Questions 187189

A 56-year-old woman experiences a loss of taste affecting the front of her tongue and the ability to smile as a result of an infection.

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187. If the sensory loss involves damage of cell bodies, the specific group of neurons so affected would be the a. Otic ganglion b. Nodose (inferior) ganglion c. Pterygopalatine ganglion d. Geniculate ganglion e. Trigeminal ganglion

188. The cranial nerve most immediately affected is a. Nerve V

b. Nerve VI

c. Nerve VII

d. Nerve IX

e. Nerve X

189. The components of the nerve that is affected include a. General somatic afferent and general somatic efferent b. Special visceral afferent and special visceral efferent c. General visceral afferent and general somatic efferent d. General somatic afferent and general visceral efferent e. Special visceral afferent and general visceral efferent

Questions 190-193

A 55-year-old man, who has been suffering from hypertension for the past 8 years, experiences attacks of pain in the regions of the pharynx and ear, which are usually preceded by swallowing and coughing spells. Each attack, which lasted for an average of 1 minute, occurred a number of times; ultimately, this condition showed remission. Although the neurological examination was basically normal, a subsequent MRI was taken and revealed an abnormality at the base of the skull.

190. The most likely cranial nerve involved in this disorder is a. Nerve V

b. Nerve VII

c. Nerve IX

d. Nerve XI

e. Nerve XII

191. The motor component of this cranial nerve arises from the a. Otic ganglion b. Nodose ganglion c. Nucleus ambiguus d. Inferior salivatory nucleus e. Lateral reticular nucleus

192. The cell bodies of the sensory component of the affected nerve are located in the a. Solitary nucleus b. Superior ganglion c. Geniculate ganglion d. Vestibular nuclei e. Trigeminal ganglion

193. The motor and sensory components of this nerve that were affected are respectively characterized as a. General visceral efferent and general visceral afferent b. Special visceral efferent and general somatic afferent c. General somatic efferent and special visceral afferent d. Special visceral efferent and special visceral afferent e. General somatic efferent and general somatic afferent

Questions 194-195

In a classic experiment performed by Sherrington in the cat, marked rigidity was demonstrated in a decerebrate preparation. Similarly, an 80-year-old woman displayed rigidity, which resembled that shown in the cat after having a stroke.

194. The likely location of the stroke is in the a. Thalamus b. Hypothalamus c. Upper midbrain d. Pons e. Spinal cord

195. The rigidity can be accounted in part by the unopposed action of the a. Rubrospinal tract b. Lateral vestibulospinal tract c. Corticospinal tract d. Medial vestibulospinal tract e. Lateral reticulospinal tract

Questions 196-198

A 43-year-old male is recovering from an infectious disease and experiences a marked instability in his blood pressure with episodes of spiking of blood pressure. After a series of extensive examinations, it was concluded that this disorder was due to the effects of the infectious agent upon a component of the peripheral nervous system.

196. Logical sites where an infectious agent could produce such an effect include the a. Superior ganglia of cranial nerves IX and X

b. Geniculate and trigeminal ganglia c. Otic and superior salivatory ganglia d. Carotid sinus and aortic arch e. Carotid and aortic bodies

197. The (appropriate) receptors situated in the sites listed in question 196 respond best to:

a. Stretch b. Change in chloride ion concentration c. Contractions of the gut d. Decrease in oxygen concentration e. Increase in carbon dioxide concentration

198. Neurons situated in the (appropriate) sites indicated in question 196 mediate their effects by projecting directly to the:

a. Trigeminal spinal nucleus b. Fastigial nucleus c. Midbrain reticular formation d. Solitary nucleus e. Autonomic nuclei of the facial nucleus (cranial nerve VII)

199. An individual has difficulty in adjusting his head, especially after he changes his posture. The most likely pathway affected that might cause this deficit is the a. Lateral vestibulospinal tract b. Medial vestibulospinal tract c. Medial reticulospinal tract d. Lateral reticulospinal tract e. Rubrospinal tract

Questions 200-202

An individual experiences an ipsilateral paralysis of the soft palate and pharynx, producing hoarseness and dysphagia (inability to swallow) and, in addition, displays a loss of the carotid sinus reflex.

