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Chapter 18: Disorders of the Central and Peripheral Nervous Systems and the

Neuromuscular Junction
MULTIPLE CHOICE
1. Diffuse axonal injuries (DAIs) of the brain often result in:
a. Reduced levels of consciousness
c. Fine motor tremors
b. Mild but permanent dysfunction
d. Visual disturbances
ANS: A

Focal brain injuries account for more than two-thirds of head injury deaths; DAIs accounts for
less than one third. However, more severely disabled survivors, including those in an
unresponsive state or reduced level of consciousness, have DAIs. The other options do not
appropriately complete the stem.
PTS: 1

REF: Page 582

2. What event is most likely to occur to the brain in a classic cerebral concussion?
a. Brief period of vital sign instability
b. Cerebral edema throughout the cerebral cortex
c. Cerebral edema throughout the diencephalon
d. Disruption of axons extending from the diencephalon and brainstem
ANS: A

Transient cessation of respiration can occur with brief periods of bradycardia, and a decrease
in blood pressure occurs, lasting 30 seconds or less. Vital signs stabilize within a few seconds
to within normal limits. The other options do not accurately describe an event associated with
a classic cerebral concussion.
PTS: 1

REF: Page 588

3. Which disorder has clinical manifestations that include decreased consciousness for up to 6

hours, as well as retrograde and posttraumatic amnesia?


c. Cortical contusion
d. Acute subdural hematoma

a. Mild concussion
b. Classic concussion
ANS: B

Evidence of a classic concussion is the immediate loss of consciousness, which lasts less than
6 hours. Retrograde and anterograde (posttraumatic) amnesia is also present. The other
options do not apply.
PTS: 1

REF: Page 588

4. What group is most at risk of spinal cord injury from minor trauma?
a. Children
c. Adults
b. Adolescents
d. Older adults
ANS: D

Because of preexisting degenerative vertebral disorders, older adults are particularly at risk for
minor trauma, resulting in serious spinal cord injury, especially from falls. The risk to the
other age groups is less than that of the older adult.

PTS: 1

REF: Page 634

5. The edema of the upper cervical cord after spinal cord injury is considered life threatening

because of which possible outcome?


Hypovolemic shock from blood lost during the injury
Breathing difficulties from an impairment to the diaphragm
Head injury that likely occurred during the injury
Spinal shock immediately after the injury

a.
b.
c.
d.

ANS: B

In the cervical region, spinal cord swelling may be life threatening because of the possibility
of resulting impairment of the diaphragm function (phrenic nerves exit C3-C5). The other
options do not appropriately explain the threat.
PTS: 1

REF: Page 591

6. What indicates that spinal shock is terminating?


a. Voluntary movement below the level of injury
b. Reflex emptying of the bladder
c. Paresthesia below the level of injury
d. Decreased deep tendon reflexes and flaccid paralysis
ANS: B

Indications that spinal shock is terminating include the reappearance of reflex activity,
hyperreflexia, spasticity, and reflex emptying of the bladder. Termination of a spinal cord
injury is not evidenced by any of the other options.
PTS: 1

REF: Page 592

7. What term is used to describe the complication that can result from a spinal cord injury above

T6 that is producing paroxysmal hypertension, as well as piloerection and sweating above the
spinal cord lesion?
a. Craniosacral dysreflexia
c. Autonomic hyperreflexia
b. Parasympathetic dysreflexia
d. Retrograde hyperreflexia
ANS: C

Individuals most likely to be affected have lesions at the T6 level or above. Paroxysmal
hypertension (up to 300 mm Hg systolic), a pounding headache, blurred vision, sweating
above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection
caused by pilomotor spasm, and bradycardia (30 to 40 beats/minute) characterize autonomic
hyperreflexia. No other options appropriately describe this complication.
PTS: 1

REF: Pages 593-594

8. Why does a person who has a spinal cord injury experience faulty control of sweating?
a. The hypothalamus is unable to regulate body heat as a result of damage to the

sympathetic nervous system.


b. The thalamus is unable to regulate body heat as a result of damage to the

sympathetic nervous system.


c. The hypothalamus is unable to regulate body heat as a result of damage to the

parasympathetic nervous system.

