GI, GU, Endocrine, Infectious, and Environmental Emergencies Practice Questions

25 multiple-choice questions on GI, GU, endocrine, infectious, and environmental emergencies 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 86-year-old has new confusion, a pulse of 112, a respiratory rate of 24, a BP of 94/58 mm Hg, and a temperature of 36.0°C (96.8°F). You should suspect:

   1. A. Dementia progression
   2. B. Simple dehydration
   3. C. Anxiety reaction
   4. D. Sepsis
   Show answer

   Answer: D. Sepsis

   Tachycardia, tachypnea, hypotension, and altered mentation suggest sepsis even without fever, because older adults are often normothermic or hypothermic. A low temperature makes sepsis more ominous, not less likely.

2. In an older adult with sepsis, a temperature below 36°C (96.8°F) is:

   1. A. A sign the infection is resolving
   2. B. Associated with a worse outcome
   3. C. Expected and of no significance
   4. D. Evidence against an infection
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   Answer: B. Associated with a worse outcome

   Hypothermia in sepsis reflects an overwhelmed host response and predicts higher mortality. It does not argue against infection, because many older adults cannot mount a fever.

3. A bedbound nursing home resident has a pulse of 118, BP 88/50 mm Hg, and new confusion. Her lungs are clear and her urine is clear. The area most important to examine next for a source of sepsis is:

   1. A. Her sacrum, hips, and both heels
   2. B. Her ears for otitis media
   3. C. Her sinuses by tapping on her face
   4. D. Her throat for strep pharyngitis
   Show answer

   Answer: A. Her sacrum, hips, and both heels

   Infected pressure injuries over the sacrum, hips, and heels are a common, often hidden, source of sepsis in dependent older adults, along with the lungs, urinary tract, and abdomen; turn the patient and inspect the skin, then notify the hospital of a sepsis alert. Ear, sinus, and throat infections are uncommon causes of septic shock in a bedbound resident and rarely produce this picture without local symptoms.

4. Staff say a nursing home resident is more confused today and her urine 'smells strong.' She has no fever, no urinary symptoms, and no catheter. The most accurate statement is:

   1. A. Strong-smelling urine proves she has a UTI
   2. B. Her confusion is fully explained by the urine
   3. C. Smelly urine alone does not confirm a UTI
   4. D. No further search for a cause is needed
   Show answer

   Answer: C. Smelly urine alone does not confirm a UTI

   Bacteria in the urine without urinary or systemic signs (asymptomatic bacteriuria) are very common in older women and nursing home residents, and odor or cloudiness does not establish infection; the 2019 IDSA guideline warns against attributing delirium to the urine without other signs, because doing so misses hypoxia, dehydration, drug effects, stroke, or other infections. Look for other causes and report the findings. Odor does not prove infection. Assuming the urine explains her confusion and stopping the search is exactly the error to avoid.

5. A 76-year-old man with diabetes has fever and severe perineal pain. His scrotum is swollen, dusky, and crackles under your fingers. You should suspect:

   1. A. A simple scrotal skin abscess
   2. B. A tight but harmless inguinal hernia
   3. C. A necrotizing perineal infection
   4. D. A reaction to a new soap
   Show answer

   Answer: C. A necrotizing perineal infection

   Fournier gangrene is a necrotizing soft-tissue infection of the perineum and genitals, most common in older men with diabetes, obesity, or immunosuppression; pain out of proportion, dusky skin, and crepitus from gas in the tissues signal a surgical emergency with high mortality, so treat for sepsis and transport urgently. A simple abscess is localized and does not produce crepitus or spreading dusky skin. A hernia does not crackle or cause fever with skin necrosis. A soap reaction causes redness and itching, not crepitus and sepsis.

6. An 83-year-old with chronic kidney disease has taken milk of magnesia daily for constipation. She is weak and drowsy, with a pulse of 48, a BP of 84/50 mm Hg, and absent knee reflexes. You should suspect:

   1. A. A low magnesium level
   2. B. A high magnesium level
   3. C. A low potassium level
   4. D. A high blood sugar level
   Show answer

   Answer: B. A high magnesium level

   Magnesium is cleared by the kidneys, so older adults with reduced kidney function who use magnesium-containing laxatives or antacids can accumulate it; hypermagnesemia causes loss of deep tendon reflexes, weakness, hypotension, bradycardia, and drowsiness, progressing to respiratory depression. Give calcium per protocol or medical direction, support breathing, and transport. Low magnesium causes tremor, hyperreflexia, and dysrhythmias such as torsades. Low potassium causes weakness with flattened T waves but not absent reflexes with hypotension. A high blood sugar would not explain these findings.