200. The nerve group most likely affected is the a. Cranial nerve XII

b. Cranial nerve XI

c. Cranial nerve X

d. Cranial nerve VII

e. Ventral horn cells of the cervical cord

201. The most probable nuclei damaged in this case include the a. Solitary and lateral reticular nuclei b. Deep pontine and facial nuclei c. Dorsal motor nucleus and nucleus ambiguus d. Ventral horn of the cervical segment of the spinal cord e. Inferior salivatory and medial vestibular nuclei

202. The neurons associated with the loss of functions described in this case can be characterized as a. General somatic efferent and special visceral efferent b. General visceral efferent and special visceral efferent c. General somatic efferent and general visceral efferent d. General visceral efferent and general visceral afferent e. Special visceral efferent and special visceral afferent

203. A patient complains that he cannot move his right eye to the right and that the right side of his face is expressionless. The likely locus of the lesion is the a. Dorsal aspect of the medulla b. Ventromedial medulla c. Dorsal pons d. Ventromedial pons e. Medial midbrain

204. Upon examination, the patient is unable to move his right eye medially. The lesion is likely to be located in the a. Dorsal medulla b. Ventromedial medulla c. Dorsal pons d. Ventromedial pons e. Medial midbrain

Questions 205-207

The patient experiences difficulty in walking down stairs and reports some double vision as well.

205. In this instance, the lesion is most likely located in the




Dorsal pons


Ventromedial pons




Spinal cord

206. The lesion involved the a. Cervical spinal cord ventral horn cells b. Cranial nerve VII

c. Cranial nerve VI

d. Cranial nerve IV

e. Cranial nerve III

207. This nerve is classified as a a. General somatic efferent b. Special visceral efferent c. General visceral efferent d. Combined general visceral and somatic efferent e. Combined general visceral and special visceral efferent

208. Principal afferent fiber systems that supply the inferior olivary nucleus include the a. Hypothalamus and amygdala b. Caudate nucleus and subthalamic nucleus c. Solitary nucleus and nucleus of the ventrolateral medulla d. Red nucleus and spinal cord e. Deep pontine nuclei and vestibular nuclei

209. The principal projection target of the inferior olivary nucleus is the a. Cerebral cortex b. Midbrain periaqueductal gray c. Vestibular nuclei d. Dorsal column nuclei e. Cerebellar cortex

Questions 210-211

An elderly female patient complains that she cannot taste the food that she eats. A careful neurological examination reveals no evidence of peripheral damage of the taste receptors. The evidence suggests, instead, that there was selective damage of certain regions of the brainstem.

210. One of the sites where damage could result in the selective loss of taste includes the a. Superior olivary nucleus b. Inferior salivatory nucleus c. Solitary nucleus d. Spinal nucleus of the trigeminal nerve e. Reticular tegmental nucleus of the pons

211. A principal target of the brainstem structure (referring to the answer to the previous question) is the a. Anterior thalamic nucleus b. Reticular thalamic nucleus c. Ventral posteromedial thalamic nucleus d. Ventrolateral thalamic nucleus e. Dorsomedial thalamic nucleus

Questions 212-215

A 68-year-old woman had suffered from an infectious disorder for several weeks. Following recovery from this disorder, she experienced some loss of taste and an increase in salivation, together with pain spasms in the region of the pharynx, which extended into the ear. She also experienced some bradycardia and cardiac arrhythmia, as well as deviation of the uvula to the unaffected side.

212. The cranial nerve most directly involved in this deficit is a. Cranial nerve VII

b. Cranial nerve IX

c. Cranial nerve X

d. Cranial nerve XI

e. Cranial nerve XII

213. The cell bodies of origin of the nerve fibers that directly innervate the organ responsible for an increase in salivation are called the a. Inferior salivatory nuclei b. Superior salivatory nuclei c. Otic ganglion d. Geniculate ganglion e. Nucleus ambiguus

214. The origin of the fibers that were affected causing deviation of the uvula is the:

a. Solitary nucleus b. Inferior salivatory nucleus c. Facial nucleus d. Nucleus ambiguus e. Dorsal motor nucleus of the vagus

215. The likely site of the lesion affecting this nerve is in the:

a. Upper medulla b. Lower medulla c. Lower pons d. Upper pons e. Base of the skull

Questions 216-218

A 40-year-old male who had been suffering from a disorder of unknown origin complains to his physician that he has difficulty in producing a smile from the left side of his face, and that he can't salivate or produce tears from the left eye. Further analysis showed some loss of taste and that the affected muscles were flaccid and the eyelids were open.

