Agitated Patients, Restraint, and Chemical Sedation Practice Questions

25 multiple-choice questions on Agitated patients, restraint, and chemical sedation for paramedic and EMT students, from Chapter 29 (Psychiatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The term now preferred by ACEP for the syndrome once called 'excited delirium' is:

   1. A. Acute agitated psychosis with exhaustion
   2. B. Hyperactive delirium with severe agitation
   3. C. Sympathomimetic toxidrome with agitation
   4. D. Combative delirium with sudden collapse syndrome
   Show answer

   Answer: B. Hyperactive delirium with severe agitation

   ACEP withdrew its recognition of excited delirium in 2023, and its task force describes the presentation as hyperactive delirium with severe agitation. Sympathomimetic toxicity is a common cause, not the name of the syndrome.

2. Police request EMS for a naked, sweating man smashing windows who seems unaffected by pepper spray and feels hot to the touch. The most likely condition is:

   1. A. Acute opioid intoxication with euphoria
   2. B. A panic attack with hyperventilation
   3. C. Hyperactive delirium with severe agitation
   4. D. Alcohol intoxication alone
   Show answer

   Answer: C. Hyperactive delirium with severe agitation

   Extreme agitation, hyperthermia, unusual strength, pain tolerance, and attraction to glass are classic features. Opioids cause sedation and respiratory depression, the opposite picture.

3. Hyperactive delirium with severe agitation is most commonly associated with:

   1. A. Opioids such as heroin or fentanyl in excess
   2. B. Benzodiazepines or barbiturates in high doses
   3. C. Stimulants such as cocaine or methamphetamine
   4. D. Alcohol intoxication without any other drug
   Show answer

   Answer: C. Stimulants such as cocaine or methamphetamine

   Sympathomimetics, along with underlying psychiatric illness, are the usual causes. Sedative-hypnotics depress the CNS; their withdrawal, not their use, causes agitation.

4. Which method of restraining a combative patient is prohibited in NAEMSP guidance because it can impair breathing?

   1. A. Soft limb restraints at the wrists
   2. B. Sandwiching between two backboards
   3. C. Stretcher straps across the torso
   4. D. Supine position with head elevated
   Show answer

   Answer: B. Sandwiching between two backboards

   NAEMSP guidance says patients must not be restrained prone, hog-tied, or sandwiched between backboards or scoop stretchers, because these positions restrict chest movement and have caused deaths. Padded limb restraints and torso straps on a stretcher, with the patient supine or on the side and continuously monitored, are acceptable when restraint is necessary.

5. Restraining a patient in the prone position is dangerous mainly because it:

   1. A. Impairs ventilation; can cause asphyxia
   2. B. Makes the patient more likely to escape
   3. C. Prevents the patient from seeing staff
   4. D. Makes IV access more difficult to obtain
   Show answer

   Answer: A. Impairs ventilation; can cause asphyxia

   Prone positioning, especially with weight on the back, restricts chest expansion and causes positional asphyxia. Escape risk is not the reason it is prohibited.

6. When securing soft limb restraints on an ambulance stretcher, the straps should be attached to:

   1. A. The stretcher side rails
   2. B. The patient's belt
   3. C. Each other, wrist to ankle
   4. D. The stretcher frame
   Show answer

   Answer: D. The stretcher frame

   Restraints should be tied to a fixed part of the stretcher frame so they stay secure and can be released quickly. Side rails can be lowered or moved, which can loosen the restraint or injure the limb. A belt gives no secure anchor. Tying wrists to ankles is hog-tying, which impairs breathing and is prohibited.

7. The goal of chemical sedation for a patient with severe agitation is a patient who is:

   1. A. Unresponsive even to painful stimuli
   2. B. Intubated before he is transported
   3. C. Calm enough to be assessed safely
   4. D. Asleep and without a gag reflex
   Show answer

   Answer: C. Calm enough to be assessed safely

   Sedation for agitation aims to make the patient calm and safe so that care, assessment, and transport can proceed, not to make him unconscious. Deep sedation without airway reflexes is dangerous and is not the goal. Intubation is needed only if sedation causes airway or breathing failure.

8. Ideally, physical restraint of a combative adult requires:

   1. A. At least four or five trained people
   2. B. One provider and a family member
   3. C. Two providers working very quickly together
   4. D. Police officers without EMS present
   Show answer

   Answer: A. At least four or five trained people

   One person per limb plus one to protect the head allows controlled restraint with fewer injuries. Too few people leads to prolonged struggle and more force.

