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Medical questions
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  1. You are treating a 50-year-old male who ingested a significant amount of his prescribed propranolol. He is unresponsive, bradycardic, hypotensive, and has poor respiratory effort. In addition to assisting his ventilations, applying a cardiac monitor, and establishing vascular access, the MOST appropriate treatment for him includes:
    A: calcium chloride, isoproterenol, and dopamine.
    B: 2 to 3 liters of normal saline to increase his BP.
    C: atropine, calcium gluconate, and vasopressin.
    D: cardiac pacing, glucagon, and a vasopressor.
    • D:
    • Propranolol (Inderal) is a beta-blocker. Toxicity is marked by profound bradycardia and hypotension. Untreated, death occurs due to cardiovascular collapse. Some patients with beta-blocker toxicity require ventilatory support. Transcutaneous cardiac pacing (TCP), though not always successful, should be initiated without delay as you are establishing vascular access. Glucagon is given to patients with beta-blocker toxicity; its positive inotropic and chronotropic effects have been shown to improve cardiac output. Vasopressors, such as epinephrine, are also used to treat beta-blocker toxicity, although higher-than-usual doses may be needed. There is currently no recommendation for the use of vasopressin for beta-blocker overdose. Your patient’s bradycardia is caused by sympathetic nervous system blockade, not increased parasympathetic tone; therefore, atropine will likely be ineffective. Isoproterenol (Isuprel) is contraindicated in bradycardia, regardless of the cause; its potent vasodilator effects may exacerbate hypotension. Hypotension and bradycardia are not consistent with hypovolemia. If you give fluid boluses, use extreme caution! Too much fluid in a bradycardic patient may cause pulmonary edema. Calcium chloride is used to treat hypocalcemia and calcium channel-blocker overdose. Calcium gluconate is used to treat hypocalcemia and magnesium sulfate toxicity; the gel form of calcium gluconate is used to treat patients with hydroflouric acid burns.
  2. Which of the following is MOST indicative of hyperglycemic ketoacidosis?

    A: Bradypnea
    B: Acute onset
    C: Diaphoresis
    D: Hyperpnea
    • D.
    • When glucose does not reach the cell where it can be used for energy, the cell will metabolize fat instead, which produces ketoacids. As the body attempts to rid itself of these acids, the respirations become deep (hyperpnea) and rapid (tachypnea) with a noted fruity or acetone breath odor (Kussmaul respirations). Hyperglycemic ketoacidosis manifests over several hours to even a few days. As blood glucose levels rise, the kidneys attempt to excrete the excess glucose, taking water with it. This results in dehydration, which typically manifests with warm, dry skin that has poor turgor.
  3. After performing your primary assessment and initial treatment of an
    unresponsive patient who has not been injured, you should:

    A: obtain vital signs.
    B: perform a detailed head-to-toe exam.
    C: obtain a SAMPLE history.
    D: perform a rapid assessment.
    • D.
    • When the primary assessment and initial treatment of an unresponsive medical patient is complete, the next step is to perform a rapid scan of the patient's body, which involves a quick head-to-toe assessment. The purpose of the rapid body scan is to further assess for and treat life-threats not detected in the primary assessment. If the patient is responsive, perform a secondary assessment, which should focus on his or her chief complaint. At this point, you should also obtain vital signs and a SAMPLE history.
  4. When assessing a patient who was stung by a bee, which of the following assessment findings is MOST indicative of anaphylactic shock?

    A: A fine, red rash
    B: Diaphoretic skin
    C: Flushing of the skin
    D: Known allergy to bees
    B

    Allergic reactions can be mild, moderate, or severe. General signs of an allergic reaction include a fine red rash or hives (urticaria), flushed skin, itching or burning of the skin (pruritis), and watery eyes. In a mild or moderate allergic reaction, respiratory and circulatory functions are generally not affected. If the histamine release is overwhelming, however, the patient develops anaphylactic shock, which is characterized by general signs of an allergic reaction plus respiratory and circulatory compromise. Diaphoresis, a sign of shock, is not typically observed in patients with mild or moderate allergic reactions because systemic perfusion is not compromised. A known allergic history is not, in and of itself, an indicator of anaphylactic shock; however, it should raise your concern that an allergic reaction may occur.
  5. Treatment for a patient who has a pulse and a documented core body temperature of 92.8°F includes:

    A: 20 mL/kg boluses of warm normal saline.
    B: prophylactic antidysrhythmic therapy.
    C: passive rewarming only.
    D: passive and active external rewarming.
    D

    According to current emergency cardiac care (ECC) guidelines, a patient with mild hypothermia (CBT of 93.2°F to 96.8°F [34°C to 36°C]) should be treated with passive rewarming, which involves removing wet clothing, applying warm blankets, and allowing the patient’s CBT to rise naturally. If the patient has moderate hypothermia (CBT of 86°F to 93.2°F [30°C to 34°C]), passive and active external rewarming should be performed. Active external rewarming involves the use of heating blankets, or radiant heat from hot packs placed in the groin, neck, and axillae. Active internal rewarming, including the administration of warm (109.4°F [43°C]) IV fluids, warm-water peritoneal lavage, and esophageal rewarming tubes, should be performed if the patient has severe hypothermia (CBT of less than 86°F [30°C]). In most cases, active internal (core) rewarming will take place at the hospital. Prophylactic antidysrhythmic therapy is not indicated for hypothermic patients.
  6. During your assessment of a patient with a suspected neurologic disorder, you ask him to shrug his shoulders and turn his head from side to side. Which of the following cranial nerves are you assessing?

    A: Glossopharyngeal
    B: Spinal accessory
    C: Trigeminal
    D: Vestibulocochlear
    B

    If time and patient condition permits, assessment of the 12 pairs of cranial nerves should be performed. The spinal accessory nerve (XI), a motor nerve, controls shoulder and neck movements. Asking the patient to shrug his shoulders and turn his head from side to side assesses cranial nerve XI. The trigeminal nerve (V) provides motor control to the muscles of chewing and sensory control to the face, sinuses, and teeth. Asking the patient to clench his teeth and then lightly stroking your finger over his forehead and cheeks and asking him to identify where he is being touched assesses cranial nerve V. The vestibulocochlear nerve (VIII), a sensory nerve, controls hearing and balance perception. Checking a patient's hearing and asking him to stand on one leg (if safe to do so) assesses cranial nerve VIII. The glossopharyngeal nerve (IX) provides motor control to the throat and swallowing mechanism and sensory control to the tongue, throat and ear. Asking the patient to swallow assesses cranial nerve IX. Refer to your paramedic textbook regarding assessment of all of the cranial nerves.
  7. Which of the following medications is classified as a tricyclic antidepressant?

    A: Midazolam hydrochloride
    B: Fluoxetine hydrochloride
    C: Buspirone hydrochloride
    D: Nortriptyline hydrochloride
    D

    Nortriptyline (Pamelor), amyltriptyline (Elavil), and clomipramine hydrochloride (Anafranil) are commonly prescribed tricyclic antidepressant (TCA) medications. Fluoxetine hydrochloride (Prozac) is a selective serotonin reuptake inhibitor (SSRI) that is also used to treat depression as well as obsessive-compulsive disorder. Midazolam hydrochloride (Versed) is a benzodiazepine sedative-hypnotic. Buspirone hydrochloride (Buspar) is an anxiolytic medication.
  8. Which of the following is MOST indicative of an infectious or communicable disease?

    A: Vomiting and diarrhea for 3 days
    B: Persistent fever and night sweats
    C: Severe headache and photophobia
    D: Sore throat and nasal discharge
    B

    A persistent fever and night sweats should alert the paramedic to the possibility of a communicable or infectious disease. HIV and tuberculosis both present with these symptoms. Vomiting, diarrhea, sore throat, and a headache could indicate a variety of illnesses, not all of which are communicable or infectious.
  9. A known heroin abuser is found unresponsive by a law enforcement officer. Your primary assessment of the patient, a 24-year-old female, reveals that she is unresponsive, is breathing at a rate of 6 breaths/min and shallow, and has a pulse rate of 40 beats/min and weak. You should:
    A: begin immediate cardiac pacing to increase her heart rate.
    B: ensure that her airway is clear and begin assisting her ventilations.
    C: administer high-flow oxygen, start an IV, and give her atropine.
    D: intubate her trachea, start an IV line, and give her naloxone.
    • B
    • The patient’s airway must be clear and adequate oxygenation and ventilation must be established; otherwise, she will die. Respirations of 6 breaths/min and shallow (reduced tidal volume) will not provide adequate minute volume and require immediate treatment. You must first ensure that her airway is clear of secretions and assist her ventilations with a bag-mask device to increase rate, tidal volume, and minute volume. After adequate oxygenation and ventilation have been established, apply the cardiac monitor and establish vascular access. Given her history and clinical presentation—gross CNS depression—naloxone (Narcan) would be the most appropriate initial drug to administer; however, because she is a known heroin abuser, consider giving 0.4 mg instead of the standard 2 mg dose; this will minimize the risk of inducing an acute withdrawal seizure. If she remains bradycardic despite naloxone administration, prepare for immediate transcutaneous cardiac pacing (TCP); atropine (0.5 mg) should also be considered. In patients with hypoventilation secondary to a drug overdose, support ventilations with a bag-mask device first. If the patient’s condition is refractory to naloxone, intubation should then be considered, particularly if your transport time will be prolonged. In many cases, bag-mask ventilations and naloxone will improve the patient’s ventilatory status, thus avoiding the need for intubation. Remember that most narcotics outlive a single dose of naloxone and CNS depression may recur; therefore, repeat dosing with naloxone is often necessary.
  10. A 59-year-old male with a history of hypertension and diabetes presents with dark, tarry stools. He is confused, has a blood pressure of 84/62 mm Hg, and a pulse rate of 74 beats/min and weak. Which of the following would MOST likely explain his heart rate?

