Altered Mental Status and Coma Practice Questions

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

30 practice questions

1. Coma results from dysfunction of the reticular activating system or of:

   1. A. One frontal lobe
   2. B. Both hemispheres
   3. C. The cerebellum alone
   4. D. One occipital lobe
   Show answer

   Answer: B. Both hemispheres

   Unconsciousness requires either brainstem RAS dysfunction or diffuse bilateral hemispheric dysfunction; a small unilateral lesion usually does not cause coma.

2. The two broad categories of coma causes are:

   1. A. Structural and metabolic
   2. B. Cardiac and pulmonary
   3. C. Acute and chronic onset
   4. D. Infectious and traumatic
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   Answer: A. Structural and metabolic

   Structural lesions (bleeding, tumor, stroke) and toxic-metabolic problems (drugs, hypoglycemia, sepsis, organ failure) account for most coma.

3. In the AEIOU-TIPS mnemonic, the "I" stands for:

   1. A. Infarction
   2. B. Ischemia
   3. C. Ileus
   4. D. Insulin
   Show answer

   Answer: D. Insulin

   AEIOU-TIPS: Alcohol, Epilepsy/Electrolytes/Encephalopathy, Insulin, Opiates/Overdose, Uremia, Trauma/Temperature, Infection, Psychiatric/Poisoning, Stroke/Shock/Space-occupying lesion.

4. Reactive, equal pupils in a deeply comatose patient most suggest a:

   1. A. Large structural lesion
   2. B. Uncal herniation
   3. C. Toxic-metabolic cause
   4. D. Third nerve palsy
   Show answer

   Answer: C. Toxic-metabolic cause

   Pupillary reflexes are relatively preserved in most metabolic comas, while structural lesions often cause asymmetric or fixed pupils.

5. Months after a severe brain injury, a patient opens his eyes, has sleep-wake cycles and breathes on his own, but shows no sign of awareness or purposeful response. Which term best describes this?

   1. A. Locked-in syndrome
   2. B. A minimally conscious state
   3. C. A vegetative state
   4. D. Brain death
   Show answer

   Answer: C. A vegetative state

   In the vegetative state, now often called unresponsive wakefulness syndrome, the brainstem keeps breathing and sleep-wake cycles going while awareness is absent. In locked-in syndrome the patient is fully aware but paralyzed except for eye movements. A minimally conscious state shows some inconsistent purposeful responses, and brain death means no brainstem function, including no breathing.

6. A 30-year-old took a large amount of her quetiapine. She is very drowsy with HR 128 and BP 82/46 mm Hg. What best explains her low BP and fast heart rate?

   1. A. Alpha blockade dilating the vessels
   2. B. An opioid effect on the brainstem
   3. C. Serotonin syndrome from the drug
   4. D. An allergic reaction to the tablets
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   Answer: A. Alpha blockade dilating the vessels

   Quetiapine and similar antipsychotics block alpha-1 receptors, which dilates blood vessels and lowers BP, and the heart speeds up in response; their antihistamine and anticholinergic effects add sedation and tachycardia. Watch the airway and the QT interval and treat hypotension with fluids per protocol. Opioids slow the heart rather than speed it, serotonin syndrome causes agitation and clonus rather than deep sedation, and nothing suggests an allergic reaction.

7. Two days after a large left middle cerebral artery stroke, a 58-year-old is becoming more drowsy, and his left pupil is now larger than the right. What should you suspect?

   1. A. Swelling from the large stroke
   2. B. A new stroke in the right hemisphere
   3. C. Normal tiredness after a stroke
   4. D. Low blood sugar from poor intake
   Show answer

   Answer: A. Swelling from the large stroke

   Large hemispheric infarcts can swell over the following days, with the peak usually around 2 to 5 days. The swelling can push the brain across and down, causing drowsiness and a dilated pupil on the side of the stroke (herniation). This is an emergency that may need surgery to relieve pressure. A new right hemisphere stroke would not dilate the left pupil, decreasing consciousness is not normal tiredness, and low blood sugar can cause drowsiness but not a newly enlarged pupil on the side of the stroke, although the glucose should still be checked.

8. A man who uses large amounts of kratom is found drowsy with a respiratory rate of 6 and pinpoint pupils. How should kratom be viewed in this situation?

   1. A. As a harmless herbal supplement
   2. B. As a pure stimulant
   3. C. As an opioid-like drug
   4. D. As a benzodiazepine-like drug
   Show answer

   Answer: C. As an opioid-like drug

   Kratom is a plant product whose main compounds act on opioid receptors. At low doses it can feel stimulating, but large doses can cause sedation, small pupils and respiratory depression, and users can develop dependence and withdrawal. Support ventilation and consider naloxone. It is not harmless, it is not a pure stimulant at high doses, and it does not act like a benzodiazepine.

