Mental Illness, Substance Use History, Sexual and Gender Minority Patients, and Unbiased Care Practice Questions

25 multiple-choice questions on Mental illness, substance use history, sexual and gender minority patients, and unbiased care for paramedic and EMT students, from Chapter 46 (Patients With Special Challenges). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. During a heat wave, people who take antipsychotic medicines for serious mental illness are at higher risk of heat illness mainly because the drugs can:

   1. A. Cause them to stay indoors too much
   2. B. Increase their tolerance to high heat
   3. C. Impair sweating and heat regulation
   4. D. Lower their body's metabolic rate
   Show answer

   Answer: C. Impair sweating and heat regulation

   Antipsychotics impair the brain's temperature control and, through anticholinergic effects, sweating and thirst, so heat illness can develop quickly; check on these patients during heat waves and cool early. Staying indoors is not the drug effect, and isolation raises risk only in homes without cooling. The drugs reduce, not increase, heat tolerance. Lowering metabolic rate would reduce heat production, which is not how they raise risk. (CDC heat and medications.)

2. A 34-year-old man with Down syndrome is in cardiac arrest at his group home. A bystander asks, 'Is it worth it? He has a disability.' You should:

   1. A. Limit care because of his disability
   2. B. Ask the staff whether to start CPR
   3. C. Call medical control before starting CPR
   4. D. Resuscitate him as you would anyone
   Show answer

   Answer: D. Resuscitate him as you would anyone

   Disability is not a reason to limit resuscitation; decisions rest on clinical criteria and the patient's own valid directives, and federal civil rights law prohibits disability-based limits on care. Research shows that clinicians often underestimate the quality of life of people with disabilities. Limiting care for that reason is discrimination. Group-home staff cannot decline CPR for him without a valid directive, and pausing to ask them or to call medical control delays CPR that should start at once. (HHS OCR 2020; Iezzoni 2021.)

3. A patient taking an atypical antipsychotic such as olanzapine is at increased risk for:

   1. A. Hearing loss and tinnitus
   2. B. Weight gain and diabetes
   3. C. Hyperthyroidism and tremor
   4. D. Kidney stones and gout
   Show answer

   Answer: B. Weight gain and diabetes

   Second-generation antipsychotics cause metabolic syndrome: weight gain, insulin resistance, diabetes, and high lipids. Check glucose in any patient on these drugs who has altered mental status.

4. While treating a transgender woman, you accidentally refer to her as 'he.' The best response is to:

   1. A. Explain at length why you made the error
   2. B. Ignore it so you do not draw attention
   3. C. Briefly apologize, correct, and continue
   4. D. Ask her to show ID to confirm her gender
   Show answer

   Answer: C. Briefly apologize, correct, and continue

   A short apology, using the correct pronoun, and moving on shows respect without making her comfort your task. A long explanation centers the provider and prolongs the discomfort. Ignoring the error suggests it does not matter. Identification documents do not define her gender identity and are irrelevant to her care. (Fenway Institute; WPATH SOC8.)

5. A family member of a man on methadone for opioid use disorder says the treatment 'just replaces one drug with another.' You should know that treatment with methadone or buprenorphine:

   1. A. Lowers the risk of death by about half
   2. B. Is meant as a short detox, then stopped
   3. C. Increases the rate of fatal overdose
   4. D. Has no proven effect on survival
   Show answer

   Answer: A. Lowers the risk of death by about half

   Large cohort studies show that all-cause and overdose deaths are roughly halved while people stay on methadone or buprenorphine, and the risk climbs after stopping; opioid use disorder is a chronic illness treated with long-term medication. These are maintenance treatments, not short detox programs. They lower, not raise, overdose deaths. Their survival benefit is well proven. (Sordo, BMJ 2017; Larochelle 2018.)