    A: Inadvertent overdose of his prescribed hypoglycemic medication
    B: Increased parasympathetic tone in response to hypovolemia
    C: Insulin suppressing the patient’s sympathetic nervous system
    D: A prescribed adrenergic blocking agent to treat his hypertension
    D


    Adrenergic blocking medications, such as beta blockers, are commonly used to treat hypertension. Examples of beta blockers include propranolol (Inderal), metaprolol (Lopressor), atenolol (Tenormin), and labetalol (Normodyne). Beta blockers suppress the sympathetic nervous system, which reduces heart rate and myocardial contractility. The patient in this scenario is in shock due to gastrointestinal bleeding. His heart rate—which you would expect to be fast—is in a normal range. This is most likely the result of his prescribed beta blocker medication, which is blunting the sympathetic nervous system’s compensatory response to shock. In hypovolemic shock, the sympathetic nervous system—not the parasympathetic nervous system—is stimulated, resulting in tachycardia, pallor, and diaphoresis, among other signs.
  11. A 42-year-old male presents with difficulty
    breathing, diffuse wheezing, urticaria, and a blood pressure of 74/44
    mm Hg. His skin is cool and clammy. Given his clinical presentation,
    which of the following interventions would be the LEAST effective?A:
    Diphenhydramine, 25 mg IV
    B:
    1 to 2 L saline bolus
    C:
    Epinephrine, 2 µg/min IV
    D:
    Epinephrine, 0.3 mg SC
    D

    The patient in this scenario is experiencing signs and symptoms of anaphylactic shock—dyspnea, wheezing, urticaria (hives). Furthermore, the fact that he is hypotensive indicates that he is in decompensated shock. Poor peripheral perfusion is evidenced by his cool, clammy skin; blood has been shunted away from the skin to the vital organs. Compared to the intravenous (IV) and intraosseous (IO) routes, medications given via the subcutaneous (SC) and intramuscular (IM) routes take longer to absorb into the central circulation—even in patients with adequate peripheral perfusion. Therefore, it would clearly stand to reason that a medication administered via the SC route to a patient with poor peripheral perfusion would have an even more delayed effect. For patients with anaphylactic shock, epinephrine should be administered via the IV or IO route. The appropriate dose is 0.1 mg (1 mL) of a 1:10,000 solution. An IV infusion of epinephrine at 1 to 4 µg/min also would be appropriate, and may avoid the need to give repeated epinephrine boluses for severely hypotensive patients. If hypotension does not respond rapidly to epinephrine, crystalloid fluid boluses should be given; as much as 1 to 2 L may be needed initially. Diphenhydramine (Benadryl), 25 to 50 mg IV, is given after epinephrine; it blocks the release of histamines that are causing the allergic reaction. Patients with mild or moderate allergic reactions who have adequate peripheral perfusion are commonly given epinephrine 1:1,000 via the SC or IM route in a dose of 0.3 to 0.5 mg (0.3 to 0.5 mL). Benadryl can also be given via the IM route.
  12. The clinical presentation of thyroid storm MOST closely resembles that of:

    A: ketoacidosis.
    B: myxedema.
    C: amphetamine use.
    D: heroin overdose.
    C

    Thyroid storm is a life-threatening condition that may occur in patients with hyperthyroidism. Hyperthyroidism is a condition in which the thyroid gland produces too much of the thyroid hormones triiodothyronine (T3) and thyroxine (T4). T3 and T4 play a key role in controlling the body’s basal metabolic rate (BMR). When produced in excess, these thyroid hormones produce signs and symptoms of adrenergic hyperactivity (ie, tachycardia, sweating, palpitations, anxiety). In thyroid storm, these clinical signs would be more severe, including profound tachycardia, dysrhythmias, agitation and paranoia, and cardiovascular collapse. Amphetamines also cause adrenergic hyperactivity; of the choices listed, amphetamine use and thyroid storm would produce the most similar clinical signs. Heroin, a narcotic, causes central nervous system depression, resulting in a decreased level of consciousness, hypoventilation, bradycardia, and hypotension. Advanced hypothyroidism, called myxedema, results from a severe deficiency of T3 and T4. In contrast to thyroid storm, myxedema does not present with signs of adrenergic hyperactivity.
  13. What portion of the brain regulates a person's level of consciousness?

    A: Cerebellum
    B: Cerebrum
    C: Reticular activating system
    D: Medulla oblongata
    C

    The reticular activating system (RAS), which is located within the brainstem, controls a person’s state of awareness and level of consciousness. Coma following severe head injury indicates brainstem involvement and injury to the RAS. The pons and medulla, also located within the brainstem, are the respiratory centers. The cerebrum, the largest part of the brain, controls thought processes and memory. The cerebellum, located inferoposterior to the cerebrum, regulates coordination, balance, and equilibrium.
  14. A 27-year-old female overdosed on an unknown type of drug. Her skin is hot and flushed, her breathing is rapid and deep, and she has an acetone odor on her breath. Her BP is 98/64 mm Hg and her heart rate is 120 beats/min. Which of the following drugs would MOST likely explain her clinical presentation?

    A: Aspirin
    B: Heroin
    C: Cocaine
    D: Alcohol
    A

    Of the drugs listed, aspirin (acetylsalicylic acid [ASA]) overdose would be the most likely cause of the patient's clinical presentation. Aspirin toxicity causes significant metabolic acidosis; the respiratory buffer system responds by increasing the rate and depth of breathing, resulting in a compensatory respiratory alkalosis. Hyperthermia (as evidenced by hot, flushed skin) is often associated with aspirin toxicity. Although an acetone breath odor is classically associated with hyperglycemic ketoacidosis, methyl alcohol, isopropyl alcohol, and aspirin toxicity can also cause an acetone breath odor. Heroin overdose is clearly unlikely. Heroin is a narcotic CNS depressant; overdose would result in slow, shallow breathing; hypotension, and bradycardia. Alcohol is also a CNS depressant; although the intoxicated patient can present with a breath odor that could be mistaken for ketoacidosis, severe toxicity causes respiratory depression. An overdose of cocaine, a sympathomimetic drug, can also cause hyperthermia; however, you would expect the patient to be significantly hypertensive and tachycardic.
  15. Which of the following is a defining factor in the transition from human immunodeficiency virus (HIV) infection to acquired immunodeficiency syndrome (AIDS)?

    A: Fever that lasts greater than 7 days
    B: Antibodies are detected in the blood
    C: Development of opportunistic infections
    D: Transient increase in the T-cell count
    C

    Acquired immunodeficiency syndrome (AIDS) is the end-stage disease process caused by infection with the human immunodeficiency virus (HIV). Although it can obviously be stated that all patients with AIDS are HIV positive, it cannot be stated that all HIV-positive patients have AIDS. A diagnosis of AIDS is made when the number of T-helper lymphocytes (CD4 cells) fall below a certain level, or when the patient develops one of a specific group of opportunistic infections (also called AIDS-defining or AIDS-related conditions). Such opportunistic infections include Pneumocystis carinii pneumonia, cytomegalovirus, red or purple malignant skin lesions called Kaposi sarcoma, atypical tuberculosis, and cryptococcol meningitis. The point at which antibodies to the virus are detected in the blood is called seroconversion; this usually occurs within the first 3 months following exposure to HIV. With antiretroviral therapy, patients can remain HIV-positive for many years without showing any evidence of infection.
  16. A 40-year-old female presents with diffuse abdominal cramping, nausea, vomiting, and diarrhea. She tells you that this began the day before, and is worse today. She is conscious and alert, lightheaded, and has a resting heart rate of 120 beats/min. Her temperature is 97.7°F orally, blood pressure is 110/70 mm Hg, and oxygen saturation is 95% on room air. She denies any past medical history, but states that she has been taking ibuprofen for a headache. The MOST appropriate treatment for this patient includes:

    A: supplemental oxygen, an IV of normal saline set to keep the vein open, and 25 to 50 mg of diphenhydramine IV.

    B: high-flow oxygen via nonrebreathing mask, an IV of normal saline, sequential 20 mL/kg fluid boluses, and 2 mg of morphine.

    C: oxygen as tolerated via nasal cannula, an IV of normal saline, a 500 mL fluid bolus, and 12.5 mg of promethazine IV.

    D: obtaining orthostatic vital signs, oxygen as tolerated, establishing vascular access, and setting the flow rate at 125 mL/hr.
    C

    The patient likely has gastroenteritis, inflammation or infection of the GI tract, and is dehydrated due to vomiting and diarrhea. An absence of fever suggests a viral cause, but may be the result of the antipyretic effects of the ibuprofen she has been taking. The norovirus (Norwalk virus) causes most cases of viral gastroenteritis in adults. Treatment includes fluid rehydration, oxygen as needed, and transport. Establish IV access, give a 500 mL fluid bolus, and reassess the patient. Give additional fluid boluses as needed. The patient is not in shock; therefore, sequential 20 mL/kg fluid boluses are not indicated. Nausea and vomiting is treated with an antiemetic such as promethazine (Phenergan), 12.5 to 25 mg, or ondansetron (Zofran), 4 mg. Oxygen via nasal cannula is appropriate for this patient; she is conscious and alert and has a room air Sp02 of 95%. Avoid putting an oxygen mask on nauseated patients unless significant hypoxemia is present. Lightheadedness and resting tachycardia are obvious signs of dehydration; orthostatic vital signs will yield little additional information. Analgesia is usually not necessary for patients with gastroenteritis. Furthermore, morphine often causes nausea and vomiting, an undesirable side effect in an already dehydrated patient. Diphenhydramine (Benadryl), an antihistamine, is used to treat allergic reactions, although it does possess antiemetic properties.
  17. You are called to a local park where a 30-year-old man has collapsed. When you arrive, you find that the patient is disoriented. His skin is hot and moist and his respirations are rapid and shallow. You should suspect:

    A: heat cramps.
    B: heat exhaustion.
    C: heatstroke.
    D: heat prostration.
    C

    Hot (dry or moist) skin, tachypnea, and an altered mental status are indicative of heatstroke. Two major factors help differentiate heat exhaustion from heatstroke. In heat exhaustion, sometimes called heat prostration, the patient is usually conscious and alert with cool, moist skin. In heatstroke, the patient's mental status is typically altered and his or her skin is hot to the touch. Although the patient in heatstroke is not actively sweating, he or she may have residual perspiration on the skin; this is especially true in patients with extertional heatstroke. Do not rule out heatstroke just because the patient's skin is moist.
  18. Treatment for a patient with a severe migraine headache, nausea, and vomiting includes:

    A: transport in a supine position.
    B: 2 mg of morphine sulfate IV.
    C: 5 mg of prochlorperazine IV.
    D: heat packs to the forehead.
    C

    Prochlorperazine (Compazine), a phenothiazine, is an antiemetic medication that will not only relieve nausea and vomiting from a migraine headache but has been found to be effective in terminating the headache itself. Patients with headaches such as migraines or cluster headaches generally prefer to lay flat (unless they are actively vomiting) with the lights dimmed. In some cases, chemical ice packs or a cool wash cloth to the forehead may afford the patient additional pain relief. Narcotic analgesia should generally be avoided in patients with a headache, even if the patient believes that he or she knows the cause. If the patient is experiencing an intracranial hemorrhage, vasodilator drugs (ie, morphine, fentanyl) could exacerbate their condition.
  19. A 23-year-old male is found unresponsive. According to a friend, the patient had a headache and said that he was going to take a nap. His breathing is rapid and shallow, his pulse is rapid and weak, and he is profusely diaphoretic. Which of the following represents the MOST appropriate treatment for this patient?

    A: Apply oxygen via nonrebreathing mask, start an IV line, administer 25 g of 50% dextrose, apply a cardiac monitor, and obtain vital signs.

    B: Assist ventilations with a bag-mask device, assess his blood glucose level, apply the cardiac monitor, obtain vital signs, and establish vascular access.

    C: Preoxygenate him and prepare to intubate, start an IV line, administer 2 mg of naloxone, assess his vital signs, and apply the cardiac monitor.

