Chapter 17: Alterations in Cognitive Systems, Cerebral Hemodynamics, and Motor

Function
MULTIPLE CHOICE
1. Cognitive operations cannot occur without the effective functioning of the brains:
a. Pons
c. Reticular activating system
b. Medulla oblongata
d. Cingulate gyrus
ANS: C

Cognitive cerebral functions require a functioning reticular activating system (RAS).

Cognitive operations are not managed by any of the other options.
PTS: 1

REF: Page 528

2. Which intracerebral disease process is capable of producing diffuse dysfunction?

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

Disorders within the brain substance (intracerebral)bleeding, infarcts emboli, and tumors
primarily functioning as masses may cause diffuse dysfunction. Such localized destructive
processes directly impair functioning of the thalamic or hypothalamic activating systems.
Disorders outside the brain but within the cranial vault (extracerebral), including neoplasms,
closed-head trauma with subsequent bleeding, and subdural empyema (accumulation of pus),
can cause similar dysfunction.
PTS: 1

REF: Page 528

3. What is the most common infratentorial brain disease process that results in the direct

destruction of the reticulating activation system (RAS)?

c. Neoplasms
d. Abscesses

a. Cerebrovascular disease
b. Demyelinating disease
ANS: A

Infratentorial disorders produce a decline in arousal through a direct destruction of the RAS
and its pathways. The most common cause of direct destruction is cerebrovascular disease, but
demyelinating diseases, neoplasms, granulomas, abscesses, and head injury also may cause
brainstem destruction by tissue compression.
PTS: 1

REF: Page 528

4. What stimulus causes posthyperventilation apnea (PHVA)?

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

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

PTS: 1

REF: Pages 529-530 | Table 17-4

5. Posthyperventilation apnea (PHVA) ceases and rhythmic breathing is resumed when levels of

arterial:
a. Carbon dioxide increase
b. Carbon dioxide become normal

c. Oxygen increase
d. Oxygen decrease

ANS: B

Rhythmic breathing returns when the PCO2 level returns to normal. None of the remaining
options would affect normal rhythmic breathing after PHVA.
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REF: Page 530 | Table 17-4

6. Cheyne-Stokes respirations are described as a:

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

irregular pauses
ANS: B

Cheyne-Stokes respiration is an abnormal rhythm of breathing (periodic breathing) that

alternates between hyperventilation and apnea. Cheyne-Stokes respirations do not include a
sustained deep respiratory rate. Altered inspiratory and expiratory periods are not
characteristic of Cheyne-Stokes respirations. Random, irregular breathing patterns are not
observed during Cheyne-Stokes respirations.
PTS: 1

REF: Pages 529-530 | Page 532 | Table 17-4

7. Vomiting is associated with central nervous system (CNS) injuries that compress which of the

brains anatomic locations?

a. Vestibular nuclei in the lower brainstem
b. Floor of the third ventricle
c. Any area in the midbrain
d. Diencephalon
ANS: A

Vomiting, yawning, and hiccups are complex reflexlike motor responses that are integrated by
neural mechanisms in the lower brainstem. Vomiting often accompanies CNS injuries that
involve the vestibular nuclei. The remaining options will not trigger vomiting when
compressed.
PTS: 1

REF: Page 533

8. Which midbrain dysfunction causes pupils to be pinpoint size and fixed in position?
a. Diencephalon dysfunction
b. Oculomotor cranial nerve dysfunction
c. Dysfunction of the tectum
d. Pontine dysfunction
ANS: D

Pinpoint fixed pupils are a result of pontine dysfunction. The diencephalon, oculomotor
cranial nerve, and tectum are not involved in such a pupil reaction.
PTS: 1

REF: Page 532

9. What characteristic is a medical criterion of brain death?

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

Apnea is viewed as a criterion of brainstem death, whereas the remaining options reflect
cerebral death.
PTS: 1

