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APEA 3P EXAM PREP NEURO|2025-2026|REAL EXAM
QUESTIONS WITH ANSWERS AND
RATIONALES|RATED A+
A patient who is 82 years old is brought into the clinic. His wife states that he was working in his garden today and became disoriented and had slurred speech. She helped him back into the house, gave him cool fluids, and within 15 minutes his symptoms resolved. He appears in his usual state of health when he is examined. He states that although he was scared by the event, he feels fine now. How should the nurse practitioner proceed? Prescribe an aspirin daily. Re- examine him tomorrow. Send him to the emergency department. Order an EKG. This patient likely suffered a transient ischemic attack. He needs urgent evaluation with head CT and/or MRI, ECG, lab work (CBC, PTT, lytes, creatinine, glucose, lipids and sedimentation rate); possible magnetic resonance angiography, carotid ultrasound, and/or transcranial Doppler ultrasonography. He is at increased risk of stroke within the first 48 hours after an event like this one. On initial evaluation, the most important determination to be made is whether the etiology of the stroke or TIA is ischemic or hemorrhagic. After this determination, treatment can begin. Unfortunately, this determination cannot be made in the clinic. The patient needs urgent referral to a center where this evaluation and possible treatment can be performed. The most common presenting sign of Parkinson’s disease is: muscular rigidity. tremor. falling. bradykinesia.
Approximately 70% of patients with Parkinson’s disease have tremor as the presenting symptom. The tremor typically involves the hand but can involve thelegs, jaw, lips, tongue. It seldom involves the head. Muscular rigidity and bradykinesia are two less common presenting signs. When should medications be initiated in a patient who is diagnosed with Parkinson’s disease? As soon as the disease is diagnosed When symptoms interfere with life’s activities When nonpharmacologic measures have been exhausted After MRI and CT have ruled out stroke or tumor The medications used to treat patients who have Parkinson’s disease do not preventthe progression of the disease. Therefore, it is not necessary to start medications until symptoms interfere with the patient's quality of life. Levodopa is often used initially at the lowest dose that helps a patient manage symptoms. It can be titratedupward as needed. Orthostatic hypotension is a common side effect of levodopa, so blood pressure should be monitored closely. A 72 - year-old patient with history of polymyalgia rheumatica complains of new onset, unilateral headache and visual changes. Her neurologic exam is otherwise normal. Her CT results are WNL. ESR is 75 (Normal: 0 - 29). VS: BP 140/82, HR 67, RR 18, T 100. What is the most likely reason for her symptoms? Transient ischemic attack Temporal arteritis Meningitis CVA Polymyalgia rheumatica (PMR) is a chronic inflammatory condition that produces morning stiffness in the neck, shoulders, and hips. Its peak incidence is 70 - 80 years old. PMR is commonly associated with temporal arteritis, also known as giant cell arteritis. Temporal arteritis is a chronic vasculitis of the medium and large vessels. Temporal arteritis is characterized by new onset unilateral temporal headache, abrupt onset of visual disturbances, elevated sedimentation rate, jaw claudication, and unexplained fever. This is best diagnosed by temporal artery biopsy. She shouldbe referred to neurology for evaluation today. What recommendation should be made to an older adult who is diagnosed with mild dementia?
risk of ischemic stroke is reduced. The dosage of aspirin needed to prevent an eventis debatable. Most studies found that 75 - 150 mg daily was as effective in preventing stroke as was higher doses. Lower doses of aspirin are associated with less GI toxicity and fewer side effects. A 75 - year-old is diagnosed with essential tremor. What is the most commonly used medication to treat this? Carbidopa Long-acting propanolol Phenobarbital Gabapentin Tremor is the most common of all movement disorders and essential tremor is the most common cause of all tremors. It is characterized by rhythmic movement of a body part, commonly the hands or head. Beta blockers are the most commonly used medication class to treat essential tremor. Propanolol is the most commonly used medication, but other beta blocking agents are used as well. Both gabapentin and phenobarbital are used, but, not nearly as often. Carbidopa is used in patients with Parkinson’s disease. A patient who had an embolic stroke has recovered and is performing all of heractivities of daily living. Taking aspirin for stroke prevention is an example of: primary prevention. secondary prevention. tertiary prevention. quaternary prevention. The patient is taking aspirin to prevent recurrent stroke. Research demonstrates that taking an aspirin daily can significantly reduce the risk of subsequent strokes and MI. Secondary prevention means that the intervention is performed to prevent another occurrence of the deleterious event. If she had never had a stroke but tookaspirin daily for prevention of stroke, that would be primary prevention. Taking aspirin at home during the course of having an MI is an example of tertiary prevention. There is no reference in the literature to quaternary prevention. An older adult patient with organic brain syndrome is at increased risk of abusebecause she: lives in a nursing home.has multiple caregivers.