9. A 64-year-old with hypertension collapsed suddenly. He is comatose with pinpoint pupils, a temperature of 39.5 °C (103.1 °F) and irregular breathing. Naloxone produces no change. What is the most likely cause?

   1. A. A heroin overdose
   2. B. Clonidine poisoning
   3. C. Severe heat exhaustion
   4. D. A pontine hemorrhage
   Show answer

   Answer: D. A pontine hemorrhage

   A pontine hemorrhage (a bleed into the pons) can cause sudden coma, pinpoint but often reactive pupils, irregular breathing and high fever from damage to temperature control. The lack of any response to naloxone and the high fever argue against an opioid such as heroin. Clonidine poisoning causes small pupils and coma but usually with low temperature and bradycardia, and heat exhaustion does not cause coma or pinpoint pupils.

10. A 26-year-old who is 14 weeks pregnant has vomited several times a day for weeks. She is now confused, unsteady and has jerking eye movements. Glucose is normal. What should you suspect?

    1. A. Eclampsia of pregnancy
    2. B. Low blood sugar from vomiting
    3. C. Thiamine deficiency (Wernicke)
    4. D. A migraine with brainstem aura
    Show answer

    Answer: C. Thiamine deficiency (Wernicke)

    Wernicke encephalopathy is caused by thiamine deficiency. It occurs in people with heavy alcohol use and also after prolonged vomiting, such as hyperemesis gravidarum, or after bariatric surgery. Confusion, ataxia and nystagmus need prompt thiamine. Eclampsia occurs after 20 weeks with high BP, her glucose is normal, and a migraine aura does not cause ataxia and nystagmus over weeks.

11. A 45-year-old has 3 days of fever and headache, and now has trouble finding words, odd behavior and a first seizure. What is the most likely diagnosis?

    1. A. Herpes simplex encephalitis
    2. B. A migraine with aura
    3. C. Alcohol withdrawal
    4. D. A primary psychiatric illness
    Show answer

    Answer: A. Herpes simplex encephalitis

    Fever and headache followed by behavior change, speech problems and seizures suggest viral encephalitis. Herpes simplex is the most common cause in the US, and it affects the temporal lobes, which handle language, memory and behavior. Early antiviral treatment improves survival, so rapid transport matters. Migraine does not cause fever with seizures, alcohol withdrawal does not cause fever and aphasia, and a psychiatric illness does not cause fever or seizures.

12. A patient with cirrhosis is confused with a flapping tremor of the outstretched hands. This is most consistent with:

    1. A. Wernicke encephalopathy
    2. B. Uremic encephalopathy
    3. C. Hepatic encephalopathy
    4. D. Hypoglycemic coma
    Show answer

    Answer: C. Hepatic encephalopathy

    Asterixis with confusion in a cirrhotic patient suggests hepatic encephalopathy from accumulated ammonia and other toxins.

13. A dialysis patient who missed several treatments is lethargic and confused. Which cause from AEIOU-TIPS fits best?

    1. A. Insulin
    2. B. Uremia
    3. C. Infection
    4. D. Psychiatric
    Show answer

    Answer: B. Uremia

    Uremic encephalopathy results from accumulated waste products in renal failure; also consider hyperkalemia in these patients.

14. A patient with a brain tumor started high-dose dexamethasone a week ago. He now is agitated, cannot sleep and talks rapidly about grand plans. His glucose is 310 mg/dL. What is the most likely cause?

    1. A. Side effects of the steroid
    2. B. A new primary psychiatric illness
    3. C. Opioid withdrawal
    4. D. Hypoglycemia
    Show answer

    Answer: A. Side effects of the steroid

    High-dose corticosteroids such as dexamethasone can cause insomnia, agitation, mania or psychosis, and they raise blood glucose, so a recent start or dose increase is the likely cause here. A new psychiatric illness is less likely given the clear medication trigger, opioid withdrawal causes yawning, sweating and diarrhea, and his glucose is high, not low (hypoglycemia).

15. On the AVPU scale, an unresponsive patient responds only to a painful stimulus. What does this level of response usually suggest?

    1. A. A GCS of about 13, with mild injury
    2. B. A GCS of 15, with full alertness
    3. C. A GCS of 3, with no response
    4. D. A GCS of about 8, with airway risk
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    Answer: D. A GCS of about 8, with airway risk

    Studies comparing the two scales show that responding only to pain on AVPU corresponds roughly to a GCS of about 8, the level at which patients often cannot protect their airway, so watch the airway closely. A GCS around 13 corresponds to a patient who responds to voice, 15 is fully alert, and 3 means no response even to pain (U on AVPU).

16. A 78-year-old with pneumonia is newly confused and pulling at her blanket. Her SpO2 is 83% on room air. What should you do first?