7. An 82-year-old has abdominal distension, cramping pain, vomiting, and no bowel movement for 5 days. The most likely problem is:

   1. A. Peptic ulcer
   2. B. Acute gastroenteritis
   3. C. Cholecystitis
   4. D. Bowel obstruction
   Show answer

   Answer: D. Bowel obstruction

   Distension, colicky pain, vomiting, and no stool suggest obstruction from adhesions, hernia, tumor, volvulus, or fecal impaction. Gastroenteritis causes diarrhea, not absent bowel movements.

8. An 83-year-old has vomiting and cramping abdominal pain. He has a tender, firm, red lump in his right groin that he says used to 'go back in' but will not now. You should suspect:

   1. A. An incarcerated hernia
   2. B. A swollen lymph node
   3. C. A simple groin strain
   4. D. A kidney stone in transit
   Show answer

   Answer: A. An incarcerated hernia

   A groin bulge that no longer reduces, now tender and red, with vomiting and cramping pain, is an incarcerated (possibly strangulated) inguinal or femoral hernia causing bowel obstruction, a surgical emergency that older adults often delay reporting; do not try to force it back, keep him NPO, and transport. An inflamed lymph node is not a reducible lump and does not cause obstructive vomiting. A muscle strain does not produce a firm, red mass that previously reduced. A kidney stone causes flank-to-groin pain without a groin mass.

9. An 80-year-old with 2 days of black, tarry stools now has chest pressure, a pulse of 110, and ST depression on the ECG. The chest pressure is most likely caused by:

   1. A. Too little oxygen delivery from blood loss
   2. B. A new clot that has formed in a coronary artery
   3. C. Inflammation of the sac around the heart
   4. D. Reflux of stomach acid into the esophagus
   Show answer

   Answer: A. Too little oxygen delivery from blood loss

   Blood loss lowers hemoglobin and blood pressure while tachycardia raises demand, so older hearts with fixed coronary narrowing become ischemic (a type 2, or demand, MI); treat the bleeding and hypovolemia, and withhold aspirin because of the active bleed. A primary coronary clot (type 1 MI) is less likely when the trigger is obvious blood loss, although the hospital will evaluate both. Pericarditis causes positional, pleuritic pain with diffuse ST elevation. Reflux does not cause ST depression with tachycardia after melena.

10. A 78-year-old with lung cancer has 1 week of increasing confusion, constipation, thirst, and frequent urination. Her glucose is normal, and the ECG shows a short QT interval. You should suspect:

    1. A. A low blood calcium level
    2. B. A high blood glucose level
    3. C. A low blood sodium level
    4. D. A high blood calcium level
    Show answer

    Answer: D. A high blood calcium level

    Hypercalcemia of malignancy causes 'stones, bones, groans, and psychiatric overtones': confusion, constipation, polyuria with dehydration, weakness, and a shortened QT; give IV fluid per protocol and transport. Low calcium lengthens the QT and causes tetany and cramps. Hyperglycemia is excluded by the normal glucose. Low sodium causes confusion but does not shorten the QT or cause polyuria with thirst.

11. An 84-year-old widower who lives alone has eaten little but tea and toast for weeks while drinking a lot of water. He is confused and weak. Which electrolyte problem is most likely?

    1. A. High sodium from too little water in his diet
    2. B. Low sodium from too little salt and protein
    3. C. High potassium from eating mostly bread
    4. D. Low glucose from drinking too much tea
    Show answer

    Answer: B. Low sodium from too little salt and protein

    A diet very low in salt and protein gives the kidneys too few solutes to excrete free water, so with ordinary or high fluid intake the sodium falls ('tea and toast' or low-solute hyponatremia), causing confusion, falls, and seizures; it often accompanies isolation, depression, and poor nutrition. His problem is water excess relative to solute, not too little water. Bread is not high in potassium. Tea does not lower glucose.

