bulbar, and
skeletal muscles. This can result in ptosis, diplopia, slurred speech, diffi culty with chewing,
respiratory problems, and weakness (proximal more than distal).

306
Q 
Botulism is caused by:
A) Gram-positive streptococci
B) Gram-positive Clostridium
C) Gram-negative Escherichia coli
D) Gram-negative Shigella
A

B) Botulism is due to toxins produced by Clostridium botulinum. These toxins block the
release of acetylcholine at the neuromuscular junction

307
Q

Duchenne muscular dystrophy is a progressive hereditary disease with a predictable
course. However, with corticosteroids and physical medicine and rehabilitation (PM&R)
treatment, the disease course can be:
A) Modifi ed
B) Cured
C) Unaffected
D) Halted

A

A) Corticosteroids and PM&R can help prolong independence by several years, hence
modifying the disease course. No defi nitive cure is available yet.

308
Q 
Duchenne muscular dystrophy (DMD) can affect all of the following except:
A) Pulmonary system
B) Intelligence quotient (IQ)
C) Gastrointestinal (GI) system
D) Cardiac system
E) All of the above may be affected
A

E) DMD is a multisystem disease affecting:
1) Musculoskeletal system causing weakness and scoliosis
2) Pulmonary system affecting respiratory function and sleep problem (due to weakness
of intercostal and diaphragmatic muscles)
3) Cardiac system causing cardiomyopathy
4) IQ and causing mental retardation
5) GI system causing problems with megacolon and malabsorption

309
Q

A 4-year-old boy presents with a history of diffi culty climbing stairs, falling, waddling
gait, and large calf muscles. You suspect Duchenne muscular dystrophy (DMD). Of the
following, the easiest and best confi rmatory diagnosis test is:
A) Serum level of creatine kinase (CK)
B) Polymerase chain reaction (PCR) genetic test
C) Muscle biopsy
D) Family history

A

B) CK may be increased by 10,000 times, but not diagnostic of DMD. A muscle
biopsy is diagnostic, but invasive. The PCR genetic test is a simple blood test that is
confi rmatory.

310
Q

An 8-year-old with a diagnosis of Duchenne muscular dystrophy (DMD) is referred for
exercise. All of the following are allowed except:
A) Swimming
B) Daily walking
C) Weight lifting
D) Playing Wii

A

C) Children with DMD should avoid high-resistance exercises such as weight lifting.
Keeping an active life with sustained nonresistive activities such as swimming is
best.

311
Q

A 9-year-old suffered a traumatic brain injury (TBI). He is noted to be fi dgety and have
piano playing movements of the fi ngers, and has diffi culty maintaining tongue protrusion.
These symptoms are not seen when he is sleeping. This describes what type of
movements?
A) Chorea
B) Tics
C) Dystonia
D) Tremors

A

A) Chorea describes brief, random, repetitive, rapid, purposeless movements. Dystonia
is a repetitive, sustained abnormal posture that typically has a twisting quality. Tics are
stereotyped, repetitive nonrhythmic movements that mainly involve the head and upper
body. Tremor is a rhythmic oscillation.

312
Q

You are providing rehabilitation to a 12-year-old spinal cord injured boy. He has been
complaining of intermittent headaches with nasal congestion and nausea. He perspires
profusely on his face and neck. His blood pressure is elevated intermittently. The most
likely level of his spinal cord injury is:
A) T6
B) T12
C) L4

A

A) This patient has an acute and potentially life-threatening syndrome called autonomic
dysrefl exia. This can occur with complete spinal cord injuries at the T6 level or above and
is due to imbalanced sympathetic discharges of the splanchnic outfl ow

313
Q 
In the child’s early years, all of the following are important parameters to monitor
except:
A) Head circumference
B) Weight
C) Height
D) Body Mass Index
A

D) Head circumference, height, and weight are all important parameters that must be
closely monitored in a child’s early years. BMI is not routinely monitored.

314
Q 
A child should be able to maintain its head in the midline position by what age?
A) 2 months
B) 3 months
C) 4 months
D) 5 months
A

A) A child should be able to maintain its head in the midline position at 2 months of age.
By 3 months, it should be able to prone prop on extended elbows. At 4 months, it can roll
prone to supine, while at 5 months, it should be able to roll supine to prone.

315
Q 
A child should be able to maintain its head in the midline position by what age?
A) 2 months
B) 3 months
C) 4 months
D) 5 months
A

D) A child should be able to pivot circles in prone at 5 months of age. It can maintain their
head in the midline position at 2 months of age. By 3 months, it should be able to prone
prop on extended elbows. At 4 months, it can roll prone to supine

316
Q 
You observe a child that is able to crawl on its hands and knees (“creeps”). At what age
should this milestone be met?
A) 6 months
B) 9 months
C) 10 months
D) 12 months
A

B) A child “creeps” at 9 months. They can pull to stand through half-kneel at 10 months,
while independently ambulating at 1 year of age. Sitting with a straight back occurs at 6
months.