d. The thalamus is unable to regulate body heat as a result of damage to spinal nerve

roots.
ANS: A

A spinal cord injury results in disturbed thermal control because the hypothalamus is unable to
regulate a damaged sympathetic nervous system. This damage causes faulty control of
sweating and radiation through capillary dilation. The other options do not appropriately
describe the process that causes faulty control of sweating.
PTS: 1

REF: Page 592

9. Autonomic hyperreflexiainduced bradycardia is a result of stimulation of the:


a. Sympathetic nervous system to -adrenergic receptors to the sinoatrial node
b. Carotid sinus to the vagus nerve to the sinoatrial node
c. Parasympathetic nervous system to the glossopharyngeal nerve to the

atrioventricular node

d. Bundle branches to the -adrenergic receptors to the sinoatrial node


ANS: B

The intact autonomic nervous system reflexively responds with an arteriolar spasm that
increases blood pressure. Baroreceptors in the cerebral vessels, the carotid sinus, and the aorta
sense the hypertension and stimulate the parasympathetic system. The heart rate decreases, but
the visceral and peripheral vessels do not dilate because efferent impulses cannot pass through
the cord. The process is not appropriately described by the other options.
PTS: 1

REF: Pages 593-595 | Figure 18-13

10. A herniation of which disk will likely result in motor and sensory changes of the lateral lower

legs and soles of the feet?


a. L2-L3
b. L3-L5

c. L5-S1
d. S2-S3

ANS: C

Clinical manifestations of posterolateral protrusions include radicular pain exacerbated by


movement and straining (medial calf suggests L5; lateral calf suggests S1 root compression).
Herniation of any of the other vertebrae will not result in the described symptoms.
PTS: 1

REF: Pages 595-596 | Figure 18-14

11. Which condition poses the highest risk for a cerebrovascular accident (CVA)?
a. Insulin-resistant diabetes mellitus
c. Polycythemia
b. Hypertension
d. Smoking
ANS: B

Hypertension is the single greatest risk factor for stroke. The other options are recognized risk
factors but do not carry the intensity of hypertension.
PTS: 1

REF: Page 598

12. A right hemisphere embolic CVA has resulted in left-sided paralysis and reduced sensation of

the left foot and leg. Which cerebral artery is most likely affected by the emboli?
c. Posterior cerebral

a. Middle cerebral

b. Vertebral

d. Anterior cerebral

ANS: D

Symptoms of an embolic stroke in only the right anterior cerebral artery would include leftsided contralateral paralysis or paresis (greater in the foot and thigh) and mild upper extremity
weakness with mild contralateral lower extremity sensory deficiency with loss of vibratory
and/or position sense and loss of two-point discrimination.
PTS: 1

REF: Page 600 | Table 18-5

13. Atrial fibrillation, rheumatic heart disease, and valvular prosthetics are risk factors for which

type of stroke?
a. Hemorrhagic
b. Thrombotic

c. Embolic
d. Lacunar

ANS: C

High-risk sources for the onset of embolic stroke are atrial fibrillation (15% to 25% of
strokes), left ventricular aneurysm or thrombus, left atrial thrombus, recent myocardial
infarction, rheumatic valvular disease, mechanical prosthetic valve, nonbacterial thrombotic
endocarditis, bacterial endocarditis, patent foramen ovale, and primary intracardiac tumors.
These are not risk factors for the other options provided.
PTS: 1

REF: Page 599

14. Microinfarcts resulting in pure motor or pure sensory deficits are the result of which type of

stroke?
a. Embolic
b. Hemorrhagic

c. Lacunar
d. Thrombotic

ANS: C

A lacunar stroke (lacunar infarct) is a microinfarct smaller than 1 cm in diameter. Because of


the subcortical location and small area of infarction, these strokes may have pure motor and
sensory deficits. The other options would not result in the complications described.
PTS: 1

REF: Page 599

15. Which vascular malformation is characterized by arteries that feed directly into veins through

vascular tangles of abnormal vessels?


a. Cavernous angioma
b. Capillary telangiectasia

c. Arteriovenous angioma
d. Arteriovenous malformation

ANS: D

In only an arteriovenous malformation (AVM), do arteries feed directly into veins through a
vascular tangle of malformed vessels.
PTS: 1