is incontinent of stool and urine. has declining cognitive function. Older adults are at increased risk of abuse because of their decline in cognitive function. Caregiver strain, stress, and depression occur at higher rates than in the general population. According to the National Center of Elder Abuse, family members are likely to be abusers of infirm older adults. Healthcare providers should remain alert to signs of abuse and caregiver stress. A patient with migraine headaches and hypertension should receive whichmedication class with caution? Beta blockers Triptans Pain medications ACE inhibitors The class of medications called “triptans” work to eradicate migraine headaches byproducing vasoconstriction. This can produce a potentially serious drug-disease interaction in patients with hypertension. An episode of severe hypertension can result. Triptans may be used in patients with well-controlled hypertension, but a hypertensive episode is always possible. A patient who is 60 years old complains of low back pain for the last 5 - 6 weeks. She states that the severity is about 4/10 and that she gets no relief from sitting, standing, or lying. The NP should consider: sciatica. ankylosing spondylitis. disk disease. systemic illness. Systemic illness, like cancer or infection, is a serious consideration when patients report no relief of pain with position change. Additionally, this patient is female, older, and has had pain longer than 4 weeks. These are three risk factors for systemic cause of low back pain. Sciatica presents with pain that radiates down theleg. Ankylosing spondylitis is typical in males in their 40s and produces pain at nighttime that is improved with being upright. Disk disease is a consideration, but, an absence of relief with lying down is unusual.
A 68 - year-old smoker with a history of well-controlled hypertension describes an event that occurred yesterday while mowing his lawn. He felt very dizzy and "passed out" for less than 1 minute. He awakened spontaneously. Today, he has nocomplaints and states that he feels fine. Initially, the NP should: perform a complete neurological and cardiac exam with auscultation of the carotid arteries. order a 12 - lead ECG and carotid ultrasound, and perform a physical exam.order a CT of the brain, blood clotting studies, and cardiac enzymes. check blood pressure in three positions, order a 12 - lead ECG, and schedule anexercise stress test. The event described is syncope. Syncope is a brief and sudden loss of consciousness that occurs with spontaneous recovery. This is a significant event but it is especially so in a smoker with hypertension. The assessment of this patient must start with an examination of the cardiac and neurological systems. Based on the findings and tentative diagnosis of syncope, coupled with the patient’s history ofthe event, other tests might be ordered to evaluate arrhythmias, stroke, transient ischemic attack, myocardial infarct, carotid stenosis, other vascular etiologies. A referral to specialty care is indicated after initial workup by the nurse practitioner. Which characteristic is true of tension headaches, but not of cluster headaches? Cluster headaches are always bilateral. Tension headaches are always bilateral. Cluster headaches always cause nausea. Tension headaches cause photosensitivity. Cluster headaches are always unilateral. The affected side produces a red, teary eye with nasal congestion on the affected side. Nausea and photosensitivity are common. Tension headaches are always bilateral with no nausea or photosensitivity associated with them. Which condition listed below does NOT impact an elder’s ability to eat?Stroke Parkinson’s disease Dysphagia Hyperlipidemia
Many, many diseases impact an elder patient’s ability to eat. About 50% of patients who have had stroke have impaired ability to eat. This can include difficulty feeding self as well as difficulty swallowing. Parkinson’s disease and many other neurological diseases have great impact on eating, since coordinated muscle movement is needed for swallowing and feeding. Hyperlipidemia has no significant impact on a patient’s ability to eat. Mr. Williams has moderate cognitive deficits attributed to Alzheimer’s disease andhas been started on a cholinesterase inhibitor. The purpose of this drug is to: decrease agitation. increase anticholinergic stimulation of the brain. improve depression. slow progression of his cognitive deficits. This drug is a cholinesterase inhibitor. It will cause more acetylcholine to be available to neurons. Many patients show a slowing of cognitive decline when these medications are used for at least 1 year. A small percentage of patients, 10 - 25%, show significant improvement in symptoms. An anticholinergic medication would becontraindicated in these patients. There is no direct benefit on agitation or depression in patients who take this class of medications. A neurologic disease that produces demyelination of the nerve cells in the brain andspinal cord is: Parkinson’s disease. late stage Lyme disease. multiple sclerosis. amyotrophic lateral sclerosis. Multiple sclerosis (MS) is a disease of the central nervous system characterized by demyelination of the nerve cells. This produces varied neurological symptoms and deficits. This disease is typical in women between the ages of 16 and 40 years. It israrely diagnosed after age 50 years. MS can be diagnosed in an adult who has one or more clinically distinct episodes of CNS dysfunction followed by at least partial remission. An older adult patient is at increased risk of stroke and takes an aspirin daily. Aspirin use in this patient is an example of: primary prevention. secondary prevention.