216. The cell bodies of origin within the central nervous system (CNS) whose peripheral innervation of skeletal muscles were affected by this disorder lie in the a. Upper medulla b. Lower pons c. Upper pons d. Lower midbrain e. Upper midbrain

217. The preganglionic parasympathetic fibers of this nerve arise from the a. Dorsal motor nucleus of the vagus b. Nucleus ambiguus c. Inferior salivatory nucleus d. Superior salivatory nucleus e. Edinger-Westphal nucleus of cranial nerve III

218. Where is the most likely locus of this lesion?

a. Nucleus of the facial nerve b. Inferior and superior ganglia of cranial nerve IX

c. Geniculate ganglion d. Cerebral cortex e. Reticular formation

DIRECTIONS: Each group of questions below consists of lettered options followed by a set of numbered items. For each numbered item, select the one lettered option with which it is most closely associated. Each lettered option may be used once, more than once, or not at all.

Questions 219-223

Match each type of cell or fiber with the appropriate site.

219. Cells in this structure respond to movement of the lower limb

220. Cells in this structure respond to a vibratory stimulus applied to the hand

221. Fibers in this region mediate reflexes associated with the head

222. First-order pain and temperature fibers are found here

223. These fibers mediate conscious proprioception and two-point discrimination from the opposite side of the body

Questions 224-232

Match each description with the appropriate site.



224. This nucleus responds to taste impulses

225. Neurons respond to vestibular inputs and project to the spinal cord

226. Neurons receive inputs from the red nucleus and spinal cord

227. Neurons respond to changes in blood pressure

228. Neurons contribute the largest number of fibers that are contained in the inferior cerebellar peduncle

229. This nucleus participates in the gag reflex

230. Neurons mediate voluntary control of motor functions

231. This nucleus innervates muscles of the tongue

232. Fibers in this bundle arise from the spinal cord and the brainstem and project directly to the cerebellum

Questions 233-238

Match each description with the appropriate site.

233. Neurons that project to the reticular formation

234. Neurons that project to the vestibular nuclei

235. Neurons that project to the ventrolateral nucleus of the thalamus

236. Neurons that project primarily to the red nucleus

237. Structure that receives inputs from the vermal region of the cerebel-lar cortex

238. Neurons that receive inputs from the lateral aspects of the cerebellar hemispheres

Questions 239-245

Match each description with the correct site.

239. This structure receives direct inputs from the vestibular apparatus

240. These fibers arise from vestibular nuclei

241. This structure transmits taste impulses to the thalamus

242. This structure is a general somatic efferent nucleus

243. These fibers arise from the dorsal column nuclei

244. These fibers transmit pain and temperature signals from the region of the head to the thalamus

245. These fibers convey muscle spindle afferents to the cerebellum

Questions 246-250

Match each structure with the correct site.

246. Axons that are second-order corticocerebellar neurons

247. Lower motor neurons (LMNs)

248. Upper motor neurons (UMNs)

249. Axons that terminate, in part, in the ventrolateral thalamic nucleus

250. Somatotopically organized sensory pathways

Questions 251-255

Match each structure with the correct site.

251. Sensory relay nucleus

252. Fibers that arise from the contralateral dentate and interposed nuclei

253. Fibers that arise from the cerebral cortex

254. Nucleus that receives inputs from vestibular structures

255. Structure that is rich in enkephalin-positive cells and nerve terminals

Questions 256-260

Match each description with the appropriate site.

256. Site of neurons that respond to moving stimuli

257. Specific relay nucleus

258. Source of dopaminergic innervation of the striatum

259. Nucleus that receives direct inputs from the cerebellum and cerebral cortex

260. LMNs

DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.