12. An 84-year-old woman has gained weight and become slow, cold-intolerant, and forgetful over several months. Her pulse is 52 and her skin is dry. You should suspect:

    1. A. Hyperthyroidism
    2. B. Addison disease
    3. C. Hypothyroidism
    4. D. Cushing syndrome
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    Answer: C. Hypothyroidism

    Hypothyroidism is common in older women, and its slowness, fatigue, and memory loss are often mistaken for aging or dementia; severe cases can progress to myxedema coma. Hyperthyroidism causes tachycardia and heat intolerance.

13. In older adults, hyperthyroidism may present atypically with:

    1. A. Weight loss, apathy, and new atrial fibrillation
    2. B. Weight gain, cold intolerance, and bradycardia
    3. C. Bulging eyes and a visibly large goiter
    4. D. Fever and a rash on both cheeks
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    Answer: A. Weight loss, apathy, and new atrial fibrillation

    'Apathetic hyperthyroidism' in older adults may show only lethargy, weight loss, and AF rather than the classic nervousness and tremor. Cold intolerance and bradycardia point to hypothyroidism.

14. An 86-year-old is found confused at home with a core temperature of 33 °C (91.4 °F), though the house is only mildly cool. Besides rewarming, you should specifically look for:

    1. A. A history of recent hard outdoor exercise
    2. B. A broken furnace or a faulty home thermostat
    3. C. An illness that caused it, such as sepsis
    4. D. Frostbite on her fingers and toes
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    Answer: C. An illness that caused it, such as sepsis

    Hypothermia in a mildly cool home suggests an underlying problem that impaired heat production or behavior, such as sepsis, hypoglycemia, stroke, hypothyroidism, a fall with a long lie, alcohol, or sedating drugs; check glucose, look for infection and injury, and handle her gently because the cold heart is irritable. Outdoor exercise does not explain indoor hypothermia in a confused older adult. The house is only mildly cool, so a heating failure does not explain a core temperature of 33 °C, and frostbite requires freezing tissue temperatures that a mildly cool home does not produce.

15. During a heat wave, which older adult is at greatest risk for heat stroke?

    1. A. One who lives with family in a cooled home
    2. B. One who walks daily in the early morning
    3. C. One who spends the day at a cooling center
    4. D. One living alone without air conditioning
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    Answer: D. One living alone without air conditioning

    Social isolation and lack of air conditioning are the strongest risk factors for heat deaths in older adults, worsened by diuretics, anticholinergics, and impaired sweating. Cooling centers exist precisely to lower that risk.

16. During a heat wave with indoor temperatures near 36 °C (97 °F), an 82-year-old says her electric fan keeps her safe. The best advice is that:

    1. A. A fan cools her well enough in this weather
    2. B. A fan may not prevent heat illness this hot
    3. C. She should close the windows to stay cool
    4. D. She should drink less to avoid extra sweat
    Show answer

    Answer: B. A fan may not prevent heat illness this hot

    When air temperature approaches body temperature, a fan mainly blows hot air and can even add heat stress; the CDC advises that fans do not prevent heat illness in the high 90s °F, so older adults need air conditioning, a cooling center, or a cool shower, plus regular checks by family or neighbors. Closing the windows traps heat in the home. Restricting fluids raises the risk of dehydration and heat stroke.

17. A 74-year-old has painful blisters in a band across her forehead on one side, and new blisters on the tip of her nose on the same side. The main concern is that:

    1. A. The rash will spread to both sides
    2. B. Facial paralysis will follow
    3. C. It will leave her nose badly scarred
    4. D. The infection may involve the eye
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    Answer: D. The infection may involve the eye

    Shingles in the first branch of the trigeminal nerve (herpes zoster ophthalmicus) can involve the eye; vesicles on the tip of the nose (Hutchinson sign) suggest involvement of the nasociliary branch, which also supplies the eye, and raise the risk of keratitis, uveitis, and vision loss, so she needs prompt antiviral therapy and eye evaluation. Shingles follows a dermatome and does not cross the midline. Facial paralysis comes from zoster of the facial nerve near the ear (Ramsay Hunt syndrome), not from this forehead and nose distribution. Scarring is a minor issue next to the threat to her vision.

18. A 72-year-old has burning pain and a band of clustered blisters on one side of her chest. The most likely cause is:

    1. A. Herpes zoster (shingles)
    2. B. Allergic contact dermatitis
    3. C. Acute MI
    4. D. Impetigo
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    Answer: A. Herpes zoster (shingles)

    Shingles is reactivation of varicella-zoster virus, common in older adults, and causes a painful vesicular rash in one dermatome that does not cross the midline. Pain can precede the rash and mimic MI, but the blisters identify zoster.

