Neurologic and Behavioral Medications Practice Questions

81 multiple-choice questions on Neurologic and behavioral medications for paramedic and EMT students, from Chapter 15 (Emergency Medications). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

81 practice questions

1. A patient has had a continuous tonic-clonic seizure for 6 minutes. The family asks you to wait because 'his seizures usually stop on their own.' What is best?

   1. A. Give oral diazepam from his supply
   2. B. Wait until 15 minutes before treating
   3. C. Treat now; this is status epilepticus
   4. D. Wait for the hospital to give a drug
   Show answer

   Answer: C. Treat now; this is status epilepticus

   A convulsive seizure lasting 5 minutes or longer is treated as status epilepticus, and a benzodiazepine (IM, IN, or IV) should be given now, because seizures become harder to stop the longer they last. Waiting until 15 minutes or until hospital arrival lets the seizure become refractory. An oral tablet cannot be safely swallowed during a seizure.

2. A newborn of a mother on long-term methadone is apneic at birth. Why is naloxone avoided?

   1. A. It causes neonatal hypoglycemia
   2. B. It is too slow to act
   3. C. It has no effect in newborns
   4. D. It can trigger seizures
   Show answer

   Answer: D. It can trigger seizures

   In a newborn chronically exposed to opioids in utero, naloxone can cause abrupt withdrawal with seizures, so NRP focuses on effective positive-pressure ventilation instead. Naloxone does work in newborns, does not cause hypoglycemia, and is not slow; the risk is withdrawal.

3. The main adverse effect to monitor after benzodiazepine administration is:

   1. A. Respiratory depression and hypotension
   2. B. Tachycardia and ventricular ectopy
   3. C. Hyperglycemia and metabolic acidosis
   4. D. Severe hypertension and reflex bradycardia
   Show answer

   Answer: A. Respiratory depression and hypotension

   Have airway equipment ready before administering.

4. A seizing patient with a blood glucose of 38 mg/dL should receive:

   1. A. Nothing until the seizure stops on its own
   2. B. Naloxone to reverse a possible opioid
   3. C. A benzodiazepine only, then a recheck
   4. D. Dextrose to correct the hypoglycemia
   Show answer

   Answer: D. Dextrose to correct the hypoglycemia

   Treat the underlying cause whenever it is identified.

5. Dextrose 10 percent is often preferred over dextrose 50 percent because it:

   1. A. Can be safely given IM if no IV is available
   2. B. Is gentler on veins and overshoots less
   3. C. Works faster because it is more dilute
   4. D. Is more concentrated per milliliter
   Show answer

   Answer: B. Is gentler on veins and overshoots less

   D10 is less irritating to veins and causes less tissue damage if it extravasates, and it can be titrated in small doses, so it is less likely to overshoot into hyperglycemia. D10 is less concentrated rather than more, its dilution does not make it work faster, and hypertonic dextrose should not be given IM; glucagon is the IM option when no IV is available. Titrate until the patient responds.

6. Fifteen minutes after glucagon 1 mg IM, an unresponsive diabetic with a glucose of 30 mg/dL remains unresponsive, and IV attempts have failed. What is next?

   1. A. Place an IO and give dextrose
   2. B. Squeeze glucose gel into the cheek
   3. C. Wait 30 more minutes for glucagon
   4. D. Give the patient's own insulin
   Show answer

   Answer: A. Place an IO and give dextrose

   When glucagon fails and IV access cannot be obtained, IO access allows dextrose to be given directly; the glucagon label also allows a repeat dose after 15 minutes. Oral or gel glucose in an unresponsive patient risks aspiration and is not reliably absorbed. Further waiting prolongs neuroglycopenia. Insulin would lower the glucose further.

7. A bystander gave nalmefene nasal spray (Opvee) to a patient who now has severe withdrawal. Compared with naloxone, what should you expect?

   1. A. Return of sedation within 10 minutes
   2. B. Withdrawal that resolves in minutes
   3. C. No effect on breathing whatsoever
   4. D. Longer-lasting withdrawal symptoms
   Show answer

   Answer: D. Longer-lasting withdrawal symptoms

   Nalmefene is an opioid antagonist that lasts considerably longer than naloxone (hours), so precipitated withdrawal can also last longer; supportive care and monitoring are needed. Its long action also makes quick re-sedation less likely. It does restore breathing in opioid toxicity.

8. Ketamine used for agitation or procedural sedation:

   1. A. Lowers blood pressure sharply in most patients
   2. B. Profoundly depresses respiration in most patients
   3. C. Is contraindicated in any patient with trauma
   4. D. Usually preserves airway reflexes and breathing
   Show answer

   Answer: D. Usually preserves airway reflexes and breathing

   Laryngospasm and emergence reactions are recognized risks. Monitoring is still essential.

9. A combative patient with a head injury is fighting the crew, and the SpO2 reads 82%. What should be addressed before or with sedation?

   1. A. Apply prone restraints first
   2. B. Correct the hypoxia
   3. C. Nothing; sedate him first
   4. D. Give naloxone for the injury
   Show answer

   Answer: B. Correct the hypoxia

   Hypoxia, hypoglycemia, and head injury commonly cause combativeness; oxygen (and a glucose check) may calm the patient and makes sedation safer, since sedatives can worsen hypoxia. Sedating without addressing hypoxia risks respiratory arrest. Naloxone does not treat injury. Prone restraint impairs breathing.

10. A sweating, combative man with an insulin pump is fighting the crew. Before sedation, which quick check could reveal a reversible cause?