9. A combative man with a large scalp laceration after a fight needs chemical sedation. Before giving it, you should, if at all possible:

   1. A. Wait for a CT scan at the hospital
   2. B. Record his GCS and pupil findings
   3. C. Have police place him in handcuffs
   4. D. Withhold all sedation for head injury
   Show answer

   Answer: B. Record his GCS and pupil findings

   Sedation will mask changes in level of consciousness, so a baseline GCS, pupil exam, and motor findings let the hospital tell later whether he is getting worse from a brain injury. A head injury does not forbid sedation when he is a danger to himself or others, and agitation can itself be a sign of brain injury or hypoxia. A CT cannot be obtained in the field.

10. Restrained extremities should be checked regularly for:

    1. A. Muscle strength and deep tendon reflexes
    2. B. Range of motion and joint flexibility
    3. C. Joint swelling and old bruising
    4. D. Distal pulses, sensation, and skin color
    Show answer

    Answer: D. Distal pulses, sensation, and skin color

    Overtight restraints can cause nerve injury and ischemia. Strength and reflex testing do not detect compromised circulation.

11. A man arrives handcuffed behind his back and lying face down on the ground with an officer kneeling on him. You should:

    1. A. Transport him prone so he stays under control
    2. B. Ask police to add a hobble to his ankles
    3. C. Leave his positioning to law enforcement
    4. D. Have him moved supine or to his side
    Show answer

    Answer: D. Have him moved supine or to his side

    Once in EMS care, you are responsible for safe positioning, and weight on the back causes asphyxia. Deferring to police does not transfer your duty to the patient.

12. Using a dose of 4 mg/kg IM, a 90-kg agitated man would receive how much ketamine?

    1. A. 360 mg
    2. B. 36 mg
    3. C. 90 mg
    4. D. 900 mg
    Show answer

    Answer: A. 360 mg

    4 mg/kg x 90 kg = 360 mg. Many systems now use a range of about 2 to 4 mg/kg with a maximum dose, so follow local protocol.

13. A severely agitated patient who lacks decision-making capacity is sedated for safety without agreeing to it. The legal basis for this is usually:

    1. A. Consent from police on scene
    2. B. Emergency (implied) consent
    3. C. A bystander's written consent
    4. D. Consent he gave on an old call
    Show answer

    Answer: B. Emergency (implied) consent

    When a patient lacks capacity and is a danger to himself or others, EMS treats under emergency or implied consent, following protocol and medical direction, and documents the reasons. Police cannot consent to medical treatment for a patient, and the decision to sedate must be a medical one. Bystanders cannot consent for an unrelated adult, and consent from a past encounter does not apply.

14. Five minutes after IM midazolam for agitation, the patient is still restless. A reason to wait a little longer before repeating the dose is that:

    1. A. IM midazolam works only in children
    2. B. A second dose is never allowed
    3. C. IM onset can take several minutes
    4. D. Midazolam must be given IV to work
    Show answer

    Answer: C. IM onset can take several minutes

    IM midazolam usually takes about 5 to 15 minutes to reach its peak effect, so redosing too early can stack doses and cause oversedation and respiratory depression. Repeat dosing is allowed by many protocols after an appropriate interval. IM midazolam works in adults and is effective without IV access.

15. A sedated patient who is restrained supine on the stretcher begins to vomit. Your first action is to:

    1. A. Remove all restraints and step back
    2. B. Give more sedation to stop vomiting
    3. C. Turn him to his side and suction
    4. D. Wait for vomiting to stop by itself
    Show answer

    Answer: C. Turn him to his side and suction

    A sedated patient may not protect his airway, so turn him onto his side and suction at once to prevent aspiration; this is why restrained patients must be positioned and secured so they can be turned quickly. Releasing every restraint can endanger the crew and is not needed to clear the airway. More sedation further weakens airway reflexes, and waiting invites aspiration.

16. Compared with a healthy 30-year-old, when sedating an agitated 85-year-old you should generally:

    1. A. Use the same dose to work quickly
    2. B. Double the dose for a lasting effect
    3. C. Avoid every type of sedative drug
    4. D. Use smaller doses and titrate slowly
    Show answer

    Answer: D. Use smaller doses and titrate slowly

    Older adults are more sensitive to sedatives because of less body water, slower drug clearance, and brain changes, so start low and go slow. Full adult doses risk respiratory depression, hypotension, falls, and worse delirium. Sedation is sometimes still necessary for safety, so it is not banned outright, but look for causes such as pain, hypoxia, and urinary retention first.