317
Q

You observe a child that is able to independently ambulate as well as come to stand independently.
However, you note they cannot go up and down stairs. Approximately how
old would you expect this child to be?
A) 12 months
B) 15 months
C) 18 months
D) 24 months

A

C) This child is 18 months old. At this point, it is unlikely they would be able to navigate
steps.

318
Q

A friend is telling you of his little girl who just celebrated her third birthday. Which of the
following do you not expect her to be able to complete?
A) Up and down stairs with hands on rail
B) Jumps clearing ground and lands on feet together
C) Walks down stairs alternating feet
D) Pedals tricycle

A

C) She would be able to complete all of the following with the exception of walking down
stairs alternating feet. This is typically accomplished by the age of 4

319
Q

You are caring for a child with a known central nervous system (CNS) lesion. His upper
extremities are characteristically kept in which position?
A) Shoulder adduction, fl exion, and internal rotation with elbow fl exion, wrist pronation
and fl exion, and fi nger and thumb fl exion
B) Shoulder abduction, fl exion, and external rotation with elbow fl exion, wrist pronation
and fl exion, and fi nger and thumb fl exion
C) Shoulder adduction, extension, and internal rotation with elbow fl exion, wrist supination
and fl exion, and fi nger and thumb fl exion
D) Shoulder abduction, fl exion, and internal rotation with elbow extension, wrist pronation
and fl exion, and fi nger and thumb extension

A

A) Full fl exor pattern is commonly seen in the upper extremity of children with CNS
lesions. Upper extremity fl exor patterns include shoulder adduction, fl exion, and internal
rotation with elbow fl exion, wrist pronation and fl exion, and fi nger and thumb fl exion.
Extensor patterns are typically seen in the lower extremities

320
Q

You are caring for a child with a known central nervous system (CNS) lesion. Her lower
extremities are characteristically kept in which position?
A) Hip abduction, extension, and internal rotation, along with knee fl exion, internal tibial
rotation, and equinovarus foot posturing
B) Hip adduction, extension, and internal rotation, along with knee extension, internal
tibial rotation, and equinovarus foot posturing
C) Hip adduction, fl exion, and internal rotation, along with knee fl exion, internal tibial
rotation, and equinovarus foot posturing
D) Hip adduction, extension, and external rotation, along with knee extension, external
tibial rotation, and equinovarus foot posturing

A

B) Extensor patterns are usually seen in the lower extremity of children with CNS lesions.
The extension posture of the lower limb includes hip adduction, extension, and internal
rotation, along with knee extension, internal tibial rotation, and equinovarus foot posturing.
Flexor patterns are seen in the upper extremities. This includes shoulder adduction,
fl exion, and internal rotation with elbow fl exion, wrist pronation and fl exion, and fi nger
and thumb fl exion.

321
Q

With the asymmetric tonic neck refl ex (ATNR), lateral rotation of the head on the trunk
produces which of the following?
A) Flexion in the upper and the lower limbs on the nasal side, and extension of both limbs
on the occipital side
B) Flexion in the upper and the lower limbs on the nasal side, and fl exion of both limbs
on the occipital side
C) Extension in the upper and the lower limbs on the nasal side, and fl exion of both limbs
on the occipital side
D) Extension in the upper and the lower limbs on the nasal side, and extension of both
limbs on the occipital side

A

C) This is the classical fencer’s posture of extension in the upper and the lower limbs on
the nasal side, and fl exion of both limbs on the occipital sid

322
Q

Which best describes the symmetric tonic neck refl ex (STNR)?
A) Flexion of the neck facilitates extension in the upper limbs and extension of the lower
limbs. Extension of the neck facilitates fl exion in the upper limbs and fl exion of the
lower limbs
B) Flexion of the neck facilitates extension in the upper limbs and fl exion of the lower
limbs. Extension of the neck facilitates fl exion in the upper limbs and extension of the
lower limbs
C) Flexion of the neck facilitates fl exion in the upper limbs and extension of the lower
limbs. Extension of the neck facilitates extension in the upper limbs and fl exion of the
lower limbs
D) Flexion of the neck facilitates fl exion in the upper limbs and extension of the lower
limbs. Extension of the neck facilitates extension in the upper limbs and fl exion of the
lower limbs

A

D) The STNR describes the effects of fl exing and extending the head. On fl exion of the
neck, fl exion in the upper limbs and extension of the lower limbs is observed. On extension
of the neck, the opposite pattern will be seen

323
Q 
By what age should the palmar grasp refl ex disappear?
A) 2 months
B) 4 months
C) 6 months
D) 12 months
A

C) The palmar grasp refl ex is seen when an object is placed in the infant’s hand and strokes
their palm. The fi ngers will close and they will grasp it. It is seen initially at birth and
should disappear by 6 months of age.