    1. A. A fingerstick glucose
    2. B. A 12-lead ECG
    3. C. A pupil exam
    4. D. A urine toxicology screen
    Show answer

    Answer: A. A fingerstick glucose

    Hypoglycemia can cause agitation, sweating, and combativeness, and it is quickly corrected with dextrose, so a fingerstick glucose should be checked as soon as it is safe, ideally before or right after sedation. An ECG and pupil exam are useful but do not reveal this common reversible cause. A urine drug screen is not available in the field and would not change immediate care.

11. A patient with suspected stroke should generally:

    1. A. Receive dextrose routinely to protect brain tissue
    2. B. Receive nitroglycerin to lower the blood pressure
    3. C. Avoid aspirin and anticoagulants until imaging
    4. D. Receive aspirin 324 mg as soon as stroke is suspected
    Show answer

    Answer: C. Avoid aspirin and anticoagulants until imaging

    Check the glucose, protect the airway, and get to a stroke center fast. Hemorrhage must first be excluded by imaging.

12. Physical restraint combined with sedation requires:

    1. A. Continuous monitoring of ABCs and positioning
    2. B. Monitoring only once the patient becomes quiet
    3. C. Removal of monitors to avoid agitation
    4. D. Prone positioning to protect the airway
    Show answer

    Answer: A. Continuous monitoring of ABCs and positioning

    Prone restraint has caused deaths and should be avoided. Thorough documentation is also required.

13. Thiamine may be given with dextrose in patients with suspected chronic alcohol use because:

    1. A. It speeds the absorption of dextrose
    2. B. It prevents alcohol withdrawal seizures
    3. C. It prevents Wernicke encephalopathy
    4. D. It raises blood glucose more quickly
    Show answer

    Answer: C. It prevents Wernicke encephalopathy

    Do not delay dextrose to give it. Thiamine deficiency can lead to Wernicke encephalopathy.

14. A patient with an altered mental status of unknown cause should routinely have:

    1. A. Glucose, oxygenation, and opioid toxicity evaluated
    2. B. A benzodiazepine for possible ongoing seizure activity
    3. C. Thiamine and dextrose before a glucose check
    4. D. Restraints applied before any assessment
    Show answer

    Answer: A. Glucose, oxygenation, and opioid toxicity evaluated

    The reversible causes should be checked first. Naloxone is considered if opioid toxicity is suspected.

15. An 80-kg adult remains in status epilepticus after two benzodiazepine doses. Medical control orders levetiracetam 60 mg/kg IV, maximum 4,500 mg. What dose is given?

    1. A. 6,000 mg IV
    2. B. 4,500 mg IV
    3. C. 4,800 mg IV
    4. D. 480 mg IV
    Show answer

    Answer: B. 4,500 mg IV

    60 mg/kg x 80 kg = 4,800 mg, which exceeds the 4,500-mg maximum, so 4,500 mg is given (the ESETT dosing). 4,800 mg ignores the cap. 480 mg is a tenfold error. 6,000 mg uses 75 mg/kg and ignores the cap.

16. Midazolam IM for status epilepticus in adults is:

    1. A. 10 mg IM
    2. B. 20 mg IM
    3. C. 50 mg IM
    4. D. 2 mg IM
    Show answer

    Answer: A. 10 mg IM

    IM midazolam is as effective as IV lorazepam and faster to administer prehospital. Patients 13 to 40 kg receive 5 mg.

17. Lorazepam IV dose for status epilepticus is:

    1. A. 10 mg IV (0.4 mg/kg), single dose only
    2. B. 40 mg IV (1 mg/kg), may repeat once
    3. C. 4 mg IV (0.1 mg/kg), may repeat once
    4. D. 0.5 mg IV (0.01 mg/kg), may repeat once
    Show answer

    Answer: C. 4 mg IV (0.1 mg/kg), may repeat once

    Lorazepam is long-acting; refrigeration is required.

18. Diazepam IV dose for seizures is:

    1. A. 50 mg IV, repeat every 30 min
    2. B. 0.5 mg/kg IV, repeat every 2 to 3 min
    3. C. 1 mg IV, repeat every 10–15 min
    4. D. 5–10 mg IV, repeat every 10–15 min
    Show answer

    Answer: D. 5–10 mg IV, repeat every 10–15 min

    Rectal diazepam 0.2–0.5 mg/kg is an alternative in children.

19. A 9-kg infant has been seizing for 6 minutes with no IV. Protocol calls for midazolam 0.2 mg/kg IM. What dose is given?

    1. A. 0.18 mg IM
    2. B. 5 mg IM
    3. C. 1.8 mg IM
    4. D. 18 mg IM
    Show answer

    Answer: C. 1.8 mg IM

    0.2 mg/kg x 9 kg = 1.8 mg. 18 mg and 0.18 mg are tenfold errors. 5 mg is the fixed RAMPART-based dose for patients 13 to 40 kg and is too much for a 9-kg infant.

20. A patient who abruptly stopped long-term alprazolam 2 days ago is tremulous, anxious, and then has a generalized seizure. Which drug class treats the cause?

    1. A. A benzodiazepine
    2. B. An antipsychotic
    3. C. Flumazenil
    4. D. An opioid agonist
    Show answer

    Answer: A. A benzodiazepine

    Abrupt benzodiazepine withdrawal, like alcohol withdrawal, causes GABA-related hyperexcitability with tremor, anxiety, and seizures, and it is treated with a benzodiazepine. Opioids do not treat it. Antipsychotics lower the seizure threshold. Flumazenil blocks benzodiazepine receptors and would worsen withdrawal.