    D: Hyperventilate him with a bag-mask device, conduct an in-depth neurologic exam, obtain a 12-lead ECG, and administer 1 mg of glucagon IM.
    B

    The patient’s respirations are likely not producing adequate minute volume and should be assisted with a bag-mask device. Hyperventilation should be avoided; it increases the incidence of gastric distention and may impair venous return to the heart due to increased intrathoracic pressure. You must next try to determine the cause of his unresponsiveness. Tachypnea and tachycardia are not consistent with a narcotic overdose; therefore, naloxone (Narcan) will likely have no effect. He may be hypoglycemic; however, before administering dextrose or glucagon, assess his blood glucose level first. Cardiac monitoring is indicated in order to detect life-threatening dysrhythmias; obtain a 12-lead ECG when possible. Vascular access is indicated in case fluid boluses or drug therapy is necessary. Intubation may be necessary if the patient requires prolonged ventilatory support or if you are unable to effectively ventilate with a bag-mask device. The ability to rule out (or in) causes of altered mental status in the field is relatively limited; therefore, rapid transport is essential.
  20. A 30-year-old man complains of difficulty breathing and a fever for the past 10 days. He is emaciated, is coughing, and has purple blotches on his trunk. This patient's clinical presentation is MOST consistent with:

    A: pneumonia.
    B: tuberculosis.
    C: hepatitis.
    D: HIV/AIDS.
    D

    Signs and symptoms of advanced HIV disease (AIDS) include weight loss, which gives the patient an emaciated appearance; persistent fever; night sweats; fatigue; and purple blotches on the skin, which are malignant lesions called Kaposi’s sarcoma. The patient may have pneumonia; however, this would be the result of the immunosuppression associated with HIV/AIDS. Kaposi's sarcoma are not observed in patients with tuberculosis, pneumonia (without HIV/AIDS), or hepatitis.
  21. Which of the following ECG abnormalities is associated with hypothermia?

    A: Osborn wave
    B: Peaked T waves
    C: Sine wave
    D: Flat T waves
    A. If a patient's core body temperature falls below 90°F (32.2°C), an Osborn wave (J wave) may be observed on the ECG. An Osborn wave is a positive deflection that causes elevation of the J point (intersection of the QRS complex and ST segment) above the isoelectric line. A sine wave (sinusoidal waveform), which may be observed on the ECG in patients with severe hyperkalemia, is characterized by a widening QRS that merges with its corresponding T wave. Tall, peaked T waves are also an ECG indicator of significant hyperkalemia. Flattened or inverted T waves, a prominent U wave, and a wide PR interval, are ECG indicators of significant hypokalemia.
  22. A person's level of consciousness is regulated by the:

    A: reticular activating system.
    B: diencephalon.
    C: medulla oblongata.
    D: limbic system.
    A. A person’s level of consciousness is regulated by the reticular activating system (RAS), which is at the level of the midbrain—a part of the brain stem. The thalamic region of the diencephalon acts as a relay center; it filters important signals from routine signals. The hypothalamic region of the diencephalon regulates functions such as emotions (pleasure), body temperature, and interaction with the endocrine system. The limbic system is the region of the brain where the emotions of rage and anger are generated. The medulla oblongata is part of the brain stem. It regulates functions such as heart rate, respiratory rate, and blood pressure. The medulla and the pons (portion of the brain stem that regulates respiratory patterning and depth) function as the respiratory centers of the brain.
  23. A 43-year-old woman was stung by a scorpion. Within 5 minutes, she developed swelling to her face and diffuse urticaria. She is confused and has a BP of 80/60 mm Hg. After administering supplemental oxygen, you should give:

    A: a rapid 500 mL normal saline bolus.
    B: 0.1 mg of epinephrine 1:10,000 IV.
    C: 25 to 50 mg of diphenhydramine IM.
    D: 125 mg of methylprednisolone IV.
    B. The patient is in anaphylactic shock; she has an altered mental status, is hypotensive, has diffuse urticaria (hives), and facial swelling (angioedema). After ensuring a patent airway and improving ventilation and oxygenation, the most crucial intervention is epinephrine. For anaphylactic shock, the adult dose is 0.1 mg (1 mL) of a 1:10,000 solution IV. Through its alpha-1 and beta-2 adrenergic effects of vasoconstriction and bronchodilation, epinephrine reverses the hypotension and bronchospasm associated with anaphylactic shock. For refractory hypotension, administer fluid boluses and consider an epinephrine infusion. Diphenhydramine (Benadryl) is given after epinephrine to block the release of histamines that are causing the allergic reaction; the adult dose is 25 to 50 mg IV. Methylprednisolone (Solu-Medrol), a glucocorticoid (steroid) anti-inflammatory drug, may be given as an adjunct to epinephrine and diphendydramine; the adult dose is 125 mg.
  24. Polycythemia is a condition that results in:

    A: spontaneous bleeding due to a low platelet count.

    B: lactic acidosis due to anaerobic metabolism.

    C: increased oxygen-carrying capacity of the blood.

    D: a marked increase in the core body temperature.
    C. Polycythemia is defined as an increase in red blood cell production. It often occurs in response to hypoxia, but may occur for other reasons. Patients with emphysema, for example, are often polycythemic in response to chronic hypoxia; this is why they are commonly referred to as “pink puffers.” Because red blood cells attach to the hemoglobin molecule and carry oxygen, polycythemia increases the oxygen-carrying capacity and efficiency of the blood. Of course, how well the tissues actually get oxygenated depends on the oxyhemoglobin saturation. A marked increase in core body temperature results from environment factors (eg, heatstroke), inflammation, and infection. Pyrogens are fever-causing agents that are produced by the immune system. When an infectious or inflammatory process exists, the body produces excess levels of pyrogens, resulting in pyrexia (fever). Patients with thrombocytopenia—a reduction in platelets—commonly experience spontaneous bleeding. Furthermore, thrombocytopenic patients have impaired hemostasis; even minor internal bleeding can be extremely serious. Aerobic metabolism is the normal metabolic process; it produces carbon dioxide and water as its byproducts. In the absence of oxygen, the cells convert from aerobic to anaerobic metabolism and produce lactic acid.
  25. Which of the following patients is at greatest risk for hypothermia?

    A: 65-year-old man with coronary artery disease

    B: 45-year-old man with hyperglycemia

    C: 60-year-old woman with Cushing syndrome

    D: 55-year-old woman with hypothyroidism
    D. Hypothyroidism is a condition in which the thyroid gland produces too little T3 (triiodothyronine) and T4 (thyroxine), resulting in a decrease in the metabolic rate. Any time the metabolic rate decreases, heat energy production is reduced; therefore, the patient is prone to hypothermia. Cushing syndrome is caused by excessive cortisol production by the adrenal glands or by excessive use of cortisol or other similar glucocorticoid hormones (ie, prednisone, hydrocortisone, methylprednisolone). This increase in cortisol would cause an increase in the metabolic rate. Patient's with Cushing syndrome are not at risk for hypothermia, nor are patients with hyperglycemia or coronary artery disease.
  26. You arrive at a local community center where a 30-year-old man has been having a seizure for the past 20 minutes. After properly managing his airway and establishing vascular access, you should give:

    A: 100 mg of thiamine.
    B: 5 to 10 mg of diazepam.
    C: 0.4 to 2 mg of naloxone.
    D: 25 g of glucose.
    B. A patient that has been having a seizure continuously for more than 10 minutes is said to be in status epilepticus. After ensuring airway patency and adequate ventilation, your next priority should be to pharmacologically terminate the seizure. Benzodiazepines, such as diazepam (Valium) and lorazepam (Ativan) are effective in terminating seizures. The correct dose of diazepam for seizure termination is 5 to 10 mg. If vascular access cannot be obtained, administer the benzodiazepine via the intramuscular route. If you suspect a narcotic overdose as the underlying cause of the seizure, given naloxone (Narcan) accordingly. If hypoglycemia is documented, administer 25 g of 50% dextrose. Thiamine (vitamin B1) is not routinely given to patients who are experiencing a seizure, although it should be considered if your patient has a history of alcoholism and is hypoglycemic.
  27. Which of the following clinical presentations is consistent with significant insecticide exposure?

    A:A dry cough, tachycardia, and hypertension

    B: Extreme hyperactivity and pupillary dilation

    C: Excessive salivation and severe bradycardia

    D: Acute urinary retention and abdominal pain
    C. Organophosphates, such as what is found in pesticides/insecticides and chemical nerve agents (VX, sarin, tabun, soman), deactivate acetylcholinesterase (AChE), an enzyme that regulates the degradation of acetylcholine (ACh). ACh is the chemical neurotransmitter of the parasympathetic nervous system. Without AChE, there is nothing to regulate ACh degradation; this would cause cardiovascular collapse secondary to massive parasympathetic stimulation. The clinical presentation of severe organophosphate toxicity can be recalled using the mnemonic DUMBELS, which stands for defecation, urination, miosis (pupillary constriction), bronchorrhea and bradycardia, emesis, lacrimation, and salivation. Treatment includes atropine sulfate, which blocks the effects of ACh, and pralidoxime chloride (2-PAM, Protopam), which reactivates AChE. A commercial auto-injector (DuoDote) is available; it contains both pralidoxime and atropine.
  28. A patient with a blood glucose level of 650 mg/dL would be expected to present with:

    A: hypopnea, oliguria, abdominal pain, and vomiting.
    B: hyperpnea, dehydration, warm skin, and tachycardia.
    C: tachypnea, anuria, alkalosis, and a bounding pulse.
    D: hypercarbia, anorexia, hyperactivity, and diaphoresis.
    B. Patients with diabetic coma (diabetic ketoacidosis [DKA], hyperglycemic crisis) have a significantly elevated blood glucose level. In the absence of insulin, glucose cannot enter the cell; this results in metabolic acidosis secondary to ketoacid production from cellular fat metabolism. Excess blood glucose levels promote an osmotic diuresis, resulting in excessive urination (polyuria) and significant dehydration. Signs of dehydration include warm, dry skin with poor turgor; and a rapid, weak pulse. The respiratory buffer system attempts to eliminate ketones from the blood by increasing the rate and depth of respirations (tachypnea and hyperpnea); this is called Kussmaul respirations, and is associated with an acetone odor on the patient’s breath. Patients with DKA typically have a decreasing level of consciousness that progresses to coma; hyperactivity would not be observed.
  29. You are called to a residence for a 39-year-old woman, who, according to her husband, is "not acting right." She is confused, is experiencing hallucinations, and is repetitively smacking her lips. Which of the following should you suspect? 
    A: Generalized seizure
    B: Focal motor seizure
    C: Complex partial seizure
    D: Simple partial seizure
    C. Seizures are classified as being generalized or partial. Your patient's presentation is consistent with a complex partial seizure. Partial seizures affect a limited part of the brain and are further divided into simple partial and complex partial. Simple partial seizures involve movement (frontal lobe) or sensations (parietal lobe) to one part of the body. A focal motor seizure is a simple partial seizure with localized motor activity. There may be spasm or clonus (jerking) of one muscle or muscle group, which may remain localized or may spread to adjacent muscles (Jacksonian march). Complex partial seizures involve changes in level of consciousness. The patient can become confused, lose alertness, experience hallucinations, or may be unable to speak. Automatisms, such as lip smacking, chewing, swallowing, may occur with complex partial seizures. Generalized seizures affect the entire brain. Tonic/clonic seizures (full body jerking movements), absence seizures (freezing or staring), and pseudoseizures (tonic/clonic, but caused by a psychiatric mechanism) are examples of generalized seizures.
  30. Prehospital treatment for a patient in ventricular fibrillation who has a core body temperature of less than 86°F (30°C) includes:

    A: hyperventilation with warm humidified oxygen.