324
Q 
All of the following are proven teratogens except:
A) Rubella virus
B) Rubeolla virus
C) Cytomegalovirus
D) Toxoplasmosis
A

B) Exposure to potential teratogens increases the chances of malformations in the fetus. Of
those listed, the only one not proven to be teratogenic is Rubeolla virus

325
Q

An infant with features of upward slant of palpebral fi ssures, low set ears, prominent
occiput, hypoplastic fi nger nails, and short sternum is most consistent with which chromosomal
syndrome?
A) Trisomy 18 (Edwards syndrome)
B) 45, X (Turner syndrome)
C) Trisomy 13 (Patau syndrome)
D) Trisomy 21 (Down syndrome)

A

D) The above clinical features all describe someone with Down syndrome or trisomy
21. Turner syndrome is characterized by being a female of short stature with a webbed
neck, a broad “shield” chest, and wide-set nipples. In trisomy 18, the infant suffers from
intrauterine growth retardation (IUGR), small mouth, and rocker-bottom feet.

326
Q

An infant with features of intrauterine growth retardation (IUGR), small mouth, low set
abnormal ears, spasticity, and rocker-bottom feet is most consistent with which chromosomal
syndrome?
A) Trisomy 18 (Edwards syndrome)
B) 45, X (Turner syndrome)
C) Trisomy 13 (Patau syndrome)
D) Trisomy 21 (Down syndrome)

A

A) The above clinical features all describe someone with Edwards syndrome or trisomy
18. Turner syndrome is characterized by being a female of short stature with a webbed
neck, a broad “shield” chest, and wide-set nipples. In trisomy 21, the infant presents with
the following features: upward slant of palpebral fi ssures, low set auricles, prominent
occiput, hypoplastic fi nger nails, and short sternum. Patau syndrome, trisomy 13, is characterized
by intrauterine growth retardation, coloboma (a gap in part of the structure) of
the iris, cleft lip and palate, and urinary tract abnormalities.

327
Q 
What is the most common congenital limb defi ciency?
A) Left terminal transradial
B) Left transhumeral
C) Right terminal transradial
D) Right transhumeral
A

A) The most common congenital limb defi ciency is a left terminal transradial defi ciency.

328
Q

Around what age should the fi rst prosthetic fi tting for a unilateral defi ciency occur?
A) 3 to 4 months
B) 6 to 7 months
C) When the child begins to walk
D) When the child is able to navigate stairs

A

B) At around 6 to 7 months, a normally developing child should achieve sitting balance. It
is at this time they should undergo the fi rst fi tting for a unilateral device. A device with a
more sophisticated terminal device is provided at around 11 to 13 months when the child
begins to walk.

329
Q 
What is the most common congenital lower limb defi ciency?
A) Unilateral partial tibial defi ciency
B) Fibular longitudinal defi ciency
C) Partial proximal femoral defi ciency
D) Bilateral partial tibial defi cienc
A

B) Fibula hemimelia is the most common congenital lower limb defi ciency. One-fourth of
the time, this defi ciency occurs bilaterally

330
Q

Each of the following is true of tibia vara (Blount’s disease) except?
A) Bowing of the proximal tibia is a result of abnormal function of the medial portion of
the proximal tibial growth plate
B) This disease is found most commonly in obese children who walk at 9 to 10 months
C) It is more common in Caucasians than other racial groups
D) Treatment is usually surgical, involving osteotomy of the proximal tibia and fi bula

A

C) Blount’s disease, or tibia vara, is most common in children of African American race.
As such, it should be expected in all children in this population who suffer from persistent
tibial bowing past the age of 2.

331
Q 
The most common cause of congenital torticollis is fi brosis of which muscle?
A) Trapezius
B) Levator scapulae
C) Sternocleidomastoid (SCM)
D) Scalenes
A

C) The most common cause of congenital torticollis is fi brosis of the SCM

332
Q

A 5-year-old child is being lifted by the hand over a curb while crossing the street.
Suddenly, the child experiences exquisite pain and refuses to move the affected arm. This
child has most likely suffered a subluxation of which bone?
A) Ulna
B) Radius
C) Humerus
D) Scaphoid

A

B) In this situation described, the child is most at risk for subluxation of the radial head
and neck distal to the annular ligament. This is referred to as nursemaid’s elbow.

333
Q

What is the most common cause of limping and pain in the hip of children?
A) Slipped capital femoral epiphysis (SCFE)
B) Trochanteric bursitis
C) Legg–Calve–Perthes disease
D) Transient toxic synovitis

A

D) Transient toxic synovitis is the most common cause of limping and hip pain in children.
SCFE is commonly seen in preadolescent-adolescent obese boys and is a separation
of the proximal femoral epiphysis through the growth plate. Trochanteric bursitis is not
commonly seen in children. In Legg–Calve–Perthes disease, there is avascular necrosis at
the femoral head. It is seen in children age 4 to 10 who have pain in the groin that radiates
to the anterior/medial thigh toward the knee

334
Q 
What is the most common connective tissue disease seen in children?
A) Ankylosing spondylitis
B) Juvenile rheumatoid arthritis (JRA)
C) Reactive arthritis
D) Systemic lupus erythematosus (SLE)
A

B) JRA is the most common connective tissue disease in children. A diagnosis of JRA is
made in the presence of arthritis lasting greater than or equal to 6 weeks with an onset less
than 16 years of age. The incidence is 13.9 per 100,000 per year, and the etiology remains
unknown.