17. A 45-year-old man in alcohol withdrawal is severely agitated, tremulous, and sweating. The preferred sedative is:

    1. A. Midazolam
    2. B. Haloperidol
    3. C. Droperidol
    4. D. Ketamine
    Show answer

    Answer: A. Midazolam

    Benzodiazepines treat the underlying withdrawal and prevent seizures. Antipsychotics calm agitation but lower the seizure threshold and do not treat withdrawal.

18. A combative woman who is 32 weeks pregnant must be physically restrained for safety. She should be positioned:

    1. A. Prone, to control her arms
    2. B. Supine with a left tilt
    3. C. Flat supine with no tilt
    4. D. Seated upright, hands tied
    Show answer

    Answer: B. Supine with a left tilt

    Restrained patients must never be prone, and lying flat on the back lets the uterus compress the inferior vena cava and lower her blood pressure, so she should be supine with a left lateral tilt or on her left side and continuously monitored. Prone restraint risks positional asphyxia and injury to the fetus. Tying her hands while seated does not keep her or the crew safe during transport.

19. An elderly man is combative and screaming after a fall. His thigh is shortened and rotated. Before chemical sedation, the best first step is to:

    1. A. Restrain him before any assessment
    2. B. Give haloperidol at the full dose
    3. C. Treat his pain and then reassess
    4. D. Ignore the leg until he is calm
    Show answer

    Answer: C. Treat his pain and then reassess

    Severe pain from an injury such as a hip fracture can drive agitation and delirium, and analgesia often calms the patient without a sedative. Physical restraint without assessment risks injury and misses the cause. Full-dose antipsychotics are risky in older adults and do not treat pain. The deformed leg is the likely reason for his behavior.

20. Some agitation protocols give diphenhydramine along with IM haloperidol. The main purpose is to:

    1. A. Help prevent acute dystonia
    2. B. Shorten the QT interval
    3. C. Reverse haloperidol's sedation
    4. D. Raise the blood pressure
    Show answer

    Answer: A. Help prevent acute dystonia

    Haloperidol commonly causes extrapyramidal reactions such as acute dystonia, and giving an anticholinergic such as diphenhydramine with it lowers that risk and adds sedation. Diphenhydramine does not shorten the QT, does not reverse sedation (it adds to it), and does not raise blood pressure.

21. In hyperactive delirium with severe agitation, early chemical sedation is preferred over a long physical struggle mainly because struggling:

    1. A. Drives the serum potassium down
    2. B. Worsens acidosis and arrest risk
    3. C. Makes the blood pressure fall quickly
    4. D. Lowers the body temperature
    Show answer

    Answer: B. Worsens acidosis and arrest risk

    Continued struggling against restraints drives heat production, lactic acidosis, high potassium, and catecholamine release, all of which raise the risk of sudden cardiac arrest; prompt sedation limits the struggle. Struggling raises potassium, blood pressure, and temperature rather than lowering them.

22. A prolonged physical struggle increases the risk of:

    1. A. Hypokalemia and metabolic alkalosis
    2. B. Hypothermia and bradycardia
    3. C. Hypercalcemia and constipation
    4. D. Rhabdomyolysis and hyperkalemia
    Show answer

    Answer: D. Rhabdomyolysis and hyperkalemia

    Muscle breakdown releases potassium and myoglobin, and acidosis shifts potassium out of cells. Alkalosis would lower potassium, the opposite effect.

23. Once an agitated patient is safely sedated, you should next:

    1. A. Remove all of the restraints at once
    2. B. Stop monitoring now that he is calm
    3. C. Give a second sedative dose right away
    4. D. Check glucose and look for other causes
    Show answer

    Answer: D. Check glucose and look for other causes

    Sedation controls behavior but not its cause, so look for hypoglycemia, hypoxia, trauma, and toxins. Monitoring must continue because sedation adds respiratory risk.

24. A restrained patient keeps spitting at the crew. The safest option is to:

    1. A. Drape a towel over his face and head
    2. B. Place a surgical mask over his mouth and nose
    3. C. Apply a nonrebreather mask with no oxygen flow
    4. D. Turn him face down on the stretcher
    Show answer

    Answer: B. Place a surgical mask over his mouth and nose

    A loose surgical mask with provider face protection limits exposure while allowing breathing and airway observation. Covering the face with a towel hides the airway and vomiting.

25. Police used a conducted electrical weapon on a severely agitated man; one probe is in his back. The greatest danger is usually:

    1. A. The underlying cause of the agitation
    2. B. Electrical burns at the probe sites
    3. C. Direct electrocution of the heart
    4. D. Infection from the probe wounds
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    Answer: A. The underlying cause of the agitation

    Deaths after these devices are mostly linked to hyperactive delirium, stimulants, and struggle rather than the current itself. Assess for injuries, causes of agitation, and monitor the ECG.