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Chapter 15: Alterations in Cognitive Systems, Cerebral Hemodynamics, and Motor

Function
Huether & McCance: Understanding Pathophysiology, 6th Edition

MULTIPLE CHOICE

1. A neurologist explains that arousal is mediated by the:


a. cerebral cortex.
b. medulla oblongata.
c. reticular activating system.
d. cingulate gyrus.
ANS: C
Arousal is mediated by the reticular activating system, which regulates aspects of attention
and information processing and maintains consciousness. The cerebral cortex affects
movement. The medulla oblongata controls things such as hiccups and vomiting. The
cingulate gyrus plays other roles in response.

REF: p. 359

2. A 20-year-old experiences a severe closed head injury as a result of a motor vehicle accident.
Which of the following structures is most likely keeping the patient in a vegetative state (VS)
1 month after the accident?
a. Cerebral cortex
b. Brainstem
c. Spinal cord
d. Cerebellum
ANS: B
When a person loses cerebral function, the reticular activating system and brainstem can
maintain a crude waking state known as a VS. Cognitive cerebral functions, however, cannot
occur without a functioning reticular activating system. A VS is not associated with the
cerebral cortex, spinal cord, or cerebellum.

REF: p. 364

3. A 16-year-olds level of arousal was altered after taking a recreational drug. Physical exam
revealed a negative Babinski sign, equal and reactive pupils, and roving eye movements.
Which of the following diagnoses will the nurse most likely see on the chart?
a. Psychogenic arousal alteration
b. Metabolically induced coma
c. Structurally induced coma
d. Structural arousal alteration
ANS: B
Persons with metabolically induced coma generally retain ocular reflexes even when other
signs of brainstem damage are present. Psychogenic arousal activation demonstrates a general
psychiatric disorder. Structurally induced coma is manifested by asymmetric responses.
Structural arousal alteration does not have drug use as its etiology.
REF: p. 360, Table 15-2

4. The breathing pattern that reflects respirations based primarily on carbon dioxide (CO2) levels
in the blood is:
a. Cheyne-Stokes.
b. ataxic.
c. central neurogenic.
d. normal.
ANS: A
Cheyne-Stokes respirations occur as a result of CO2 levels in the blood. Ataxic breathing
occurs as a result of dysfunction of the medullary neurons. Central neurogenic patterns occur
as a result of uncal herniation. Normal respirations are based on the levels of oxygen (O2) in
the blood.

REF: p. 361

5. A teenager sustains a severe closed head injury following an all-terrain vehicle (ATV)
accident and is in a state of deep sleep that requires vigorous stimulation to elicit eye opening.
How should the nurse document this in the chart?
a. Confusion
b. Coma
c. Obtundation
d. Stupor
ANS: D
Stupor is a condition of deep sleep or unresponsiveness from which a person may be aroused
or caused to open his or her eyes only by vigorous and repeated stimulation. Confusion is the
loss of the ability to think rapidly and clearly and is characterized by impaired judgment and
decision making. Coma is a condition in which there is no verbal response to the external
environment or to any stimuli; noxious stimuli such as deep pain or suctioning do not yield
motor movement. Obtundation is a mild-to-moderate reduction in arousal (awakeness) with
limited response to the environment.

REF: p. 361, Table 15-3

6. A patient experiences a severe head injury hitting a tree while riding a motorcycle. Breathing
becomes deep and rapid but with normal pattern. What term should the nurse use for this
condition?
a. Gasping
b. Ataxic breathing
c. Apneusis
d. Central neurogenic hyperventilation
ANS: D
Central neurogenic hyperventilation is a sustained, deep, rapid, but regular, pattern
(hyperpnea) of breathing. Gasping is a pattern of deep all-or-none breaths accompanied by a
slow respiratory rate. Ataxic breathing is completely irregular breathing that occurs with
random shallow and deep breaths and irregular pauses. Apneusis is manifested by a prolonged
inspiratory pause alternating with an end-expiratory pause.
REF: p. 362, Table 15-4

7. A patient presents to the emergency room (ER) reporting excessive vomiting. A CT scan of
the brain reveals a mass in the:
a. skull fractures.
b. thalamus.
c. medulla oblongata.
d. frontal lobe.
ANS: C
Vomiting is due to disruptions in the medulla oblongata. Skull fractures can result in vomiting
but would not be related to the mass. The thalamus controls other things such as temperature.
The frontal lobe deals with emotions.

REF: p. 363

8. For legal purposes, brain death is defined as:


a. cessation of entire brain function.
b. lack of cortical function.
c. a consistent vegetative state (VS).
d. death of the brainstem.
ANS: A
Brain death occurs when there is cessation of function of the entire brain, including the
brainstem and cerebellum. Lack of cortical function or brainstem death is not enough to define
brain death. A VS is complete unawareness of the self or surrounding environment and
complete loss of cognitive function.