    B: doubling the dose of all medications.

    C: administering lidocaine instead of amiodarone.

    D: limiting defibrillation to one attempt only.
    D. Although severely hypothermic patients in cardiac arrest usually does not respond to conventional ACLS therapies, one shock (360 monophasic joules or equivalent biphasic) can be attempted if the patient is in V-Fib or pulseless V-Tach. If the patient does not respond to one shock, further defibrillation attempts should be deferred; the paramedic should focus on providing high-quality CPR with minimal interruptions, airway management (do NOT hyperventilate the patient), rewarming per local protocol, and prompt transport. If the patient's core body temperature is less than 86°F (30°C), cardiac medications (ie, epinephrine, amiodarone, lidocaine) will be ineffective because the patient's metabolic rate is so low. Furthermore, they can accumulate to toxic levels if given repeatedly. For these reasons, cardiac medications should be wittheld until the patient is properly rewarmed at the hospital.
  31. Multiple sclerosis is a disease caused by: 

    A:inflammation of the trigeminal nerve that leads to deterioration of the myelin sheath and causes severe, chronic pain.

    B:dysfunction or damage to the portion of the brain that is responsible for the production of dopamine.

    C:a genetic disorder in which defective DNA causes an error in muscle tissue, such that the malformed muscle cells rupture.

    D:an autoimmune disorder in which the body attacks the myelin sheath of the neurons in the brain and spinal cord.
    D:an autoimmune disorder in which the body attacks the myelin sheath of the neurons in the brain and spinal cord.

    Multiple sclerosis (MS) is an autoimmune disorder in which the immune system recognizes the protein that makes up the myelin sheath—the protective insulation that coats the axons of most nerve cells (neurons)—as being foreign and creates antibodies, called autoantibodies, that destroy it. This leads to areas of scarring that produce symptoms such as muscle weakness; impairment of pain, temperature, and touch senses; pain (moderate to severe); ataxia; tremors; and speech disturbances. Parkinson’s disease results from damage to or dysfunction of the substantia nigra—the portion of the brain that produces dopamine. Patients with Parkinson’s disease classically present with fine muscle tremors. A genetic disorder in which defective DNA causes an error in muscle tissue, such that the malformed muscle cells rupture more easily, is called muscular dystrophy (MD). MD typically presents with progressive muscle weakness, delayed development of muscle motor skills, ptosis (drooping of the upper eyelid), drooling, and poor muscle tone. Trigeminal neuralgia—also called tic douloureux—is an inflammation of the trigeminal nerve (fifth cranial nerve). The trigeminal nerve receives sensory information from the face. The usual cause of trigeminal neuralgia is irradiation by an artery lying too close to the nerve. Over time, as the artery changes diameter to meet blood supply needs, the myelin sheath is grated off the nerve. With its insulation gone, the nerve may “short circuit,” causing severe shock-like or stabbing pain, usually on one side of the face.
  32. Which of the following conditions would produce the MOST rapid loss of consciousness? 

    A:Insulin shock

    B:Ketoacidosis

    C:Hyperglycemia

    D:Ischemic stroke
    A:Insulin shock

    Insulin shock (hypoglycemic crisis) is most noted for its rapid onset of symptoms, which includes loss of consciousness. Hyperglycemia, which can lead to ketoacidosis, typically presents over a period of hours to days. Unlike a hemorrhagic stroke, an ischemic stroke generally does cause a rapid or immediate loss of consciousness.
  33. A 60-year-old male with chronic alcoholism presents with an acute onset of hematemesis. His blood pressure is 80/40 mm Hg, pulse is 130 beats/min and weak, and respirations are 28 breaths/min and shallow. What pathophysiologic process is MOST likely responsible for his condition?

    A:Abnormally enlarged esophageal veins secondary to impaired blood flow to the liver

    B:Erosion of the large esophageal blood vessels caused by the toxic effects of alcohol

    C:Acute rupture of an esophageal artery secondary to repeated episodes of vomiting

    D:Severe bleeding from gastric ulcers that formed due to the excessive intake of alcohol
    A:Abnormally enlarged esophageal veins secondary to impaired blood flow to the liver

    This patient likely has ruptured esophageal varices. Esophageal varices are a complication of portal hypertension (increased pressure in the portal vein [the vein that carries blood from the intestines to the liver]) due to liver disease. Liver disease (ie, hepatitis, cirrhosis) is common in patients with chronic alcoholism. As blood flow to the diseased liver is blocked, blood backs up into the smaller, more fragile blood vessels in the lower part of the esophagus. As a result, these esophageal vessels become abnormally enlarged (varices). Esophageal varices are generally asymptomatic unless they rupture, in which case life-threatening hemorrhage can occur. Other complications associated with chronic alcoholism include impaired blood-clotting mechanisms, hypoglycemia, and gastritis due to the irritant effect of alcohol on the gastric lining. Repeated episodes of vomiting could rupture an esophageal vessel and cause hematemesis; however, there is no indication that this patient has had repeated episodes of vomiting.
  34. A 39-year-old man is unresponsive, pulseless, and apneic after being lost in the woods during the middle of winter. He has a core body temperature of 85°F (29.4°C). When treating this patient, you should avoid:

    A:defibrillation.
    B:cardiac medications.
    C:passive rewarming.
    D:intubation.
    B:cardiac medications.

    Treatment for patients with cardiac arrest and severe hypothermia (core body temperature less than 86°F [30°C]) includes CPR, intubation (or an alternative airway device), limiting defibrillation to one attempt if the patient is in ventricular fibrillation or pulseless ventricular tachycardia, passive rewarming, and active external rewarming (ie, heating blankets, radiant heat from hot packs). Active internal (core) rewarming is usually performed at the hospital. Cardiac medications should be withheld for two reasons: 1) the patient's metabolic rate is too slow to distribute the drugs, and 2) medications can accumulate to toxic levels in the severely hypothermic patient, which can be detrimental as the patient is rewarmed.
  35. Your assessment of a patient reveals a diffuse petechial rash. Which of the following hematologic disorders does this indicate?

    A:Leukopenia
    B:Hemolytic anemia
    C:Thrombocytopenia
    D:Polycythemia vera
    C:Thrombocytopenia

    Of the conditions listed, only one would cause a petichial rash. Thrombocytopenia, a reduction in the number of circulating platelets, can cause cutaneous bleeding and bleeding from the mucous membranes (ie, nosebleeds, rectal bleeding). Petechiae, tiny purple or red spots that appear on the skin, is caused by bleeding within the skin or under the mucous membranes. Localized petichiae may be harmless; however, a diffuse petichial rash indicates significant thrombocytopenia. Leukopenia is a reduction in the number of white blood cells (leukocytes); this condition places the patient at increased risk for infection. Polycythemia vera, also called primary polycythemia, is a hematologic disoder in which the bone marrow makes too many red blood cells; it may also result in an overproduction of white blood cells and platelets. Hemolytic anemia is a form of anemia caused by hemolysis, the abnormal breakdown (lysis) of red blood cells.
  36. Which of the following findings is MOST suggestive of myxedema? 

    A:Hypothermia
    B:Hyperactivity
    C:Weight loss
    D:Tachycardia
    A:Hypothermia

    Advanced hypothyroidism is sometimes called myxedema. Frequently, patients have localized accumulations of mucinous material in the skin, which gives the disease its name (the prefix myx- refers to "mucin," and edema means "swelling"). Myxedema manifests as a general slowing of the body's metabolic processes due to a significant reduction or absence of the thyroid hormones T3 (triiodothyronine) and T4 (thyroxine). Since the thyroid gland regulates the metabolic rate and metabolism produces heat energy, patients with myxedema are prone to hypothermia. This also explains why patients with hypothyroidism are poorly tolerant of cold temperatures. Other signs and symptoms of myxedema include lethargy, depression, bradycardia, and weight gain. In severe cases, coma and death can occur.
  37. At 2:30 AM, you respond to a crowded homeless shelter for a 52-year-old male who is sick. The patient complains of intense itching to his hands and axillae. Assessment of these areas reveals the presence of a rash. The patient denies any medical problems, but states that he was stung by a hornet two days ago. Which of the following should you suspect? 

    A:Lice
    B:Herpes simplex
    C:Allergic reaction
    D:Scabies
    D:Scabies

    This patient’s presentation is classic for scabies. Scabies are caused by infection with Sarcoptes scabiei, a parasite. Infection with scabies commonly affects families, children, sexual partners, and persons in communal living (ie, homeless shelters). Signs and symptoms of scabies include nocturnal itching and the presence of a rash involving the hands, flexor aspects of the wrists, axillary folds, ankles, toes, and genital area. Lice also present with itching and irritation; however, unlike the nocturnal presentation of scabies, the symptoms of lice occur at any time of the day or night. Herpes simplex is characterized by small vesicles; a rash is not common. It is highly unlikely that the patient is experiencing an allergic reaction; he was stung by a hornet two days ago. An allergic reaction would have presented shortly following exposure—not two days later.
  38. A patient with diabetic ketoacidosis would typically present with which of the following signs and/or symptoms? 

    A:Hypoglycemia and dehydration
    B:Hyperglycemia and oliguria
    C:Hyperglycemia and dehydration
    D:Hypoglycemia and polyuria
    C:Hyperglycemia and dehydration

    Diabetic ketoacidosis (DKA), also referred to as diabetic coma or hyperglycemic crisis, is characterized by hyperglycemia, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Other findings include warm, dry skin, dehydration, and deep, rapid respirations (Kussmaul respirations). The progression to DKA is typically slow, often over several hours to a few days. By contrast, insulin shock (hypoglycemic crisis) is characterized by a rapid onset, often within a few minutes.
  39. You are assessing a young female and are trying to determine if she experienced a seizure or a syncopal episode. Which of the following findings is MOST consistent with a seizure? 

    A:A bottle of lorazepam is found in her purse.

    B:The episode occurred while she was standing.

    C:Her heart rate is 120 beats/min.

    D:The cardiac monitor displays sinus bradycardia.
    C:Her heart rate is 120 beats/min.

