Cardiovascular, Respiratory, and Neurologic Emergencies: MI, Heart Failure, Pneumonia, Stroke, Syncope, and Delirium Practice Questions

25 multiple-choice questions on Cardiovascular, respiratory, and neurologic emergencies: MI, heart failure, pneumonia, stroke, syncope, and delirium for paramedic and EMT students, from Chapter 45 (Geriatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. An 81-year-old with heart failure weighs herself daily. Which report most suggests she is retaining fluid and starting to decompensate?

   1. A. A loss of 1 kg (2 lb) over a month
   2. B. A steady weight for the past month
   3. C. A gain of 2 kg (about 5 lb) in a year
   4. D. A gain of 2 kg (about 5 lb) in a week
   Show answer

   Answer: D. A gain of 2 kg (about 5 lb) in a week

   Rapid weight gain, about 1 kg (2 to 3 lb) in a day or 2 kg (about 5 lb) in a week, reflects fluid retention and often comes before dyspnea and edema; ask about daily weights on every heart failure call. A small loss over a month or a stable weight does not suggest fluid retention. A 2-kg gain spread over a year is more likely tissue weight than retained fluid.

2. An 80-year-old with a mechanical heart valve has had low-grade fevers, tiredness, and weight loss for 3 weeks. You notice tiny dark lines under several fingernails. You should suspect:

   1. A. Infective endocarditis of the valve
   2. B. A viral illness that is slow to resolve
   3. C. Cancer causing weight loss and fever
   4. D. Normal bruising from warfarin therapy
   Show answer

   Answer: A. Infective endocarditis of the valve

   Prosthetic valves are a major risk for endocarditis, which in older adults is often slow and vague, with fever, fatigue, and weight loss rather than an acute illness. Splinter hemorrhages under the nails are a clue. Bacteria on the valve can also send emboli to the brain, so watch for stroke signs.

3. An 80-year-old with heart failure began taking OTC naproxen twice daily for knee arthritis 2 weeks ago. She now has more leg edema and dyspnea. The naproxen most likely contributed by:

   1. A. Lowering her BP so the heart pumps less
   2. B. Causing a slow, steady loss of red cells
   3. C. Making her kidneys retain salt and water
   4. D. Dilating her coronary arteries too much
   Show answer

   Answer: C. Making her kidneys retain salt and water

   NSAIDs block renal prostaglandins, causing sodium and water retention, raising blood pressure, and blunting diuretics, so they are a common, avoidable trigger of heart failure decompensation in older adults; ask specifically about OTC pain relievers. NSAIDs tend to raise rather than lower BP. Chronic GI blood loss from NSAIDs can cause anemia, but that would not explain new edema in 2 weeks. NSAIDs do not dilate coronary arteries.

4. Which finding most suggests heart failure, rather than COPD, in a dyspneic older adult?

   1. A. A long history of cigarette smoking
   2. B. Waking at night gasping for air
   3. C. Barrel-shaped chest
   4. D. Pursed-lip breathing
   Show answer

   Answer: B. Waking at night gasping for air

   Paroxysmal nocturnal dyspnea reflects fluid shifting to the lungs when lying flat and is characteristic of left heart failure. A barrel chest and pursed-lip breathing are signs of COPD.

5. In older adults, a leaking abdominal aortic aneurysm is most often misdiagnosed as:

   1. A. Acute asthma
   2. B. Migraine headache
   3. C. Angina pectoris
   4. D. Renal colic
   Show answer

   Answer: D. Renal colic

   Back or flank pain leads many leaking AAAs to be mistaken for kidney stones, a dangerous error in an older patient; any older adult with new flank or back pain and hypotension should be treated as a possible AAA. Angina causes chest pain rather than flank pain.

6. An 80-year-old suddenly lost all vision in his right eye, without pain, 40 minutes ago. His eye looks normal. This should be treated as:

   1. A. A stroke equivalent needing rapid transport
   2. B. A minor eye problem for a routine clinic visit
   3. C. A migraine aura that will soon resolve
   4. D. Cataract progression needing surgery later
   Show answer

   Answer: A. A stroke equivalent needing rapid transport

   Sudden painless loss of vision in one eye is often a central retinal artery occlusion, caused by an embolus like an ischemic stroke and sharing its risk factors. It is time-sensitive and needs rapid transport to a center that can evaluate stroke. Cataracts progress over months, not minutes.