REF: p. 364

9. When thought content and arousal level are intact but a patient cannot communicate and is
immobile, the patient is experiencing:
a.cerebral death.
b.locked-in syndrome.
c.dysphagia.
d.cerebellar motor syndrome.
ANS: B
Locked-in syndrome occurs when the individual cannot communicate through speech or body
movement but is fully conscious, with intact cognitive function. In cerebral death, the person
is in a coma with eyes closed. Dysphagia is difficulty speaking. Cerebellar motor syndrome is
characterized by problems with coordinated movement.

REF: p. 365

10. What term is used to describe an explosive, disorderly discharge of cortical neurons?
a. Reflex
b. Seizure
c. Inattentiveness
d. Brain death
ANS: B
An explosive, disorderly discharge of cortical neurons is a seizure. A reflex is an expected
response. Inattentiveness is a form of neglect. Brain death is a cessation of function.

REF: p. 372

11. A patient has memory loss of events that occurred before a head injury. What cognitive
disorder does the nurse suspect the patient is experiencing?
a. Selective memory deficit
b. Anterograde amnesia
c. Retrograde amnesia
d. Executive memory deficit
ANS: C
Retrograde amnesia is manifested by loss of past personal history memories or past factual
memories. In selective memory deficit, the person reports inability to focus attention and has
failure to perceive objects and other stimuli. Anterograde amnesia is a loss of the ability to
form new memories. Executive memory deficit involves the failure to stay alert and oriented
to stimuli.

REF: p. 365

12. A 65-year-old patient who recently suffered a cerebral vascular accident is now unable to
recognize and identify objects by touch because of injury to the sensory cortex. How should
the nurse document this finding?
a. Hypomimesis
b. Agnosia
c. Dysphasia
d. Echolalia
ANS: B
Agnosia is the failure to recognize the form and nature of objects. Hypomimesis is a disorder
of communication. Dysphasia is an impairment of comprehension of language. Echolalia is
the ability to repeat.

REF: p. 367

13. A patient experiences a stroke and now has difficulty writing and producing language. This
condition is most likely caused by occlusion of the:
a. anterior communicating artery.
b. posterior communicating artery.
c. circle of Willis.
d. middle cerebral artery.
ANS: D
Occlusion of the left middle cerebral artery leads to the inability to find words and difficulty
with writing. The inability to find words and difficulty with writing are not associated with
occlusions of the anterior or posterior communicating arteries or the circle of Willis.

REF: p. 367
14. A patient with an addiction to alcohol checked into a rehabilitation center as a result of
experiencing delirium, inability to concentrate, and being easily distracted. What term would
be used to document this state?
a. Acute confusional state
b. Echolalia
c. Dementia
d. Dysphagia
ANS: A
Delirium and the inability to concentrate are characteristics of acute confusional state.
Echolalia is the repeating of words and phrases. Dementia is characterized by loss of recent
and remote memory. Dysphagia is difficulty speaking.

REF: p. 367, Box 15-3

15. The patient is experiencing an increase in intracranial pressure. This increase results in:
a. brain tissue hypoxia.
b. intracranial hypotension.
c. ventricular swelling.
d. expansion of the cranial vault.
ANS: A
Brain tissue hypoxia occurs as a result of increased intracranial pressure as it places pressure
on the brain. Increased intracranial pressure leads to intracranial hypertension.
Ventricular swelling may lead to increased intracranial pressure, but increased pressure does
not lead to either ventricular swelling or the expansion of the cranial vault.

REF: p. 374

16. A compensatory alteration in the diameter of cerebral blood vessels in response to increased
intracranial pressure is called:
a. herniation.
b. vasodilation.
c. autoregulation.
d. amyotrophy.
ANS: C
Autoregulation is the compensatory alteration in the diameter of the intracranial blood vessels
designed to maintain a constant blood flow during changes in cerebral perfusion pressure.
Herniation is the downward protrusion of the brainstem. Vasodilation is an enlargement in
vessel diameter and a part of autoregulation, but the vessels should not dilate in the presence
of increased intracranial pressure. Amyotrophy is involved with the anterior horn cells of the
spinal cord and not related to autoregulation.

REF: p. 374

17. A patient is admitted to the neurological critical care unit with a severe closed head injury.
When an intraventricular catheter is inserted, the intracranial pressure (ICP) is recorded at 24
mm Hg. How should the nurse interpret this reading?
a. Higher than normal
b. Lower than normal
c. Normal
d. Borderline
ANS: A
Normal ICP is 1-15 mm Hg; at 24 mm Hg, the patients ICP is higher than normal.