261. Which of the following statements concerning the spinal trigeminal nucleus is correct?

a. It receives direct inputs from first-order descending sensory fibers contained in the ipsilateral spinal tract of cranial nerve V

b. It projects its axons mainly contralaterally to the ventral posterolateral nucleus of the thalamus c. Cells contained in the most caudal aspect of this nucleus respond mainly to mechanical and tactile stimuli d. It receives inputs from primary afferent fibers entering the spinal cord at levels C3 and C4

e. It contains cells whose axons project to the hypothalamus

262. Which of the following features concerning the area postrema is true?

a. It is located in the ventral medulla at a position that is caudal to the fourth ventricle b. It is considered part of the brain because the cells of this structure are protected by the blood-brain barrier c. It plays a role in the regulation of emetic functions d. The cells synthesize norepinephrine e. It receives major inputs from the forebrain

263. The vagus nerve (cranial nerve X) includes which of the following components?

a. General somatic afferent, special visceral afferent, general visceral afferent, and general visceral efferent b. Special visceral afferent, special sensory afferent, general visceral afferent, and general visceral efferent c. General visceral afferent and general visceral efferent only d. General visceral efferent and special visceral efferent only e. Special visceral efferent, general visceral efferent, and general visceral afferent only

264. Lesions involving the dorsolateral medulla can produce a. Loss of pain and thermal sensation on the contralateral half of the face b. Loss of pain and temperature sensation on the ipsilateral side of the body c. Dysphonia d. Hemiparesis e. Intention tremor

265. Which of the following statements concerning the olivocochlear bundle is correct?

a. It arises from the inferior olivary nucleus and projects to the cochlea b. Stimulation of it inhibits acoustic fiber responses to auditory stimuli c. It communicates directly with the medial lemniscus d. It can be seen easily in brainstem sections taken from the upper pons e. It is part of the ascending auditory pathway to the dorsal cochlea nucleus

266. Unilateral deafness may result from a lesion of a. The auditory cortex of one side b. The lateral lemniscus of one side c. Cranial nerve VIII on one side d. The medial geniculate e. The medial lemniscus

267. Which of the following contains first-order sensory neurons with their cell bodies located within the CNS?

a. Geniculate ganglion b. Spiral ganglion c. Mesencephalic nucleus of cranial nerve V

d. Solitary nucleus e. Scarpa's ganglia

268. In a lateral gaze paralysis, both eyes are conjugatively directed to the side opposite the lesion. In this condition, the locus of the lesion is the a. Root fibers of cranial nerve III

b. Nucleus of cranial nerve III

c. Root fibers of cranial nerve VI

d. Nucleus of cranial nerve VI

e. Nucleus and root fibers of cranial nerve IV

269. Which of the following statements concerning the paramedian pon-tine reticular formation is true?

a. It projects fibers directly to the hypoglossal nucleus b. Bilateral lesions cause a partial deafness c. It projects its fibers to the basal ganglia d. It is a critical site for the integration of impulses regulating vertical and horizontal gaze e. It is a major site of noradrenergic fibers that project to the forebrain

270. A patient displays an ipsilateral paralysis of lateral gaze coupled with a contralateral hemiplegia. A lesion is most likely situated in the a. Ventromedial medulla b. Dorsomedial medulla c. Ventrocaudal pons d. Dorsorostral pons e. Ventromedial midbrain

271. Which of the following cranial nerves all carry special visceral afferent fibers?

272. A patient displays the following constellation of symptoms: UMN paralysis of the left leg, paralysis of the lower half of the left side of the face, and a left homonymous hemianopsia. The lesion is most likely located in





Basilar pons


Pontine tegmentum





273. When a patient is asked to follow an object when it is placed in the right side of his visual field, he is unable to move his right eye either up or down. The lesion is most likely situated in the a. Medulla b. Basilar aspect of the pons c. Pontine tegmentum d. Midbrain e. Cerebellum

274. A patient is capable of displaying pupillary constriction during an accommodation reaction but not in response to a direct-light stimulus. The lesion is most likely present in the a. Optic nerve b. Ventral cell column of cranial nerve III

c. Pretectal area d. Visual cortex e. Edinger-Westphal nucleus of cranial nerve III

