Neurologic Assessment Practice Questions

30 multiple-choice questions on Neurologic assessment for paramedic and EMT students, from Chapter 19 (Neurologic Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. You find a 70-year-old man slumped in a chair, unresponsive to voice. Which assessment step comes first?

   1. A. Assess the airway and breathing
   2. B. Obtain a full Glasgow Coma Scale score
   3. C. Perform a Cincinnati stroke screen
   4. D. Check pupils with a penlight
   Show answer

   Answer: A. Assess the airway and breathing

   The primary survey always comes first; neurologic scoring and detailed exam follow once immediate life threats to the ABCs are addressed.

2. A 45-year-old has 2 days of numbness from the level of his nipples downward on both sides, with weak legs and trouble urinating. His arms and face are normal. Where is the problem most likely located?

   1. A. The thoracic spinal cord
   2. B. Both cerebral hemispheres
   3. C. The peripheral nerves of the legs
   4. D. The cauda equina nerve roots
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   Answer: A. The thoracic spinal cord

   A sensory level, meaning normal sensation above a horizontal line on the trunk and reduced sensation below it, points to the spinal cord. The nipple line is the T4 dermatome, so the lesion is in the upper thoracic cord, and bladder trouble with leg weakness supports cord compression or inflammation that needs urgent imaging. Lesions in both hemispheres would affect the face and arms, peripheral nerve disease starts in the feet without a trunk level, and cauda equina compression causes saddle numbness below the waist.

3. A patient opens her eyes spontaneously, is confused, and obeys commands. Her GCS is:

   1. A. 13
   2. B. 15
   3. C. 14
   4. D. 12
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   Answer: C. 14

   Spontaneous eye opening = 4, confused = 4, obeys commands = 6, for a total of 14.

4. On the GCS motor scale, abnormal flexion of the arms to a painful stimulus (decorticate posturing) scores:

   1. A. 2
   2. B. 3
   3. C. 4
   4. D. 5
   Show answer

   Answer: B. 3

   Abnormal flexion scores 3, withdrawal 4, and extension (decerebrate) 2. Decorticate posturing suggests injury above the brainstem.

5. To a painful stimulus, a patient's right arm flexes abnormally while his left arm reaches up and localizes the stimulus. Which GCS motor score should you record?

   1. A. 3, the worst response
   2. B. 4, the average of both
   3. C. 5, the best response
   4. D. 6, since he moves purposefully
   Show answer

   Answer: C. 5, the best response

   The GCS records the best motor response from either side, so localizing on the left scores 5. The difference between the two sides should be documented separately because it suggests a focal lesion. Recording the worst side (3) or an average (4) underestimates the score. Localizing is purposeful, but a score of 6 is reserved for obeying commands, so 6 would overstate this response.

6. A stroke patient answers your questions with fluent but jumbled words. Which test best shows whether he understands what you say?

   1. A. Ask him to close his eyes
   2. B. Ask him to repeat a short sentence
   3. C. Ask him to name your watch
   4. D. Ask him what today's date is
   Show answer

   Answer: A. Ask him to close his eyes

   Asking a patient to follow a simple one-step command, such as closing his eyes, tests comprehension without relying on his own speech output. Repeating a sentence, naming an object such as your watch, and stating the date all require him to produce words, so a speech problem could make him fail them even if he understands you.

7. A patient knows his name and where he is but not the date or what happened. How is his orientation best documented?

   1. A. Oriented times three
   2. B. Oriented to person, not place
   3. C. Oriented to person and place
   4. D. Disoriented to place and time
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   Answer: C. Oriented to person and place

   Document the specific elements. He knows who he is and where he is, so he is oriented to person and place, but not to time or event, which reflects a degree of disorientation. 'Times three' would also require him to know the date, 'person, not place' undercounts because he knows where he is, and he is not disoriented to place.

8. A 45-year-old has a high-stepping gait on the right because the toes of his right foot drag and slap the floor. He can push the foot down but cannot lift it. Which finding does this describe?

   1. A. Right foot drop
   2. B. Right leg spasticity
   3. C. Cerebellar ataxia
   4. D. Parkinsonian gait
   Show answer

   Answer: A. Right foot drop

   A steppage gait, with the knee lifted high so the toes clear the floor, means the patient cannot lift the front of the foot. This is foot drop, often from peroneal nerve compression or an L5 root problem. Spasticity causes a stiff, circling leg, cerebellar ataxia causes a wide, unsteady gait, and parkinsonism causes short shuffling steps.