    1. A. Restrain her for her own safety
    2. B. Give a sedative to calm her
    3. C. Give oxygen and reassess her
    4. D. Test her orientation in detail
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    Answer: C. Give oxygen and reassess her

    Hypoxia is a common and quickly reversible cause of confusion, especially in older adults with pneumonia. Give oxygen to a target SpO2 of 94% to 98% and reassess, since her mental status may improve. Restraint and sedation do not treat the cause and a sedative can depress breathing further, while a detailed orientation test delays the treatment she needs.

17. A 22-year-old woman developed anxiety and strange behavior 2 weeks ago. Now she has seizures, repetitive mouth movements and swings in heart rate and BP. Her drug screen is negative. What should be considered?

    1. A. A first episode of schizophrenia
    2. B. An autoimmune encephalitis
    3. C. Psychogenic nonepileptic seizures
    4. D. Simple panic attacks
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    Answer: B. An autoimmune encephalitis

    Anti-NMDA receptor encephalitis, an autoimmune brain inflammation that often affects young women, typically begins with psychiatric symptoms and then causes seizures, abnormal movements, reduced consciousness and unstable vital signs. It is treatable, so recognizing a medical cause matters. Schizophrenia, psychogenic seizures and panic attacks do not cause autonomic instability with true seizures and abnormal movements.

18. During transport, a patient with an acute ischemic stroke has a temperature of 38.9 °C (102 °F). Why is this important?

    1. A. Fever may worsen the brain injury
    2. B. It confirms the stroke is hemorrhagic
    3. C. It rules out an ischemic stroke
    4. D. It means the stroke is resolving
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    Answer: A. Fever may worsen the brain injury

    Fever raises the brain's metabolic demand and is linked to worse outcomes after stroke, so stroke guidelines advise finding the source and lowering the temperature. Fever can also point to a cause or complication, such as aspiration pneumonia or endocarditis. It does not confirm a hemorrhagic stroke, does not rule out an ischemic stroke, and does not mean the stroke is resolving.

19. During an interfacility transfer, a family asks whether their ventilated relative might be brain dead. Which finding shows the brainstem is still working?

    1. A. Leg withdrawal to a toe pinch
    2. B. Fixed, dilated pupils in both eyes
    3. C. Breaths taken over the ventilator
    4. D. No response to voice
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    Answer: C. Breaths taken over the ventilator

    Spontaneous breaths come from the brainstem, so breathing over the ventilator shows the brainstem still functions and the patient is not brain dead. A leg moving away from a toe pinch can be a spinal reflex and can occur even in brain death. Fixed pupils and no response to voice are compatible with brain death but do not prove it, which requires a formal hospital evaluation.

20. A patient appears comatose but can blink and move his eyes vertically to command. He most likely has:

    1. A. Persistent vegetative state
    2. B. Brain death
    3. C. Locked-in syndrome
    4. D. Psychogenic coma
    Show answer

    Answer: C. Locked-in syndrome

    Locked-in syndrome, usually from a pontine lesion, leaves the patient awake and aware but paralyzed except for vertical eye movement and blinking.

21. An unresponsive patient resists eye opening and lets his raised hand fall to the side of his face, avoiding it. This suggests:

    1. A. Brainstem (pontine) stroke
    2. B. Psychogenic unresponsiveness
    3. C. Prolonged postictal state
    4. D. Hypoglycemic coma
    Show answer

    Answer: B. Psychogenic unresponsiveness

    Active resistance and protective movements suggest preserved awareness. Even so, rule out organic causes and document findings objectively.

22. A 29-year-old who injects drugs has a fever, a new heart murmur, and sudden aphasia with right arm weakness. Why is this history important to the stroke team?

    1. A. It proves the stroke is from cocaine
    2. B. Infected clots make alteplase unsafe
    3. C. It means the stroke is a migraine
    4. D. It rules out a large vessel occlusion
    Show answer

    Answer: B. Infected clots make alteplase unsafe

    Fever, a new murmur and injection drug use suggest infective endocarditis, and a sudden deficit means infected material has broken off the valve and blocked a brain artery (septic embolism). Alteplase is not recommended in endocarditis because of a high risk of brain bleeding, although clot removal may still be considered. Nothing proves cocaine as the cause, a migraine would not explain fever and a murmur, and a large vessel can still be blocked.

23. A 70-year-old with diabetes suddenly developed wild, flinging movements of his left arm and leg that he cannot control. He is alert. What should you suspect?

    1. A. A focal seizure in the left brain
    2. B. A small deep stroke on the right
    3. C. A psychogenic movement disorder
    4. D. A tardive drug reaction
    Show answer

    Answer: B. A small deep stroke on the right

    Sudden, large, flinging movements of one side (hemiballismus) are usually caused by a small stroke in the subthalamic nucleus or nearby deep structures on the opposite side, so this needs stroke evaluation and transport. A seizure in the left brain would affect the right side and is usually rhythmic. Psychogenic movements and tardive reactions do not begin suddenly on one side in this way. Very high glucose can also cause it, so check the glucose.