own decisions. Her daughter requests a family conference with the nurse practitioner. Some important principles that need discussion currently, if not previously documented, are: bereavement support for the family, quality of life for the resident, and living will.health care proxy, living will, and hospice referral. withdrawing therapy, hospice referral, and managing symptoms.end of life decisions, quality of life, and advance directives. American Geriatrics Society stresses not only care of the patient but the care of the family as well. This includes meeting the current and future needs of the patient, family needs, and end- of-life issues with the living will. The living will is recognized as a valid advanced directive. Care includes developmental landmarks for the patient and family. A young male patient with a herniated disk reports bilateral sciatica and leg weakness. If he calls the NP with complaints of urinary incontinence, what should besuspected? Opioid overuse Medial or lateral herniation Rupture of the disc Cauda equina syndrome Cauda equina syndrome is a medical emergency. It is characterized by compression of the spinal cord. A common manifestation of this is bowel or bladder dysfunction. This may include incontinence or the inability to urinate or have a bowel movement. This patient needs immediate neurosurgical or orthopedic referral. The Snellen chart is used to assess: near vision. distant vision. color vision. peripheral vision. The Snellen eye chart was named after Dr. Hermann Snellen. The Snellen fractions, 20/20, 20/30, etc. are measures of sharpness of distant vision. Actually, 20/20 is not normal vision; it is a reference standard. Average acuity in a population is 20/15 or 20/10 (hence the reason there are two lines beneath the 20/20 vision line). When
visual acuity is assessed, each eye is covered and assessed independently; this istermed monocular. The Mini-Cog is helpful in screening patients who have suspected: delirium. dementia. Parkinson’s disease stroke. The Mini-Cog is a screening tool for dementia. It is performed by telling the patient the names of three unrelated but familiar items. The patient is distracted by being asked to draw the face of a clock, and to indicate two specific times by drawing the hands on the clock. Then, the patient is asked to repeat the names of the three objects. Scores are received for correct naming of the items and clock drawings. Which of the following would NOT be part of the differential diagnosis for an 84-year- old patient with dementia symptoms? Tumor Cerebral hemorrhage Cerebral infarct Normal aging process Changes in cognition are not associated with the aging process, though 50% of adults over age 90 have some form of dementia. All patients should have some type of imaging to rule out tumor, infection, hemorrhage, infarct, etc. Experts have not agreed on which neuroimaging studies are most valuable. A patient is diagnosed with carpal tunnel syndrome. Which finger is not affected bycarpal tunnel syndrome? Thumb Second fingerFourth finger Fifth finger Carpal tunnel syndrome is an entrapment neuropathy of the median nerve at the wrist due to inflammation of the wrist tendons, transverse carpal ligament, and/or surrounding soft tissue. Compression of the median nerve produces paresthesias in
of the forehead. Early treatment with oral steroids like prednisone (60 mg/d and tapered over 10 days) should be started within 72 hours of the onset of symptoms. This has been found to decrease the risk of permanent facial paralysis. Oral antiviralagents may be of benefit because of the likely possibility of Bell’s palsy occurring secondary to infection with the herpes simplex virus. A patient is examined and found to have a positive Kernig's and Brudzinski's signs. What is the most likely diagnosis? Hepatitis Encephalitis Meningitis Pneumonitis The findings of positive Kernig’s and Brudzinski’s signs are highly suggestive of meningitis. Kernig’s sign is elicited by leg extension, then observing for neck pain and flexion. Brudzinski’s sign is elicited by passively flexing the neck and observingfor flexion of the legs. The "get up and go" test in an older adult patient is used to evaluate:risk for falls. lower extremity strength. mental acuity. driving safety. The “get up and go” test is used to evaluate musculoskeletal function. The patient isasked to rise from a seated position in an armchair, walk across the room, turn around, and return to the chair. This test evaluates the patient’s gait, balance, leg strength, and vestibular function. It should be assessed in patients who report a fall or who present after a fall but who appear without injury. Sumatriptan (Imitrex) is a medication used to abort migraine headaches. It may also be used to treat: tension headaches. cluster headaches. serotonin abnormalities.depression.