9. An alert stroke patient with global aphasia cannot speak or follow commands. His GCS verbal score is 1. How should this score be interpreted?

   1. A. It shows he is in a deep coma
   2. B. It means the stroke involves the brainstem
   3. C. It requires a rescore with a sternal rub
   4. D. It reflects aphasia, not low arousal
   Show answer

   Answer: D. It reflects aphasia, not low arousal

   The GCS verbal score measures speech output, so a patient with severe aphasia can score 1 while fully awake with eyes open. Report that the low score is from aphasia so the receiving team does not misread it as coma. Aphasia comes from the dominant cortex rather than the brainstem, and rescoring after a sternal rub will not improve a language deficit.

10. A man with a long history of heavy drinking walks with his feet wide apart and sways badly when he tries to walk heel to toe. His arm coordination and strength are nearly normal. What best explains this?

    1. A. Weakness of both hip muscles
    2. B. Damage to the midline cerebellum
    3. C. An inner-ear balance disorder
    4. D. Parkinsonian rigidity and slowness
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    Answer: B. Damage to the midline cerebellum

    The midline part of the cerebellum (vermis) controls the trunk and gait, so damage there, as with long-term alcohol use, causes a wide-based, unsteady walk with relatively normal limb coordination. Hip weakness causes a waddling gait with weak strength. Inner-ear problems cause spinning vertigo, and parkinsonism causes short shuffling steps with rigidity.

11. A 66-year-old has sudden weakness of his right arm and a right facial droop. He is alert, oriented and obeys commands, so his GCS is 15. How should you interpret the GCS?

    1. A. It does not detect focal deficits
    2. B. It rules out a large stroke
    3. C. It shows the stroke is resolving
    4. D. It means a stroke scale is not needed
    Show answer

    Answer: A. It does not detect focal deficits

    The GCS measures level of consciousness, not focal deficits, so a patient with a major stroke can still score 15. Use a stroke scale (such as the Cincinnati scale plus a large vessel occlusion screen) to document weakness, speech and facial findings. A normal GCS does not rule out a large stroke, does not show improvement, and does not replace a stroke assessment.

12. When you test strength, a patient can slide his left arm across the bed but cannot lift it against gravity. How should you grade this strength?

    1. A. 2 out of 5
    2. B. 1 out of 5
    3. C. 3 out of 5
    4. D. 4 out of 5
    Show answer

    Answer: A. 2 out of 5

    On the 0-to-5 muscle strength scale, 2 is movement with gravity removed (sliding across the bed), 1 is a flicker of contraction without movement, 3 is movement against gravity but not resistance, and 4 is movement against some resistance. Grading lets you compare strength between sides and track changes.

13. A patient sees double when looking to the right. The double vision goes away when he covers either eye. What does this suggest?

    1. A. A cataract clouding one lens
    2. B. The eyes are out of alignment
    3. C. Dry eyes from long screen use
    4. D. Normal focusing fatigue
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    Answer: B. The eyes are out of alignment

    Double vision that disappears when either eye is covered is binocular diplopia. It means the two eyes are not aligned, often from a cranial nerve, brainstem or eye muscle problem, and it can be a sign of stroke, aneurysm or myasthenia. A cataract causes double vision that persists in the affected eye when the other is covered. Dry eyes and focusing fatigue cause blur rather than true double vision.

14. To test cerebellar function, you ask an alert patient to touch her nose and then your finger repeatedly. This is the:

    1. A. Pronator drift test
    2. B. Romberg test
    3. C. Babinski test
    4. D. Finger-to-nose test
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    Answer: D. Finger-to-nose test

    Finger-to-nose tests coordination. Past-pointing or tremor suggests cerebellar dysfunction.

15. A patient says his right leg is paralyzed. You place a hand under his right heel and ask him to raise his left leg, and his right heel presses firmly down. What does this show?

    1. A. The right leg is truly paralyzed
    2. B. He has a left hemisphere stroke
    3. C. He has a spinal cord injury
    4. D. The right leg has real strength
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    Answer: D. The right leg has real strength

    This is a positive Hoover sign. When a person lifts one leg, the opposite leg pushes down automatically, so firm downward pressure from the 'paralyzed' leg shows that strength is present. It supports a functional (nonorganic) weakness, though the patient still deserves a full assessment and respectful care. True paralysis from a stroke or cord injury would not produce this involuntary push.