21. Ten days after a normal delivery, a woman has a severe headache, a BP of 168/110, and then a generalized seizure. What is the first-line drug?

    1. A. Labetalol, then observe for seizures
    2. B. Magnesium sulfate 4 to 6 g IV
    3. C. Oxytocin 10 units IM for the uterus
    4. D. Phenytoin, since pregnancy is over
    Show answer

    Answer: B. Magnesium sulfate 4 to 6 g IV

    Eclampsia can occur up to about 6 weeks postpartum, and magnesium sulfate is still the first-line seizure drug (a benzodiazepine is used if magnesium is not available or the seizure continues). Phenytoin is less effective for eclampsia. Labetalol treats the BP but does not stop seizures. Oxytocin has no role.

22. A woman at 34 weeks with preeclampsia has a headache and BPs of 166/112 and 164/110 measured 15 minutes apart. Per ACOG, what is appropriate?

    1. A. Treat promptly with IV labetalol
    2. B. Lower the BP below 110/70 within minutes
    3. C. Give furosemide 40 mg IV to lower BP
    4. D. Wait 4 hours, then recheck the BP
    Show answer

    Answer: A. Treat promptly with IV labetalol

    Sustained severe hypertension in pregnancy (SBP 160 or higher or DBP 110 or higher for 15 minutes) should be treated within 30 to 60 minutes with IV labetalol or hydralazine, or oral immediate-release nifedipine, per medical control, to prevent maternal stroke. Waiting hours is unsafe. Dropping the BP too low reduces placental blood flow. Diuretics are not used for this.

23. An adult still seizing after two benzodiazepine doses receives phenobarbital per medical control. What should you be ready for?

    1. A. Hypertension and high fever
    2. B. Breathing depression, hypotension
    3. C. Hyperglycemia and heavy urination
    4. D. Tachycardia and agitation
    Show answer

    Answer: B. Breathing depression, hypotension

    Phenobarbital is an effective second-line drug, but after benzodiazepines it adds marked respiratory depression and hypotension, so airway support and BP monitoring are needed. It does not cause hypertension, fever, hyperglycemia, or agitation.

24. Hypoglycemia with altered mental status in an adult is treated with:

    1. A. D10 25 g (250 mL) or D50 25 g IV
    2. B. Oral glucose 15 g by mouth only, then recheck
    3. C. Glucagon 1 mg IM before any IV
    4. D. D5W 250 mL by rapid IV bolus
    Show answer

    Answer: A. D10 25 g (250 mL) or D50 25 g IV

    D10 is increasingly preferred to reduce extravasation injury and overshoot.

25. An adult with hypoglycemia received 100 mL of D10 and is still confused. When should the glucose be rechecked?

    1. A. At the hospital, not before
    2. B. Not needed if the IV runs
    3. C. After about 1 hour
    4. D. In about 5 to 10 minutes
    Show answer

    Answer: D. In about 5 to 10 minutes

    Glucose is rechecked about 5 to 10 minutes after a D10 dose (sooner with ongoing symptoms), and another dose is given if it is still low; titration is the reason D10 is used. Waiting an hour or until arrival prolongs hypoglycemia. A running IV does not confirm the glucose has improved.

26. Glucagon dose for hypoglycemia without IV access (adult) is:

    1. A. 0.01 mg/kg IM
    2. B. 10 mg IM or SC
    3. C. 1 mg IM or SC
    4. D. 0.1 mg IM or SC
    Show answer

    Answer: C. 1 mg IM or SC

    Glucagon works only if glycogen stores are present; onset 10–20 min. Intranasal glucagon is a separate fixed 3-mg dose.

27. Glucagon is ineffective in:

    1. A. Type 1 diabetics on insulin pumps
    2. B. Older adults taking oral hypoglycemics
    3. C. Patients with depleted glycogen stores
    4. D. Children who weigh less than 25 kg
    Show answer

    Answer: C. Patients with depleted glycogen stores

    No glycogen means no glucose release. Examples include malnutrition, alcoholism, and prolonged fasting.

28. While D50 is being pushed, the IV site swells and the patient reports burning. What is the first action?

    1. A. Slow the push and keep going
    2. B. Stop the push at the infiltrated site
    3. C. Flush 20 mL NS through the swollen site
    4. D. Apply heat and finish the push
    Show answer

    Answer: B. Stop the push at the infiltrated site

    D50 is hypertonic and can cause tissue necrosis if it infiltrates, so stop the injection at once, leave the catheter briefly to aspirate if possible, elevate the limb, document, and give the remaining dextrose through a new site (or use D10). Slowing the push or warming the site and finishing still drives more hypertonic drug into the tissue, and flushing the infiltrated site worsens the injury.

29. Haloperidol for acute agitation is dosed at:

    1. A. 5–10 mg IM
    2. B. 0.5–1 mg IM
    3. C. 50 mg IM
    4. D. 1 mg/kg IM
    Show answer

    Answer: A. 5–10 mg IM

    Often combined with a benzodiazepine; monitor QT and for dystonia.

30. Droperidol for agitation carries a black box warning for:

    1. A. Malignant hyperthermia
    2. B. Respiratory arrest
    3. C. QT prolongation
    4. D. Hypertensive crisis
    Show answer

    Answer: C. QT prolongation

    Monitor ECG; still used at low doses (2.5–5 mg).