7. A frail 86-year-old has had three pneumonias this year, but staff never see her cough or choke during meals. A likely reason is that:

   1. A. She is too tired to swallow her food at meals
   2. B. Heart failure is being mistaken for pneumonia
   3. C. Her pneumonias are caused by a virus each time
   4. D. A weak cough reflex lets her aspirate silently
   Show answer

   Answer: D. A weak cough reflex lets her aspirate silently

   With age, stroke, dementia, and sedating drugs, the cough and swallow reflexes weaken, so food, drink, or saliva can enter the airway with no visible coughing or choking. This silent aspiration is a common cause of recurrent pneumonia in frail older adults. Thickened liquids and upright positioning help reduce it. Fatigue at meals does not explain repeated lung infections, there is nothing in her history to suggest heart failure being misread, and a new virus each time would not explain the pattern of recurrent aspiration-prone pneumonia.

8. You are called to a senior center dining room for choking. The age group with the highest death rate from choking on food is:

   1. A. Toddlers aged 1 to 3
   2. B. Teenagers 13 to 19
   3. C. Adults 65 and older
   4. D. Adults 20 to 40
   Show answer

   Answer: C. Adults 65 and older

   Weaker chewing and swallowing, dentures, dementia, stroke, sedating drugs, and dry mouth make older adults the group with the highest death rate from food-related choking, higher than young children; treat a severe obstruction with abdominal thrusts (chest thrusts if needed) and start CPR if the patient becomes unresponsive. Toddlers choke often, especially on round foods, but their death rate is lower than that of older adults. Teens and younger adults have the lowest rates. (Kramarow 2014, NCHS data.)

9. An 88-year-old with old left-sided weakness from a prior stroke now has new trouble speaking and facial droop. To decide which deficits are new, the most useful step is to:

   1. A. Score the old weakness as part of this stroke
   2. B. Ask family what her usual baseline exam is
   3. C. Assume the deficits are old and not urgent
   4. D. Wait for the hospital to compare old records
   Show answer

   Answer: B. Ask family what her usual baseline exam is

   Prior strokes, dementia, and Parkinson disease leave baseline deficits, so ask someone who knows the patient what is new and when it began; new aphasia and facial droop here are an acute stroke despite the old weakness, and stroke-scale scores and LVO screens should reflect the new findings. Counting the old weakness as new can misdirect destination decisions. Assuming everything is old misses a treatable stroke. Waiting for old records delays time-sensitive care.

10. A 79-year-old who lives alone is found at 1400 with right arm weakness. She spoke normally with her daughter by phone at 2000 last night, and a neighbor saw her collecting mail, acting normally, at 0900 today. Her last known well time is:

    1. A. 2000 last night
    2. B. 1400 today
    3. C. Unknown
    4. D. 0900 today
    Show answer

    Answer: D. 0900 today

    Last known well is the most recent time anyone observed the patient at her baseline, here the neighbor at 0900, so symptoms began between 0900 and 1400 and she may still be a treatment candidate; record who saw her and when. The 2000 phone call is earlier and would wrongly lengthen the window. The 1400 discovery time is when symptoms were found, not when she was last normal. 'Unknown' discards a reliable witness and could deny her time-sensitive treatment.

11. An 87-year-old nursing home resident has new confusion, a respiratory rate of 28, and an SpO2 of 89%. Her temperature is 36.9 °C (98.4 °F), and she has no cough. Pneumonia is:

    1. A. Ruled out, because her temperature is normal
    2. B. Still possible; fever and cough may be absent
    3. C. Ruled out, because she does not have a cough
    4. D. Unlikely, since confusion is normal at her age
    Show answer

    Answer: B. Still possible; fever and cough may be absent

    Older adults with pneumonia often lack fever, cough, or sputum, and may present only with confusion, falls, a fast breathing rate, or low SpO2. A rapid respiratory rate is one of the most sensitive clues. New confusion is never normal aging and should prompt a search for infection, hypoxia, or other causes.

12. In older adults, syncope should be treated as potentially serious mainly because it is often caused by:

    1. A. A benign vasovagal reflex response
    2. B. Anxiety with hyperventilation episodes
    3. C. A cardiac cause such as dysrhythmia
    4. D. Low blood sugar after large meals
    Show answer

    Answer: C. A cardiac cause such as dysrhythmia

    Older adults have a much higher rate of cardiac syncope (heart block, ventricular dysrhythmias, aortic stenosis), which carries high mortality, so obtain a 12-lead ECG and monitor. Vasovagal syncope is more typical of younger patients.