6. A transgender woman says that hours ago she had silicone injected into her hips at a 'pumping party.' She now has sudden dyspnea, cough, and an SpO2 of 84%. You should suspect:

   1. A. An anxiety attack from the procedure
   2. B. Embolism of silicone to the lungs
   3. C. A local allergy at the injection site
   4. D. Simple asthma
   Show answer

   Answer: B. Embolism of silicone to the lungs

   Illicit liquid silicone injections given by unlicensed people can cause silicone embolism syndrome, with hypoxia, alveolar hemorrhage, and sometimes neurologic signs, and it carries high mortality; give oxygen, support ventilation, and transport rapidly, without judgment. Anxiety does not drop the SpO2 to 84%. A local allergy does not cause hypoxia. Asthma does not explain the timing after the injections. (Schmid, Chest 2005.)

7. A 30-year-old man with opioid use disorder was released from jail yesterday after 6 months without using. He plans to use heroin tonight. His overdose risk is high mainly because:

   1. A. Naloxone does not work after abstinence
   2. B. Abstinence makes his body clear opioids more slowly
   3. C. He no longer knows how to use safely
   4. D. His tolerance has fallen while he was away
   Show answer

   Answer: D. His tolerance has fallen while he was away

   After weeks to months without opioids, tolerance falls, so a dose he once used can stop his breathing; in the first two weeks after release, the risk of overdose death is many times higher than in the general population. Offer naloxone and treatment referral without judgment. Naloxone still works after abstinence. Abstinence does not slow opioid clearance. Loss of skill is not the main danger. (Binswanger, NEJM 2007.)

8. Which term is preferred when documenting a patient's substance use?

   1. A. Frequent drug abuser in the area
   2. B. Chronic addict with known history
   3. C. Person with a substance use disorder
   4. D. Habitual user well known to EMS
   Show answer

   Answer: C. Person with a substance use disorder

   Person-first, clinical language such as 'person with a substance use disorder' reduces stigma, which research shows affects the care clinicians give. Labels like 'abuser' or 'addict' are linked to more punitive attitudes.

9. A man who uses a manual wheelchair is waiting at the curb when you arrive. Before pushing his chair toward the ambulance, you should:

   1. A. Ask if he wants help, and how to help
   2. B. Push it quickly to save time on scene
   3. C. Tilt it back without saying anything
   4. D. Hold his arms so that he stays seated
   Show answer

   Answer: A. Ask if he wants help, and how to help

   A wheelchair is part of a person's personal space; ask whether he wants help and follow his directions for curbs and tilting. Pushing without asking takes away his control. Tilting without warning can startle him and cause a fall. Holding his arms is a restraint and is never appropriate here. (ADA National Network, disability etiquette.)

10. Gender identity refers to a person's:

    1. A. Physical attraction to other people
    2. B. Sex recorded on the birth certificate
    3. C. Outward style of clothing and speech
    4. D. Internal sense of their own gender
    Show answer

    Answer: D. Internal sense of their own gender

    Gender identity is one's inner sense of being a man, a woman, both, or neither; sexual orientation is attraction, sex assigned at birth is what the certificate records, and gender expression is outward presentation. These are separate and do not predict one another.

11. A patient's gender identity is not clear to you. The best approach is to:

    1. A. Use the name and sex on the driver's license
    2. B. Ask the patient's name and pronouns respectfully
    3. C. Decide based on how the patient's voice sounds to you
    4. D. Avoid using any name or pronoun during care
    Show answer

    Answer: B. Ask the patient's name and pronouns respectfully

    Simply asking what name and pronouns the patient uses avoids misgendering and builds trust. Identification documents may not reflect the patient's identity, and guessing from voice or appearance is unreliable.