REF: Pages 533-534

10. A clinical manifestation caused by damage to the lower pons includes an abnormal:
a. Flexion with or without extensor response of the lower extremities
b. Extension response of the upper and lower extremities
c. Extension response of the upper extremities and flexion response of the lower

extremities
d. Flaccid response in the upper and lower extremities
ANS: B

A flaccid state with little or no motor response to stimuli is characteristic of damage to the
pons. None of the other responses are considered a clinical manifestation of damage to the
lower pons.
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REF: Page 534 | Table 17-6

11. Which person is at the greatest risk for developing delirium?

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

Delirium is associated with autonomic nervous system overactivity and typically develops in
2 to 3 days, most commonly in critical care units, postsurgically, or during withdrawal from
CNS depressants (e.g., alcohol, narcotic agents). Age, gender, and chronic illnesses are not
generally associated with delirium triggers.
PTS: 1

REF: Page 545

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

a. Reflex
c. Epilepsy
b. Seizure
d. Convulsion
ANS: B

A sudden, explosive, disorderly discharge of cerebral neurons describes a seizure. This

description is not accurate for the other options.
PTS: 1

REF: Page 550

13. A complex partial seizure is described as:

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

A complex partial seizure results is impaired consciousness, as well as the inability to respond
to exogenous stimuli. None of the other options accurately describe a complex partial seizure.
PTS: 1

REF: Page 552

14. Status epilepticus is considered a medical emergency because of the:

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

Status epilepticus is a true medical emergency because a single seizure can last longer than 30
minutes, resulting in hypoxia of the brain. The other options are not the criteria used to
consider status epilepticus.
PTS: 1

REF: Page 553

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

Although the history may be supplemented with the remaining options, it remains the pivotal
tool for establishing the cause of a seizure disorder.
PTS: 1

REF: Page 555

16. What type of seizure starts in the fingers and progressively spreads up the arm and extends to

the leg?
a. Complex-psychomotor seizure
b. Focal (partial) Jacksonian seizure

c. Generalized seizures
d. Atonic-drop seizure

ANS: B

Focal (partial) Jacksonian seizures most often begin in the face and fingers and then
progressively spread to other body parts. The other options do not begin and spread in the
fashion described.
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REF: Page 551 | Table 17-16

17. What area of the brain mediates the executive attention functions?
a. Limbic
c. Parietal
b. Prefrontal
d. Occipital
ANS: B

The prefrontal areas mediate several cognitive functions, called executive attention functions
(e.g., planning, problem solving, setting goals). The remaining options are not areas involved
with the mediation of executive attention functions.
PTS: 1

REF: Page 538

18. What term describes the loss of the comprehension or production of language?
a. Agnosia
c. Akinesia
b. Aphasia
d. Dysphasia
ANS: B

Aphasia is the loss of the comprehension or production of language. The remaining options
are not terms used to describe this loss of function.
PTS: 1

REF: Page 539

19. With receptive dysphasia (fluent), the individual is able to:

a. Respond in writing, but not in speech.
b. Produce verbal speech, but not comprehend language.
c. Comprehend speech, but not verbally respond.
d. Neither respond verbally nor comprehend speech.
ANS: C

The individual experiencing receptive dysphasia may be able to produce verbal language, but
language is meaningless because of a disturbance in understanding all language. The
remaining options do not describe receptive dysphasia.
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REF: Page 543 | Table 17-10

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

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

Intracranial pressure is normally 5 to 15 mm Hg or 60 to 180 cm water (H2O). The remaining

options reflect increased intracranial pressure.
PTS: 1

REF: Pages 555-556

21. Cerebral edema is an increase in the fluid content of the brains:

a. Ventricles
c. Neurons
b. Tissue
d. Meninges
ANS: B

Cerebral edema is an increase in the fluid content of brain tissue; that is, a net accumulation of
water within the brain. Cerebral edema is not noted in the brains ventricles, neurons, or
meninges.
PTS: 1

REF: Page 557

22. What type of cerebral edema occurs when permeability of the capillary endothelium increases

after injury to the vascular structure?

a. Cytotoxic
b. Interstitial

c. Vasogenic
d. Ischemic

ANS: C

Increased permeability of the capillary endothelium of the brain after injury to the vascular
structure causes vasogenic edema. The remaining options are not consistent with this
description.
PTS: 1

REF: Pages 557-558

23. A communicating hydrocephalus is caused by an impairment of the:

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

Hydrocephalus from impaired absorption outside the ventricles is called communicating

(extraventricular) hydrocephalus. The other options do not accurately describe the cause of a
communicating hydrocephalus.
PTS: 1

REF: Page 558

24. Which edema is most often observed with noncommunicating hydrocephalus?

a. Metabolic
c. Vasogenic
b. Interstitial
d. Ischemic
ANS: B

Interstitial edema is observed most often with noncommunicating hydrocephalus.