16. Why should you report the eye, verbal and motor GCS scores separately rather than only the total?

    1. A. The parts show the cause of the coma
    2. B. The total is not valid in older adults
    3. C. The same total can hide different deficits
    4. D. The verbal score counts double in the total
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    Answer: C. The same total can hide different deficits

    Two patients with a GCS of 9 can be very different. For example, E3 V1 M5 and E2 V3 M4 both total 9, but the first patient localizes pain while the second only withdraws, and the motor score best predicts outcome. Reporting the components lets the receiving team track specific changes. The GCS is used at all ages. The component scores describe how the patient responds but do not reveal what is causing the coma, and the three parts are simply added, with no part weighted more than another.

17. Which finding is a sign of meningeal irritation rather than a focal brain lesion?

    1. A. Nuchal rigidity
    2. B. Unilateral arm drift
    3. C. One-sided facial droop
    4. D. Expressive aphasia
    Show answer

    Answer: A. Nuchal rigidity

    Neck stiffness with pain on flexion suggests meningitis or subarachnoid blood irritating the meninges. The others are focal deficits.

18. A patient speaks fluently but uses wrong words and cannot follow your commands. This is best described as:

    1. A. Expressive aphasia
    2. B. Dysarthria
    3. C. Dysphagia
    4. D. Receptive aphasia
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    Answer: D. Receptive aphasia

    Receptive (Wernicke) aphasia impairs comprehension with fluent but nonsensical speech. Dysarthria is slurred speech from impaired motor control with intact language.

19. A 77-year-old suddenly cannot speak or understand anything you say, and his right face and arm are weak. Which territory is most likely affected?

    1. A. A small right thalamic infarct
    2. B. The vertebrobasilar circulation
    3. C. The left middle cerebral artery
    4. D. The right anterior cerebral artery
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    Answer: C. The left middle cerebral artery

    Loss of both speech production and comprehension (global aphasia) with right face and arm weakness means a large stroke in the left middle cerebral artery territory, which covers both language areas and the motor cortex for the face and arm. This pattern often means a large vessel occlusion. A small thalamic stroke causes sensory loss, posterior (vertebrobasilar) circulation strokes cause vertigo, ataxia and visual loss, and the right anterior cerebral artery affects the left leg.

20. A dizzy 70-year-old has nystagmus that beats straight up and down. What does this finding most suggest?

    1. A. Benign paroxysmal positional vertigo
    2. B. A middle ear infection
    3. C. A normal finding at end gaze
    4. D. A brainstem or cerebellar cause
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    Answer: D. A brainstem or cerebellar cause

    Purely vertical nystagmus points to a central cause in the brainstem or cerebellum, such as a posterior circulation stroke, and calls for stroke evaluation. Inner-ear problems such as benign positional vertigo and labyrinth inflammation usually cause horizontal or torsional nystagmus, a middle ear infection does not cause nystagmus, and a few beats of normal end-gaze nystagmus are horizontal and fade quickly.

21. A 78-year-old who had a stroke 2 years ago with mild left weakness now has a UTI and fever. Her left-sided weakness is clearly worse today, with no new deficits. Which explanation should you consider along with a new stroke?

    1. A. A normal aging change
    2. B. Illness unmasking old deficits
    3. C. Expected recovery from the old stroke
    4. D. A sign of medication overdose
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    Answer: B. Illness unmasking old deficits

    Infection, fever, hypotension, hypoglycemia or sedating drugs can temporarily worsen the deficits from an old stroke (recrudescence) without new brain injury. Because a new stroke cannot be excluded in the field, she still needs stroke screening, a glucose check and transport. Worsening weakness is not normal aging or recovery, and nothing here suggests an overdose.

22. A febrile, confused 30-year-old can bend his chin to his chest without obvious pain. How should this affect your concern for meningitis?

    1. A. It rules out bacterial meningitis
    2. B. It confirms a viral illness
    3. C. It means he can go home
    4. D. It does not exclude meningitis
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    Answer: D. It does not exclude meningitis

    Neck stiffness is absent in many patients with meningitis, especially early in the illness, in older adults and in those who are confused. Fever with altered mental status still requires transport and a concern for meningitis or encephalitis. A normal neck exam does not rule meningitis out, does not confirm a viral cause, and does not make it safe to stay home.

