Neurology ICU Prophecy Exam Evaluation –
Prophecy Learning Systems / Neurocritical Care
Society
SECTION I: NEUROLOGICAL ASSESSMENT & EXAMINATION
Questions 1-20
Question 1
A 68-year-old male with a history of hypertension presents with acute onset of
right-sided weakness and expressive aphasia. Which area of the brain is most
likely affected?
A) Left temporal lobe
B) Right frontal lobe
C) Left frontal lobe
D) Right parietal lobe
Correct Answer: C) Left frontal lobe
Rationale: Expressive (Broca's) aphasia is characterized by non-fluent,
effortful speech with relatively preserved comprehension. Broca's area is located
in the inferior frontal gyrus of the dominant hemisphere, which is the left
hemisphere in approximately 95% of right-handed individuals. The left frontal
lobe also contains the motor cortex, which would explain the right-sided
weakness. The temporal lobe (A) is associated with Wernicke's aphasia
(receptive). The right frontal lobe (B) would cause left-sided weakness but not
aphasia in a right-handed patient. The right parietal lobe (D) is associated with
spatial neglect and hemispatial inattention.
Question 2
A patient is found to have a Glasgow Coma Scale (GCS) score of 9. Which of the
following correctly represents this score?
,A) Eye opening 3, Verbal 2, Motor 4
B) Eye opening 2, Verbal 3, Motor 4
C) Eye opening 4, Verbal 2, Motor 3
D) Eye opening 2, Verbal 2, Motor 5
Correct Answer: B) Eye opening 2, Verbal 3, Motor 4
Rationale: The Glasgow Coma Scale ranges from 3-15, with three
components: Eye opening (1-4), Verbal response (1-5), and Motor response (1-6).
A GCS of 9 can be achieved through various combinations. Option B (2+3+4=9)
correctly represents a patient who opens eyes to pain (2), uses inappropriate
words (3), and withdraws from pain (4). Option A (3+2+4=9) would include eye
opening to voice (3), incomprehensible sounds (2), and withdrawal (4) - this is also
a valid GCS of 9, but in the context of an exam question requiring a specific
combination, B is considered correct as it represents the most typical clinical
scenario of a patient with a GCS of 9. Option C (4+2+3=8) totals 9 incorrectly as
4+2+3=9, but a patient with spontaneous eye opening (4) and abnormal flexion
(3) would rarely have only incomprehensible sounds (2). Option D (2+2+5=9) is
less clinically consistent as localized pain response (5) with poor verbal and eye
responses is unusual.
Question 3
Which cranial nerve is responsible for the corneal reflex?
A) CN V and CN VII
B) CN III and CN VI
C) CN II and CN III
D) CN VIII and CN IX
Correct Answer: A) CN V and CN VII
Rationale: The corneal reflex involves the sensory (afferent) limb of the
trigeminal nerve (CN V) and the motor (efferent) limb of the facial nerve (CN VII).
When the cornea is touched, CN V transmits the sensation to the brainstem, and
CN VII causes the eyelids to close via contraction of the orbicularis oculi muscle.
CN III (B) controls pupillary constriction and most extraocular movements, CN VI
,(B) controls lateral rectus muscle, CN II (C) is optic nerve for vision, CN VIII (D) is
vestibulocochlear for hearing and balance, and CN IX (D) is glossopharyngeal for
taste and swallowing.
Question 4
A 55-year-old female presents with acute onset of vertigo, diplopia, dysarthria,
and ataxia. Which artery occlusion is most likely responsible?
A) Middle cerebral artery
B) Anterior cerebral artery
C) Basilar artery
D) Posterior cerebral artery
Correct Answer: C) Basilar artery
Rationale: The basilar artery supplies the brainstem, cerebellum, and occipital
lobes. Occlusion of the basilar artery classically presents with the "dizziness,
diplopia, dysarthria, and ataxia" constellation, often progressing to "locked-in
syndrome" if bilateral pontine involvement occurs. These symptoms represent
brainstem and cerebellar dysfunction. MCA occlusion (A) typically causes
contralateral hemiparesis, hemisensory loss, and homonymous hemianopia with
aphasia (dominant hemisphere) or neglect (non-dominant). ACA occlusion (B)
causes contralateral leg weakness greater than arm weakness, apathy, and abulia.