24. Which environmental cause of coma should you suspect in a patient found outdoors in winter with a core temperature of 26 °C (78.8 °F)?

    1. A. Exertional heat stroke
    2. B. Myxedema coma
    3. C. Severe hypothermia
    4. D. Carbon monoxide
    Show answer

    Answer: C. Severe hypothermia

    A core temperature this low is severe hypothermia, which depresses the level of consciousness. Handle the patient gently, because rough movement can trigger ventricular fibrillation. Heat stroke causes a high temperature, myxedema coma is an endocrine rather than environmental cause and is not suggested by outdoor exposure, and carbon monoxide does not cause a core temperature this low.

25. A patient who takes valproic acid for epilepsy is drowsy, vomiting and confused. His glucose is normal and he has not had a seizure. What drug-related cause should be considered?

    1. A. Low blood sugar from the drug
    2. B. A buildup of ammonia
    3. C. Excess calcium
    4. D. Excess potassium
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    Answer: B. A buildup of ammonia

    Valproic acid can raise ammonia even at normal drug levels, causing lethargy, vomiting and confusion (hyperammonemic encephalopathy). The patient's medication list matters in any altered mental status. His glucose is normal, so low blood sugar is excluded, and valproate does not typically raise calcium or potassium.

26. A 2-year-old chewed one of his grandmother's buprenorphine films. He is drowsy with a respiratory rate of 12, then improves. Why does he still need transport and observation?

    1. A. It causes delayed liver failure
    2. B. It causes seizures hours later
    3. C. It cannot be detected by monitors
    4. D. Its effects can last many hours
    Show answer

    Answer: D. Its effects can last many hours

    Buprenorphine binds opioid receptors very tightly and acts for a long time, and in young children even one film can cause sedation and dangerous respiratory depression that may return after naloxone wears off. Children need prolonged observation. Buprenorphine does not typically cause delayed liver failure or later seizures, and its effect on breathing shows up on SpO2 and ETCO2 monitoring.

27. A family says their father's confusion came on gradually over 3 days. Compared with a sudden onset, which group of causes does this course more often suggest?

    1. A. Metabolic or infectious causes
    2. B. A subarachnoid hemorrhage
    3. C. An embolic stroke from the heart
    4. D. A sudden cardiac dysrhythmia
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    Answer: A. Metabolic or infectious causes

    The onset of altered mental status is a key clue. A gradual change over hours to days suggests metabolic problems, infection, drug effects or a slowly growing lesion such as a subdural hematoma. Subarachnoid hemorrhage, embolic stroke and dysrhythmias cause sudden changes. Gradual onset never rules out a dangerous cause, but it guides your search.

28. An unconscious patient's capillary glucose is 72 mg/dL. Why should you still consider other causes?

    1. A. It confirms a stroke is present
    2. B. It suggests a drug overdose
    3. C. It points to a postictal state
    4. D. It excludes only one cause
    Show answer

    Answer: D. It excludes only one cause

    A normal glucose rules out hypoglycemia, an essential and reversible cause, but it excludes only that one cause. Continue a systematic search for toxins, stroke, seizure, infection, hypoxia and trauma. A normal glucose does not confirm a stroke, suggest an overdose or point to a postictal state; it simply leaves those possibilities open.

29. When an unresponsive patient's cause is unknown, why is a trauma assessment important?

    1. A. A hidden injury may exist
    2. B. It shows the baseline mental status
    3. C. It changes how the GCS is scored
    4. D. It rules out a medical cause
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    Answer: A. A hidden injury may exist

    A patient may have fallen when he became unresponsive, or a head injury may be the cause, so look for signs of trauma and protect the spine as indicated per protocol. The glucose check is still needed. A trauma assessment does not reveal the patient's baseline mental status, which comes from family or records, the GCS is scored the same way with or without injury, and finding an injury does not rule out a medical cause that led to the fall.

30. A 16-year-old drank most of a bottle of cough syrup. He is giggling, hallucinating, unsteady, and has nystagmus. His glucose is normal. What is the most likely cause?

    1. A. Organophosphate poisoning
    2. B. Dextromethorphan intoxication
    3. C. Low blood sugar from skipping meals
    4. D. Opioid withdrawal from the syrup
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    Answer: B. Dextromethorphan intoxication

    Large doses of dextromethorphan, a common cough suppressant, block NMDA receptors and cause a dissociative state with hallucinations, ataxia, nystagmus and agitation; combined with an SSRI it can also cause serotonin syndrome. Organophosphates cause secretions and small pupils, his glucose is normal so low blood sugar is excluded, and opioid withdrawal causes yawning, sweating and diarrhea rather than hallucinations.