275. Structures associated with the taste pathway include the a. Geniculate ganglion, chorda tympani, and medial lemniscus b. Solitary nucleus, parabrachial nucleus, and ventral posteromedial nucleus c. Solitary nucleus, ventral posterolateral nucleus, and postcentral gyrus d. Solitary nucleus, ventral posteromedial nucleus, and superior parietal lobule e. Geniculate ganglion and ventral posterolateral nucleus

Questions 276-279

276. The lesion at A most likely resulted from an occlusion of the a. Basilar artery b. Superior cerebellar artery c. Anterior spinal artery d. Vertebral artery e. Posterior inferior cerebellar artery

277. The lesion at B is most likely the result of an occlusion of the a. Paramedian branch of the basilar artery b. Circumferential branch of the basilar artery c. Superior cerebellar artery d. Anterior inferior cerebellar artery e. Anterior spinal artery

278. Structures affected by the lesion at B include a. Medial lemniscus b. Lateral lemniscus c. Corticospinal tract d. Medial longitudinal fasciculus e. Tectospinal tract

279. The lesion at B would most likely result in which of the following deficits?

a. Paralysis of the contralateral limbs b. Loss of conscious proprioception of the contralateral side of the body c. Nystagmus d. Lateral gaze paralysis e. Facial paralysis

Questions 280-282

280. A patient with the lesion at A will generally show which of the following deficits?

a. Partial blindness b. Loss of ability to gaze medially c. Loss of ability to show tracking movements d. Loss of accommodation reflex e. Nystagmus

281. Which of the following deficits is likely to occur as a result of the lesion at B?

a. Contralateral loss of conscious proprioception b. Transient tremor of the ipsilateral limb c. Ipsilateral fourth-nerve palsy d. Hearing loss e. Contralateral loss of taste sensation

282. The deficits associated with the lesion at C are the result of damage to the a. Substantia nigra and crus cerebri b. Red nucleus and crus cerebri c. Crus cerebri and cranial nerve III

d. Red nucleus and substantia nigra e. Substantia nigra and cranial nerve III

283. Which of the following statements best describes the regions of the ventral tegmental area and pars compacta of the substantia nigra?

a. Both regions contain dopaminergic neurons but project to different populations of forebrain structures b. Both regions provide converging dopaminergic inputs to the hypothalamus c. Both regions provide converging dopaminergic inputs to the neostriatum d. Both regions are innervated by GABAergic fibers and project to the cerebral cortex e. Lesions of either region result in the development of a parkinsonian-like syndrome

284. The principal ascending auditory pathway of the brainstem is the a. Medial lemniscus b. Lateral lemniscus c. Trapezoid body d. Trigeminal lemniscus e. Brachium of the superior colliculus

Questions 285-289

Emma is a 64-year-old woman who has had heart disease for many years. While carrying chemicals down the stairs of the dry-cleaning shop where she worked, she suddenly lost control of her right leg and arm. She fell down the stairs and was able to stand up with some assistance from a coworker. When attempting to walk on her own, she had a very unsteady gait, with a tendency to fall to the right side. Her supervisor asked her if she was all right, and noticed that her speech was very slurred when she tried to answer. He called an ambulance to take her to the nearest hospital. The physician who was called to see Emma in the emergency room noted that her speech was slurred as if she were intoxicated, but the grammar and meaning were intact. Her face appeared symmetric, but when asked to pro-

trade her tongue, it deviated toward the left. She was unable to tell if her right toe was moved up or down by the physician when she closed her eyes, and she couldn't feel the buzz of a tuning fork on her right arm and leg. In addition, her right arm and leg were markedly weak. The physician could find no other abnormalities on the remainder of Emma's general medical examination.