31. Ketamine for hyperactive delirium with severe agitation is dosed:

    1. A. 100 mg IV as a fixed adult dose
    2. B. 4–5 mg/kg IM (or 1–2 mg/kg IV)
    3. C. 10 mg/kg IM (or 5 mg/kg IV)
    4. D. 0.5 mg/kg IM (or 0.1 mg/kg IV)
    Show answer

    Answer: B. 4–5 mg/kg IM (or 1–2 mg/kg IV)

    The dissociative dose for severe agitation is about 4 to 5 mg/kg IM or 1 to 2 mg/kg IV, with monitoring for laryngospasm, emergence reactions, and hypersalivation; some systems now use lower doses to reduce intubation. A fixed 100-mg dose ignores weight. 10 mg/kg IM is about double the dose. 0.5 mg/kg IM is closer to an analgesic dose and will not control severe agitation.

32. Fosphenytoin is ordered as 20 mg PE/kg. What does 'PE' mean?

    1. A. Phenytoin sodium equivalents
    2. B. Per each kilogram of body weight
    3. C. Pediatric emergency dose
    4. D. Pre-hospital emergency units
    Show answer

    Answer: A. Phenytoin sodium equivalents

    Fosphenytoin is labeled and dosed in phenytoin sodium equivalents (PE) to avoid conversion errors between the two drugs; dosing errors from confusing mg and mg PE have caused overdoses. PE does not mean per kilogram, pediatric, or prehospital.

33. Olanzapine for agitation is given:

    1. A. 25 mg rectal suppository
    2. B. 50–100 mg IM or ODT
    3. C. 0.5–1 mg IV only
    4. D. 5–10 mg IM or ODT
    Show answer

    Answer: D. 5–10 mg IM or ODT

    Avoid combining IM olanzapine with benzodiazepines due to respiratory depression risk. ODT is an orally disintegrating tablet.

34. Midazolam for agitation (adult) is:

    1. A. 0.5 mg/kg IV/IM titrated
    2. B. 0.5 mg IV, single dose
    3. C. 2–5 mg IV/IM titrated
    4. D. 20 mg IV/IM at once
    Show answer

    Answer: C. 2–5 mg IV/IM titrated

    Benzodiazepines are preferred in stimulant intoxication and alcohol withdrawal.

35. Neuroleptic malignant syndrome presents with:

    1. A. Hypothermia, flaccidity, and bradycardia
    2. B. Fever, rigidity, confusion, and autonomic instability
    3. C. Clonus, hyperreflexia, diarrhea, and shivering after SSRIs
    4. D. Pinpoint pupils, bradypnea, and hypotension
    Show answer

    Answer: B. Fever, rigidity, confusion, and autonomic instability

    Supportive care, cooling, and benzodiazepines; dantrolene in hospital. It follows antipsychotic use.

36. Flumazenil reversed procedural midazolam oversedation in a benzodiazepine-naive patient. What must you watch for next?

    1. A. Re-sedation as flumazenil wears off
    2. B. An allergic reaction to midazolam
    3. C. Rebound high BP from the midazolam
    4. D. Opioid withdrawal caused by flumazenil
    Show answer

    Answer: A. Re-sedation as flumazenil wears off

    Flumazenil's effect lasts about an hour, often shorter than the benzodiazepine, so re-sedation and respiratory depression can return; monitor and redose as directed. Rebound hypertension is not expected. Flumazenil does not act on opioid receptors. Nothing suggests allergy.

37. Flumazenil dose when used is:

    1. A. 10 mg IV as a single push
    2. B. 0.02 mg IV, given as a single dose
    3. C. 2 mg IV, repeated to max 10 mg
    4. D. 0.2 mg IV, repeated to max 1 mg
    Show answer

    Answer: D. 0.2 mg IV, repeated to max 1 mg

    Titrated in 0.2-mg increments.

38. Ketamine for pain (sub-dissociative) is dosed at:

    1. A. 4–5 mg/kg IV slowly
    2. B. 0.01–0.03 mg/kg IV slowly
    3. C. 1–2 mg/kg IV slowly
    4. D. 0.1–0.3 mg/kg IV slowly
    Show answer

    Answer: D. 0.1–0.3 mg/kg IV slowly

    Low-dose ketamine provides analgesia without dissociation. The IN dose is 0.5 to 1 mg/kg.

39. After a fentanyl overdose reversed with naloxone, a patient in an EMS buprenorphine program wants buprenorphine now, before any withdrawal. Why is waiting needed?

    1. A. It fully reverses the naloxone
    2. B. It causes immediate respiratory arrest
    3. C. It can precipitate sudden withdrawal
    4. D. Buprenorphine is too weak to help
    Show answer

    Answer: C. It can precipitate sudden withdrawal

    Buprenorphine is a high-affinity partial agonist; given while full agonists still occupy the receptors, it displaces them and causes precipitated withdrawal, so programs wait for objective withdrawal (for example, a COWS score of about 8 or more). It is effective, does not reverse naloxone, and has a ceiling on respiratory depression.

40. Etomidate for RSI induction is dosed at:

    1. A. 30 mg IV for all
    2. B. 3 mg/kg IV
    3. C. 0.03 mg/kg IV
    4. D. 0.3 mg/kg IV
    Show answer

    Answer: D. 0.3 mg/kg IV

    Etomidate is hemodynamically neutral; causes transient adrenal suppression.

41. Ketamine for RSI induction is dosed at:

    1. A. 0.5 mg/kg IM
    2. B. 1–2 mg/kg IV
    3. C. 5 mg/kg IV
    4. D. 0.1 mg/kg
    Show answer

    Answer: B. 1–2 mg/kg IV

    Ketamine is preferred in hypotensive or bronchospastic patients.