335
Q 
There are three different types of hemophilia. Which of the following is the hallmark of
this disease?
A) Hemarthrosis
B) Spondylosis
C) Retinal hemorrhages
D) Hematuria
A

A) Hemarthrosis is the hallmark of hemophilia. There are three different types of hemophilia
(A, B, C), which are defi ciencies of factor VIII, factor IX, and factor XI, respectively.
Hemarthrosis is defi ned as bleeding into the joints causing pain, swelling, and limited
joint movement.

336
Q 
The majority of cerebral palsy (CP) cases occur during which period?
A) Prenatal
B) Perinatal
C) Infancy
D) Childhood
A

A) Approximately 70% to 80% of cerebral palsy cases occur during the prenatal period.
Some of the risk factors for CP include prenatal intracranial hemorrhage, placental complications,
gestational toxins, or teratogenic agents

337
Q 
Which is the most common type of cerebral palsy (CP)?
A) Spastic quadriplegia
B) Dyskinetic CP
C) Spastic diplegia
D) Mixed CP
A

C) Spastic diplegia is the most common type of CP. Approximately 75% of those with CP
is of this type. There is greater involvement of the lower extremities in comparison with
the upper extremities of those with spastic diplegia. Dyskinetic and mixed CP, which
exhibits patterns of both spastic and dyskinetic CP, make up approximately 25% of those
with CP.

338
Q 
Which of the following is not a type of dyskinetic cerebral palsy (CP)?
A) Dystonia
B) Ataxia
C) Athetosis
D) Hemiballismus
A

D) Each is a characteristic type of CP except hemiballismus. Dystonia is characterized by
slow rhythmic movements with tone changes generally found in the trunk and extremities,
whereas ataxic-type involves uncoordinated movements associated with nystagmus,
dysmetria, and a wide-based gait. Slow writhing involuntary movements, particularly in
the distal extremities, describe athetosis

339
Q 
In a child diagnosed with cerebral palsy (CP), independent sitting by what age is a good
prognostic indicator for ambulation?
A) 6 months
B) 12 months
C) 24 months
D) 36 months
A

C) As described by Molnar, if independent sitting occurs by age two, prognosis for ambulation
is good. “Will my child walk?” is usually the most frequent question asked by the
parent of a newly diagnosed CP child.

340
Q 
Arnold–Chiari malformation complicated by hydrocephalus occurs most commonly in
which type of spina bifi da?
A) Spina bifi da occulta
B) Meningocele
C) Myelomeningocele
D) Myelocele
A

C) This malformation is seen in more than 90% of the cases with myelomeningocele.
The protruding sac contains meninges, spinal cord, and spinal fl uid. Spina bifi da
occulta results when there is failure of fusion of the posterior elements of the vertebrae.
Meningocele is characterized by a protruding sac, which contains meninges and spinal
fl uid, whereas myelocele is the presence of a cystic cavity in front of the anterior wall of
the spinal cord.

341
Q

Which type of spinal muscular atrophy (SMA) is associated with good long-term
survival?
A) Type I (Werdnig–Hoffmann disease)
B) Type II
C) Type III (Kugelberg–Welander syndrome)
D) Type IV

A

C) Type III, or Kugelberg–Welander syndrome, is associated with good long-term survival
but dependent on respiratory function. It is an autosomal recessive disorder characterized
by proximal weakness predominantly of the legs. Fasciculations are common, and
scoliosis is frequent

342
Q

A 12-year-old boy presents with waddling gait and diffi culty in climbing stairs. On examination,
he demonstrates signifi cant weakness in his proximal lower extremity muscles,
especially the quadriceps, and some calf hypertrophy. What is the genetic inheritance of
this disorder?
A) Autosomal dominant
B) X-linked recessive
C) Autosomal recessive
D) There is no genetic linkage

A

B) The abnormal gene for Duchenne muscular dystrophy (DMD) and Becker muscular
dystrophy (BMD) is on the short arm of the X chromosome at position Xp21. Both DMD
and BMD are inherited X-linked recessive diseases affecting primarily skeletal muscle and
myocardium.