Noncommunicating hydrocephalus is not the cause of any of the other options.
PTS: 1

REF: Page 558

25. Which dyskinesia involves involuntary movements of the face, trunk, and extremities?
a. Paroxysmal
c. Hyperkinesia
b. Tardive
d. Cardive
ANS: B

Tardive dyskinesia is the involuntary movement of the face, trunk, and extremities. The other
terms do not describe involuntary movements of the face, trunk, and extremities.
PTS: 1

REF: Page 562

26. Antipsychotic drugs cause tardive dyskinesia by mimicking the effects of increased:
a. Dopamine
c. Norepinephrine
b. Gamma-aminobutyric acid
d. Acetylcholine
ANS: A

The antipsychotic drugs cause denervation hypersensitivity, which mimics the effect of too
much dopamine. None of the other options produce such an affect.
PTS: 1

REF: Page 562

27. The existence of regular, deep, and rapid respirations after a severe closed head injury is

indicative of neurologic injury to the:

a. Lower midbrain
b. Pontine area

c. Supratentorial
d. Cerebral area

ANS: A

Central reflex hyperpnea, which is a sustained deep and rapid but regular respiratory pattern
that is the result of central nervous system (CNS) damage or disease, involves the lower
midbrain and upper pons. This neurologic injury is observed after increased intracranial
pressure and blunt head trauma. Damage to any of the other areas listed would not produce
this breathing pattern.
PTS: 1

REF: Page 530 | Table 17-4

28. What type of posturing exists when a person with a severe closed head injury has all four

extremities in rigid extension with the forearms in hyperpronation and the legs in plantar
extension?
a. Decorticate
c. Spastic
b. Decerebrate
d. Cerebellar
ANS: B

Decerebrate posturing includes opisthotonos (hyperextension of the vertebral column) with

clenching of the teeth; extension, abduction, and hyperpronation of the arms; and extension of
the lower extremities including plantar extension. The other options do not describe such
posturing.
PTS: 1

REF: Page 534 | Page 575 | Table 17-6

29. Since his cerebrovascular accident, a man has been denying his left hemiplegia. What term is

used to describe this finding?

a. Visual agnosia
b. Anosognosia

c. Amusia agnosia
d. Agraphia agnosia

ANS: B

Anosognosia is ignorance or denial of the existence of disease. None of the remaining options
describes such denial.
PTS: 1

REF: Page 542 | Table 17-9

30. After a cerebrovascular accident, a man is unable to either feel or identify a comb with his

eyes closed. This is an example of:

a. Agraphia
b. Tactile agnosia

c. Anosognosia
d. Prosopagnosia

ANS: B

Tactile agnosia is the inability to recognize objects by touch. None of the other options define
the inability to recognize objects by touch.
PTS: 1

REF: Page 542 | Table 17-9

31. Most dysphasias are associated with cerebrovascular accidents involving which artery?
a. Anterior communicating
c. Circle of Willis

b. Posterior communicating

d. Middle cerebral

ANS: D

Dysphasias are usually associated with a cerebrovascular accident involving the middle
cerebral artery or one of its many branches. Damage to or occlusion of any of the other
options does not cause dysphasias.
PTS: 1

REF: Pages 539-540

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

a. Frontotemporal
c. Temporal
b. Parietal
d. Broca area
ANS: B

Tactile agnosia (astereognosis) is the inability to recognize objects by touch as a result of

damage to the parietal lobe. Tactile agnosia is not related to an injury to any of the other
options.
PTS: 1