    It can be difficult to determine whether a patient experienced a seizure or a syncopal episode (fainting). Therefore, it is important to ascertain what happened before and after the episode. Tachycardia is a common finding following a seizure, when the patient is postictal; it is caused by a sympathetic nervous system discharge that occurred during the seizure. Bradycardia often causes syncope secondary to an increase in vagal tone. Seizures occur regardless of the patient’s position, whereas syncope typically occurs while the patient is standing. Most patients with a history of seizures take medications that prevent seizures, such as phenytoin (Dilantin), valproic acid (Depakote), and carbamazepine (Tegretol), among others. Although benzodiazepines (ie, diazepam [Valium], lorazepam [Ativan]) are the most common class of drugs used to terminate seizures, they are more commonly prescribed for anxiety; they are rarely prescribed to prevent seizures.
  40. What is a common finding in both fresh water and salt water drownings? 

    A:Pulmonary edema
    B:Severe metabolic alkalosis
    C:Loss of surfactant
    D:Inadequate oxygenation
    D:Inadequate oxygenation

    Though the mechanisms are different in salt water drownings as opposed to fresh water drownings, inadequate oxygenation, which leads to hypoxia and metabolic acidosis, is common to both and is typically the result of laryngospasm.
  41. A 34-year-old woman overdosed on amitriptyline. She is unresponsive and has slow, shallow breathing. Her BP is 70/40 mm Hg and her heart rate is 140 beats/min. The cardiac monitor reveals sinus tachycardia. Initial treatment for her should include: 

    A:endotracheal intubation and 1 to 2 mEq/kg of sodium bicarbonate IV push.

    B:assisted ventilation with a bag-mask device and 20 mL/kg normal saline boluses.

    C:assisted ventilation with a bag-mask device and 0.2 mg of flumazenil IV push.

    D:high-flow oxygen via nonrebreathing mask and 0.4 to 2 mg of naloxone IV push.
    C:assisted ventilation with a bag-mask device and 0.2 mg of flumazenil IV push.

    Slow, shallow breathing will not produce adequate minute volume and should be treated with assisted ventilation. The patient may require endotracheal intubation, but you must restore minute volume first (think basic!). Amitriptyline is a tricyclic antidepressant (TCA); naloxone (Narcan), a narcotic antagonist, will not reverse its effects. Treat the patient's hypotension with sequential normal saline boluses (20 mL/kg); monitor closely for signs of pulmonary edema. Flumazenil (Romazicon), a benzodiazepine antagonist, should not be given to patients with a TCA overdose; it may cause seizures. Provide continuous ECG monitoring and watch for widening of the QRS complex. If QRS widening occurs, consult with medical control regarding the administration of sodium bicarbonate.
  42. Which of the following drug overdoses could be reversed with the administration of naloxone? 

    A:Adderall
    B:Phenobarbitol
    C:Midazolam
    D:Meperidine
    D:Meperidine

    Meperidine hydrochloride (Demerol) is a potent narcotic analgesic; its CNS depressant effects can be reversed with the administration of naloxone. Naloxone (Narcan) is a narcotic antagonist that binds to opiate/opioid receptor sites in the body, thus blocking the CNS depressant effects (ie, respiratory depression, hypotension, bradycardia) that narcotics cause. It is important to note that the effects of many narcotic/opiate drugs outlive the effects of a single dose of naloxone; therefore, repeat doses of naloxone are often needed. Midazolam (Versed) is a benzodiazepine sedative-hypnotic and anticonvulsant; it is not a narcotic. Phenobarbitol (Luminal) is a barbiturate sedative-hypnotic and anticonvulsant; it is not a narcotic. Adderall (amphetamine/dextroamphetamine) is a CNS stimulant used to treat ADHD; it is not a narcotic.
  43. A 64-year-old man presents with an acute onset of left-sided weakness, right-sided facial droop, and slurred speech. He is conscious, but confused. You should be MOST suspicious for: 

    A:right-sided hemorrhagic stroke.
    B:right-sided ischemic stroke.
    C:left-sided hemorrhagic stroke.
    D:left-sided ischemic stroke.
    B:right-sided ischemic stroke.

    Recalling that the right side of the brain controls the left side of the body and vice versa, this patient's clinical presentation is most consistent with an ischemic stroke to the right cerebral hemisphere. Ischemic strokes, caused by a blocked cerebral artery, typically present with confusion, unilateral weakness (hemiparesis) or paralysis (hemiplegia) on the opposite (contralateral) side of the stroke, a facial droop on the same (ipsilateral) side as the stroke, and dysarthria (slurred or poorly articulated speech). Pupillary abnormalities, if observed, typically occur on the ipsilateral side because of optic nerve crossover in the brain. The patient's clinical presentation is less consistent with a hemorrhagic stroke, which typically presents with a sudden, severe headache; a rapid loss of consciousness; and signs of increased intracranial pressure (ie, hypertension, bradycardia, breathing abnormalities). A hemorrhagic stroke is the result of a ruptured cerebral artery (ie, an aneurysm).
  44. Pickwickian syndrome is a condition in which: 

    A:hypoventilation secondary to morbid obesity leads to hypoxemia, hypercarbia, and polycythemia.

    B:an autoimmune disorder causes destruction of the myelin and nerve axons within the brain and spinal cord.

    C:antibodies prevent acetylcholine from reaching the muscles by blocking or damaging the receptor sites.

    D:voluntary muscles are poorly controlled secondary to developmental brain defects that occur in utero.
    A:hypoventilation secondary to morbid obesity leads to hypoxemia, hypercarbia, and polycythemia.

    Some morbidly obese patients suffer from a condition called Pickwickian syndrome. When they lie in a supine position, excess adipose (fat) tissue on their chest wall impedes the mechanics of breathing, resulting in hypoventilation or apnea. As a result, hypoxemia and hypercarbia occur. Excess red blood cell production (polycythemia) occurs in response to hypoxemia. The patient commonly presents with a red face (due to polycythemia) and complains of daytime sleepiness. Multiple sclerosis (MS) is a chronic disease of the CNS caused by an autoimmune disorder that destroys myelin and nerve axons within the brain and spinal cord. MS causes random areas of myelin to become inflamed, detach from the axon, and self-destruct. The areas of destruction become sclerosed, hence the name multiple (many) sclerosis (to harden). Cerebral palsy (CP) is a nonprogressive, bilateral neuromuscular disorder in which voluntary muscles are poorly controlled. It results from developmental brain defects in utero, brain trauma at birth or in early childhood, or postpartum CNS infections. Patients with CP often have spastic movements of their limbs and poor posture; this impairs their ability to move in a controlled manner. Myasthenia gravis is characterized by chronic fatigability and muscle weakness, especially in the face and throat. In myasthenia gravis, antibodies prevent acetylcholine from reaching the muscles by blocking or damaging the receptor sites. This interruption in communication results in acute bouts of muscle weakness, usually during activity; the condition often improves with rest.
  45. A 30-year-old female is found unresponsive by her roommate. According to the roommate, the patient, who has type I diabetes, was fine 30 minutes ago. On assessment, the patient has rapid, shallow respirations; pallor and diaphoresis; and a weak, thready pulse. Additional assessment of this patient will MOST likely reveal: 

    A:marked hyperglycemia.

    B:a blood glucose level less than 70 mg/dL.

    C:peaked T waves and wide QRS complexes.

    D:an acetone or fruity odor on her breath.
    B:a blood glucose level less than 70 mg/dL.

    This patient’s clinical presentation—pallor, diaphoresis, tachypnea, tachycardia, unresponsiveness—is classic for insulin shock (hypoglycemic crisis). The fact that she was fine 30 minutes ago indicates that her condition occurred acutely, another hallmark feature of insulin shock. When you assess her blood glucose level, it will likely read well below 70 mg/dL (hypoglycemia). Unlike insulin shock, diabetic ketoacidosis (DKA) progresses slowly, over 12 to 48 hours, and is the result of hyperglycemia. In DKA, blood glucose levels of 400 mg/dL or higher are not uncommon. Other signs of DKA include deep, rapid respirations with a fruity or acetone breath odor (Kussmaul respirations), which is a response of the respiratory system to eliminate ketoacids from the blood; warm, dry skin, which is the result of dehydration secondary to the osmotic diuresis caused by hyperglycemia; and a rapid, full pulse, which is also the result of dehydration. Changes in serum potassium are possible in patients with DKA. The associated osmotic diuresis may cause dangerously low potassium levels (hypokalemia), resulting in marked myocardial instability. On the ECG, hypokalemia may manifest with flattened T waves, prominent U waves, ST segment depression, and prolongation of the PR and QT intervals.
  46. You respond to a lake at a state park where bystanders pulled a 44-year-old male from the water and are performing CPR on him. According to a park ranger, the water temperature of the lake is 85°F. No one witnessed the patient's submersion; however, one of his friends tells you that he is a diabetic and had been drinking beer all day. The cardiac monitor reveals a wide-complex bradycardic rhythm. In addition to CPR, further treatment should include: 

    A:cardiac pacing, intubation, gastric tube insertion, vascular access, 40 units of vasopressin, thermal management, and 25 g of 50% dextrose.

    B:spinal precautions, intubation, gastric tube insertion, vascular access, 1 mg of epinephrine, blood glucose assessment, and thermal management.

    C:manual gastric decompression, insertion of an advanced airway device, vascular access, 1 mg of epinephrine, and 25 g of 50% dextrose.

    D:spinal precautions, insertion of an advanced airway device, hyperventilation, vascular access, 1 mg of epinephrine, and 50 mEq of sodium bicarbonate.
    B:spinal precautions, intubation, gastric tube insertion, vascular access, 1 mg of epinephrine, blood glucose assessment, and thermal management.

    Full spinal precautions are clearly indicated, especially following an unwitnessed submersion. When a swimmer panics, large amounts of water are swallowed; this causes gastric distention, which increases the risk of aspiration and makes ventilations difficult to perform. Intubate the patient and then insert a gastric tube to decompress the stomach. Following intubation, perform asynchronous CPR and deliver 8 to 10 breaths/min. Do not hyperventilate! Manual gastric decompression is dangerous and should be avoided, especially in nonintubated patients. Rescue airway devices (ie, King LT, LMA, CobraPLA) may provide better ventilation than a bag-mask device, but they do not eliminate the risk of aspiration. Establish vascular access and give 1 mg of epinephrine 1:10,000. A single dose of vasopressin (40 units) can be given to replace the first or second dose of epinephrine, but not both. There is currently no evidence to support the use of transcutaneous cardiac pacing (TCP) in cardiac arrest. Because the patient is a diabetic, assess his blood glucose level early and give 50% dextrose if he is hypoglycemic. Keep the patient warm; remove wet clothes and apply warm blankets. Treat suspected acidosis with adequate ventilation first, then contact medical control or follow your local protocols regarding the administration of sodium bicarbonate.
  47. Angioedema in a patient with a severe allergic reaction poses an immediate threat to life secondary to: 

    A:compartment syndrome.
    B:intracranial pressure.
    C:airway compromise.
    D:congestive heart failure.
    C:airway compromise.

