NR 603 WEEK 1 APEA PREDICTOR EXAM REVIEW
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES 2025 LATEST UPDATE// ALREADRY
GRADED A+
A .75-year-old .man .is .involved .in .a .motor .vehicle .accident .and .strikes .his .forehead .on .the .windshield. .He
.complains .of .neck .pain .and .severe .burning .in .his .shoulders .and .arms. .His .physical .examination .reveals
.weakness .of .his .upper .extremities. .What .type .of .spinal .cord .injury .does .this .patient .have?
A . anterior .cord .syndrome
B . central .cord .syndrome
C . Brown-Séquard .syndrome
D .complete .cord .transection
E . cauda .equina .syndrome .ANS: .B
Central .Cord .Syndrome
the .central .cord .syndrome .involves .loss .of .motor .function .that .is .more .severe .in .the .upper
.extremities .than .in .the .lower .extremities, .and .is .more .severe .in .the .hands. .There .is .typically
.hyperesthesia .over .the .shoulders .and .arms. .Anterior .cord .syndrome .presents .with .paraplegia .or
.quadriplegia, .loss .of .lateral .spinothalamic .function .with .preservation .of .posterior .column .function.
.Brown-Séquard .syndrome .consists .of .weakness .and .loss .of .posterior .column .function .on .one .side
.of .the .body .distal .to .the .lesion .with .contralateral .loss .of .lateral .spinothalamic .function .one .to .two
.levels .below .the .lesion. .Complete .cord .transection .would .affect .motor .and .sensory .function .distal
.to .the .lesion. .Cauda .equina .syndrome .typically .presents .as .low .back .pain .with .radiculopathy.
A .37-year-old .man .fell .from .a .ladder .as .he .finished .hanging .the .Christmas .lights .on .his .house. .The
.right .side .of .his .head .hit .the .alley .cement, .and .he .lost .consciousness .for .about .1 .minute; .he .woke
.up .with .a .headache, .but .he .had .no .other .complaints. .A .few .hours .later, .the .patient .is .brought .to
.the .emergency .room .by .his .neighbor .because .of .an .intense .headache, .confusion, .and .left .hand
.hemiparesis. .On .examination, .the .patient .has .a .bruise .located .over .the .right .temporal .region,
.mydriasis, .and .right .deviation .of .the .right .eye, .papilledema, .and .left .extensor .plantar .response. .An
.emergency .CT .scan .of .the .head .without .contrast .reveals .a .lens-shaped .hyper-density .under .the
.right .temporal .bone .with .mass .effect .and .edema. .What .is .the .most .likely .diagnosis?
Answer .Choices
1 Epidural .hematoma
2 Subdural .hematoma
3 Subarachnoid . hemorrhage
,4 Intracerebral .parenchymal .hemorrhage
5 Acute .meningitis .ANS: .1
Epidural .Hematoma
Epidural .hematoma .most .often .results .from .a .traumatic .tear .of .the .middle .meningeal .artery.
.Although .a .lucid .interval .ranging .from .minutes .to .hours .followed .by .altered .mental .status .and
.focal .deficits .is .typical .for .epidural .hematoma, .this .clinical .picture .is .only .encountered .in .up .to .1/3
.of .the .patients. .The .collection .of .blood .between .the .skull .and .dura .mater .causes .an .evident .mass
.effect .with .ophthalmic .nerve .palsy .and .the .contralateral .hemiparesis. .Surgical .evacuation .of .the
.clot .via .burr .holes .is .the .treatment .of .choice.
Subdural .hematoma .results .from .a .traumatic .rupture .of .the .bridging .veins .that .connect .the
.cerebrum .to .the .venous .sinuses .within .the .dura. .This .venous .hemorrhage .will .result .in .a .gradual
.increase .of .the .hematoma, .with .a .progressive .clinical .picture .over .days .or .weeks. .The .CT .scan .will
.show .a .concave, .crescent-shaped .hyper-density .compared .to .the .convex, .lens-shaped .hyper-density
.in .epidural .hematoma.