13. An 84-year-old has fainted twice this week, each time about 45 minutes after a large lunch. Orthostatic vital signs before meals are normal. The most likely cause is:

    1. A. Blood pooling in the gut after eating
    2. B. Hypoglycemia from eating too much
    3. C. Carotid sinus pressure from a collar
    4. D. Seizures brought on by a full stomach
    Show answer

    Answer: A. Blood pooling in the gut after eating

    Postprandial hypotension is common in older adults: blood shifts to the splanchnic circulation after a meal, and blunted baroreflexes cannot compensate, so BP falls within about 2 hours of eating, especially after large, carbohydrate-rich meals and with antihypertensives; still obtain a 12-lead ECG to look for a cardiac cause. Eating raises rather than lowers glucose. Carotid sinus syncope follows neck pressure or head turning, not meals. A full stomach does not trigger seizures.

14. Which bedside task best tests the inattention that is central to delirium?

    1. A. Naming the current president
    2. B. Reciting the months backward
    3. C. Recalling a childhood address
    4. D. Stating his date of birth
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    Answer: B. Reciting the months backward

    Delirium's core feature is inattention, which tasks such as saying the months backward or spelling a word backward reveal quickly; the Confusion Assessment Method builds on this. Remote memories such as a childhood address are often preserved even in delirium.

15. An 85-year-old woman with mild dementia has become agitated and disoriented over the past day and is now drowsy at times. Her family says this is new. You should:

    1. A. Attribute it to her dementia and sundowning
    2. B. Request a psychiatric facility for transport
    3. C. Restrain her and give a sedative first
    4. D. Treat it as delirium and seek a cause
    Show answer

    Answer: D. Treat it as delirium and seek a cause

    A sudden change on top of dementia is delirium until proven otherwise; look for hypoglycemia, hypoxia, infection, drug effects, and urinary retention. Sundowning is a chronic pattern of evening behavior, not a new acute change.

16. A delirious 86-year-old keeps pulling at her oxygen tubing. A crew member suggests tying both wrists to the stretcher for the rest of the trip. The best response is that restraints:

    1. A. Are the first-line treatment for delirium
    2. B. Calm most patients within a few minutes
    3. C. Often worsen agitation and cause injury
    4. D. Help to reorient a confused patient fast
    Show answer

    Answer: C. Often worsen agitation and cause injury

    Physical restraints increase agitation, falls, skin injury, aspiration, and the duration of delirium, so use the least restrictive measures first: a calm voice, reorientation, a family member at the side, securing tubing out of reach, and treating causes such as hypoxia, pain, or retention; restrain only if needed for safety, per protocol, with close monitoring. Restraint is not a treatment for delirium. Most patients fight restraints rather than calm. Restraints are disorienting rather than reorienting.

17. A 79-year-old widower says he feels like a burden and 'won't be around much longer.' Besides asking directly about suicidal thoughts, the most important question is whether he:

    1. A. Has access to a gun at home
    2. B. Has lost weight lately
    3. C. Has a regular family doctor
    4. D. Has told his family how he feels
    Show answer

    Answer: A. Has access to a gun at home

    Older men have the highest suicide rate, and firearms are the method in about three quarters of suicides by older men, with very high lethality, so ask directly about suicidal intent and about access to firearms or stockpiled medications, keep the scene safe, and do not leave him alone; transport or arrange crisis care per protocol. Weight loss, whether he has a regular doctor, and whether he has confided in family all matter to his overall assessment, but none is as urgent as access to lethal means.

18. A 79-year-old has had poor appetite, sleeplessness, and slowed thinking since her husband died 3 months ago. Her family worries she has dementia. Another condition to consider is:

    1. A. Depression
    2. B. Delirium tremens
    3. C. Normal pressure hydrocephalus
    4. D. Parkinson disease
    Show answer

    Answer: A. Depression

    Depression in older adults can cause memory and concentration problems (pseudodementia) and is often missed; the timing after bereavement is a strong clue. Normal pressure hydrocephalus causes gait disturbance, incontinence, and dementia, which this history lacks.