343
Q 
The pathophysiology of Duchenne muscular dystrophy (DMD) involves:
A) Merosin defi ciency
B) Abnormally low levels of dysfertin
C) Absence of dystrophin
D) Mutations of sarcoglycan
A

C) The absence of dystrophin is the basis of the pathophysiology of DMD. Most of the
genes in the affected area of the X chromosome encode for components of the dystrophinglycoprotein
complex

344
Q

Which of the following complications is common in both Duchenne muscular dystrophy
(DMD) and Becker muscular dystrophy (BMD)?
A) Cardiomyopathy
B) Large bowel obstruction
C) Ureteral refl ux
D) Obstructive respiratory disease

A

A) Signifi cant cardiac involvement occurs in both DMD and BMD

345
Q 
Which of the following muscular dystrophies is usually associated with a markedly
reduced lifespan?
A) Facioscapulohumeral dystrophy (FSHD)
B) Becker muscular dystrophy (BMD)
C) Limb girdle dystrophy
D) Duchenne muscular dystrophy (DMD)
A

D) Although facioscapulohumeral dystrophy can be quite heterogeneous in its clinical
presentation and course, it is typically only slowly progressive. The same is true of BMD
and limb girdle dystrophy. Only DMD is usually associated with a markedly shortened
life expectancy. DMD is a progressive myopathy that is universally fatal, with death usually
occurring from respiratory or cardiac complications

346
Q 
Which of the following is consistent with myopathy?
A) Brisk muscle stretch refl exes
B) Weakness and atrophy
C) Sensory loss
D) Urinary retention
A

B) Although the various forms of myopathy are clinically dissimilar, they all involve loss
of muscle strength, causing loss of refl exes rather than hyperrefl exia, along with weakness
and atrophy. Sensation remains intact, as only muscle fi bers are affected. Urinary retention
is not part of these diseases, and the sensory nerves remain completely intact

347
Q

A 12-year-old girl with limb girdle muscular dystrophy is having trouble keeping up in
school. She cannot ambulate fast enough to get to her next class on time. She is having
diffi culty writing her examination papers and fi nishing on time. The ultimate cause of the
majority of her clinical problems is:
A) Skeletal muscle weakness
B) Spasticity
C) Cardiomyopathy
D) Joint contracture

A

A) The vast majority of clinical problems encountered in neuromuscular disease can be
directly linked to skeletal muscle weakness. Despite other comorbid conditions, studies
have indicated that what causes most of the functional problems and impairs quality of
life for people with neuromuscular disease is muscle weakness

348
Q

A physiatrist evaluating patients in a muscular dystrophy clinic wants to start the boys
with Duchenne muscular dystrophy (DMD) on an exercise program. Knowing that dystrophin-
defi cient muscle is very susceptible to exercise-induced muscle injury, the best
way to begin the program would be:
A) To allow the boys to play as hard and as long as they want, stopping only when they
are too tired to play any more
B) To have the boys exercise in a playful manner but with the supervision of a physical
therapist
C) To have the boys participate in the standard school physical program
D) The exercise program is not a good idea, as it could make the disease progress faster
stopping only when they are too tired to play anymore

A

B) Intervention with submaximal exercise training in neuromuscular disease has been
shown to improve physical performance and increase muscle effi ciency while reducing
fatigue and improving quality of life. However, in children, the exercise program must be
worked into an enjoyable, playful setting. Supervision is necessary to make sure that the
children do not play to exhaustion, which could produce muscle damage and overwork
weakness.

349
Q 
Which of the following is the major factor limiting ambulation in Duchenne muscular
dystrophy (DMD)?
A) Joint contracture
B) Weakness
C) Scoliosis
D) Restrictive lung disease
A

C) Transition to a wheelchair, because it leads to prolonged static positioning of
the limbs, is the largest contributor to the formation of joint contractures in DMD.
Although poor nutrition and obesity might lead to wheelchair dependence sooner,
they are not primary causes of joint contractures. Muscular atrophy is not directly
related to contractures, although the pseudohypertrophy seen in the calf muscles of
boys with DMD is associated with tightness in the heel cord and ankle plantar fl exion
contractures.

350
Q 
Restrictive lung disease is common in severe myopathies and is due primarily to:
A) Recurrent pneumonia
B) Obesity
C) Respiratory muscle weakness
D) Intrinsic lung damage
A

C) Respiratory impairment in the setting of a myopathy is due to weakness of the diaphragm,
chest, and abdominal musculature. The other listed factors have not been shown
to play a signifi cant role in restrictive lung dise

351
Q

Which gait characteristic is least likely to be associated with muscular dystrophy or
myopathy?
A) Toe walking in a child
B) Ipsilateral foot drop
C) Gluteus medius gait
D) Increase in lumbar lordosis with standing or ambulation

A

B) The gait characteristic least likely to be associated with a myopathic process is an ipsilateral
foot drop. In general, muscular dystrophy and the myopathic process typically
affect the proximal more than the distal muscles. Because of hip abduction weakness,
gluteus medius gait or a Trendelenburg gait can be noted with myopathic disorders. A
child presenting with toe walking should be carefully evaluated for a neuromuscular
disorder. In muscular dystrophy with hip extensor weakness, the stability of the hip can
be maintained by lumbar lordosis, which places the center of gravity line posterior to the
hip joint.

352
Q

The laboratory serum creatine kinase level would most likely be highest in which of the
following?
A) A 5-year-old boy with Becker muscular dystrophy (BMD)
B) A 20-year-old man with BMD
C) A 5-year-old boy with Duchenne muscular dystrophy (DMD)
D) A 20-year-old man with DMD

A

C) A normal serum creatine kinase value essentially helps to exclude either BMD or
DMD. Higher creatine kinase values are noted in the early disease stages and tend to
decrease over time with loss of muscle fi bers. DMD children can present with a signifi -
cantly elevated creatine kinase value, typically in the range of 20,000 international units/
liter or greater, and is usually higher than in BMD.