REF: Pages 604-605

16. Which clinical finding is considered a diagnostic indicator for an arteriovenous malformation

(AVM)?
a. Systolic bruit over the carotid artery
b. Decreased level of consciousness
c. Hypertension with bradycardia

d. Diastolic bruit over the temporal artery


ANS: A

A systolic bruit over the carotid in the neck, the mastoid process, or (in a young person) the
eyeball is almost always diagnostic of an AVM. The other options are not as indicative as the
systolic bruit.
PTS: 1

REF: Page 605

17. Which cerebral vascular hemorrhage causes meningeal irritation, photophobia, and positive

Kernig and Brudzinski signs?


a. Intracranial
b. Subarachnoid

c. Epidural
d. Subdural

ANS: B

Assessment findings related to only a subarachnoid hemorrhage include meningeal irritation


and inflammation, causing neck stiffness (nuchal rigidity), photophobia, blurred vision,
irritability, restlessness, and low-grade fever. A positive Kernig sign, in which straightening
the knee with the hip and knee in a flexed position produces pain in the back and neck
regions, and a positive Brudzinski sign, in which passive flexion of the neck produces neck
pain and increased rigidity, may appear.
PTS: 1

REF: Pages 605-606

18. In adults, most intracranial tumors are located:


a. Infratentorially
c. Laterally
b. Supratentiorially
d. Posterolaterally
ANS: A

Approximately 70% to 75% of all intracranial tumors diagnosed in adults are located
supratentorially (above the tentorium cerebella). The other options are not primary locations
for intracranial tumors in adults.
PTS: 1

REF: Page 626

19. In children, most intracranial tumors are located:


a. Infratentorially
c. Laterally
b. Supratentiorially
d. Posterolaterally
ANS: B

Approximately 70% of all intracranial tumors in children are located infratentorially (below
the tentorium cerebelli) and not in the locations provided by the other options.
PTS: 1

REF: Page 626

20. The most common primary central nervous system (CNS) tumor is the:
a. Microglioma
c. Astrocytoma
b. Neuroblastoma
d. Neuroma
ANS: C

Astrocytomas are the most common primary CNS tumors (50% of all brain and spinal cord
tumors). The other options do not occur as frequently.

PTS: 1

REF: Page 629

21. Meningiomas characteristically compress from:


a. Within neural tissues
c. Outside the spinal cord
b. Outside spinal nerve roots
d. Within the subarachnoid space
ANS: C

Extramedullary spinal cord tumors produce dysfunction by compression of adjacent tissue,


not by direct invasion. The pathologic characteristic of meningiomas is not appropriately
described by the other options.
PTS: 1

REF: Page 633

22. What is the central component of the pathogenic model of multiple sclerosis?
a. Myelination of nerve fibers in the peripheral nervous system (PNS)
b. Demyelination of nerve fibers in the CNS
c. Development of neurofibrillary tangles in the CNS
d. Inherited autosomal dominant trait with high penetrance
ANS: B

Multiple sclerosis (MS) is an autoimmune disorder diffusely involving the degeneration of


CNS myelin and loss of axons. The other options are not central components of the
pathogenic model of MS.
PTS: 1

REF: Pages 618-619

23. A blunt force injury to the forehead would result in a coup injury to which region of the brain?
a. Frontal
c. Parietal
b. Temporal
d. Occipital
ANS: A

Coup injuries occur directly below the point of impact. Objects striking the front of the head
usually produce only coup injuries (contusions and fractures) because the inner skull in the
occipital area is smooth. A coup injury is not nearly as likely when other portions of the brain
are affected.
PTS: 1

REF: Page 583

24. A blunt force injury to the forehead would result in a contrecoup injury to which region of the

brain?
a. Frontal
b. Temporal

c. Parietal
d. Occipital

ANS: A

The focal injury produces a contrecoup (on the pole opposite the site of impact) injury. The
frontal portion of the brain is opposite of the site of impact. Objects striking the back of the
head usually result in both coup and contrecoup injuries because of the irregularity of the
inner surface of the frontal bones. A contrecoup injury is not nearly as likely when other
portions of the brain are affected.
PTS: 1

REF: Page 583

25. Spinal cord injuries most likely occur in which region?


a. Cervical and thoracic
c. Lumbar and sacral
b. Thoracic and lumbar
d. Cervical and thoracic-lumbar
ANS: D