REF: p. 374, Box, 15-4

18. A 70-year-old patient is being closely monitored in the neurological critical care unit for a
severe closed head injury. After 48 hours, signs of deterioration occur: pupils are small and
sluggish, pulse pressure is widening, and heart rate is bradycardic. These clinical findings are
evidence of what stage of intracranial hypertension?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: C
Stage 3 is characterized by decreasing levels of arousal or central neurogenic hyperventilation,
widened pulse pressure, bradycardia, and pupils that become small and sluggish. Stage 1 is
characterized by an ICP that may not change because of the effective compensatory
mechanisms, and there may be few symptoms. Stage 2 is characterized by subtle and transient
symptoms, including episodes of confusion, restlessness, drowsiness, and slight pupillary and
breathing changes. Stage 4 is characterized by cessation of cerebral blood flow.

REF: p. 374

19. The primary care provider states that the patient is experiencing vasogenic edema. The nurse
realizes vasogenic edema is clinically important because:
a. it usually has an infectious cause.
b. the blood-brain barrier is disrupted.
c. ICP is excessively high.
d. it always causes herniation.
ANS: B
Vasogenic edema is clinically important because the blood-brain barrier (selective
permeability of brain capillaries) is disrupted, and plasma proteins leak into the extracellular
spaces. Vasogenic edema does not have an infectious cause. ICP is increased, but not more so
than other forms of edema. Vasogenic edema does not always cause herniation.

REF: p. 375

20. The progress notes read: the cerebellar tonsil has shifted through the foramen magnum due to
increased pressure within the posterior fossa. The nurse would identify this note as a
description of _____ herniation.
a. supratentorial
b. central
c. cingulated gyrus
d. infratentorial
ANS: D
In infratentorial herniation, the cerebellar tonsil shifts through the foramen magnum because
of increased pressure within the posterior fossa. Supratentorial herniation involves temporal
lobe and hippocampal gyrus shifting from the middle fossa to posterior fossa. Central
herniation is a type of supratentorial herniation and is the straight downward shift of the
diencephalon through the tentorial notch. Gyrus herniation occurs when the cingulate gyrus
shifts under the falx cerebri. Little is known about its clinical manifestations.

REF: p. 375, Box 15-5

21. An infant is diagnosed with noncommunicating hydrocephalus. What is an immediate priority


concern for this patient?
a. Metabolic edema
b. Interstitial edema
c. Vasogenic edema
d. Ischemic edema
ANS: B
An immediate concern for the infant with noncommunicating hydrocephalus is interstitial
edema. Neither metabolic, vasogenic, nor ischemic edema is observed as a result of
noncommunicating hydrocephalus.

REF: p. 376

22. An adult is diagnosed with communicating hydrocephalus. The form of hydrocephalus in


adults is most often caused by:
a. overproduction of CSF.
b. intercellular edema.
c. elevated arterial blood pressure.
d. defective CSF reabsorption.
ANS: D
Communicating hydrocephalus occurs because of defective reabsorption of the fluid.
Hydrocephalus can occur because of overproduction of CSF, but in adults it occurs most often
because of defective reabsorption of the fluid. Hydrocephalus is not due to either intercellular
edema or elevated arterial blood pressure.

REF: p. 376

23. A 16-year-old male fell off the bed of a pickup truck and hit his forehead on the road. He now
has resistance to passive movement that varies proportionally with the force applied. He is
most likely suffering from:
a. spasticity.
b. paratonia.
c. rigidity.
d. dystonia.
ANS: B
Paratonia is manifested by resistance to passive movement that varies in direct proportion to
force applied. Spasticity is manifested by a gradual increase in tone causing increased
resistance until tone suddenly reduces. Rigidity is manifested by muscle resistance to passive
movement of a rigid limb that is uniform in both flexion and extension throughout the motion.
Dystonia is manifested by sustained involuntary twisting movement.

REF: p. 377, Table 15-16

24. A patient reports tiring easily, having difficulty rising from a sitting position, and the inability
to stand on toes. The nurse would expect a diagnosis of:
a. Parkinson disease.
b. hypotonia.
c. Huntington disease.
d. paresis.
ANS: B
Individuals with hypotonia tire easily (asthenia) or are weak. They may have difficulty rising
from a sitting position, sitting down without using arm support, and walking up and down
stairs, as well as an inability to stand on their toes. Individuals with Parkinson disease have
rigidity and stiffness. Symptoms of Huntington disease include irregular, uncontrolled, and
excessive movement. Paresis, or weakness, is partial paralysis with incomplete loss of muscle
power.