Subarachnoid .hemorrhage .is .the .result .of .an .aneurysm .rupture; .the .most .common .is .the .congenital
.berry .aneurysm. .The .clinical .picture .is .of .a .sudden, .severe .headache .with .meningeal .irritation. .A .CT
.scan .will .show .blood .in .the .subarachnoid .space, .and .a .lumbar .puncture .will .reveal .xanthochromia
.CSF.
Intracerebral .parenchymal .hemorrhage .is .most .likely .caused .by .hypertension .complicated .with
.CharcotBouchard .aneurysms. .The .blood .accumulates .into .the .brain .substance .and .most .commonly
.involves .the .basal .ganglia.
Acute .meningitis .is .not .associated .with .trauma. .Fever .and .signs .of .meningeal .irritation .dominate .the
.clinical .picture. .Lumbar .puncture, .indicated .if .there .are .no .focal .neurological .signs .on .clinical
.examination, .will .be .the .diagnostic .procedure. .The .CT .scan .of .the .patient .presented .in .this .case .is
.characteristic .for .epidural .hematoma, .and .there .is .no .indication .for .a .lumbar .puncture.
A .31-year-old .woman .presents .with .a .purpural .rash .covering .her .arms, .legs, .and .abdomen. .She .also
.has .fever, .chills, .nausea, .abdominal .tenderness, .tachycardia, .and .generalized .myalgias. .Prior .to .the
.development .of .the .rash, .the .patient .noted .that .she .had .a .headache, .cough, .and .sore .throat.
.Laboratory .studies .were .positive .for .Gram-negative .diplococci .in .the .blood, .along .with
.thrombocytopenia .and .an .elevation .in .PMNs. .Urinalysis .showed .blood, .protein, .and .casts. .Vital .signs
.are .as .follows: .PB .92/66, .P .96, .RR .14, .T .39. .The .patient .denies .any .foreign .travel .and .does .not
.have .any .sick .contacts. .However, .she .does .work .part .time .as .a .nurse .in .a .local .hospital.
Question
The .patient .is .diagnosed .with .Meningococcemia; .she .is .admitted .to .the .hospital .and .placed .in
.respiratory .isolation. .What .major .course .of .therapy .should .this .patient .receive?
Answer .Choices
,1 Steroids
2 Supportive .care
3 Antibiotics
4 Transfusion
5 Bactericidal/permeability-increasing . protein
ANS:3
Antibiotics
Antibiotics .are .the .treatment .of .choice .for .meningococcemia. .The .preferred .drug .for .active .infection
.is .penicillin .G. .For .those .allergic .to .penicillin, .chloramphenicol .and .cephalosporins .(ie, .cefotaxime,
.cefuroxime) .may .be .used .as .alternatives.
Patients .will .also .receive .supportive .care, .but .antibiotic .therapy .must .be .initiated .quickly .if .the
.patient .is .to .survive. .Intensive .care .placement .may .be .necessary .if .organ .failure .is .imminent.
.Ventilatory .support, .inotropic .support, .and .IV .fluids .are .necessary .in .some. .If .adrenal .insufficiency
.occurs, .corticosteroid .replacement .may .be .considered. .A .central .venous .line .helps .to .provide .large
.amounts .of .volume .expanders .and .inotropic .medications .for .adequate .tissue .perfusion.
Steroids .have .not .been .shown .to .play .a .major .role .in .the .treatment .of .meningococcemia. .However,
.they .have .been .used .in .addition .to .antibiotic .therapy. .In .the .case .of .adrenal .insufficiency, .for
.example, .steroid .replacement .has .been .shown .to .be .beneficial.
Transfusion .does .not .generally .play .a .major .role .in .treatment. .If .the .patient .suffers .from .a .devastating
.coagulopathy, .blood .or .blood .products .may .be .replaced .as .necessary.