REF: Page 542 | Table 17-9

33. Neurofibrillary tangles characterize which neurologic disorder?

a. Dementia syndrome
c. Alzheimer disease
b. Delirium
d. Parkinson disease
ANS: C

Amyloid plaques, neurofibrillary tangles, as well as neuronal and synaptic losses in the brain,
characterize Alzheimer disease.
PTS: 1

REF: Pages 546-549 | Table 17-13

34. The body compensates for a rise in intracranial pressure by first displacing the:
a. Cerebrospinal fluid
c. Venous blood
b. Arterial blood
d. Cerebral cells
ANS: A

A rise in intracranial pressure necessitates an equal reduction in the volume of the other
contents. The most readily displaced content of the cranial vault is cerebrospinal fluid (CSF),
not any of the other options.
PTS: 1

REF: Pages 555-556

35. Stage 1 intracranial hypertension is caused by the:

a. Loss of autoregulation that normally maintains constant blood flow during changes

in cerebral perfusion pressure

b. Displacement of cerebrospinal fluid, followed by compression of the cerebral
venous system
c. Vasoconstriction of the cerebral arterial system with reciprocal increase in systemic
blood pressure
d. Compression of the medulla oblongata in the brainstem by herniation of the
cerebral cortex
ANS: B

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

REF: Page 556

36. Dilated and sluggish pupils, widening pulse pressure, and bradycardia are clinical findings

evident of which stage of intracranial hypertension?

c. 3
d. 4

a. 1
b. 2

ANS: C

Stage 3 intracranial hypertension exhibits clinical manifestations that include decreasing

levels of arousal, Cheyne-Stokes respiration or central neurogenic hyperventilation, pupils
that become sluggish and constricted, widened pulse pressure, and bradycardia. These
responses are not characteristic of any other stage.
PTS: 1

REF: Page 556

37. Dilation of the ipsilateral pupil, following uncal herniation, is the result of pressure on which

cranial nerve (CN)?

a. Optic (CN I)
b. Abducens (CN VI)

c. Oculomotor (CN III)

d. Trochlear (CN IV)

ANS: C

The oculomotor CN (III) is involved in this manifestation of pupil dilation. None of the other
options would result in pupil dilation when subjected to pressure.
PTS: 1

REF: Page 557 | Box 17-4

38. Which characteristic is the most critical index of nervous system dysfunction?
a. Size and reactivity of pupils
c. Motor response
b. Pattern of breathing
d. Level of consciousness
ANS: D

Level of consciousness is the most critical clinical index of nervous system function or
dysfunction. An alteration in consciousness indicates either improvement or deterioration of a
persons condition. No other option is used as the critical index of nervous system.
PTS: 1

REF: Page 529

39. Diagnostic criteria for a persistent vegetative state include:

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

Diagnostic criteria for vegetative state (VS) include the return of professed vegetative
(autonomic) functions, including sleep-wake cycles and normalization of respiratory and
digestive system functions. Only the correct option appropriately describes the diagnostic
criteria for a VS.
PTS: 1

REF: Page 534

40. Uncal herniation occurs when:

a. The hippocampal gyrus shifts from the middle fossa through the tentorial notch into

the posterior fossa.

b. The diencephalon shifts from the middle fossa straight downward through the

tentorial notch into the posterior fossa.

c. The cingulate gyrus shifts under the falx cerebri.
d. A cerebellar tonsil shifts through the foramen magnum.
ANS: A

Uncal herniation (i.e., hippocampal herniation, lateral mass herniation) occurs when the uncus
or hippocampal gyrus (or both) shifts from the middle fossa through the tentorial notch into
the posterior fossa. This shift results in the compression of the ipsilateral third cranial nerve
(CN), impairing parasympathetic function. This impairment is carried on in the periphery of
the nerve, then in the contralateral third CN, and finally in the mesencephalon, inducing coma.
The other options do not appropriately describe when uncal herniation occurs.
PTS: 1

REF: Page 557 | Box 17-4

41. Which assessment finding marks the end of spinal shock?

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

A gradual return of spinal reflexes marks the end of spinal shock. The other options are not an
indication of the cessation of spinal shock.
PTS: 1

REF: Pages 570-571

42. Characteristics of primary motor neuron atrophy include:

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

Fasciculations are particularly associated with primary motor neuron injury, and muscle
cramps are common. The other options do not describe characteristics of primary motor
neuron atrophy.
PTS: 1

REF: Pages 571-572

43. The weakness resulting from the segmental paresis and paralysis characteristic of anterior

horn cell injury is difficult to recognize because:

a.
b.
c.
d.