42. Succinylcholine RSI dose is:

    1. A. 0.1–0.5 mg/kg IV
    2. B. 3–4 mg/kg IV
    3. C. 1–1.5 mg/kg IV
    4. D. 0.5 mg/kg IV
    Show answer

    Answer: C. 1–1.5 mg/kg IV

    Onset 45–60 seconds, duration 5–10 minutes. Actual body weight is used.

43. Rocuronium RSI dose is:

    1. A. 0.1 mg/kg IV
    2. B. 4–5 mg/kg IV
    3. C. 1–1.2 mg/kg IV
    4. D. 0.01–0.1 mg/kg IV
    Show answer

    Answer: C. 1–1.2 mg/kg IV

    Onset ~60 seconds at this dose; duration 30–60 minutes — a plan for failed airway is essential.

44. Minutes after succinylcholine for RSI, a patient has jaw rigidity, a rapidly rising ETCO2 despite more ventilation, tachycardia, and a climbing temperature. What is the most likely cause?

    1. A. Malignant hyperthermia; give dantrolene
    2. B. Serotonin syndrome from the induction drug
    3. C. Bronchospasm; give nebulized albuterol
    4. D. Hypoglycemia; give D10 IV
    Show answer

    Answer: A. Malignant hyperthermia; give dantrolene

    Masseter rigidity, an unexplained rising ETCO2, tachycardia, and hyperthermia after succinylcholine suggest malignant hyperthermia; treatment is stopping triggers, giving dantrolene, cooling, and treating hyperkalemia. Serotonin syndrome is caused by serotonergic drugs, not RSI drugs. Bronchospasm and hypoglycemia do not cause rigidity and a rising temperature.

45. Post-intubation sedation options include:

    1. A. Atropine alone to prevent bradycardia
    2. B. Ongoing sedation and analgesia per protocol
    3. C. Naloxone to prevent post-intubation respiratory depression
    4. D. No sedation once the paralytic is given
    Show answer

    Answer: B. Ongoing sedation and analgesia per protocol

    Paralyzed patients must be sedated and analgesed. Options include midazolam/fentanyl, ketamine, or a propofol infusion.

46. Tranexamic acid (TXA) for traumatic hemorrhage is given:

    1. A. 1 g IV over 10 min within 3 hours of injury
    2. B. 1 g IV push any time within 24 hours
    3. C. 1 mg/kg IM within 6 hours of injury
    4. D. 10 mg IV over 10 min within 3 hours of injury
    Show answer

    Answer: A. 1 g IV over 10 min within 3 hours of injury

    TXA is an antifibrinolytic; benefit diminishes after 3 hours. It is followed by a 1-g infusion.

47. A patient with sudden aphasia takes apixaban. Why is it important to record the time of her last dose?

    1. A. Recent use may rule out thrombolytics
    2. B. It sets her prehospital BP target
    3. C. It sets the oxygen flow she needs
    4. D. It predicts how large the stroke will become
    Show answer

    Answer: A. Recent use may rule out thrombolytics

    Recent direct oral anticoagulant use (generally within 48 hours) can exclude IV thrombolysis, so the drug, dose, and last-dose time help the stroke team choose between thrombolysis and thrombectomy. It does not set the field BP target or oxygen flow, and it does not predict stroke size.

48. Hypertension in acute ischemic stroke is treated prehospital:

    1. A. Aggressively, to a target below 140/90
    2. B. Generally not treated unless above 220/120
    3. C. With sublingual nitroglycerin every 5 min
    4. D. With IV metoprolol to a heart rate under 60
    Show answer

    Answer: B. Generally not treated unless above 220/120

    Permissive hypertension is standard before thrombolysis decisions. Perfusion of the penumbra depends on BP; treat only per medical control.

49. A heavy drinker who stopped drinking 18 hours ago has a brief generalized seizure and is now postictal. Which explanation is most likely?

    1. A. Withdrawal seizures occur after 7 days
    2. B. Alcohol toxicity is the cause of seizures
    3. C. Thiamine deficiency is causing the seizure
    4. D. Withdrawal seizures peak at 6 to 48 hours
    Show answer

    Answer: D. Withdrawal seizures peak at 6 to 48 hours

    Alcohol withdrawal seizures typically occur 6 to 48 hours after the last drink, often before delirium tremens, and are treated with benzodiazepines. Seizures a week later suggest another cause. Withdrawal, not intoxication, is the likely cause here. Thiamine deficiency causes Wernicke encephalopathy, not withdrawal seizures.

50. A 30-kg child has been seizing for 7 minutes and has no IV access. Using RAMPART-based dosing, what IM midazolam dose is appropriate?

    1. A. 0.5 mg IM
    2. B. 5 mg IM
    3. C. 10 mg IM
    4. D. 30 mg IM
    Show answer

    Answer: B. 5 mg IM

    RAMPART-based dosing uses 5 mg IM for patients 13 to 40 kg and 10 mg IM for those over 40 kg.

51. A 22-kg child is seizing with an IV in place. Protocol calls for midazolam 0.1 mg/kg IV, maximum 5 mg. What dose is given?

    1. A. 22 mg IV
    2. B. 0.22 mg IV
    3. C. 2.2 mg IV
    4. D. 5 mg IV
    Show answer

    Answer: C. 2.2 mg IV

    0.1 mg/kg x 22 kg = 2.2 mg, which is below the 5-mg maximum. 22 mg and 0.22 mg are tenfold errors. 5 mg is the maximum single dose, not this child's weight-based dose.