Bactericidal/permeability-increasing .protein .is .a .protein .stored .in .the .granules .of .neutrophils. .It .binds
.to .endotoxin .in .vitro .and .neutralizes .it. .This .technique .is .experimental, .and .it .is .not .used .in
.everyday .treatment .of .meningococcemia.
In .myasthenia .gravis, .weakness .is .a .result .of .insufficient .acetylcholine .transmission .at .the
.neuromuscular .junction; .however, .weakness .can .also .occur .with .overdosing .of .the .cholinergic
.medications .used .to .treat .myasthenia. .What .symptom .helps .differentiate .a .myasthenic .crisis .from .a
.cholinergic .crisis?
Answer .Choices
1 Respiratory .failure
2 Bilateral .ptosis
3 Muscle .fasciculations
4 Diplopia
5 Normal .muscle .stretch .reflexes
, ANS: .3
Muscle .Fasiculations
Signs .of .cholinergic .overdosage .include .muscle .fasciculation, .rhinorrhea, .lacrimation, .salivation,
.increased .bronchial .secretions, .nausea, .or .diarrhea. .The .presence .of .any .of .these .suggests .that .the
.patient's .weakness .may .be .due .to .cholinergic .crisis. .The .other .signs .are .due .to .weakness .and .can
.occur .in .either .condition.
A .54-year-old .man .presents .after .having .a .generalized .seizure. .The .patient .is .HIV .positive, .but .he
.has .been .unable .to .afford .antiretroviral .therapy .since .losing .his .job .2 .years .ago. .Other .than
.cachexia, .the .physical .exam .is .unremarkable. .Upon .further .inquiry, .the .patient .also .notes .that .he
.has .become .shorttempered .and .hypercritical; .at .times, .he .seems .confused. .An .MRI .of .the .brain .is
.performed, .and .it .reveals .several .cortical .ring-enhancing .lesions.
Question
What .is .the .most .likely .diagnosis?
.Answer .Choices
1 AIDS .dementia .complex
2 Cryptococcal .meningitis
3 Cytomegalovirus .encephalitis
4 Progressive .multifocal .leukoencephalopathy
5 Toxoplasma .encephalitis .ANS:5
Toxoplasma .encephalitis
The .patient's .symptoms .and .MRI .findings .are .most .consistent .with .the .diagnosis .of .toxoplasma
.encephalitis. .Toxoplasmosis .is .the .most .common .cerebral .mass .lesion .among .HIV-positive .patients.
.Infection .with .the .Toxoplasma .gondii .parasite .is .relatively .common .and .usually .asymptomatic.
Reactivation .occurs .in .HIV .positive .patients .due .to .failing .cellular .immunity, .and .it .causes .a
.multifocal .necrotizing .encephalitis. .Seizures .may .be .the .initial .manifestation .of .central .nervous
.system .(CNS) .infection; .other .common .clinical .manifestations .include .focal .neurologic .deficits, .such
.as .impaired .speech .and .hemiparesis. .Personality .change, .lethargy, .headache, .and .confusion .are .also
.observed. .The .MRI .in .patients .with .toxoplasma .encephalitis .characteristically .reveals .multiple, .ring-
enhancing .lesions .with .surrounding .edema; .these .lesions .usually .occur .bilaterally .in .the .frontal .and
.parietal .cortices.
AIDS .dementia .complex .describes .a .constellation .of .cognitive .symptoms .seen .among .HIV .positive
.patients. .The .condition .occurs .when .HIV .virus .disseminates .to .the .CNS. .Within .the .CNS, .the .virus
.tends .to .concentrate .in .the .basal .ganglia .and .subcortical .regions. .Symptoms .include .a .constellation
.of .cognitive, .behavioral, .and .motor .disturbances .that .cause .varying .degrees .of .functional
.impairment.
Characteristic .MRI .findings .include .non-enhancing .white .matter, .cerebral .atrophy, .and .ventricular
.enlargement. .The .diagnosis .requires .that .other .central .nervous .system .infections, .carcinoma, .as .well .as
.general .medical .conditions .and .substance .abuse .have .been .excluded.