Sumatriptan is a member of the medication class used to abort migraine headaches. Sumatriptan is also used to treat patients who experience cluster headaches. Relief is usually realized in about 10 minutes or less after using sumatriptan. The triptans are not helpful for patients with tension headaches. Migraine prophylactic agents may be helpful in patients who have serotonin abnormalities or depression. A 70 - year-old male who is diabetic presents with gait difficulty, cognitive disturbance, and urinary incontinence. What is part of the nurse practitioner’sdifferential diagnosis? Diabetic neuropathy Normal pressure hydrocephalus Parkinson’s Disease Multiple sclerosis The classic triad of normal pressure hydrocephalus is described above. Diabetic neuropathy would not be typical because this involves three different areas of complaint. Parkinson’s disease presents with tremor, gait disturbance, and bradykinesia. Multiple sclerosis almost never presents beyond the age of 50 years and would be even less likely presentation in a 70 - year-old. The incidence of normal pressure hydrocephalus varies from 2 - 20 million people per year. It is more common in elderly patients and affects both genders equally. This is diagnosed by the presence of enlarged ventricles on CT scan. An older adult patient has an audible carotid bruit. He has a history of hypertension, hyperlipidemia, and a myocardial infarction 5 years ago. He has no complaints today. The finding of a bruit indicates that the patient: probably will have a stroke. has five times the risk of stroke compared to individuals who do not have a carotidbruit. is more likely to die from cardiovascular disease than cerebrovascular disease.probably has a significant carotid artery lesion.
Any of these findings should compel the examiner to order an imaging study. Thestudy most likely to be ordered is a CT scan or MRI with and without contrast. However, an MRA may be ordered depending on the suspected underlyingabnormality. A 70 - year-old male patient is diagnosed with vertigo. Which choice below indicates that the vertigo is more likely to be of central etiology? Brief duration Nystagmus present Nausea and vomiting Persistent symptoms Central etiologies involve the brainstem or cerebellum; peripheral etiologies typically involve the vestibular system. Vertigo in a patient is a common complaint and can be due to multiple etiologies. Hyperventilation can produce dizziness. In an older adult, the etiology is more likely from multiple factors: taking 5 or more medications, orthostatic hypotension. Tinnitus (ringing in the ears) and hearing loss typically indicate a peripheral etiology. An audible carotid bruit would steer the healthcare provider to explore carotid stenosis and underlying cardiovascular disease. A 60 - year-old patient has anosmia. Which cranial nerve must be assessed?I II V X Anosmia refers to the inability to smell. Cranial nerve I is the olfactory nerve and isnot usually tested. However, cranial nerve I lesions do occur. Anosmia would be a clinical manifestation of this. If CN I is assessed, the examiner uses a familiar smelllike coffee or peppermint and asks the examinee to identify the smell. The inability to do this with a familiar smell is termed anosmia. A typical description of sciatica is:
deep and aching. worse with lying down.burning and sharp. precipitated by coughing. Sciatica is irritation of the nerve root. Patients usually complain of sharp, burning pain that can be accompanied by numbness, tingling and radiating pain down theposterior, lateral, or anterior aspect of one leg. Disk herniation, which could cause sciatica, produces increased pain with coughing, sneezing, or the Valsalva maneuver. A patient complains of right leg numbness and tingling following a back injury. Hehas a diminished right patellar reflex and his symptoms are progressing to both legs. What test should be performed? Lumbar X-rays Lumbar CT scan Lumbar MRI Correct Lumbar MRI with contrast This patient has symptoms that could indicate an urgent neurological situation. Acute radiculopathy could indicate the need for intervention by a neurosurgeon. An MRI is a superior study because it provides excellent information about the soft tissues, like the lumbar disks. Contrast might be used in this patient if he had a history of previous back surgery. Then, contrast would be helpful to distinguish scartissue from disks. Which cranial nerve is assessed by administering the Snellen test?II III IV VI The Snellen chart is used to assess vision. Cranial nerve II, the optic nerve, must beintact for intact visual acuity. Cranial nerves III, IV, and VI are responsible for eye movement, not vision. Which class of medications is NOT used for migraine prophylaxis?