285. Where in the nervous system has the damage occurred?

a. Right lateral medulla b. Occipital lobe c. Left lateral medulla d. Right cervical spinal cord e. Left medial medulla

286. Where in the nervous system could a lesion occur that causes arm and leg weakness, but spares the face?

a. Right corticospinal tract in the cervical spinal cord b. Left inferior frontal lobe c. Left medullary pyramids d. Occipital lobe e. Both A and C are plausible sites

287. Other than the weakness on her right side, what type of deficit could cause Emma's gait problem, and where could a lesion causing this deficit occur?

a. Proprioceptive, left medial lemniscus b. Sight, left eye c. Descending component of the medial longitudinal fasciculus d. Pain, left spinothalamic tract e. Proprioceptive, right medial lemniscus

288. Deviation of the tongue to the left, away from the right hemiparesis, implies a lesion in which area of the nervous system?

a. Right hypoglossal nucleus b. Left hypoglossal nucleus c. Right inferior frontal lobe d. Left inferior frontal lobe e. Right cerebral peduncle

289. What type of speech problem does Emma have?

a. Broca's aphasia b. Wernicke's aphasia c. Mixed aphasia d. Dysarthria e. Agnosia

Questions 290-294

Julie is a 29-year-old office worker with diabetes, who awoke one morning with the inability to close her left eye and a left facial droop. Her left eye felt a bit dry, as well. She had run out of sick days and, hoping that the problem would go away, went to work. After several coworkers noticed that her face was drooping and that she was especially sensitive to loud noises on her left side, they convinced her to go to the nearest emergency room in order to make sure that she did not have a stroke. She was examined right away in the emergency room because of her age. The doctor noted right away that her mouth drooped on the left side. Her left eye was slightly closed. He tested her speech and mental status, which were normal, other than some slight slurring of her speech. Her vision and eye movements were also normal. Sensation and jaw movement were also normal, but when she was asked to wiggle her eyebrows, only the right side of her forehead moved. When asked to close her eyes tightly, and not allow him to open her eyes, her right eye would not open, but her left eye could not oppose the force. She was not able to hold air in her cheeks when asked to hold her breath, and when asked to smile, only the right side of her mouth elevated. She was very sensitive to noise on her left side. When asked to protrude her tongue, it did not deviate to either side, but if she closed her eyes and sugar water was placed on the left side of the anterior portion of her tongue, she could not identify it. The remainder of her examination was normal. A nurse asked if a head CT should be ordered in order to look for a stroke or tumor, but the doctor said that it wasn't necessary. He told Julie that he would draw some blood and give her a medication to take for a while.

290. Assuming that the doctor was correct, and that this isn't a stroke, where in the nervous system has the damage occurred?

a. Buccinator muscle b. Trigeminal nerve c. Facial nerve d. Glossopharyngeal nerve e. Hypoglossal nerve

291. Julie's facial weakness is characteristic of a. A muscle lesion b. A lesion of the internal capsule c. A superior brainstem lesion d. A UMN seventh-nerve lesion e. An LMN seventh-nerve lesion

292. Damage to which area may have produced the defect in taste in the anterior two-thirds of her tongue?

a. Intermediate nerve b. Glossopharyngeal nerve c. Lingual nerve d. Facial nerve, distal to the chorda tympani nerve e. Facial nerve, proximal to the chorda tympani nerve

293. Assuming that Julie had no prior problems with her ears or cochlear nerve, damage to the nerve supply of which muscle could cause the sensitivity to or distortion of noises?

a. Digastric b. Platysma c. Buccinator d. Geniohyoid e. Stapedius

294. If Julie did not have the loss of taste and noise sensitivity, but did have the inability to move her left eye to the left, which area would now be damaged?

a. The trigeminal and abducens nerves b. The facial and trigeminal nerves, distal to their exit from the brainstem c. The facial and abducens nerve nuclei within the pons d. The facial nerve, distal to the chorda tympani nerve e. The facial nerve, distal to the geniculate ganglion

Questions 295-299

A second-year medical student was asked to see a nursing home patient as a requirement for a physical diagnosis course. The patient was a 79-year-old man who was apparently in a coma. The student wasn't certain of how to approach this case, so he asked the patient's wife, who was sitting at the bedside, why this patient was in a coma. The wife replied: "Oh, Paul isn't in a coma. But he did have a stroke." Slightly confused, the student leaned over and asked Paul to open his eyes. He opened his eyes immediately. However, when asked to lift his arm or speak, Paul did nothing. The student then asked Paul's wife if she was certain that his eye opening was not simply a coincidence, and that he really was in a coma, since he was unable to follow any commands. Paul's wife explained that he was unable to move or speak as a result of his stroke. However, she knew that he was awake, because he could communicate with her by blinking his eyes. The student appeared rather skeptical, so Paul's wife asked her husband to blink once for "yes" and twice for "no." She then asked him if he were at home and he blinked twice. When asked if he were in a nursing home, he blinked once. The student then asked him to move his eyes, and he was able to look in his direction. However, when the student asked him if he could move his arms or legs, he blinked twice. He also blinked twice when asked if he could smile. He did the same when asked if he could feel someone moving his arm. The student thanked Paul and his wife for their time, made notes of his findings, and returned to class.