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES 2025 LATEST UPDATE// ALREADRY
GRADED A+
A .75-year-old .man .is .involved .in .a .motor .vehicle .accident .and .strikes .his .forehead .on .the .windshield. .He
.complains .of .neck .pain .and .severe .burning .in .his .shoulders .and .arms. .His .physical .examination .reveals
.weakness .of .his .upper .extremities. .What .type .of .spinal .cord .injury .does .this .patient .have?
A . anterior .cord .syndrome
B . central .cord .syndrome
C . Brown-Séquard .syndrome
D .complete .cord .transection
E . cauda .equina .syndrome .ANS: .B
Central .Cord .Syndrome
the .central .cord .syndrome .involves .loss .of .motor .function .that .is .more .severe .in .the .upper
.extremities .than .in .the .lower .extremities, .and .is .more .severe .in .the .hands. .There .is .typically
.hyperesthesia .over .the .shoulders .and .arms. .Anterior .cord .syndrome .presents .with .paraplegia .or
.quadriplegia, .loss .of .lateral .spinothalamic .function .with .preservation .of .posterior .column .function.
.Brown-Séquard .syndrome .consists .of .weakness .and .loss .of .posterior .column .function .on .one .side
.of .the .body .distal .to .the .lesion .with .contralateral .loss .of .lateral .spinothalamic .function .one .to .two
.levels .below .the .lesion. .Complete .cord .transection .would .affect .motor .and .sensory .function .distal
.to .the .lesion. .Cauda .equina .syndrome .typically .presents .as .low .back .pain .with .radiculopathy.
A .37-year-old .man .fell .from .a .ladder .as .he .finished .hanging .the .Christmas .lights .on .his .house. .The
.right .side .of .his .head .hit .the .alley .cement, .and .he .lost .consciousness .for .about .1 .minute; .he .woke
.up .with .a .headache, .but .he .had .no .other .complaints. .A .few .hours .later, .the .patient .is .brought .to
.the .emergency .room .by .his .neighbor .because .of .an .intense .headache, .confusion, .and .left .hand
.hemiparesis. .On .examination, .the .patient .has .a .bruise .located .over .the .right .temporal .region,
.mydriasis, .and .right .deviation .of .the .right .eye, .papilledema, .and .left .extensor .plantar .response. .An
.emergency .CT .scan .of .the .head .without .contrast .reveals .a .lens-shaped .hyper-density .under .the
.right .temporal .bone .with .mass .effect .and .edema. .What .is .the .most .likely .diagnosis?
Answer .Choices
1 Epidural .hematoma
2 Subdural .hematoma
3 Subarachnoid . hemorrhage
,4 Intracerebral .parenchymal .hemorrhage
5 Acute .meningitis .ANS: .1
Epidural .Hematoma
Epidural .hematoma .most .often .results .from .a .traumatic .tear .of .the .middle .meningeal .artery.
.Although .a .lucid .interval .ranging .from .minutes .to .hours .followed .by .altered .mental .status .and
.focal .deficits .is .typical .for .epidural .hematoma, .this .clinical .picture .is .only .encountered .in .up .to .1/3
.of .the .patients. .The .collection .of .blood .between .the .skull .and .dura .mater .causes .an .evident .mass
.effect .with .ophthalmic .nerve .palsy .and .the .contralateral .hemiparesis. .Surgical .evacuation .of .the
.clot .via .burr .holes .is .the .treatment .of .choice.
Subdural .hematoma .results .from .a .traumatic .rupture .of .the .bridging .veins .that .connect .the
.cerebrum .to .the .venous .sinuses .within .the .dura. .This .venous .hemorrhage .will .result .in .a .gradual
.increase .of .the .hematoma, .with .a .progressive .clinical .picture .over .days .or .weeks. .The .CT .scan .will
.show .a .concave, .crescent-shaped .hyper-density .compared .to .the .convex, .lens-shaped .hyper-density
.in .epidural .hematoma.