52. A 25-kg child is in status epilepticus with an IV in place. What lorazepam dose is appropriate?

    1. A. 25 mg IV (1 mg/kg)
    2. B. 10 mg IV (0.4 mg/kg)
    3. C. 0.25 mg IV (0.01 mg/kg)
    4. D. 2.5 mg IV (0.1 mg/kg)
    Show answer

    Answer: D. 2.5 mg IV (0.1 mg/kg)

    Lorazepam for status epilepticus is 0.1 mg/kg IV with a maximum single dose of 4 mg.

53. A 3-year-old weighing 14 kg is seizing, and the parents have rectal diazepam gel. Using 0.5 mg/kg for this age group, what dose is appropriate?

    1. A. 14 mg rectally
    2. B. 7 mg rectally
    3. C. 0.7 mg rectally
    4. D. 70 mg rectally
    Show answer

    Answer: B. 7 mg rectally

    Rectal diazepam for ages 2 to 5 years is dosed at 0.5 mg/kg.

54. An adult continues to seize after two appropriately dosed benzodiazepine doses. Per many protocols, what is the next step?

    1. A. Consult medical control for a second-line agent
    2. B. Keep giving midazolam every 5 minutes with no maximum
    3. C. Give a third benzodiazepine dose IM instead
    4. D. Give IV dextrose without checking the glucose
    Show answer

    Answer: A. Consult medical control for a second-line agent

    Seizures persisting after two benzodiazepine doses are established status epilepticus and need a second-line antiseizure drug and airway readiness. A second-line agent such as levetiracetam is commonly used. A third benzodiazepine dose adds respiratory depression with little added effect, and glucose is checked and treated if low rather than given blindly.

55. After 10 mg of IM midazolam, a patient's seizure stops, but the respiratory rate falls to 6/min with an SpO2 of 86%. What is the priority?

    1. A. Support ventilation with a bag-valve mask
    2. B. Place in recovery position and recheck in 10 minutes
    3. C. Give another midazolam dose to prevent recurrence
    4. D. Give flumazenil 0.2 mg IV immediately
    Show answer

    Answer: A. Support ventilation with a bag-valve mask

    Benzodiazepine respiratory depression is managed with ventilatory support; flumazenil can precipitate refractory seizures.

56. A patient who is 32 weeks pregnant with a BP of 172/112 has a tonic-clonic seizure. What is the most appropriate drug?

    1. A. Magnesium sulfate 1 g IV push over 30 seconds
    2. B. Magnesium sulfate 4 to 6 g IV over 15 to 20 minutes
    3. C. Phenytoin 20 mg/kg IV as the first-line drug
    4. D. Labetalol 20 mg IV push as the sole therapy
    Show answer

    Answer: B. Magnesium sulfate 4 to 6 g IV over 15 to 20 minutes

    Magnesium is the drug of choice for eclamptic seizures, given as a loading dose over 15 to 20 minutes.

57. During a magnesium infusion for preeclampsia, the patient's patellar reflexes disappear and the respiratory rate drops to 8/min. What should be done?

    1. A. Give naloxone to reverse the respiratory drop
    2. B. Slow the infusion by half and reassess
    3. C. Stop the infusion and recheck in an hour
    4. D. Stop the infusion and give calcium gluconate
    Show answer

    Answer: D. Stop the infusion and give calcium gluconate

    Loss of deep tendon reflexes and respiratory depression signal magnesium toxicity; calcium is the antidote. Slowing the infusion or stopping it without the antidote leaves dangerous toxicity untreated, and naloxone does not reverse magnesium.

58. A 68-kg unresponsive diabetic has a glucose of 32 mg/dL and a working IV. Per many protocols, which D10 dose is appropriate?

    1. A. 100 mL (10 g) IV, recheck, and repeat as needed
    2. B. 500 mL (50 g) as a rapid bolus
    3. C. 50 mL (5 g) IV, then wait 30 minutes before rechecking
    4. D. 10 mL (1 g) IV as a single dose only
    Show answer

    Answer: A. 100 mL (10 g) IV, recheck, and repeat as needed

    D10 is commonly given in 100-mL (10-g) increments up to 250 mL (25 g), titrated to mental status and glucose. Fifty grams at once overshoots and adds needless volume, and 5 g followed by a 30-minute wait undertreats an unresponsive patient and delays the recheck.

59. A toddler who may have swallowed a grandparent's propranolol is lethargic with a heart rate of 70. Which check is especially important?

    1. A. Core temperature
    2. B. Pupil size and reaction
    3. C. Blood glucose
    4. D. Hourly urine output
    Show answer

    Answer: C. Blood glucose

    Beta-blocker poisoning in young children commonly causes hypoglycemia (and seizures) along with bradycardia and hypotension, so check the glucose early and treat with dextrose. Temperature, pupils, and urine output matter less for immediate treatment.

60. A 3.5-kg newborn has symptomatic hypoglycemia with a glucose of 30 mg/dL. Using 2 mL/kg, what D10 dose is appropriate?

    1. A. 35 mL IV
    2. B. 0.7 mL IV
    3. C. 7 mL IV
    4. D. 70 mL IV
    Show answer

    Answer: C. 7 mL IV

    Neonatal hypoglycemia is treated with D10 at 2 mL/kg (0.2 g/kg); concentrated dextrose is avoided.

61. A 15-kg child is hypoglycemic and unresponsive, and no IV can be obtained. What glucagon dose is appropriate?

    1. A. 0.5 mg IM
    2. B. 0.05 mg IM
    3. C. 1 mg IM
    4. D. 5 mg IM
    Show answer

    Answer: A. 0.5 mg IM

    Children under about 20 to 25 kg commonly receive 0.5 mg glucagon; larger children and adults receive 1 mg.