295. Where in the nervous system could a lesion occur that can cause paralysis of the extremities bilaterally, as well as the face, but not of the eyes?

a. High cervical spinal cord bilaterally b. Bilateral thalamus c. Bilateral basal ganglia d. Bilateral pontine tegmentum e. Bilateral frontal lobe

296. An infarct in what vascular distribution could cause this lesion?

a. Anterior spinal artery b. Vertebral artery c. Basilar artery d. Middle cerebral artery e. Posterior cerebral artery

297. Damage to which tracts caused Paul's inability to move his arms and legs?

a. Corticospinal and corticobulbar tracts b. Spinothalamic tract c. Solitary tract d. Superior cerebellar peduncle e. Inferior cerebellar peduncle

298. Damage to which tract caused Paul's lack of perception of someone moving his arm?

a. Corticospinal and corticobulbar b. Middle cerebellar peduncle c. Spinothalamic tract d. Rubrospinal tract e. Medial lemniscus

299. What area is spared to preserve consciousness?

a. Deep frontal white matter b. Pontine reticular formation c. Temporal lobes d. Prefrontal cortex e. Occipital lobe

Questions 300-304

Herb, a 62-year-old man who has smoked two packs of cigarettes per day for 35 years, was suffering from a chronic cough that was attributed to smoking habit by his physician. One day, Herb noticed that his right eyelid drooped slightly and that his right pupil was smaller than the left. He also noticed that the inner side of his right hand was numb and that he had begun to drop things from his right hand. He had no other symptoms. Herb consulted his physician who directed him to a neurologist.

The neurologist noted that although the right pupil was smaller than the left, it was still reactive to light. Although Herb's right eyelid drooped slightly, he could close his eyes tightly when asked to do so. The neurologist noted that Herb did not sweat on the right side of his face. He was unable to feel a pinprick on the inner surface of his right hand, and his right triceps and hand muscles were weak.

300. Where in the nervous system has damage occurred?

a. Left oculomotor nerve b. Right oculomotor nerve c. Edinger-Westphal nucleus d. Sympathetic fibers coursing from the hypothalamus to the intermediolateral cell column e. Parasympathetic fibers coursing from the Edinger-Westphal nucleus

301. Herb's small pupil is due to a. Unopposed action of the muscles with parasympathetic innervation b. Unopposed action of the muscles with sympathetic innervation c. Both sympathetic and parasympathetic damage d. A lesion in the nucleus of the third nerve e. A lesion distal branches of the trochlear nerve

302. Why was Herb able to close his eye tightly, despite a drooping eyelid?

a. The facial nerve does not innervate muscles mediating eye closure b. The facial nerve is only partially affected c. The facial nerve is unaffected by this lesion d. The trigeminal nerve compensates for eye closure e. This lesion only affects involuntary eye closure

303. Which pair of neurotransmitters is involved in the pathway that has been damaged?

a. Substance P and acetylcholine (ACh)

b. Norepinephrine and epinephrine c. 5-HT and GABA

d. GABA and ACh e. ACh and norepinephrine

304. Damage to which fibers caused the numbness and weakness of his hand?

a. Damage to the ipsilateral cerebral peduncle b. Damage to the corticospinal tract c. Damage to the cervical spinal roots entering the brachial plexus d. Infarction of the basilar artery e. Damage to the median nerve

Questions 305-309

Mike is a 35-year-old man who had optic neuritis (an inflammation of the optic nerve causing blurred vision) several years before. He was told that he had a 50% chance of eventually developing multiple sclerosis (MS), a degenerative disease of the CNS white matter. One day, he noticed that he had double vision and felt weak on his right side. Although he noted that the symptoms were becoming steadily worse throughout the day, he attributed this to stress from his job as a stockbroker, and in order to relax, he decided to take a drive in his car. While he was driving, his vision became steadily worse. As he was about to pull over to the side of the road, he saw two trees on the right side of the road. Uncertain which was the actual image, he attempted to place his right foot on the break pedal. Mike suddenly realized that he was unable to lift his right leg, and his car collided with the tree. A pedestrian on the side of the road called the EMS, and Mike was brought to a nearby emergency room.