REF: pp. 376-377

25. A patient has paralysis of both legs. What type of paralysis does the patient have?
a. Paraplegia
b. Quadriplegia
c. Infraparaplegia
d. Paresthesia
ANS: A
Paraplegia is the paralysis of both legs. Quadriplegia is the paralysis of all four extremities.
Infraparaplegia is not a description of paralysis. Paresthesia is a loss of sensation, not
paralysis.

REF: p. 382, Box 15-6

26. Spinal shock is characterized by:


a. loss of voluntary motor function with preservation of reflexes.
b. cessation of spinal cord function below the lesion.
c. loss of spinal cord function at the level of the lesion only.
d. temporary loss of spinal cord function above the lesion.
ANS: B
Spinal shock is the complete cessation of spinal cord function below the lesion. The reflexes
are not preserved in spinal shock. Spinal shock is the complete cessation of spinal cord
function below the lesion, not at the lesion only.

REF: p. 382

27. A patient has excessive movement. What disorder will the nurse see documented on the chart?
a. Hypokinesia
b. Akinesia
c. Hyperkinesia
d. Dyskinesia
ANS: C
Excessive movement is the definition of hyperkinesia. Hypokinesia is decreased movement.
Akinesia is loss of movement. Dyskinesia is abnormal movement.

REF: p. 378

28. A 40-year-old male complains of uncontrolled excessive movement and progressive


dysfunction of intellectual and thought processes. He is experiencing movement problems that
begin in the face and arms and eventually affect the entire body. The most likely diagnosis is:
a. tardive dyskinesia.
b. Huntington disease.
c. hypokinesia.
d. Alzheimer disease.
ANS: B
Huntington disease is manifested by chorea, abnormal movement that begins in the face and
arms and eventually affects the entire body. There is progressive dysfunction of intellectual
and thought processes. Tardive dyskinesia is manifested by rapid, repetitive, and stereotypic
movements. Most characteristic is continual chewing with intermittent protrusions of the
tongue, lip smacking, and facial grimacing. Hypokinesia is a loss of voluntary movement
despite preserved consciousness and normal peripheral nerve and muscle function. Alzheimer
disease is manifested by cognitive deficits and not movement problems; motor impairments
will occur in the later stages.

REF: p. 378 | p. 380

29. A nurse notes that a patient walks with the leg extended and held stiff, causing a scraping over
the floor surface. What type of gait is the patient experiencing?
a. Spastic gait
b. Cerebellar gait
c. Basal ganglion gait
d. Scissors gait
ANS: A
An individual who walks with the leg extended and held stiff, causing a scraping over the
floor surface, is experiencing a spastic gait. A cerebellar gait is wide based with the feet apart
and often turned outward or inward for greater stability. A basal ganglion gait occurs when the
person walks with small steps and a decreased arm swing. A scissors gait is associated with
bilateral injury and spasticity. The legs are abducted so they touch each other.

REF: p. 385

30. A patient is admitted to the neurological critical care unit with a severe closed head injury. All
four extremities are in rigid extension, the forearms are hyperpronated, and the legs are in
plantar extension. How should the nurse chart this condition?
a. Decorticate posturing
b. Decerebrate posturing
c. Dystonic posturing
d. Basal ganglion posturing
ANS: B
The description is of a patient in decerebrate posturing. The description provided is not
associated with decorticate, dystonic, or basal ganglion posturing.

REF: p. 385

MULTIPLE RESPONSE

1. A nurse recalls that neural systems basic to cognitive functions include _____ systems. (select
all that apply)
a. attentional
b. memory and language
c. affective
d. sensory and motor
e. tactile
ANS: A, B, C
The neural systems that are essential to cognitive function are: (i) attentional systems that
provide arousal and maintenance of attention over time; (ii) memory and language systems by
which information is communicated; and (iii) affective or emotive systems that mediate mood,
emotion, and intention. The sensory, motor, and somatic systems are not involved. The tactile
system is not involved in cognitive functioning.

REF: p. 359

2. The nurse is explaining clinical manifestations of alterations in the extrapyramidal system.


The nurse would correctly include: (select all that apply)
a.little or no paralysis of voluntary movement.
b.normal or slightly increased tendon reflexes.
c.positive (present) Babinski.
d.presence of tremor.
e.rigidity in muscle tone.
ANS: A, B, D, E
The patient will experience little or no paralysis of voluntary movement. The patient will
experience normal or slightly increased deep tendon reflexes. Babinski will be negative
(absent). Tremor will be present. Rigidity of muscle tone occurs intermittently.

REF: p. 386, Table 15-19