Subarachnoid .hemorrhage .is .the .result .of .an .aneurysm .rupture; .the .most .common .is .the .congenital
.berry .aneurysm. .The .clinical .picture .is .of .a .sudden, .severe .headache .with .meningeal .irritation. .A .CT
.scan .will .show .blood .in .the .subarachnoid .space, .and .a .lumbar .puncture .will .reveal .xanthochromia
.CSF.
Intracerebral .parenchymal .hemorrhage .is .most .likely .caused .by .hypertension .complicated .with
.CharcotBouchard .aneurysms. .The .blood .accumulates .into .the .brain .substance .and .most .commonly
.involves .the .basal .ganglia.
Acute .meningitis .is .not .associated .with .trauma. .Fever .and .signs .of .meningeal .irritation .dominate .the
.clinical .picture. .Lumbar .puncture, .indicated .if .there .are .no .focal .neurological .signs .on .clinical
.examination, .will .be .the .diagnostic .procedure. .The .CT .scan .of .the .patient .presented .in .this .case .is
.characteristic .for .epidural .hematoma, .and .there .is .no .indication .for .a .lumbar .puncture.
A .31-year-old .woman .presents .with .a .purpural .rash .covering .her .arms, .legs, .and .abdomen. .She .also
.has .fever, .chills, .nausea, .abdominal .tenderness, .tachycardia, .and .generalized .myalgias. .Prior .to .the
.development .of .the .rash, .the .patient .noted .that .she .had .a .headache, .cough, .and .sore .throat.
.Laboratory .studies .were .positive .for .Gram-negative .diplococci .in .the .blood, .along .with
.thrombocytopenia .and .an .elevation .in .PMNs. .Urinalysis .showed .blood, .protein, .and .casts. .Vital .signs
.are .as .follows: .PB .92/66, .P .96, .RR .14, .T .39. .The .patient .denies .any .foreign .travel .and .does .not
.have .any .sick .contacts. .However, .she .does .work .part .time .as .a .nurse .in .a .local .hospital.
Question
The .patient .is .diagnosed .with .Meningococcemia; .she .is .admitted .to .the .hospital .and .placed .in
.respiratory .isolation. .What .major .course .of .therapy .should .this .patient .receive?
Answer .Choices
,1 Steroids
2 Supportive .care
3 Antibiotics
4 Transfusion
5 Bactericidal/permeability-increasing . protein
ANS:3
Antibiotics
Antibiotics .are .the .treatment .of .choice .for .meningococcemia. .The .preferred .drug .for .active .infection
.is .penicillin .G. .For .those .allergic .to .penicillin, .chloramphenicol .and .cephalosporins .(ie, .cefotaxime,
.cefuroxime) .may .be .used .as .alternatives.
Patients .will .also .receive .supportive .care, .but .antibiotic .therapy .must .be .initiated .quickly .if .the
.patient .is .to .survive. .Intensive .care .placement .may .be .necessary .if .organ .failure .is .imminent.
.Ventilatory .support, .inotropic .support, .and .IV .fluids .are .necessary .in .some. .If .adrenal .insufficiency
.occurs, .corticosteroid .replacement .may .be .considered. .A .central .venous .line .helps .to .provide .large
.amounts .of .volume .expanders .and .inotropic .medications .for .adequate .tissue .perfusion.
Steroids .have .not .been .shown .to .play .a .major .role .in .the .treatment .of .meningococcemia. .However,
.they .have .been .used .in .addition .to .antibiotic .therapy. .In .the .case .of .adrenal .insufficiency, .for
.example, .steroid .replacement .has .been .shown .to .be .beneficial.
Transfusion .does .not .generally .play .a .major .role .in .treatment. .If .the .patient .suffers .from .a .devastating
.coagulopathy, .blood .or .blood .products .may .be .replaced .as .necessary.