Vertebral injuries most often occur at vertebrae C1-C2 (cervical), C4-C7, and T1-L2 (thoracic
lumbar). None of the other options are applicable.
PTS: 1

REF: Pages 590-591

26. The most likely rationale for body temperature fluctuations after cervical spinal cord injury is

that the person has:


a. Developed bilateral pneumonia or a urinary tract infection.
b. Sustain sympathetic nervous system damage resulting in disturbed thermal control.
c. Sustained a head injury that damaged the hypothalamuss ability to regulate

temperature.
d. Developed septicemia from posttrauma infection.
ANS: B

Spinal cord injuries result in disturbed thermal control because the sympathetic nervous
system is damaged. None of the remaining options explain this complication.
PTS: 1

REF: Page 592

27. A man who sustained a cervical spinal cord injury 2 days ago suddenly develops severe

hypertension and bradycardia. He reports severe head pain and blurred vision. The most likely
explanation for these clinical manifestations is that he is:
a. Experiencing acute anxiety
b. Developing spinal shock
c. Developing autonomic hyperreflexia
d. Experiencing parasympathetic areflexia
ANS: C

Autonomic hyperreflexia is the only option that is characterized by paroxysmal hypertension


(up to 300 mm Hg systolic), a pounding headache, blurred vision, sweating above the level of
the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by
pilomotor spasm, and bradycardia (30 to 40 beats per minute).
PTS: 1

REF: Pages 593-594

28. The type of vascular malformation that most often results in hemorrhage is:
a. Cavernous angioma
c. Capillary telangiectasia
b. Venous angioma
d. Arteriovenous malformation
ANS: D

In an arteriovenous malformation (AVM), arteries feed directly into veins through a vascular
tangle of malformed vessels, causing venous hemorrhaging. The other options are not as
likely to result in a hemorrhage.
PTS: 1

REF: Pages 604-605

29. Atheromatous plaques are most commonly found:

a. In larger veins
b. Near capillary sphincters

c. At branches of arteries
d. On the venous sinuses

ANS: C

Over 20 to 30 years, atheromatous plaques (stenotic lesions) tend to form at branchings and
curves in the cerebral circulation, not at any of the other options provided.
PTS: 1

REF: Page 598

30. Multiple sclerosis is best described as a(an):


a. Central nervous system demyelination, possibly from an immunogenetic virus
b. Inadequate supply of acetylcholine at the neurotransmitter junction as a result of an

autoimmune disorder
c. Depletion of dopamine in the central nervous system as a result of a virus
d. Degenerative disorder of lower and upper motor neurons caused by viral-immune

factors
ANS: A

Multiple sclerosis (MS) is an autoimmune disorder diffusely involving the degeneration of


central nervous system (CNS) myelin and loss of axons. MS is described as occurring when a
previous infectious insult to the CNS has occurred in a genetically susceptible individual with
a subsequent abnormal immune response in the CNS. The other options do not adequately
describe MS.
PTS: 1

REF: Pages 618-619

31. What is the most common opportunistic infection associated with acquired immunodeficiency

syndrome (AIDS)?
a. Non-Hodgkin lymphoma
b. Kaposi sarcoma

c. Toxoplasmosis
d. Cytomegalovirus

ANS: C

Toxoplasmosis is the most common opportunistic infection and occurs in approximately one
third of individuals with AIDS. Cytomegalovirus encephalitis is common in those with AIDS
but is often not diagnosed while the person is alive. Other neoplasms associated with human
immunodeficiency virus (HIV) include systemic non-Hodgkin lymphoma and metastatic
Kaposi sarcoma.
PTS: 1

REF: Page 617

32. It is true that Guillain-Barr syndrome (GBS):


a. Is preceded by a viral illness.
c. Results in asymmetric paralysis.
b. Involves a deficit in acetylcholine.
d. Is an outcome of HIV.
ANS: A

GBS is considered to be an autoimmune disease triggered by a preceding bacterial or viral


infection. None of the other options are true of GBS.
PTS: 1

REF: Pages 622-623

33. It is true that myasthenia gravis:


a. Is an acute autoimmune disease.

c. May result in adrenergic crisis.

b. Affects the nerve roots.

d. Causes muscle weakness.