    Angioedema, caused by the release of histamines, is the result of vascular fluid leakage into the subcutaneous layers of the skin. It is prominent in the face and neck area in patients with severe allergic reactions and can pose a significant threat to the airway.
  48. You respond to a residence for an overdose. While en route, the dispatcher advises you that CPR is in progress. A second paramedic unit is dispatched, but their response to the scene will be delayed. When you arrive at the scene, an emergency medical responder is performing CPR on the patient, a 30-year-old male, who apparently ingested an unknown quantity of Darvon. After confirming apnea and pulselessness, you should direct resumption of CPR and then: 

    A:establish vascular access and administer 2 mg of naloxone.

    B:locate the medication bottle to confirm what he evidently ingested.

    C:apply the ECG electrodes and assess the patient’s cardiac rhythm.

    D:insert an advanced airway device to ensure adequate ventilation.
    C:apply the ECG electrodes and assess the patient’s cardiac rhythm.

    After confirming cardiac arrest, resume CPR and assess the patient’s cardiac rhythm. Although he ingested propoxyphene (Darvon), a narcotic, your first priority is to determine the need for defibrillation. If indicated, deliver a single shock and immediately resume CPR starting with chest compressions. Reassess the patient every 2 minutes and repeat defibrillation as needed. With your limited resources (delayed response of the backup crew), you must prioritize additional treatment. If bag-mask ventilation (with an oral airway inserted) is adequate, establish vascular access. If bag-mask ventilations are inadequate, insert an advanced airway device and then establish vascular access. After vascular access is established, give a vasopressor (epinephrine or vasopressin). Further treatment should be guided by the patient’s cardiac rhythm. Naloxone (Narcan), in a dose of 2 mg, should be given early. When the backup crew arrives, assign someone to search for medication bottles. Whether your resources are few or many, it is critical to perform high-quality CPR with limited interruptions and to defibrillate every 2 minutes if indicated.
  49. A 59-year-old female complains of a headache. She is conscious and alert, has a patent airway, and is breathing adequately. You should: 

    A:determine when her headache began.

    B:inquire about a history of stroke.

    C:assess her pupils for equality and reactivity.

    D:ask her if she takes any medications.
    A:determine when her headache began.

    After performing your primary assessment and treatment of a responsive medical patient, you should perform a secondary assessment. This begins by assessing the history of the present illness, which is an elaboration of the chief complaint. The OPQRST mnemonic is a helpful template to use for this purpose. Ask her when her headache began—that is, when was its onset? Did it begin acutely, or has it progressively been getting worse? An acute onset of a headache suggests a more serious problem than one that has gradually progressed. Next, determine if anything provokes or palliates the headache, ask the patient to describe the pain (eg, dull or sharp), assess the severity of her pain (0–10 pain scale), and determine the time frame of the pain. Further history information can be obtained using the SAMPLE mnemonic, during which you can inquire about her past medical history (stroke, migraines). The secondary assessment is driven by information gathered during the primary assessment and history-taking phase and should focus on the patient's chief complaint. For the patient complaining of a headache, this would be an appropriate time to assess pupils, gross neurologic functions, and so on. A systematic patient assessment will facilitate the provision of the most appropriate treatment. After all, the treatment you provide is only as good as the assessment you perform.
  50. Which of the following describes the typical sequence of events that precedes cardiac arrest in a drowning episode? 

    A:Dysrhythmias, laryngospasm, hypoxia

    B:Laryngospasm, dysrhythmias, hypoxia

    C:Hypoxia, laryngospasm, dysrhythmias

    D:Laryngospasm, hypoxia, dysrhythmias
    D:Laryngospasm, hypoxia, dysrhythmias

    Typically, when a swimmer becomes panicked, he or she starts swallowing large amounts of water. Even a small volume of aspirated water (fresh or salt) can cause laryngospasm, which leads to hypoxia and unconsciousness. As the hypoxia worsens, cardiac dysrhythmias can develop, which leads to cardiac arrest.
  51. A 16-year-old boy has a severe headache and vomiting that has progressively worsened over the past 36 hours. Which of the following questions would be MOST important to ask him? 

    A:Do you have a history of hypertension?

    B:Is there a history of meningitis in your family?

    C:Do you have any abdominal pain or diarrhea?

    D:Have you experienced a recent head injury?
    D:Have you experienced a recent head injury?

    A severe headache and vomiting that progressively worsens could indicate a subdural hemorrhage; therefore, one of the most important questions to ask the patient is if he has experienced any recent head injury, even as far back as a week. Subdural hematomas are the result of venous bleeding and can be insidious in their presentation, with symptoms that often appear hours to days after the initial injury. Hypertension is unlikely in a 16-year-old patient, and meningitis is not a hereditary disease.
  52. You are called to a residence for a woman who swallowed an unknown quantity of pills. Which of the following should you inquire about FIRST? 

    A:A history of psychiatric care

    B:The patient’s weight in kilograms

    C:What kind of pills were taken

    D:When the pills were taken
    C:What kind of pills were taken

    After ensuring scene safety, your initial action when caring for any patient is to ensure a patent airway and adequate breathing. After doing this, your next action for this patient should be to determine what kind of pills she took. Then determine how long ago she took the pills. This information will enable you to provide the most appropriate treatment, which may include an antedote. Determining the patient's weight in kilograms is also important as many antedotes are weight-based. When you have determined what was taken, when it was taken, and the patient's weight in kilograms, contact medical control or the poison control center. Whether or not the patient has a psychiatric history will not influence the immediate care that you provide, although you should inquire about this at some point.
  53. Prehospital treatment for a black widow spider bite includes: 

    A:10 mL of calcium chloride.

    B:antivenin derived from horse serum.

    C:2 mg/kg of 10% calcium gluconate.

    D:2.5 to 10 mg of diazepam.
    D:2.5 to 10 mg of diazepam.

    In addition to airway, breathing, and circulatory support, narcotics and muscle relaxants/sedatives are the prehospital mainstays of therapy when treating a black widow spider bite. To treat the muscle spasms, give 2.5 to 10 mg of diazepam (Valium); lorazepam (Ativan) may also be used. Some EMS system protocols may call for 0.1 to 0.2 mg/kg of calcium gluconate. Narcotics, such as fentanyl or morphine, can be used for pain relief. Calcium chloride is not effective in the treatment of a black widow spider bite. An antivenin is available for treatment of black widow spider bites; however, this is not a prehospital intervention. Furthermore, this antivenin is typically reserved for the young and old who have severe envenomation; it also has a high incidence of allergic reactions inherent in all equine-derived (horse serum) antivenin.
  54. Following ingestion of a toxic dose of acetaminophen, right upper quadrant abdominal pain typically begins within: 

    A:12 to 24 hours
    B:4 to 14 days
    C:24 to 72 hours
    D:72 to 96 hours
    C:24 to 72 hours

    Acetaminophen, the active ingredient in Tylenol, can cause liver failure and death if a toxic dose is ingested. A unique aspect of acetaminophen toxicity is that its signs and symptoms appear in four distinct stages. Stage I (less than 24 hours) symptoms include nausea, vomiting, anorexia, pallor, and malaise. Stage II (24 to 72 hours) symptoms include right upper quadrant (RUQ) abdominal pain and abdominal tenderness to palpation. Stage III (72 to 96 hours) symptoms include metabolic acidosis, renal failure, coagulopathies, and recurring GI symptoms. During Stage IV (4 to 14 days [or longer]), recovery slowly begins or liver failure progresses and the patient dies. The antidote for acetaminophen toxicity is acetylcysteine (Acetadote); ideally, it should be given less than 8 hours following ingestion.
  55. What is the MOST appropriate dose and route of diphenhydramine for a patient who is experiencing a severe allergic reaction? 

    A:0.3 to 0.5 mg IM
    B:25 to 50 mg IM
    C:25 to 50 mg IV
    D:0.3 to 0.5 mg SC
    C:25 to 50 mg IV

    Diphenhydramine (Benadryl) is an antihistamine and is a second line medication to epinephrine in patients with severe allergic reactions (eg, anaphylactic shock). The dose is 25 to 50 mg IV. In patients with anaphylactic shock, intramuscular (IM) injections will not be as effective since circulation of blood through the muscles is diminished secondary to the peripheral shunting of blood. As a result, drugs given by this route would have a delayed onset of action. It would be appropriate to give diphenhydramine IM to patients with mild to moderate allergic reactions because peripheral perfusion is generally adequate.
  56. A 23-year-old man was working near a wood pile when he experienced a sudden, sharp pain in his leg. Your assessment reveals that his level of consciousness is decreased and he is experiencing intense abdominal spasms. This clinical presentation is MOST consistent with the bite of a: 

    A:brown recluse spider.
    B:black widow spider.
    C:rattlesnake or other pit viper.
    D:coral snake.
    B:black widow spider

    This is a classic case of a black widow spider bite. The black widow spider typically can be found near wood piles or wood sheds. The patient will usually experience immediate sharp pain at the time of the bite, and then within a short period of time painful muscle spasms will develop in all of the major muscle groups, especially the abdomen. The black widow spider carries a neurotoxin in its venom, which explains the muscle spasms. If left untreated, CNS depression will continue and the patient will experience cardiovascular and respiratory system collapse. In contrast to a black widow spider bite, the bite of a brown recluse spider is usually painless, and the patient does not even realize he or she has been bitten until a red area with a small blister in the center of it appears several hours to a day later. Unlike the black widow spider, the brown recluse spider carries a cytotoxin (necrotoxin) in its venom. Cytotoxins cause tissue and cellular necrosis.
  57. In contrast to an anaphylactic reaction, an anaphylactoid reaction: 

    A:is an immune response mediated by IgE antibodies.

    B:usually does not respond to antihistamine medications.

    C:can occur without prior exposure to an offending agent.

    D:is usually less severe and does not require drug therapy.
    C:can occur without prior exposure to an offending agent.

    Anaphylaxis is an immune response that is mediated by IgE antibodies, whereas an anaphylactoid reaction is an immune response that does not involve IgE antibody mediation. Anaphylaxis requires the patient to be sensitized first; he or she must be exposed to the offending agent (antigen) in order to build up IgE antibodies. Because an anaphylactoid reaction is not IgE antibody mediated, prior exposure (sensitization) to the offending agent is not required. Examples of common agents that cause an anaphylactoid reaction include some contrast dyes given before radiography, morphine-derivative medications, and aspirin. Even though the process that causes an anaphylactoid reaction is different from an anaphylactic reaction, the clinical presentation, negative consequences (respiratory and circulatory failure), and treatment are the same. Do not discount a severe allergic reaction just because a patient, who presents with suggestive signs and symptoms, tells you that he or she was never exposed to the suspected trigger.
  58. A 46-year-old woman was found unresponsive on her couch by a concerned neighbor. According to the neighbor, the patient uses heroin, but recently boasted that she has “been clean.” The patient is unresponsive; has rapid, shallow breathing; and slow, weak radial pulses. You should: 

    A:apply oxygen via nonrebreathing mask, apply the cardiac monitor, establish vascular access, and administer 2 mg of naloxone slow IV push.

    B:insert an oral airway, assist her ventilations with a bag-mask device, apply the cardiac monitor, consider transcutaneous pacing, and establish vascular access.

    C:secure her airway with an endotracheal tube, apply the cardiac monitor, establish vascular access, and administer 1 mg of atropine rapid IV push.