A neurologist was called to see Mike because the emergency room physicians thought he may have had a stroke, despite his young age. The neurologist spoke to Mike, then examined him. He found that his left eye was deviated to the left and down. When he attempted to look to his right, his right eye moved normally, but his left eye was unable to move further to the right than the midline. His left pupil was dilated and did not contract to light from a penlight. His left eyelid drooped, and he had difficulty raising it. In addition, the right side of his mouth remained motionless when he attempted to smile, but his forehead was symmetric when he raised his eyebrows. Mike's right arm and leg were markedly weak. The neurologist told Mike that he wasn't certain that this was necessarily a stroke, but admitted him to the hospital for observation and tests.

305. A lesion in which nerve caused Mike's double vision?

a. Optic nerve b. Oculomotor nerve c. Cervical sympathetic fibers d. Trochlear nerve e. Abducens nerve

306. Damage to which nerve innervating which eye muscles caused Mike's eye to be deviated toward the left side and down?

a. Superior rectus, superior oblique, inferior rectus, inferior oblique b. Superior rectus, inferior rectus, inferior oblique, lateral rectus c. Superior rectus, inferior rectus, inferior oblique, medial rectus d. Lateral rectus, superior oblique, medial rectus, inferior rectus e. Lateral rectus, superior oblique, inferior oblique, medial rectus

307. Where in the nervous system did the damage occur?

a. Left frontal lobe b. Right frontal lobe c. Left eye d. Cervical spinal cord e. Midbrain

308. Damage to which fibers caused the enlarged, unreactive pupil on the left?

a. Medial longitudinal fasciculus b. Frontal or pontine eye fields c. Edinger-Westphal nucleus or preganglionic parasympathetic fibers d. Trochlear nerve e. Cervical sympathetic fibers

309. Damage to which area caused Mike's weakness?

a. Left precentral gyrus b. Right precentral gyrus c. Left cervical spinal cord d. Right cervical spinal cord e. Left cerebral peduncle

Questions 310-314

A 17-year-old high school football player presented to a neurology clinic because his mother thought that he may have acquired neck problems during a game. A month before, he had sustained a concussion from a blow to his head from another player. Shortly after, she noted that he intermittently tilted his head to the side. When asked what was the matter, he simply said that sometimes he had double vision, and that the images were situated on top of each other vertically, making it difficult to go down stairs.

When examined, there was no neck pain or limitation of motion. He tended to keep his head tilted to the right side. When asked to follow the doctor's finger with his head in a straight position, his left eye would not move downward when his eyes were turned to the right, and tended to remain slightly deviated toward the left. At this point, he stated that he had double vision, and felt better if his head was tilted to the right. The remainder of his eye movements, as well as the remainder of his exam, was normal.

310. Where has the damage occurred?

a. The oculomotor nerve b. The abducens nerve c. The trochlear nerve d. The trigeminal nerve e. The facial nerve

311. Which muscle is weakened?

a. Superior rectus b. Inferior rectus c. Lateral rectus d. Superior oblique e. Inferior oblique

312. From which portion of the brainstem has the damaged nerve emerged?

a. Right ventral midbrain b. Right dorsal midbrain c. Left ventral midbrain d. Left dorsal midbrain e. Left ventral pons

313. What is the action of the weak muscle?

a. Outward and upward rotation of the orbit b. Outward and downward rotation of the orbit c. Inward and upward rotation of the orbit d. Inward and downward rotation of the orbit e. Deviation of the orbit laterally

314. How could the head trauma have caused the double vision?

a. Direct damage to the eye b. Damage to the occipital lobes c. Damage to the midbrain d. Damage to the pons e. Damage to the cranial nerve peripherally

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