19. Which infection control step best protects older adults in long-term care from seasonal outbreaks?

    1. A. Vaccinating the residents but not the staff
    2. B. Wearing gloves in place of washing their hands
    3. C. Yearly flu vaccines for staff and residents
    4. D. Screening visitors for fever at the door
    Show answer

    Answer: C. Yearly flu vaccines for staff and residents

    Influenza spreads quickly in long-term care, and vaccinating both residents and staff reduces outbreaks and deaths. Vaccinating residents alone leaves staff to carry the virus in, and older adults respond less strongly to the vaccine. Gloves do not replace hand hygiene and can spread germs between residents. Fever screening at the door misses visitors who are infectious before symptoms begin.

20. You are transferring a nursing home resident colonized with a multidrug-resistant organism (MDRO) to the hospital. Besides contact precautions, the most important step is to:

    1. A. Keep the MDRO status private from staff
    2. B. Tell the receiving staff about the MDRO
    3. C. Give her antibiotics before you leave
    4. D. Have her wear an N95 during transport
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    Answer: B. Tell the receiving staff about the MDRO

    Residents move often between nursing homes, hospitals, and dialysis, and unrecognized MDROs (such as CRE or Candida auris) spread at these transitions, so communicate the organism and precautions at handoff (CDC's interfacility transfer form) and clean the cot and equipment afterward. Infection status is shared with health care staff for treatment, which HIPAA permits. Antibiotics do not decolonize a carrier and are not an EMS measure. Contact-spread organisms do not call for an N95 on the patient.

21. An 87-year-old has had diarrhea for 3 days and takes furosemide. She is dizzy, and her pulse rises from 80 to 110 when she sits up. Your best treatment is:

    1. A. Oral furosemide to remove excess fluid
    2. B. IV fluid with frequent reassessment
    3. C. No fluids until hospital labs return
    4. D. Nitroglycerin for dizziness
    Show answer

    Answer: B. IV fluid with frequent reassessment

    Diarrhea plus a diuretic causes volume depletion, shown by the orthostatic pulse rise, so give IV fluid while watching for overload. Withholding fluid until labs return delays treatment of a clear clinical problem.

22. A 90-year-old bedbound resident on opioids has leakage of liquid stool and lower abdominal discomfort. A likely cause is:

    1. A. Acute infectious diarrhea
    2. B. New inflammatory bowel disease
    3. C. Fecal impaction with overflow
    4. D. Laxative abuse
    Show answer

    Answer: C. Fecal impaction with overflow

    Hard stool lodged in the rectum lets liquid stool seep around it, mimicking diarrhea; immobility and opioids are major risk factors. Treating it as infectious diarrhea with antidiarrheals would worsen the problem.

23. New urinary incontinence in an older adult should be viewed as:

    1. A. A possible sign of a new medical problem
    2. B. A normal and expected change with advancing age
    3. C. A purely psychological problem
    4. D. A reason to restrict fluid intake
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    Answer: A. A possible sign of a new medical problem

    Incontinence is common but not normal; new onset can signal UTI, delirium, stroke, spinal cord compression, or drug effects. Restricting fluids invites dehydration and concentrated urine that irritates the bladder.

24. Compared with younger patients, older adults with acute cholecystitis or appendicitis are more likely to:

    1. A. Present with high fever and a rigid abdomen
    2. B. Recover without needing surgery
    3. C. Report severe, well-localized pain
    4. D. Have perforation by the time they seek care
    Show answer

    Answer: D. Have perforation by the time they seek care

    Blunted pain and fever lead older adults to seek care later, so perforation and gangrene are more common at presentation. A high fever and rigid abdomen are less, not more, likely in older adults.

25. An 83-year-old on lisinopril and spironolactone is weak with a pulse of 48 and tall, peaked T waves on the monitor. You should suspect:

    1. A. Hypokalemia
    2. B. Hypercalcemia
    3. C. Hypothermia
    4. D. Hyperkalemia
    Show answer

    Answer: D. Hyperkalemia

    ACE inhibitors and potassium-sparing diuretics, combined with declining renal function, can raise potassium dangerously, causing peaked T waves, bradycardia, and weakness. Hypercalcemia does not cause peaked T waves; it shortens the QT interval.