    D:provide some form of positive-pressure ventilation, apply the cardiac monitor, establish vascular access, and administer 25 g of 50% dextrose IV push.
    B:insert an oral airway, assist her ventilations with a bag-mask device, apply the cardiac monitor, consider transcutaneous pacing, and establish vascular access.

    This patient’s clinical presentation—specifically her rapid, shallow respirations—are not consistent with a heroin overdose. As with all narcotic overdoses, heroin causes hypoventilation (ie, slow, shallow breathing) due to its central nervous system depressant effects. Your first priority is to establish a patent airway, insert an airway adjunct to help maintain her airway, and begin assisting her ventilations. Rapid, shallow (reduced tidal volume) respirations often do not produce adequate minute volume and should be treated with positive-pressure ventilation, not a nonrebreathing mask. Transcutaneous cardiac pacing (TCP) is an acceptable intervention for any patient with unstable bradycardia and should be initiated without delay. Atropine is also an appropriate intervention; however, the correct dose for bradycardia is 0.5 mg. If TCP and atropine are ineffective, consider the possibility of a coingestion (ie, heroin and a tricyclic antidepressant). Given the patient’s history of heroin use, it would clearly be appropriate to administer naloxone; however, based on her initial presentation, it would not be the initial intervention of choice. Dextrose would be appropriate if hypoglycemia is documented by glucometer.
  59. You are called to the residence of an elderly man whose daughter states that he is not acting right. The patient becomes combative when you attempt to assess him. He refuses supplemental oxygen and states that you are not taking him anywhere. What is the MOST appropriate course of action? 

    A:Start an IV line and administer 25 gm of 50% dextrose.

    B:Gently restrain him and transport him to the hospital.

    C:Calmly talk to him and try to obtain a glucose reading.

    D:Administer 5 mg diazepam IM to calm and sedate him.
    C:Calmly talk to him and try to obtain a glucose reading.

    Any patient with an altered mental status should be ruled out for hypoglycemia by obtaining a blood glucose reading. Administering IV dextrose without assessing his blood glucose level first is not advisable. If he is experiencing an intracranial hemorrhage, dextrose may exacerbate his condition. Conversely, if you discover that he is hypoglycemic, this must be corrected. It is important to calmly approach any patient, regardless of his or her mental status. The assumption of a psychiatric crisis is not in the best interest of the patient. Focus on ruling out medical problems first.
  60. You are called to an assisted living facility for a sick resident. The patient, a 70-year-old woman, reports tinnitus and difficulty concentrating. The patient's neighbor, who is present at the scene, tells you that the patient has consumed five or six cups of ice over the past hour. You should suspect: 

    A:acute leukemia.
    B:lymphoma.
    C:polycythemia.
    D:chronic anemia.
    D:chronic anemia

    Tinnitus (ringing in the ears), a craving for ice, and difficulty concentrating are hallmark findings of chronic anemia. Anemia is defined as a deficiency of red blood cells. Other findings may include a headache, dizziness, and tachycardia. Polycythemia, an overproduction of red blood cells, causes flushing of the skin; it is not commonly associated with the clinical signs that this patient is exhibiting. Leukemia and lymphoma are types of cancer that commonly manifest with persistent weakness, fever, and swollen lymph nodes (lymphadenopathy).
  61. A 19-year-old male experienced a syncopal episode after several hours of vigorous exercise in the heat. Upon arrival at the scene, bystanders direct you to the patient, who they moved under a tree. The patient moans in response to painful stimuli, and his skin is flushed, hot, and moist. After ensuring airway and breathing adequacy, your MOST immediate action should be to: 

    A:infuse 500 mL of IV fluid.

    B:assess his blood glucose level.

    C:begin rapid cooling measures.

    D:take his temperature orally.
    C:begin rapid cooling measures.

    This patient is experiencing exertional heat stroke secondary to prolonged exposure to a hot environment. His markedly decreased level of consciousness and hot skin indicate a dangerously high core body temperature (CBT). Because the extent of brain damage depends on the severity and duration of hyperthermia, rapid cooling measures must begin immediately. Otherwise, the patient’s CBT will continue to rise and he will die. Remove the patient’s clothing (they can trap heat), and begin fanning him while keeping his skin wet. The use of ice packs or ice cold water should be avoided, however, because they may precipitate shivering and cause a further increase in his CBT. Load the patient into the ambulance and begin rapid transport, continuing cooling measures en route. Heat stroke is generally associated with volume depletion; however, IV therapy should be performed en route to the hospital. Although concomitant hypoglycemia is unlikely, you should assess the blood glucose level of any patient with an altered mental status. When assessing the patient’s CBT, a hyperthermia thermometer (ie, a rectal probe) should be used, if available. Taking his temperature orally will yield little additional information. Unlike classic heat stroke, which commonly affects young children, elderly patients, and those with significant medical problems, exertional heat stroke does not always present with dry skin. Although the patient is not actively sweating, the skin is often moist from residual perspiration
  62. After being stung by a hornet, a 34-year-old man is unresponsive, has stridorous respirations, a generalized rash, and swelling to the face and neck. His BP is 70/44 mm Hg, his pulse is 140 beats/min and thready, and his respirations are 36 breaths/min and labored. Which of the following represents the MOST appropriate treatment for him?                                   

    A:Needle cricothyrotomy and 0.3 to 0.5 mg of epinephrine 1:1,000 SC

    B:Blind nasal intubation and 3 to 5 mg of epinephrine 1:10,000 IV or IO

    C:Bag-mask ventilation and 0.3 to 0.5 mg of epinephrine 1:1,000 SC

    D:Orotracheal intubation and 0.1 mg of epinephrine 1:10,000 IV or IO
    D:Orotracheal intubation and 0.1 mg of epinephrine 1:10,000 IV or IO

    The patient’s airway is rapidly swelling, as evidenced by the stridorous respirations. Additionally, his level of consciousness and vital signs are consistent with shock. His airway is in immediate jeopardy and must be secured before it closes completely. You should insert an endotracheal tube (a smaller than normal tube may be needed) via the orotracheal route and assist his ventilations, establish IV or IO access, and administer 0.1 mg (1 mL) of epinephrine 1:10,000; an epinephrine infusion may be needed for refractory anaphylaxis. Epinephrine by the SC route will be much less effective in this patient because he is in shock and peripheral perfusion is likely minimal. If you cannot successfully intubate him via the orotracheal route, you will likely not be able to intubate him via the nasotracheal route. Therefore, if orotracheal intubation is unsuccessful, you should proceed with a cricothyrotomy at once.
  63. You enter an elderly man's residence and find him sitting on the couch with his eyes closed. His respirations appear to be deep and rapid. You should: 

    A:quickly move him to the floor.

    B:check for a carotid pulse.

    C:manually open his airway.

    D:assess his mental status.
    D:assess his mental status.

    Just because a patient’s eyes are closed does not mean that he or she is unresponsive. The primary assessment of a patient begins by assessing his or her mental status. In this particular case, if you find that the patient is unresponsive, you should quickly move him to the floor, continue with your primary assessment, and begin treatment as needed. If the patient is responsive, continue your primary assessment and then determine his chief complaint.
  64. You are dispatched to a residence for a patient having a seizure. Upon arriving at the scene, you find that the patient, a 39-year-old male, is experiencing a generalized tonic-clonic seizure and is cyanotic. His wife tells you that he has been like this since she called 9-1-1. In addition to protecting the patient from injury, you should: 

    A:apply high-flow oxygen via nonrebreathing mask, place him on his side, and wait for the seizure to stop.

    B:assist his breathing with a bag-mask device, establish vascular access, and administer 5 mg of diazepam.

    C:intubate him to prevent aspiration, establish IV or IO access, and administer 0.1 mg/kg of lorazepam.

    D:administer 0.5 mg/kg of diazepam rectally, cover him with a blanket, and administer high-flow oxygen.
    B:assist his breathing with a bag-mask device, establish vascular access, and administer 5 mg of diazepam.

    Status epilepticus is defined as a prolonged (> 10 minutes) seizure or consecutive seizures that occur without an intervening return to consciousness. During a seizure, neurons are using huge amounts of glucose and producing lactic acid. For short periods, this does not cause long-term damage. If the seizure continues, however, the body can’t remove the waste products effectively or ensure adequate glucose supplies; this can cause neuronal damage or death. Hypoventilation or apnea is common during a seizure; cyanosis is also common. In short-duration seizures, these are usually short-lived (< 30 seconds) and generally do not require assistance. However, status epilepticus causes prolonged hypoventilation or apnea and requires ventilation assistance, although this may be difficult. Patients experiencing a seizure often have clenched teeth (trismus); therefore, intubation will be nearly impossible and is generally contraindicated. Benzodiazepines (ie, Valium, Ativan) are used to terminate seizures. The dose of Valium is 5 mg IV or IM (repeated every 10 to 15 minutes up to 30 mg). If vascular access is not available, Valium can be given rectally (adult dose, 0.2 mg/kg). The dose of Ativan is 0.05 mg/kg (maximum single dose of 4 mg); this may be repeated in 10 to 15 minutes if needed. If benzodiazepines do not quickly terminate the seizure and the patient cannot be ventilated, rapid-sequence intubation (RSI) may be required.
  65. Functions of the hypothalamus include: 

    A:maintaining equilibrium and balance.

    B:controlling level of awareness.

    C:regulating appetite.

    D:influencing breathing.
    C:regulating appetite.

    The “hunger” center of the hypothalamus promotes eating. Among many other functions, the hypothalamus regulates body temperature, assists in the regulatory control of the pituitary gland, and promotes urine release from the bladder. The influence of breathing are functions of the pons and medulla, which are a part of the brainstem. Maintenance of equilibrium and balance are functions of the cerebellum. Control of emotions and level of awareness are functions of the cerebrum, which is the largest portion of the brain (also referred to as the gray mater).
  66. Which of the following statements regarding hypoglycemia is correct? 

    A:The skin of a hypoglycemic patient is typically warm and dry secondary to severe dehydration.

    B:A patient with prolonged hypoglycemia may require more than one dose of IV dextrose.

    C:Hypoglycemia typically occurs within 4 to 6 hours after inadvertently taking too much insulin.

    D:Most diabetic patients develop symptoms when their blood glucose level falls below 90 mg/dL.
    B:A patient with prolonged hypoglycemia may require more than one dose of IV dextrose.