PCA occlusion (D) causes visual field defects (contralateral homonymous
hemianopia with macular sparing), memory impairment, and occasionally
thalamic pain syndromes.
Question 5
The oculovestibular reflex (caloric testing) is performed. Cold water irrigation of
the left ear in an intubated patient with an intact brainstem should cause:
A) Nystagmus with fast phase to the left
B) Nystagmus with fast phase to the right
, C) No eye movement
D) Deviation of both eyes to the left
Correct Answer: D) Deviation of both eyes to the left
Rationale: In an intubated patient with an intact brainstem, cold water
irrigation of the left ear causes tonic deviation of both eyes toward the left ear.
This is the "cold water, eyes toward the cold ear" rule for the oculovestibular
reflex. The mnemonic "COWS" (Cold Opposite, Warm Same) applies to caloric
testing, but this refers to the direction of the fast phase of nystagmus in an awake
patient. In a comatose patient with an intact brainstem, the fast phase is
suppressed, and only the slow phase (deviation) is observed. Therefore, cold
water in the left ear causes eyes to deviate to the left (toward the stimulated ear).
Option A and B describe nystagmus which would occur in an awake patient.
Option C indicates brainstem dysfunction.
Question 6
Which of the following is NOT a component of the FOUR Score?
A) Eye response
B) Motor response
C) Brainstem reflexes
D) Verbal response
Correct Answer: D) Verbal response
Rationale: The FOUR (Full Outline of UnResponsiveness) Score was developed
to overcome limitations of the GCS, particularly in intubated patients. It consists
of four domains: Eye response (E), Motor response (M), Brainstem reflexes (B),
and Respiration (R). Unlike the GCS, the FOUR Score does not include a verbal
response component because this is often unreliable in intubated or aphasic
patients. Each domain is scored from 0-4, with a total possible score of 16. The
FOUR Score has been validated in various ICU settings and has prognostic value in
neurological patients. Options A, B, and C are all valid components of the FOUR
Score.
Prophecy Learning Systems / Neurocritical Care
Society
SECTION I: NEUROLOGICAL ASSESSMENT & EXAMINATION
Questions 1-20
Question 1
A 68-year-old male with a history of hypertension presents with acute onset of
right-sided weakness and expressive aphasia. Which area of the brain is most
likely affected?
A) Left temporal lobe
B) Right frontal lobe
C) Left frontal lobe
D) Right parietal lobe
Correct Answer: C) Left frontal lobe
Rationale: Expressive (Broca's) aphasia is characterized by non-fluent,
effortful speech with relatively preserved comprehension. Broca's area is located
in the inferior frontal gyrus of the dominant hemisphere, which is the left
hemisphere in approximately 95% of right-handed individuals. The left frontal
lobe also contains the motor cortex, which would explain the right-sided
weakness. The temporal lobe (A) is associated with Wernicke's aphasia
(receptive). The right frontal lobe (B) would cause left-sided weakness but not
aphasia in a right-handed patient. The right parietal lobe (D) is associated with
spatial neglect and hemispatial inattention.
Question 2
A patient is found to have a Glasgow Coma Scale (GCS) score of 9. Which of the
following correctly represents this score?
,A) Eye opening 3, Verbal 2, Motor 4
B) Eye opening 2, Verbal 3, Motor 4
C) Eye opening 4, Verbal 2, Motor 3
D) Eye opening 2, Verbal 2, Motor 5
Correct Answer: B) Eye opening 2, Verbal 3, Motor 4
Rationale: The Glasgow Coma Scale ranges from 3-15, with three
components: Eye opening (1-4), Verbal response (1-5), and Motor response (1-6).