nicotine intake. Migraines may be triggered by diet, skipping meals, sunlight, red wine, aged cheeses, or menses. Family history is a common finding in patients whohave migraine headaches. Which headache listed below is more likely to be triggered by food?Cluster Migraine Tension Vascular Migraine headaches are more likely to be triggered by food than tension headaches or others. Common food triggers are alcohol, chocolate, aged cheeses, nuts, nitrates, nitrites, and caffeine. Restless legs syndrome is part of the differential diagnosis for Mr. Wheaton. Whatshould be part of the laboratory workup? BUN/Cr Serum ferritin ALT/AST Urinalysis Restless legs syndrome (RLS) is the unrelenting urge to move the legs. This rarely affects the upper extremities. The symptoms are relieved by movement of the affected limbs and only occur if the affected limbs are at rest. Iron deficiency has been considered as a cause of RLS. The exact mechanism of iron deficiency is not known, but many patients who exhibit symptoms of restless legs syndrome have low serum ferritin levels and have relief of symptoms when supplemented with iron.Even in patients with normal serum levels, a month long trial of iron may be helpful. Which of the following are diagnostic criteria for migraine headache without aura?Pain is episodic during the headache Pain lasts 4 - 72 hours There are underlying neurologic abnormalities Photophobia must be present There are no specific tests that diagnose migraine headaches. The diagnosis mustbe made based on the clinical presentation of the patient and elimination of other
etiologies for the headache. In order to meet International Headache Society criteria for a migraine headache without aura, 5 criteria must be met. They include: 1) headache lasts 4 - 72 hours, 2) has 2 of these characteristics (unilateral pulsating quality, moderate to severe intensity, aggravated by routine activity), 3) at least one of the following occurs during headache (nausea and/or vomiting, photophobia, OR phonophobia), 4) 5 or more attacks have occurred with these characteristics, 5) there is no other reason for the headache's occurrence. A 72 - year-old patient with a history of coronary artery disease and hypertension reports an episode of slurred speech and right-sided facial droop that started yesterday while at home. It lasted for about an hour. She denies pain or headache. She presents to the clinic today and no longer has any of these symptoms. What isthe most likely explanation for these symptoms? Stroke Bell's palsy Trigeminal neuralgia Transient ischemic attack Transient ischemia attack (TIA) is defined as an episode of transient neurologic dysfunction without acute infarction. Stroke is defined as an infarction of the central nervous system tissue. It is considered the end point. Facial drooping and slurred speech are examples of neurologic dysfunction. Bell's palsy can produce facial drooping, but this condition would not have resolved in an hour. Trigeminal neuralgia is a neuralgia involving the 5th cranial nerve. It is characterized by intermittent electric painful sensations in the face. A 70 - year-old patient exhibits a unilateral resting tremor. This likely indicates:intention tremor. alcohol withdrawal. Parkinson’s disease. benign essential tremor. Parkinson’s disease is an idiopathic neurodegenerative movement disorder characterized by 4 prominent features: bradykinesia, muscular rigidity, resting tremor, and postural instability. The "pill-rolling" tremor is the presenting sign in 50-80% of patients with Parkinson’s disease. Approximately 30% of patients do not present with tremor s of any type.