    25 g (50 mL) of 50% dextrose (D50) is usually sufficient to restore adequate circulating blood glucose levels and improve the patient’s condition. However, if the hypoglycemic event is severe or prolonged, the patient’s response to treatment may be delayed, thus requiring additional dosing. It is important to assess the patient’s blood glucose level (BGL) and mental status after administering dextrose; doing so will help determine if additional dextrose is needed. Normal serum glucose levels range from 70 to 120 mg/dL. Hypoglycemia following an inadvertent overdose of insulin typically develops within seconds to minutes. The point at which a hypoglycemic patient becomes symptomatic varies. Some patients may develop symptoms when their BGL falls below 70 or 80 mg/dL; others may not develop symptoms until their BGL falls below 40 or 50 mg/dL. Diabetic patients with severe hypoglycemia (insulin shock, hypoglycemic crisis) usually have cool, clammy skin. Patients with severe hyperglycemia (diabetic coma, hyperglycemic crisis) typically present with warm, dry skin; this is a manifestation of dehydration secondary to the osmotic diuresis associated with hyperglycemia.
  67. Law enforcement requests your assistance at a convenience store for a combative patient. You arrive at the scene and find the patient, a 49-year-old male, sitting in the back of the police car; his hands are cuffed behind him. One of the police officers tells you that the clerk of the store called 9-1-1 because the patient was acting strange. The patient is conscious and has a patent airway; however, he is agitated, has disorganized speech, and is tachypneic. Further assessment reveals that he is diaphoretic and tachycardic. You should: 

    A:administer 5 mg of haloperidol intramuscularly to reduce his agitation.

    B:have his handcuffs removed and immediately move him to the ambulance.

    C:sit him forward and perform a finger stick to assess his blood glucose level.

    D:apply the cardiac monitor and assess for the presence of cardiac dysrhythmias.
    C:sit him forward and perform a finger stick to assess his blood glucose level

    Assess the blood glucose level (BGL) of any patient with altered mentation. Don’t be so quick to assume intoxication or mental illness, regardless of the history given to you by others. Hypoglycemic patients can present with mental status changes ranging from bizarre behavior to coma. Plus, your patient has other signs of hypoglycemia (eg, tachypnea, tachycardia, diaphoresis). Hypoglycemic patients with abnormal mentation are unaware of their behavior, but can still pose a safety threat. In this situation, sit the patient forward, leaving him handcuffed, and perform a finger stick so you can assess his BGL. If he is hypoglycemic, establish vascular access and administer 50% dextrose without delay; he may die without it. If his BGL is normal (70 to 120 mg/dL), consider other conditions that may explain his presentation (eg, drug ingestion, poisoning, hypoxia). Further assess the patient, begin appropriate treatment, and safely move him to the ambulance. If he becomes violent, and hypoglycemia has been ruled out, give 2 to 5 mg of haloperidol (Haldol) IM. Your goal is to care for the patient while keeping you and your partner safe at the same time.
  68. A 52-year-old man has a headache and visual disturbances that have progressively worsened over the past 3 months. These symptoms are MOST consistent with: 

    A:a cerebral neoplasm.

    B:an epidural hematoma.

    C:bacterial meningitis.

    D:a subdural bleed.
    A:a cerebral neoplasm.

    The patient’s symptoms are consistent with a space-occupying intracranial lesion such as a neoplasm (tumor or growth), which typically presents with a headache, visual disturbances, and other symptoms that progressively worsen over a period of several months. In some patients, a new-onset of seizures may be the only presenting sign of a brain tumor. Subdural hemorrhages commonly present with symptoms within 12 to 24 hours following head trauma. An epidural hematoma presents with symptoms immediately following a head injury and causes rapid clinical deterioration. Patients with bacterial meningitis also experience a rapid progression of symptoms.
  69. Which of the following hormones stimulates the kidneys to reabsorb sodium and excrete potassium? 

    A:Aldosterone
    B:Somatostatin
    C:Adrenocorticotropic hormone
    D:Antidiuretic hormone
    A:Aldosterone

    If the body experiences a drop in blood pressure or volume, a decrease in sodium levels, or an increase in potassium levels, the adrenal cortex is stimulated to secrete aldosterone (a mineralocorticoid). Aldosterone stimulates the kidneys to reabsorb sodium from the urine and excrete potassium by altering the osmotic gradient in the blood. When sodium is reabsorbed into the blood, water follows; this action increases both blood volume and pressure. Somotostatin is a hormone secreted by the delta cells of the pancreas; it inhibits insulin and glucagon secretion. Antidiuretic hormone (ADH), which is released by the pituitary gland, regulates water balance in the body. If a person is dehydrated, ADH secretion increases, which stimulates the renal tubules to reabsorb sodium and water and inhibits diuresis. If a person is overhydrated, ADH secretion decreases, thereby facilitating diuresis. Adrenocorticotropic hormone (ACTH) is secreted by the pituitary gland; it stimulates the adrenal cortex to manufacture and secrete cortisol.
  70. When assessing a patient with a preexisting mental illness, which of the following observations would be the MOST suggestive of the potential for violence? 

    A:Sitting, crying, unable to recall birthday

    B:Sitting, clenched fists, erratic speech

    C:Standing facing you, arms crossed

    D:Large body size, sitting, flat affect
    B:Sitting, clenched fists, erratic speech

    The potential for violence exists on every call the paramedic responds to. People respond to stress differently; anyone involved in an incident—the patient, family members, or bystanders—can become angry or violent. In patients with certain preexisting mental illnesses (eg, intermittent explosive disorder, schizophrenia), the potential for violence is clearly higher, and the paramedic must be able to recognize certain behaviors that indicate this. A “fighting stance” position—the patient is not face-to-face with you, he or she is standing sideways—is an engaging position, indicating that the patient could lunge at you at any moment. Other warning signs include a tense appearance; clenched fists; pacing; agitation; and erratic, loud, or obscene speech. Crying and a flat affect are indicative of depression; however, this does not mean that the depressed patient cannot suddenly turn violent. There is absolutely no correlation between a patient’s physical size and his or her potential for violence.
  71. Which of the following can MOST easily be assessed without talking to a patient who is experiencing a behavioral crisis? 

    A:Affect
    B:Thought
    C:Orientation
    D:Memory
    A:Affect

    Mood and affect can be assessed in a patient experiencing a behavioral crisis without talking to him or her. Mood can be objectively noted via the patient’s body language to determine if it is euphoric, sad, or labile. Affect—the expression of inner feelings—can be assessed by noting if it seems appropriate to the situation, is animated, angry, flat, or withdrawn. Assessment of memory, thought, and orientation generally require you to ask the patient direct questions. Simply observing the patient and listening to him or her can yield a lot of information, such as the potential for violence (ie, increased tone of voice, clenched fists).
  72. A 26-year-old woman was bitten on the leg by a rattlesnake while hiking. She is conscious and alert, but is anxious. Her BP is 114/66 mm Hg, her heart rate is 112 beats/min, her respirations are 20 breaths/min, and her oxygen saturation is 97%. Treatment for her should include: 

    A:oxygen via nasal cannula, splinting the affected extremity, and an IV line of normal saline set at a keep-vein-open rate.

    B:oxygen via nasal cannula, elevating the extremity above the level of the heart, and 1 gm of calcium chloride IV push.

    C:oxygen via non-rebreathing mask, applying a chemical ice pack to the bite wound, and splinting the affected extremity.

    D:oxygen via non-rebreathing mask, elevating the extremity above the level of the heart, and a 20 mL/kg IV fluid bolus.
    A:oxygen via nasal cannula, splinting the affected extremity, and an IV line of normal saline set at a keep-vein-open rate.

    Treatment for a pit viper bite includes placing the patient in a comfortable position, administering supplemental oxygen (given her oxygen saturation [97%], a nasal cannula is appropriate for this patient), splinting the affected extremity and keeping it below the level of the heart, and promptly transporting to an appropriate facility. Monitor the patient's cardiac rhythm and establish an IV line. Fluid boluses are not indicated for this patient because her BP is stable; set the IV at a keep-vein-open (KVO) rate. Calcium chloride is not indicated for snakebites. Do NOT apply ice to a snakebite; doing so causes localized vasoconstriction; if envenomation occurred, this could push the venom further into the circulation. Alert the receiving facility early and be prepared to provide cardiopulmonary support (ie, bag-mask ventilation, IV fluid boluses) if the patient's clinical status deteriorates.
  73. Which of the following patients is at greatest risk for suicide? 

    A:A woman whose mother committed suicide

    B:A man who owns multiple guns and knives

    C:A man who has not slept for over 72 hours

    D:A woman whose depression acutely improves
    D:A woman whose depression acutely improves

    Risk factors for suicide include depression, major negative life changes (ie, financial hardship, loss of a loved one, loss of a job), and marital problems, among others. You should be especially alert for the patient whose depression, especially chronic depression, acutely improves. This is a red flag indicator that the patient has developed a plan that he or she is comfortable with, and that he or she feels as though resolution is near.
  74. You would expect to encounter trismus in a patient with: 

    A:meningitis.
    B:tetanus.
    C:mumps.
    D:rabies.
    B:tetanus.

    The most common presenting manifestation in patients with tetanus is trismus—spasm of the jaw muscles that causes difficulty opening the mouth—hence the term “lockjaw.” Tetanus is a potentially fatal disease of the central nervous system caused by the bacterium Clostridium tetani. If spores of C tetani enter the circulatory system, they multiply and produce a neurotoxin called tetanospasmin, which attacks the nerves that regulate muscular activity. As tetanospasmin circulates more widely, it interferes with the normal activity of nerves throughout the body, resulting in generalized muscle spasms. Any open wound that is contaminated with soil, saliva, or feces—especially if not properly cleaned—and puncture wounds from nonsterile items such as nails or needles, are at high risk of being infected with C tetani. Rabies, mumps, and meningitis—all of which can be fatal—are typically not associated with trismus.
  75. You are dispatched to a residence for a patient with respiratory distress. The patient, a 59-year-old female, has a tracheostomy tube in place and is ventilator dependent. She has marked respiratory distress, perioral cyanosis, and an oxygen saturation of 80%. You should: 

    A:suspect tracheostomy tube dislodgement and quickly remove the tube as the patient exhales.

    B:adjust the settings on the mechanical ventilator to ensure that she is receiving adequate tidal volume.

    C:detach the ventilator tubing from the tracheostomy and suction the tracheostomy tube for 10 seconds.

    D:disconnect her from the mechanical ventilator and provide manual positive-pressure ventilation.
    D:disconnect her from the mechanical ventilator and provide manual positive-pressure ventilation.

    When caring for a ventilator-dependent patient whose condition deteriorates, you must rapidly troubleshoot and correct the problem in order to prevent further deterioration. The quickest intervention to perform involves simply disconnecting the mechanical ventilator, attaching a bag device to the tracheostomy tube, and providing manual positive-pressure ventilations. If the patient’s condition improves, then equipment malfunction was the likely cause of his or her deterioration. If the patient’s condition does not improve despite manual positive-pressure ventilation, the tracheostomy tube may be occluded with thick secretions and will require suctioning. Avoid adjusting home ventilator settings unless you have been specifically trained to work with the particular device (most paramedics are not). Soliciting the help of the patient’s caregiver can assist in assessment and troubleshooting of equipment.
  76. Shorly after his dialysis treatment, a 66-year-old man presents with confusion, a headache, and nausea. You should suspect: 

    A:disequilibrium syndrome.

    B:interstitial nephritis.

    C:severe hyperkalemia.

    D:acute air embolism.
    A:disequilibrium syndrome.

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