62. A hypoglycemic patient wakes up after IM glucagon. Which side effect should you anticipate?

    1. A. Profound hypotension
    2. B. Nausea and vomiting
    3. C. Severe bradycardia
    4. D. Hypothermia
    Show answer

    Answer: B. Nausea and vomiting

    Nausea and vomiting are common after glucagon, so airway protection and positioning matter.

63. A family member gave a hypoglycemic patient a dose of intranasal glucagon (Baqsimi) before you arrived. The dose in that device is:

    1. A. 10 mg
    2. B. 3 mg
    3. C. 1 mg
    4. D. 0.3 mg
    Show answer

    Answer: B. 3 mg

    Intranasal glucagon is supplied as a single 3-mg dose; no inhalation is required.

64. A patient on glipizide was hypoglycemic, woke after D10, and now has a glucose of 110 mg/dL. He wants to refuse transport. What is the key concern?

    1. A. The D10 protects him for about 6 hours
    2. B. A snack fully prevents a relapse
    3. C. Glipizide has fully worn off by now
    4. D. Hypoglycemia may recur for hours
    Show answer

    Answer: D. Hypoglycemia may recur for hours

    Sulfonylureas such as glipizide and glyburide act for many hours, so hypoglycemia can recur after dextrose wears off; transport and observation are strongly advised, and many protocols do not allow treat-and-release. Glipizide has not worn off, dextrose lasts minutes to an hour rather than 6 hours, and a single snack does not reliably prevent recurrence.

65. A malnourished patient with chronic alcohol use is confused and ataxic with nystagmus and a glucose of 50 mg/dL. What is the best management?

    1. A. Give glucagon first because alcohol increases glycogen
    2. B. Give dextrose alone; thiamine has no role in this case
    3. C. Give thiamine with dextrose without delaying the dextrose
    4. D. Withhold dextrose until thiamine has fully absorbed
    Show answer

    Answer: C. Give thiamine with dextrose without delaying the dextrose

    Thiamine 100 mg helps prevent or treat Wernicke encephalopathy, but hypoglycemia must still be corrected promptly.

66. A patient has sudden left-sided weakness and slurred speech, and the glucose is 38 mg/dL. What is the most appropriate action?

    1. A. Give dextrose and reassess; hypoglycemia can mimic stroke
    2. B. Transport without treatment to a stroke center
    3. C. Give aspirin 324 mg before correcting the glucose
    4. D. Withhold dextrose because it worsens stroke outcomes
    Show answer

    Answer: A. Give dextrose and reassess; hypoglycemia can mimic stroke

    Hypoglycemia is a common stroke mimic and must be corrected; deficits often resolve with dextrose.

67. An 80-year-old with Parkinson disease is acutely agitated. Which drug is particularly likely to worsen the rigidity?

    1. A. Haloperidol
    2. B. Supplemental oxygen
    3. C. Low-dose ketamine
    4. D. Low-dose lorazepam
    Show answer

    Answer: A. Haloperidol

    Dopamine-blocking antipsychotics such as haloperidol worsen parkinsonism and are generally avoided in these patients.

68. An agitated patient on high-dose methadone has a known prolonged QTc. Which sedative should be avoided?

    1. A. Lorazepam 2 mg IM
    2. B. Midazolam 5 mg IM
    3. C. Haloperidol 5 mg IM
    4. D. Ketamine IM per protocol
    Show answer

    Answer: C. Haloperidol 5 mg IM

    Butyrophenones such as haloperidol and droperidol prolong the QT interval and, added to methadone's QT effect, can precipitate torsades de pointes. Lorazepam and midazolam do not prolong the QT and are reasonable with airway monitoring. Ketamine does not prolong the QT and is an option per protocol.

69. A 19-year-old who received prochlorperazine for vomiting now has the neck twisted to one side and eyes deviated upward. What is the treatment?

    1. A. Midazolam 10 mg IM to relax the spasms
    2. B. Haloperidol 5 mg IM, repeated
    3. C. Diphenhydramine 25 to 50 mg IV or IM
    4. D. Naloxone 2 mg IV, then observe
    Show answer

    Answer: C. Diphenhydramine 25 to 50 mg IV or IM

    This is an acute dystonic reaction to a dopamine-blocking antiemetic; it responds within minutes to diphenhydramine (or benztropine). Midazolam may calm the patient but does not reverse the dopamine blockade. Haloperidol is another dopamine blocker and would worsen it. Naloxone has no role because no opioid is involved.

70. After IM ketamine is given for severe agitation, which monitoring is required?

    1. A. Blood pressure once at the hospital
    2. B. Continuous SpO2, ETCO2, and cardiac monitoring
    3. C. None, because ketamine preserves breathing
    4. D. Pupil checks every 30 minutes only
    Show answer

    Answer: B. Continuous SpO2, ETCO2, and cardiac monitoring

    Ketamine can cause laryngospasm, apnea, and hypersalivation, especially at high doses or combined with benzodiazepines.

71. Shortly after ketamine, a patient develops stridor, falling SpO2, and no air movement. What is the most likely problem and response?

    1. A. Bronchospasm; nebulized albuterol 2.5 mg
    2. B. Opioid effect; naloxone 2 mg IN immediately
    3. C. Anaphylaxis; IM epinephrine and diphenhydramine
    4. D. Laryngospasm; jaw thrust and positive-pressure ventilation
    Show answer

    Answer: D. Laryngospasm; jaw thrust and positive-pressure ventilation

    Laryngospasm is a known ketamine complication; most cases resolve with airway positioning and positive pressure, and refractory cases may need paralysis.