ANS: D

Exertional fatigue and weakness that worsens with activity, improves with rest, and recurs
with resumption of activity characterizes myasthenia gravis. None of the other options are true
of myasthenia gravis.
PTS: 1

REF: Page 626

34. In which disorder are acetylcholine receptor antibodies (IgG antibodies) produced against

acetylcholine receptors?
a. Guillain-Barr syndrome
b. Multiple sclerosis

c. Myasthenia gravis
d. Parkinson disease

ANS: C

The main defect of myasthenia gravis is the formation of autoantibodies (an immunoglobulin
G [IgG] antibody) against receptors at the Ach-binding site on the postsynaptic membrane.
This defect is not found in any of the other options.
PTS: 1

REF: Pages 625-626

35. Multiple sclerosis and Guillain-Barr syndrome are similar in that they both:
a. Result from demyelination by an immune reaction.
b. Cause permanent destruction of peripheral nerves.
c. Result from inadequate production of neurotransmitters.
d. Block acetylcholine receptor sites at the myoneuronal junction.
ANS: A

Acute inflammatory demyelinating polyneuropathy (AIDP) accounts for most occurrences of


Guillain- Barr syndrome (GBS). Multiple sclerosis (MS) is an autoimmune disorder diffusely
involving degeneration of CNS myelin and loss of axons. Only the correct option accurately
describes the similarity between MS and GBS
PTS: 1

REF: Page 618 | Pages 622-623

MULTIPLE RESPONSE
36. Which clinical manifestation is characteristic of cluster headaches? (Select all that apply.)
a. Preheadache aura
b. Severe unilateral tearing
c. Gradual onset of a tight band around the head
d. Significant unilateral, temporal pain
e. Pain lasting from 30 to 120 minutes
ANS: B, C, E

The cluster headache attack usually begins without warning and is characterized by severe,
unilateral tearing, burning, periorbital, and retrobulbar or temporal pain lasting 30 minutes to
2 hours. Neither preheadache aura nor significant unilateral, temporal pain is clinical
manifestation characteristic of cluster headaches.
PTS: 1

REF: Pages 608-609

37. What are the initial clinical manifestations immediately noted after a spinal cord injury?

(Select all that apply.)


Headache
Bladder incontinence
Loss of deep tendon reflexes
Hypertension
Flaccid paralysis

a.
b.
c.
d.
e.

ANS: B, C, E

A complete loss of reflex function in all segments below the level of the lesion characterizes a
spinal cord injury. Severe impairment below the level of the lesion is obvious; it includes
paralysis and flaccidity in muscles, absence of sensation, loss of bladder and rectal control,
transient drop in blood pressure, and poor venous circulation. Neither headache nor
hypertension is an initial clinical manifestation related to a spinal cord injury.
PTS: 1

REF: Page 592

MATCHING

Match the terms with the corresponding descriptions.


______ A. Complication of mastoiditis
______ B. Opportunistic infection
______ C. CNS manifestation of tuberculosis
______ D. Mosquito-borne viral infection
______ E. Tick-borne bacterial infection
38.
39.
40.
41.
42.

Meningitis
Encephalitis
Cryptococcus neoformans
Brain abscess
Lyme disease

38. ANS: C
PTS: 1
REF: Pages 611-612
MSC: Tubercular meningitis is the most common and serious form of central nervous system (CNS)
tuberculosis.
39. ANS: D
PTS: 1
REF: Page 614
MSC: Encephalitis is an acute febrile illness, usually of viral origin, with nervous system
involvement. Arthropod-borne (mosquito-borne) viruses and herpes simplex cause the most common
encephalitides.
40. ANS: B
PTS: 1
REF: Page 617
MSC: Opportunistic infections may be bacterial, fungal, protozoal, or viral in origin and produce
nervous system disease. Cryptococcus neoformans is an example of such an infection.
41. ANS: A
PTS: 1
REF: Page 613
MSC: Abscesses may occur in association with a contiguous spread of infection, such as the middle
ear, mastoid cells, nasal cavity, and nasal sinuses.
42. ANS: E
PTS: 1
REF: Page 617
MSC: Lyme disease, a tick-borne spirochete bacterial infection, is a common arthropod-borne
infection in the United States.