Upper motor neurons are involved.

The injury is microscopic.
Two or more nerve roots supply each muscle.
The person is unable to feel the involved muscles.

ANS: C

The paresis and paralysis associated with anterior horn cell injury are segmental; however,
because two or more roots supply each muscle, the segmental character of the weakness may
be difficult to recognize. The reason this pathophysiologic condition is difficult to recognize is
not appropriately explained by any of the other options.
PTS: 1

REF: Page 571

44. Parkinson disease is a degenerative disorder of the brains:

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

Parkinson disease is a commonly occurring degenerative disorder of the basal ganglia and not
of any of the other brain structures.
PTS: 1

REF: Pages 564-565

45. Clinical manifestations of Parkinson disease are caused by a deficit in which of the brains

neurotransmitters?
a. Gamma-aminobutyric acid
b. Dopamine

c. Norepinephrine
d. Acetylcholine

ANS: B

Parkinson disease is a commonly occurring degenerative disorder involving deficits of

dopamine, not of any of the other options.
PTS: 1

REF: Pages 565-566

46. Tremors at rest, rigidity, akinesia, and postural abnormalities are a result of the atrophy of

neurons in the brains:

a. Caudate that produces serotonin
b. Putamen that produces gamma-aminobutyric acid
c. Substantia nigra that produces dopamine
d. Hypothalamus that produces acetylcholine
ANS: C

The hallmark characteristics of Parkinson disease (PD) are a result of a loss of dopaminergicpigmented neurons in the substantia nigra pars compacta with dopaminergic deficiency in the
putamen portion of the striatum (the striatum includes the putamen and caudate nucleus). The
remaining options are not characteristics of PD.
PTS: 1
MULTIPLE RESPONSE

REF: Pages 565-566

47. Dementia is commonly characterized by the deterioration in which abilities? (Select all that

apply.)
Sociability
Balance
Memory
Speech
Decision making

a.
b.
c.
d.
e.

ANS: C, D, E

Dementia is the progressive failure (an acquired deterioration) of many cerebral functions that
include impairment of intellectual function with a decrease in orienting, memory, language,
executive attentional functions, and alterations in behavior. Loss of the need for social contact
and impaired balance are not associated with dementia, although a person with such a
diagnosis may exhibit these deficiencies.
PTS: 1

REF: Pages 545-546

48. The clinical manifestations of Parkinson disease include: (Select all that apply.)
a. Fragmented sleep
b. Drooping eyelids
c. Depression
d. Muscle stiffness
e. Bradykinesia
ANS: A, C, D, E

The classic motor manifestations of Parkinson disease (PD) are bradykinesia, tremor at rest
(resting tremor), rigidity (muscle stiffness), and postural abnormalities. Nonmotor symptoms
associated with PD include hyponosmia, fatigue, pain, autonomic dysfunction, sleep
fragmentation, depression, and dementia with or without psychosis. Drooping eyelids are not
characteristics of PD.
PTS: 1

REF: Page 566

49. In Parkinson disease the basal ganglia influence the hypothalamic function to produce which

clinical manifestations? (Select all that apply.)

a. Inappropriate diaphoresis
b. Gastric retention
c. Vomiting
d. Diarrhea
e. Urinary retention
ANS: A, B, E

The basal ganglia influence hypothalamic function (autonomic and neuroendocrine) through
pathways connecting the hypothalamus with the basal ganglia and cerebral cortex. Common
autonomic symptoms in Parkinson disease include inappropriate diaphoresis, gastric retention,
constipation, and urinary retention. Neither vomiting nor diarrhea would be clinical
manifestation observed under these circumstances.
PTS: 1

REF: Pages 567-568