72. While recovering from ketamine, a patient is frightened and describes vivid hallucinations. This most likely represents:

    1. A. A new psychotic disorder
    2. B. An emergence reaction
    3. C. Ketamine-induced stroke
    4. D. Serotonin syndrome
    Show answer

    Answer: B. An emergence reaction

    Emergence reactions are managed with a calm, low-stimulus environment and, if needed, a small benzodiazepine dose.

73. A patient who received ketamine has copious oral secretions. What is the most appropriate response?

    1. A. Intubate all patients who develop secretions
    2. B. Suction as needed; hypersalivation is an expected effect
    3. C. Turn the sedated patient prone so the secretions can drain out
    4. D. Give naloxone to reverse the ketamine immediately
    Show answer

    Answer: B. Suction as needed; hypersalivation is an expected effect

    Ketamine stimulates salivary and bronchial secretions; suctioning usually suffices, and some protocols allow an antisialagogue. Prone positioning of a sedated patient risks positional asphyxia, and naloxone does not reverse ketamine.

74. A patient on methamphetamine is violently agitated with a temperature of 40.5 C (105 F). Which approach is most appropriate?

    1. A. Prolonged physical restraint without sedation
    2. B. Rapid chemical sedation, active cooling, and no prone restraint
    3. C. Haloperidol alone, then transport without monitoring
    4. D. Hobble restraint in the prone position for transport
    Show answer

    Answer: B. Rapid chemical sedation, active cooling, and no prone restraint

    Hyperactive delirium with hyperthermia carries a high risk of sudden death; rapid sedation, cooling, and close monitoring are key.

75. A patient is unresponsive with pinpoint pupils and a respiratory rate of 4/min. After BVM ventilation is started, how should IV naloxone be given?

    1. A. In small titrated doses (e.g., 0.4 mg) until breathing is adequate
    2. B. As a 10-mg bolus to ensure complete reversal
    3. C. Withheld until a toxicology screen confirms opioids
    4. D. Only after the patient has been intubated
    Show answer

    Answer: A. In small titrated doses (e.g., 0.4 mg) until breathing is adequate

    The goal is adequate ventilation, not full arousal; titration reduces the risk of precipitated withdrawal and vomiting.

76. A 12-kg toddler who ingested methadone is breathing 4/min. The only naloxone available is a 4-mg nasal spray. What is appropriate?

    1. A. Withhold it; 4 mg is an adult dose
    2. B. Give one-tenth of the spray
    3. C. Wait for an IV to give 0.4 mg
    4. D. Ventilate and give the 4-mg spray
    Show answer

    Answer: D. Ventilate and give the 4-mg spray

    Ventilate first, and give the 4-mg naloxone nasal spray, which is labeled for patients of all ages; children are not opioid-dependent, so larger doses are safe. Withholding or waiting for IV access delays reversal. A nasal spray cannot be split into fractions.

77. A patient with a vagus nerve stimulator (VNS) is having a seizure, and the family hands you the device magnet. How is it used?

    1. A. Swipe it over the generator
    2. B. Hold it over the generator for 10 minutes
    3. C. Swipe it along the left side of the neck
    4. D. Put it under the tongue briefly
    Show answer

    Answer: A. Swipe it over the generator

    Swiping the VNS magnet over the generator (usually in the left upper chest) triggers an extra burst of stimulation that may shorten the seizure; if it continues, standard benzodiazepine treatment follows. Holding the magnet in place over the generator suspends stimulation rather than triggering it, swiping it over the neck lead does nothing, and it is not used in the mouth.

78. A patient has respiratory depression after a buprenorphine overdose. Compared with other opioids, naloxone reversal may require:

    1. A. Flumazenil in place of naloxone for reversal
    2. B. No naloxone because buprenorphine cannot overdose
    3. C. Lower doses because buprenorphine binds weakly
    4. D. Higher or repeated doses because of tight receptor binding
    Show answer

    Answer: D. Higher or repeated doses because of tight receptor binding

    Buprenorphine binds mu receptors with high affinity, so larger or repeated naloxone doses and ventilatory support may be needed.

79. An unresponsive patient on long-term alprazolam may also have ingested a tricyclic antidepressant. Your partner wants to give flumazenil. The best response is:

    1. A. Give it at double the usual dose
    2. B. Give it; it reverses both drug types
    3. C. Avoid it; it may precipitate seizures
    4. D. Give it with naloxone for synergy
    Show answer

    Answer: C. Avoid it; it may precipitate seizures

    Flumazenil can trigger withdrawal seizures in benzodiazepine-dependent patients and unmask seizures from proconvulsant co-ingestants.

80. A 2-year-old had a 2-minute febrile seizure and is now postictal and improving. What medication is indicated?

    1. A. Diazepam 0.5 mg/kg rectally right away
    2. B. Midazolam 0.2 mg/kg IN to prevent recurrence
    3. C. No benzodiazepine; provide supportive care
    4. D. Lorazepam 0.1 mg/kg IV before transport
    Show answer

    Answer: C. No benzodiazepine; provide supportive care

    Benzodiazepines are for active or prolonged seizures, not for a seizure that has already stopped.

81. A patient with chronic heavy alcohol use is tremulous, tachycardic, and hallucinating two days after his last drink. Which drug class is first-line?

    1. A. Opioids
    2. B. Antipsychotics
    3. C. Benzodiazepines
    4. D. Beta blockers
    Show answer

    Answer: C. Benzodiazepines

    Severe alcohol withdrawal and delirium tremens are treated with benzodiazepines, which act on the same GABA receptors as alcohol.