Bactericidal/permeability-increasing .protein .is .a .protein .stored .in .the .granules .of .neutrophils. .It .binds
.to .endotoxin .in .vitro .and .neutralizes .it. .This .technique .is .experimental, .and .it .is .not .used .in
.everyday .treatment .of .meningococcemia.
In .myasthenia .gravis, .weakness .is .a .result .of .insufficient .acetylcholine .transmission .at .the
.neuromuscular .junction; .however, .weakness .can .also .occur .with .overdosing .of .the .cholinergic
.medications .used .to .treat .myasthenia. .What .symptom .helps .differentiate .a .myasthenic .crisis .from .a
.cholinergic .crisis?
Answer .Choices
1 Respiratory .failure
2 Bilateral .ptosis
3 Muscle .fasciculations
4 Diplopia
5 Normal .muscle .stretch .reflexes
, ANS: .3
Muscle .Fasiculations
Signs .of .cholinergic .overdosage .include .muscle .fasciculation, .rhinorrhea, .lacrimation, .salivation,
.increased .bronchial .secretions, .nausea, .or .diarrhea. .The .presence .of .any .of .these .suggests .that .the
.patient's .weakness .may .be .due .to .cholinergic .crisis. .The .other .signs .are .due .to .weakness .and .can
.occur .in .either .condition.
A .54-year-old .man .presents .after .having .a .generalized .seizure. .The .patient .is .HIV .positive, .but .he
.has .been .unable .to .afford .antiretroviral .therapy .since .losing .his .job .2 .years .ago. .Other .than
.cachexia, .the .physical .exam .is .unremarkable. .Upon .further .inquiry, .the .patient .also .notes .that .he
.has .become .shorttempered .and .hypercritical; .at .times, .he .seems .confused. .An .MRI .of .the .brain .is
.performed, .and .it .reveals .several .cortical .ring-enhancing .lesions.
Question
What .is .the .most .likely .diagnosis?
.Answer .Choices
1 AIDS .dementia .complex
2 Cryptococcal .meningitis
3 Cytomegalovirus .encephalitis
4 Progressive .multifocal .leukoencephalopathy
5 Toxoplasma .encephalitis .ANS:5
Toxoplasma .encephalitis
The .patient's .symptoms .and .MRI .findings .are .most .consistent .with .the .diagnosis .of .toxoplasma
.encephalitis. .Toxoplasmosis .is .the .most .common .cerebral .mass .lesion .among .HIV-positive .patients.
.Infection .with .the .Toxoplasma .gondii .parasite .is .relatively .common .and .usually .asymptomatic.
Reactivation .occurs .in .HIV .positive .patients .due .to .failing .cellular .immunity, .and .it .causes .a
.multifocal .necrotizing .encephalitis. .Seizures .may .be .the .initial .manifestation .of .central .nervous
.system .(CNS) .infection; .other .common .clinical .manifestations .include .focal .neurologic .deficits, .such
.as .impaired .speech .and .hemiparesis. .Personality .change, .lethargy, .headache, .and .confusion .are .also
.observed. .The .MRI .in .patients .with .toxoplasma .encephalitis .characteristically .reveals .multiple, .ring-
enhancing .lesions .with .surrounding .edema; .these .lesions .usually .occur .bilaterally .in .the .frontal .and
.parietal .cortices.
AIDS .dementia .complex .describes .a .constellation .of .cognitive .symptoms .seen .among .HIV .positive
.patients. .The .condition .occurs .when .HIV .virus .disseminates .to .the .CNS. .Within .the .CNS, .the .virus
.tends .to .concentrate .in .the .basal .ganglia .and .subcortical .regions. .Symptoms .include .a .constellation
.of .cognitive, .behavioral, .and .motor .disturbances .that .cause .varying .degrees .of .functional
.impairment.
Characteristic .MRI .findings .include .non-enhancing .white .matter, .cerebral .atrophy, .and .ventricular
.enlargement. .The .diagnosis .requires .that .other .central .nervous .system .infections, .carcinoma, .as .well .as
.general .medical .conditions .and .substance .abuse .have .been .excluded.