353
Q

Clinically, what criterion can be used to differentiate between Duchenne muscular dystrophy
(DMD) and Becker muscular dystrophy (BMD)?
A) Utilization of Gower’s maneuver
B) The ability to ambulate past the late teenage years
C) Pseudohypertrophy of the calves
D) Neck fl exor weakness

A

B) The most useful clinical criterion to distinguish BMD from DMD is the continued
ability of the patient to walk into the late teenage years. Those with BMD will typically
remain ambulatory beyond 16 years of age, whereas even the outlier DMD patients generally
stop ambulating between 13 and 16 years of age. Gower’s maneuver, pseudohypertrophy
of the calves, and neck fl exor weakness can be seen in both BMD and DMD
and are not useful in distinguishing the two diagnose

354
Q

In a patient recently diagnosed with myotonic muscular dystrophy (MMD), all of the following
are reasonable follow-up evaluations related to the diagnosis except:
A) A check for insulin insensitivity and the presence of diabetes
B) An electrocardiogram (ECG) evaluation for possible conduction abnormalities
C) An ophthalmologic evaluation for cataracts
D) An imaging study of the kidneys for stone

A 
D) Myotonic muscular dystrophy affects skeletal muscle, smooth muscle, myocardium,
brain, and ocular structures. Associated fi ndings include frontal pattern baldness,
gonadal atrophy (in males), cataracts, insulin insensitivity, and cardiac dysrhythmias.
355
Q 
The incidence of cerebral palsy is:
A) 1 to 2.3 per 1,000 live births
B) 10 to 23 per 1,000 live births
C) 8 per 1,000 live births
D) 0.1 to 0.23 per 1,000 live births
A

A) With improvements in obstetric care and the increased survival of premature infants,
the incidence of cerebral palsy has remained the same over the past several decades
(about 1–2.3 per 1,000 live births).

356
Q

Causes of cerebral palsy include all the following except:
A) Toxoplasmosis, other agents, rubella, cytomegalovirus infection, herpes simplex
(TORCH) infection during pregnancy
B) Trauma to the child by age 2
C) Infection of the brain and/or meninges by age 2
D) Progressive lipid storage disease

A

D) Cerebral palsy is by defi nition due to a nonprogressive brain insult.

357
Q

Risk factors for cerebral palsy include all the following except:
A) Extreme or very low birth weight, or prematurity
B) Multiple gestation pregnancy
C) Chorioamnionitis
D) First delivery for mother

A

D) Obstetric care has improved, but other causes of cerebral palsy have increased, such
as prematurity and the incidence of multiple gestation pregnancy. Chorioamnionitis is
now recognized as a risk factor for cerebral p

358
Q 
What percentage of cases of cerebral palsy are found to be due to complications of childbirth
or birth asphyxia?
A) 1% to 2%
B) 5 % to 10%
C) 30% to 50%
D) 50% to 75%
A

B) About 5% to 10% of cases of cerebral palsy are due to complications of childbirth or
birth asphyxia

359
Q

Gastrointestinal symptoms in patients with cerebral palsy include all the following
except:
A) Gastroesophageal refl ux
B) Diffi culty coordinating swallow or dysphagia
C) Constipation
D) Poor pancreatic enzyme secretion

A

D) Motor function of the swallowing muscles and the bowel is affected by cerebral palsy.
Pancreatic enzyme secretion is affected in children with cystic fi brosis.

360
Q

Which of the following statements is not true?
A) Under nutrition is a goal in the management of cerebral palsy
B) Triceps skin fold helps determine nutritional status in cerebral palsy
C) Poor nutritional intake is associated with decreased community participation
D) Poor swallow, refl ux, and constipation contribute to poor nutrition in cerebral pa

A

A) Appropriate nutrition is needed in children with cerebral palsy to maximize brain,
muscle, and bone development. Undernourished children are at risk for multiple health
problems, which may result in poor community participation

361
Q 
Seizures occur in what percentage of children with cerebral palsy?
A) 10%
B) 30%
C) 50%
D) 90%
A

B) Seizures occur in about 30% of children with cerebral palsy.

362
Q 
The most common type of abuse in children with disabilities is:
A) Verbal abuse
B) Neglect
C) Physical abuse
D) Financial abuse
A

B) Although any type of abuse can occur, neglect is the most common type of abuse in
children with disabilities

363
Q 
A child with cerebral palsy who is likely to walk in the future should have at least what
skill by age 2?
A) Smiling
B) Rolling
C) Sitting
D) Cruising
A

C) Patients with cerebral palsy who are able to sit by age 2 have a good prognosis for
future ambulation

364
Q 
Which sport is not recommended for children with cerebral palsy?
A) Swimming
B) Adaptive horseback riding
C) Weight lifting
D) None of the above
A

D) Sports are a key component of a healthy lifestyle for children, including those with
cerebral palsy. Damiano’s study refuted that weight lifting is contraindicated in cerebral
palsy.