23. When testing grip strength, you should ask the patient to:

    1. A. Squeeze both your hands at once
    2. B. Squeeze one hand, then repeat later
    3. C. Test the suspected weak hand alone
    4. D. Squeeze with the strong hand first
    Show answer

    Answer: A. Squeeze both your hands at once

    Simultaneous bilateral testing allows direct side-to-side comparison, which makes subtle unilateral weakness easier to detect. Testing one hand at a time, whether the weak hand alone, the strong hand first or one hand now and the other later, loses that direct comparison.

24. Ptosis, or a drooping eyelid, combined with a constricted pupil on the same side most suggests:

    1. A. Bell palsy
    2. B. Horner syndrome
    3. C. Uncal herniation
    4. D. Opioid toxicity
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    Answer: B. Horner syndrome

    Horner syndrome (ptosis, miosis, anhidrosis) results from disruption of sympathetic fibers, such as with carotid dissection.

25. A patient cannot stand with feet together and eyes closed without swaying, but is steady with eyes open. This positive Romberg sign suggests a problem with:

    1. A. Proprioception
    2. B. Visual acuity
    3. C. Proximal muscle strength
    4. D. Hearing
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    Answer: A. Proprioception

    With eyes closed, balance depends on proprioception and vestibular input; loss of balance only with eyes closed suggests sensory (posterior column) or vestibular dysfunction.

26. Why is it important to document a baseline neurologic exam early in patient contact?

    1. A. To set the oxygen flow rate
    2. B. To replace a later stroke scale
    3. C. To detect changes over time
    4. D. To decide on spinal immobilization
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    Answer: C. To detect changes over time

    An early baseline lets you detect changes over time, so you and the receiving team can recognize improvement or deterioration, which is often the most important neurologic finding. The neurologic exam does not set the oxygen flow rate, a baseline does not replace repeating the stroke scale later, and spinal motion restriction decisions rest on the mechanism and a focused spine assessment rather than the timing of the baseline exam.

27. You need to move a stroke patient with a flaccid left arm from the bed to the stretcher. Which technique is safest?

    1. A. Have her grip the rail with both hands
    2. B. Let the weak arm hang over the side
    3. C. Roll her onto the weak shoulder
    4. D. Cradle and support the weak arm
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    Answer: D. Cradle and support the weak arm

    A flaccid arm has lost the muscle tone that holds the shoulder joint together, so pulling or letting it dangle can partly dislocate the shoulder and cause lasting pain. Support the weak arm across her body during moves. Letting the arm hang stresses the shoulder, a limp hand cannot hold a rail, so gripping with both hands drags on the weak shoulder, and rolling her onto the weak side traps and compresses that joint.

28. When assessing sensation in a suspected neurologic patient, you should compare:

    1. A. Arms only, both sides
    2. B. Left and right sides
    3. C. Proximal joints only
    4. D. Hands and face only
    Show answer

    Answer: B. Left and right sides

    Side-to-side comparison identifies unilateral sensory loss, which points to a focal lesion such as stroke.

29. Minutes after a sudden stroke, a patient's left arm and leg are completely limp with absent reflexes. How should you interpret the limp limbs?

    1. A. Limp limbs rule out an acute stroke
    2. B. Early stroke often causes limp limbs
    3. C. It proves an acute spinal cord injury
    4. D. It points to a peripheral nerve lesion
    Show answer

    Answer: B. Early stroke often causes limp limbs

    In the first hours to days after a stroke, the weak limbs are often flaccid with reduced reflexes. Spasticity and brisk reflexes develop later. One-sided flaccid weakness of the arm and leg that begins suddenly is still a stroke until proven otherwise. It does not rule out stroke, and a cord injury or single peripheral nerve would not explain sudden weakness limited to one side of the body.

30. Your partner tests the gag reflex of a drowsy overdose patient to decide whether the airway is protected. Which statement is most accurate?

    1. A. A present gag reflex means a safe airway
    2. B. An absent gag requires immediate intubation
    3. C. Testing the gag reflex prevents aspiration
    4. D. Gag reflex poorly predicts airway safety
    Show answer

    Answer: D. Gag reflex poorly predicts airway safety

    The gag reflex is absent in many healthy adults and can be present in patients who cannot clear secretions, so it predicts airway protection poorly. Testing it can also cause vomiting. Judge the airway by level of consciousness, secretions, ability to swallow and breathing. A present gag does not guarantee a safe airway, its absence alone does not mandate intubation, and testing it does not prevent aspiration.