A GCS of 9 can be achieved through various combinations. Option B (2+3+4=9)
correctly represents a patient who opens eyes to pain (2), uses inappropriate
words (3), and withdraws from pain (4). Option A (3+2+4=9) would include eye
opening to voice (3), incomprehensible sounds (2), and withdrawal (4) - this is also
a valid GCS of 9, but in the context of an exam question requiring a specific
combination, B is considered correct as it represents the most typical clinical
scenario of a patient with a GCS of 9. Option C (4+2+3=8) totals 9 incorrectly as
4+2+3=9, but a patient with spontaneous eye opening (4) and abnormal flexion
(3) would rarely have only incomprehensible sounds (2). Option D (2+2+5=9) is
less clinically consistent as localized pain response (5) with poor verbal and eye
responses is unusual.
Question 3
Which cranial nerve is responsible for the corneal reflex?
A) CN V and CN VII
B) CN III and CN VI
C) CN II and CN III
D) CN VIII and CN IX
Correct Answer: A) CN V and CN VII
Rationale: The corneal reflex involves the sensory (afferent) limb of the
trigeminal nerve (CN V) and the motor (efferent) limb of the facial nerve (CN VII).
When the cornea is touched, CN V transmits the sensation to the brainstem, and
CN VII causes the eyelids to close via contraction of the orbicularis oculi muscle.
CN III (B) controls pupillary constriction and most extraocular movements, CN VI
,(B) controls lateral rectus muscle, CN II (C) is optic nerve for vision, CN VIII (D) is
vestibulocochlear for hearing and balance, and CN IX (D) is glossopharyngeal for
taste and swallowing.
Question 4
A 55-year-old female presents with acute onset of vertigo, diplopia, dysarthria,
and ataxia. Which artery occlusion is most likely responsible?
A) Middle cerebral artery
B) Anterior cerebral artery
C) Basilar artery
D) Posterior cerebral artery
Correct Answer: C) Basilar artery
Rationale: The basilar artery supplies the brainstem, cerebellum, and occipital
lobes. Occlusion of the basilar artery classically presents with the "dizziness,
diplopia, dysarthria, and ataxia" constellation, often progressing to "locked-in
syndrome" if bilateral pontine involvement occurs. These symptoms represent
brainstem and cerebellar dysfunction. MCA occlusion (A) typically causes
contralateral hemiparesis, hemisensory loss, and homonymous hemianopia with
aphasia (dominant hemisphere) or neglect (non-dominant). ACA occlusion (B)
causes contralateral leg weakness greater than arm weakness, apathy, and abulia.
PCA occlusion (D) causes visual field defects (contralateral homonymous
hemianopia with macular sparing), memory impairment, and occasionally
thalamic pain syndromes.
Question 5
The oculovestibular reflex (caloric testing) is performed. Cold water irrigation of
the left ear in an intubated patient with an intact brainstem should cause:
A) Nystagmus with fast phase to the left
B) Nystagmus with fast phase to the right
, C) No eye movement
D) Deviation of both eyes to the left
Correct Answer: D) Deviation of both eyes to the left
Rationale: In an intubated patient with an intact brainstem, cold water
irrigation of the left ear causes tonic deviation of both eyes toward the left ear.
This is the "cold water, eyes toward the cold ear" rule for the oculovestibular
reflex. The mnemonic "COWS" (Cold Opposite, Warm Same) applies to caloric
testing, but this refers to the direction of the fast phase of nystagmus in an awake
patient. In a comatose patient with an intact brainstem, the fast phase is
suppressed, and only the slow phase (deviation) is observed. Therefore, cold
water in the left ear causes eyes to deviate to the left (toward the stimulated ear).
Option A and B describe nystagmus which would occur in an awake patient.
Option C indicates brainstem dysfunction.
Question 6
Which of the following is NOT a component of the FOUR Score?
A) Eye response
B) Motor response
C) Brainstem reflexes
D) Verbal response
Correct Answer: D) Verbal response
Rationale: The FOUR (Full Outline of UnResponsiveness) Score was developed
to overcome limitations of the GCS, particularly in intubated patients. It consists
of four domains: Eye response (E), Motor response (M), Brainstem reflexes (B),
and Respiration (R). Unlike the GCS, the FOUR Score does not include a verbal
response component because this is often unreliable in intubated or aphasic
patients. Each domain is scored from 0-4, with a total possible score of 16. The
FOUR Score has been validated in various ICU settings and has prognostic value in
neurological patients. Options A, B, and C are all valid components of the FOUR
Score.