12. A 26-year-old transgender man (assigned female at birth) has lower abdominal pain and vaginal bleeding. You should:

    1. A. Dismiss pregnancy because he takes testosterone
    2. B. Assume the bleeding is from a urinary infection
    3. C. Consider ectopic pregnancy in your assessment
    4. D. Avoid asking about anatomy to prevent offense
    Show answer

    Answer: C. Consider ectopic pregnancy in your assessment

    A transgender man with a uterus and ovaries can become pregnant, and testosterone is not reliable contraception, so pain with bleeding calls for considering ectopic pregnancy. Dismissing pregnancy because of testosterone is a dangerous error. A urinary infection does not explain vaginal bleeding. Asking respectfully about relevant anatomy is part of a proper assessment. (WPATH SOC8; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

13. A 45-year-old transgender woman taking estrogen has sudden dyspnea and pleuritic chest pain. Her hormone therapy raises her risk of:

    1. A. Pulmonary embolism
    2. B. Spontaneous pneumothorax
    3. C. Pericarditis
    4. D. Asthma
    Show answer

    Answer: A. Pulmonary embolism

    Estrogen therapy increases clotting risk, especially with smoking or immobility, so consider PE in any patient on estrogen with sudden dyspnea and tachycardia. Estrogen has no link to spontaneous pneumothorax.

14. A transgender man on testosterone therapy is at increased risk for:

    1. A. Osteoporosis
    2. B. Hypoglycemia
    3. C. Polycythemia
    4. D. Anemia
    Show answer

    Answer: C. Polycythemia

    Testosterone stimulates red cell production, raising the hematocrit and the risk of clots, stroke, and MI. Anemia is the opposite effect.

15. A 19-year-old transgender man wearing a tight chest binder is short of breath after running. You should:

    1. A. Leave the binder on to avoid upsetting him
    2. B. Cut the binder off without asking him first
    3. C. Apply oxygen but avoid listening to his lung sounds
    4. D. Explain the need and remove or loosen the binder
    Show answer

    Answer: D. Explain the need and remove or loosen the binder

    Binders restrict chest expansion and can cause dyspnea, rib pain, and skin breakdown; explain why it must come off for assessment and breathing, and get his agreement when possible. Leaving it on to avoid upsetting him leaves the cause of his dyspnea in place.

16. When assessing a transgender patient with a sprained ankle, questions about genital surgery are:

    1. A. Required for a complete patient care report
    2. B. Inappropriate because they are not relevant
    3. C. Needed to choose the right pain medicine
    4. D. Appropriate if asked in a private setting
    Show answer

    Answer: B. Inappropriate because they are not relevant

    Ask only questions that affect care; curiosity-driven questions about anatomy or surgery are intrusive and discourage people from seeking care. Anatomy questions are appropriate when relevant, such as with abdominal pain or possible pregnancy. Genital surgery history does not change ankle care or analgesic choice, and asking in private does not make an irrelevant question appropriate.

17. A 62-year-old transgender woman who has had genital surgery has acute urinary retention. You should know that:

    1. A. She still has a prostate that can enlarge
    2. B. Retention is rare after genital surgery
    3. C. The cause is most likely her hormone therapy
    4. D. Her symptoms are likely psychosomatic
    Show answer

    Answer: A. She still has a prostate that can enlarge

    Gender-affirming genital surgery generally leaves the prostate in place, so benign enlargement, prostatitis, or cancer is still possible. Estrogen may shrink the prostate but does not remove it.

18. When asking a patient about a spouse or significant other before you know the patient's sexual orientation, the most inclusive approach is to:

    1. A. Assume a partner of the opposite sex
    2. B. Skip the question to avoid offense
    3. C. Use a neutral term such as 'partner'
    4. D. Ask first whether the patient is gay
    Show answer

    Answer: C. Use a neutral term such as 'partner'

    Gender-neutral words such as 'partner' let the patient tell you about the relationship without your assumptions. Assuming a heterosexual partner signals that other relationships are unexpected and can shut down disclosure. Skipping the question loses information about support, contacts, and decision-makers. Asking about orientation first is intrusive and seldom relevant. (Fenway Institute; Joint Commission LGBT field guide.)

19. A 50-year-old man in respiratory distress asks that his husband ride with him and be involved in decisions. You should:

    1. A. Ask for proof of marriage before including him
    2. B. Contact the patient's parents instead
    3. C. Limit the husband to waiting at the hospital
    4. D. Include his husband as you would any spouse
    Show answer

    Answer: D. Include his husband as you would any spouse

    A patient chooses who is involved in his care, and a same-sex spouse has the same standing as any other spouse. Demanding proof of the relationship is discriminatory and delays care.