365
Q 
In patients with cerebral palsy, precautions for therapeutic involvement:
A) Are important for tracking severity
B) Defi ne safe limits of treatment
C) Determine location of therapy
D) Reduce parent interactions
A

B) The American Academy of Pediatrics policy statement on prescribing therapies states
that safety limits should be defi ned.

366
Q

Children with cerebral palsy should be referred to therapy:
A) When they begin to show signs of walking
B) When they display limitations in fi ne motor skills
C) Only after the diagnosis is confi rmed
D) Even if the diagnosis is not established and abnormal muscle tone exists

A

D) Early identifi cation of abnormal tone and motor development may precede diagnosis,
but early intervention treatment should be instituted.

367
Q

When parental involvement in children with cerebral palsy is high:
A) Children are more dependent
B) Therapy is less important for function
C) Compliance at home is improved
D) Leisure time is reduced

A

C) When parents are involved in the care of children with cerebral palsy, the compliance
for medications and exercise in the home is improved

368
Q

In patients with cerebral palsy, the use of augmentative communication:
A) Enhances communication
B) Creates diffi culty in classroom activities
C) Decreases parent interaction by speech
D) Meets all the communication needs of the child

A

A) Augmentative communication is important in patients with cerebral palsy who have
diffi culty communicating. This has been shown to improve all communication efforts
and has not been shown to create diffi culty in the classroom or decrease parent interaction.
It may not, however, meet all of the communication needs of the child

369
Q 
Indications for botulinum toxin in children with cerebral palsy include all of the following
except:
A) Thumb in palm deformity
B) Dynamic equinus during swing phase
C) Fixed knee fl exion contracture
D) Focal dystonia
A

C) A fi xed contracture is not an indication for treatment with botulinum toxin A. All of
the other choices relate to increased or abnormal muscle tone and may be relieved (at
least partially) by botulinum toxin

370
Q

Comparing phenol with botulinum toxin in the treatment of spasticity for children with
cerebral palsy, which of the following is true?
A) Phenol is quicker and has fewer side effects
B) Phenol is a less expensive option but more diffi cult technically to perform
C) Botulinum toxin is longer lasting but less predictable
D) Botulinum toxin has been subjected to fewer studies than phenol has

A

B) Although phenol injections may last longer than botulinum toxin injections, they are
more diffi cult injections to perform and are associated with more side effects

371
Q

In patients with cerebral palsy, the ideal candidate for a selective posterior/dorsal rhizotomy
is:
A) An adolescent who is marginally ambulatory
B) A child with mixed tone disorder
C) A child with spasticity who has no orthopedic deformities
D) A child with knee fl exion contractures but severe spasticity

A

C) Patients with spasticity but no orthopedic deformities have the best outcome after
selective posterior/dorsal rhizotomy.

372
Q

Intrathecal baclofen is a treatment that is recommended for:
A) A child with mixed tone abnormalities who has failed to respond adequately to oral
medications
B) A child with mild spastic diplegia
C) A child with mental retardation, seizure disorder, and orthopedic deformity
D) A child with severe spasticity and parents with a known history of noncompliance

A

A) Intrathecal baclofen should be considered for a child with signifi cant spasticity
or dystonia interfering with function and who has had an adequate trial of oral
medications

373
Q

Adductor myotomies should:
A) Be considered for the older child with a dislocated hip and pain
B) Be considered early in severe spasticity to prevent dislocation
C) Be delayed until 6 years
D) None of the above

A

B) Patients with severe spasticity are at risk for hip dislocation. Adductor myotomies
have been shown to decrease that risk if performed early enough.

374
Q

When advising families with children with chronic illness and disability, practitioners
should:
A) Remain dogmatic on traditional therapies alone
B) Allow for open discussion of benefi ts only
C) Allow for a risk-benefi t discussion
D) Understand that families are angry and need to act out with defi ance

A

C) According to the American Academy of Pediatrics policy statement on complementary
and alternative medicine, families that request complementary treatments should
engage in an open, risk-benefi t discussion

375
Q 
What percentage of the population age 1 to 10 has spina bifi da occulta?
A) 1%
B) 8%
C) 17%
D) 30%
A

C) Studies show a 17% incidence of spina bifi da occulta in normal individuals age 1 to
10, with no neurologic involvement and incomplete closure of the posterior elements of
the spine.

376
Q 
What is the incidence of myelomeningocele (MMC) in the United States?
A) 2 per 1,000 live births
B) 20 per 1,000 live births
C) 100 per 1,000 live births
D) 10 per 1,000 live births
A

A) Rates have varied in the United States from 2.34 per 1,000 live births to as low as 0.51
per 1,000 live births. The declining rate could be related to awareness of the need for
dietary supplements during pregnancy, especially folic acid.