19. An 84-year-old with advanced dementia who cannot speak has begun striking out at staff during care over the last 2 days. The most useful first consideration is:

    1. A. A normal stage of dementia needing no workup
    2. B. A desire to harm staff on purpose
    3. C. A need for an antipsychotic right away
    4. D. An unrecognized source of pain or illness
    Show answer

    Answer: D. An unrecognized source of pain or illness

    People with advanced dementia often show pain, urinary retention, constipation, infection, or a fracture through new agitation or resistance to care, so look for a physical cause (check the bladder, abdomen, skin, and limbs, vital signs, and glucose) before blaming the dementia. A new change over 2 days is not simply disease progression. The behavior is communication, not intent to harm. Antipsychotics carry a boxed warning in dementia and do not treat the underlying cause.

20. A 76-year-old has had a hand tremor for years. It is worst when she holds a cup or writes, eases after a glass of wine, and she has no stiffness or slow movement. The most likely cause is:

    1. A. Parkinson disease
    2. B. Essential tremor
    3. C. Alcohol withdrawal
    4. D. An overactive thyroid
    Show answer

    Answer: B. Essential tremor

    Essential tremor is the most common tremor in older adults. It appears with action, such as holding a cup or writing, often runs in families, and may improve briefly with alcohol. Parkinson disease causes a resting tremor with rigidity and slow movement. Withdrawal and hyperthyroidism cause tremor with other signs such as sweating, tachycardia, or anxiety.

21. A 77-year-old with no seizure history has a generalized seizure. Which cause should you most strongly consider?

    1. A. Epilepsy that began in childhood
    2. B. Febrile seizure from viral illness
    3. C. Prior stroke or a brain lesion
    4. D. Psychogenic nonepileptic event
    Show answer

    Answer: C. Prior stroke or a brain lesion

    New-onset seizures in older adults are most often due to stroke, tumor, subdural hematoma, or metabolic causes such as hyponatremia or hypoglycemia. Febrile seizures occur in young children, not older adults.

22. When caring for an agitated patient with advanced dementia, the most helpful approach is to:

    1. A. Correct each mistaken belief firmly and repeatedly
    2. B. Keep the lights bright so that she stays fully oriented
    3. C. Apply soft restraints early, before she escalates further
    4. D. Use a calm voice, simple words, and minimal stimuli
    Show answer

    Answer: D. Use a calm voice, simple words, and minimal stimuli

    Reducing noise and light, using short sentences, and reassuring the patient lower agitation, and a familiar caregiver helps. Repeatedly arguing with false beliefs usually escalates distress. Bright lights add stimulation rather than orienting her, and restraint without an immediate safety need increases fear and struggling.

23. A bedbound 89-year-old with advanced dementia depends on staff for drinks. After a week of fever she is lethargic, with dry mucosa. The electrolyte problem most likely is:

    1. A. Low sodium from water excess
    2. B. High potassium from fever
    3. C. High sodium from water loss
    4. D. Low calcium from bed rest
    Show answer

    Answer: C. High sodium from water loss

    Older adults who depend on others for water, have a blunted thirst response, and lose extra water through fever cannot replace losses, so their sodium rises (hypernatremic dehydration), causing lethargy, confusion, and seizures; give fluids per protocol and transport. Low sodium follows water excess or drugs such as thiazides and SSRIs, not inadequate intake. Fever does not by itself raise potassium. Immobility tends to raise, not lower, calcium.

24. The CURB-65 score for pneumonia severity includes which factor?

    1. A. Age of 65 years or older
    2. B. Heart rate over 100
    3. C. Oxygen saturation under 94%
    4. D. Temperature over 39°C (102.2°F)
    Show answer

    Answer: A. Age of 65 years or older

    CURB-65 counts confusion, elevated urea, respiratory rate of 30 or more, low blood pressure, and age 65 or older; each point raises the risk of death. Heart rate, SpO2, and temperature are not part of the score.

25. A 79-year-old with atrial fibrillation stopped her anticoagulant 2 weeks ago because of cost. She is at greatest risk for:

    1. A. Hemorrhagic stroke
    2. B. Embolic stroke
    3. C. Aortic dissection
    4. D. Hyperkalemia
    Show answer

    Answer: B. Embolic stroke

    In AF, stasis in the left atrium forms clots that can embolize to the brain, and stopping anticoagulation removes that protection. Hemorrhagic stroke risk falls, not rises, when an anticoagulant is stopped.