20. When documenting care for a transgender patient whose legal name differs from the name she uses, you should:

    1. A. Record the legal name and note the name she uses
    2. B. Use the insurance name and ignore her chosen name
    3. C. Use her chosen name and omit her legal name
    4. D. Leave the name field blank to avoid confusion
    Show answer

    Answer: A. Record the legal name and note the name she uses

    The legal name is needed for identification and records, and noting the name and pronouns she uses lets hospital staff address her correctly. Leaving out the legal name can cause errors in matching records.

21. Implicit bias is best described as:

    1. A. Openly stated prejudice toward a group
    2. B. Unconscious attitudes that affect our decisions
    3. C. A hospital policy for treating patients equally
    4. D. A legal rule against discrimination
    Show answer

    Answer: B. Unconscious attitudes that affect our decisions

    Implicit biases are automatic associations that can shape care even in providers who consciously reject prejudice, for example, undertreating pain in some groups. Openly stated prejudice is explicit bias.

22. Studies of prehospital analgesia have found that, compared with White patients with similar injuries, Black and Hispanic patients are:

    1. A. Less likely to receive pain medication
    2. B. More likely to receive pain medication
    3. C. Equally likely to receive pain medication
    4. D. Less likely to report their pain
    Show answer

    Answer: A. Less likely to receive pain medication

    EMS studies of fractures and other painful injuries show that Black and Hispanic patients receive analgesia less often than White patients with comparable pain, a gap linked to implicit bias rather than to clinical differences; ED studies show the same pattern for opioid prescribing. They are not more likely, or equally likely, to be treated. The gap persists after accounting for reported pain scores, so it is not explained by patients reporting less pain. Using a pain scale and protocol consistently for every patient helps close it. (Hewes 2018; Kennel 2019; Pletcher 2008.)

23. A practical way for a paramedic to reduce the effect of bias on care is to:

    1. A. Rely on first impressions to save time
    2. B. Treat patients differently based on appearance
    3. C. Avoid patients from unfamiliar backgrounds
    4. D. Use a standard assessment for every patient
    Show answer

    Answer: D. Use a standard assessment for every patient

    Structured, consistent assessment and treatment protocols leave less room for snap judgments shaped by bias. First impressions are exactly where implicit bias does its work.

24. A 40-year-old man with HIV has a deep laceration. When caring for him, you should:

    1. A. Wear a gown, N95 mask, and double gloves
    2. B. Use droplet precautions because he has HIV infection
    3. C. Use standard precautions as with any patient
    4. D. Plan PEP for the crew after skin contact
    Show answer

    Answer: C. Use standard precautions as with any patient

    HIV is spread by blood and certain body fluids, so standard precautions protect you, and treating every patient as potentially infectious avoids stigmatizing anyone. Airborne precautions such as an N95 add nothing against HIV. HIV is not spread by droplets, and post-exposure prophylaxis is for significant exposures such as needlesticks or blood on broken skin, not for contact with intact skin.

25. A 35-year-old veteran with combat PTSD becomes tense and pulls away when you reach to cut his shirt after a minor crash. He is alert and stable. The best approach is to:

    1. A. Have your partner distract him while you cut
    2. B. Explain each step and ask before touching
    3. C. Cut the shirt quickly before he can react
    4. D. Skip the exam since he is alert and stable
    Show answer

    Answer: B. Explain each step and ask before touching

    Trauma-informed care gives predictability, choice, and control: explain what you need to do, ask before touching, offer to let him remove the shirt himself, and reduce noise and crowding. Cutting quickly or having a partner distract him removes his sense of control and can trigger a flashback. Skipping the exam because he is alert risks missing crash injuries; a calm, explained exam lets you assess him safely. (SAMHSA trauma-informed approach; VA National Center for PTSD.)