377
Q 
Which of the following interventions was found to reduce the frequency of myelomeningocele
(MMC)?
A) Vitamin B
B) Vitamin E
C) Folic acid
D) Ascorbic acid
A

C) Folic acid supplementation was fi rst shown to decrease the rate of neural tube defi cits
in the early 1980s in Wales

378
Q 
What percentage of myelomeningoceles (MMCs) are associated with hydrocephalus at
birth?
A) 5%
B) 15%
C) 25%
D) 50%
A

B) Approximately 15% of these babies have severe hydrocephalus and require immediate
shunting

379
Q 
Which is/are the most common shunt complication(s) when treating hydrocephalus in
an infant with myelomeningocele?
A) Infection and obstruction
B) Lower limb weakness
C) Pain and swelling
D) Incontinence of bowel and bladder
A

A) The two most common shunt complications are infection and obstruction. Signs and
symptoms vary with the age of the chil

380
Q 
What is a leading cause of death for infants with myelomeningocele (MMC)?
A) Symptomatic Chiari II malformation
B) Infection
C) Hydrocephalus
D) Renal failure
A

A) Symptomatic Chiari II malformation remains the leading cause of death for infants
with MMC

381
Q 
What are frequent signs and symptoms of spinal cord “tethering”?
A) Infection
B) Increased weakness
C) Cognition loss
D) Gastrointestinal upset
A

B) Cord tethering may result in increasing weakness, scoliosis, pain, urologic dysfunction,
or orthopedic deformities

382
Q 
What percentage of those with myelomeningocele (MMC) will have normal urinary
control?
A) 50%
B) 25%
C) 10%
D) 1%
A

C) Fewer than 10% of children with MMC have normal urinary control. Continence is an
important issue and must be addressed.

383
Q 
What is a frequent allergy in myelomeningocele (MMC)?
A) Soap
B) Poison ivy
C) Latex
D) Urine
A

C) Although the prevalence of latex allergy in the general population is estimated to be
less than 1% to 2%, its prevalence in children with MMC ranges from 20% to 65% because
of the repeated exposure

384
Q 
What is the most common level of myelomeningocele (MMC)?
A) Upper thoracic
B) Cervical
C) Lower thoracic
D) Lumbar
A

D) The majority of children with MMC have lumbar lesions, with one-fourth having
midlumbar lesions. Very few have cervical and upper thoracic levels

385
Q

Which is the major cause of calcaneal deformity in myelomeningocele (MMC)?
A) Unopposed contraction of foot dorsifl exors
B) Unopposed contraction of plantar fl exors
C) Weakness of foot intrinsics
D) Hip dislocation

A

A) Calcaneal deformities result from unopposed contraction of foot dorsifl exors and can
be present at birth or develop later

386
Q 
Which would best describe the ambulation potential for a patient with thoracic myelomeningocele
(MMC)?
A) Community ambulatory
B) Household ambulatory
C) Functional ambulatory
D) Nonambulatory
A

C) Most patients with lumbar lesions will have some level of ambulation, but those with
thoracic MMC can be functional ambulators.

387
Q 
Which of the following affects IQ scores of children with myelomeningocele (MMC)?
A) Central nervous system infections
B) Recurrent shunt revisions
C) Ability to ambulate
D) Pressure ulcers
A

A) IQ scores are adversely affected by central nervous system infections but not by recurrent
shunt revisions.

388
Q

Which best describes the development of female patients with myelomeningocele
(MMC)?
A) Normal
B) Markedly reduced
C) Increased likelihood of late puberty
D) Increased likelihood of precocious puberty

A

D) Between 12% and 15% of girls with MMC show precocious puberty; 95% have
menses

389
Q 
Of those patients with myelomeningocele (MMC) who complete high school, about what
percentage go on to further education?
A) < 10%
B) 20%
C) 40%
D) 50%
A

D) About one-half of those who fi nish high school go on to further education.

390
Q

What must accompany rehabilitation in those with myelomeningocele (MMC) as they
move to adulthood?
A) Anticipation and prevention of life-threatening events
B) Rechecks as needed
C) Avoidance of activity
D) Insistence on employment

A

A) MMC presents lifelong challenges to affected patients, their families, and clinicians.
Surveillance and education are required to prevent life-threatening events related to ventriculoperitoneal
shunt malfunction, Chiari II malformation, renal failure, infection, and
latex allergy-all in conjunction with maximizing function

391
Q

sole of foot stroked; fans out toes and twists foot in

A

babinski

392
Q

flash of light or puff of air; closes eyes

A

blinking

393
Q

palms touched, grasps tightly

A

grasping

394
Q

sudden move or loud noise; startles throws out arms and legs

A

moro

395
Q

cheek stroked or side of mouth touhed; turns towards source opens mouth and sucks

A

rooting

396
Q

infant held upright with feet touching ground; moves feet as if to walk

A

stepping

397
Q

mouth touched by object; suck on object

A

sucking

398
Q

placed face down in water; makes coordinated swimming movements

A

swimming

399
Q

place on back; makes fists and turns head to the right

A

tonic neck

Rehab (1 decks)

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