Opioids, Sedative-hypnotics, and Alcohol Practice Questions

25 multiple-choice questions on Opioids, sedative-hypnotics, and alcohol for paramedic and EMT students, from Chapter 28 (Toxicology). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A man who just injected a fentanyl product is apneic. Despite a good mask seal and positioning, the bag is very hard to squeeze. A cause linked to potent opioids is:

   1. A. An allergic bronchospasm from the drug
   2. B. Chest wall and vocal cord rigidity
   3. C. A tension pneumothorax on one side
   4. D. A foreign body lodged in the airway
   Show answer

   Answer: B. Chest wall and vocal cord rigidity

   Potent opioids such as fentanyl, especially given rapidly, can cause 'wooden chest': rigidity of the chest wall muscles and closure of the vocal cords that makes ventilation very hard. Naloxone usually relieves it, and paralysis may be needed if it does not. Allergic bronchospasm would usually come with hives or swelling. A tension pneumothorax needs trauma or a lung injury. A foreign body is possible but is not tied to the drug.

2. Some EMS systems now give buprenorphine to patients with opioid use disorder after naloxone has reversed an overdose. The main purpose is to:

   1. A. Re-sedate the patient for transport
   2. B. Ease withdrawal and link to treatment
   3. C. Reverse the remaining naloxone
   4. D. Treat pain caused by the naloxone dose
   Show answer

   Answer: B. Ease withdrawal and link to treatment

   Field buprenorphine relieves the withdrawal that naloxone causes and starts evidence-based treatment for opioid use disorder, which lowers the risk of death after discharge. It is not meant to sedate the patient, and as a partial agonist with a ceiling on respiratory depression it is safer than full agonists. It does not reverse naloxone in any meaningful sense, and naloxone does not cause pain that needs treatment.

3. A man who takes kratom powder every day has run out. He has yawning, sweating, a runny nose, and diarrhea. Kratom produces dependence because it acts mainly on:

   1. A. Mu-opioid receptors in the brain
   2. B. GABA receptors, like a benzodiazepine
   3. C. Cannabinoid receptors, like THC
   4. D. Nicotinic receptors, like tobacco
   Show answer

   Answer: A. Mu-opioid receptors in the brain

   Kratom's main alkaloids are partial agonists at mu-opioid receptors, so daily use leads to tolerance and an opioid-type withdrawal (yawning, rhinorrhea, sweating, diarrhea), and large doses can depress breathing. Benzodiazepine withdrawal causes tremor and seizures rather than rhinorrhea and yawning. Kratom is not a cannabinoid or a nicotinic drug.

4. A 35-year-old woman revived with naloxone wants to refuse transport. The main reason to encourage transport is that:

   1. A. Naloxone commonly causes delayed seizures
   2. B. She is likely to develop severe hypertension
   3. C. Naloxone causes liver injury after reversal
   4. D. Naloxone may wear off before the opioid does
   Show answer

   Answer: D. Naloxone may wear off before the opioid does

   Naloxone lasts 30 to 90 minutes, while many opioids such as methadone last much longer, so resedation and apnea can recur. Naloxone itself is very safe.

5. A patient with a long history of heroin use is given a large IV naloxone dose and immediately becomes agitated, vomits, and has piloerection. This is:

   1. A. An allergic reaction to naloxone
   2. B. Serotonin syndrome from the drug
   3. C. Acute opioid withdrawal
   4. D. A new stimulant coingestion
   Show answer

   Answer: C. Acute opioid withdrawal

   Rapid full reversal in a dependent patient precipitates withdrawal. Titrating small doses to breathing avoids this and the aspiration risk from vomiting.

6. Fentanyl and its analogs are especially dangerous because they:

   1. A. Cannot be reversed by any dose of naloxone
   2. B. Are very potent and may need repeat naloxone doses
   3. C. Are absorbed only by injection into a vein
   4. D. Cause seizures rather than respiratory depression
   Show answer

   Answer: B. Are very potent and may need repeat naloxone doses

   Tiny amounts cause apnea, and high-potency analogs can need several doses. Casual skin contact is unlikely to cause toxicity, but the drug is fully reversible with naloxone.

7. A patient who overdosed on a fentanyl mixture resumes breathing after naloxone but remains sedated with RR 14 and normal SpO2, and has a large necrotic wound on the forearm. The most likely adulterant is:

   1. A. Cocaine
   2. B. Ketamine
   3. C. Xylazine
   4. D. Scopolamine
   Show answer

   Answer: C. Xylazine

   Xylazine is a veterinary sedative mixed with fentanyl that does not respond to naloxone and causes severe skin wounds. Continue to support breathing, since naloxone still reverses the opioid.

8. An overdose of methadone is concerning because methadone:

   1. A. Has a long half-life and can prolong the QT
   2. B. Is too short acting to need any naloxone at all
   3. C. Causes dilated rather than pinpoint pupils
   4. D. Cannot be reversed by naloxone at any dose
   Show answer

   Answer: A. Has a long half-life and can prolong the QT

   Methadone can cause respiratory depression for more than 24 hours and torsades de pointes. Naloxone works but must be repeated or infused.

9. A 21-year-old at a club suddenly becomes unresponsive with RR 8 and HR 48, then abruptly wakes up combative 2 hours later. The most likely drug is:

   1. A. Cocaine
   2. B. LSD
   3. C. MDMA
   4. D. GHB
   Show answer

   Answer: D. GHB

   GHB causes rapid deep coma, bradycardia, and sudden awakening, often with agitation. It is also used in drug-facilitated sexual assault. Cocaine and MDMA cause stimulation.

10. Management of suspected GHB intoxication is mainly:

    1. A. Flumazenil given to reverse the sedation quickly
    2. B. Naloxone given in large repeated doses
    3. C. Airway and ventilation support until it wears off
    4. D. Physostigmine to restore consciousness
    Show answer

    Answer: C. Airway and ventilation support until it wears off

    GHB has no antidote, but it is short acting, so supportive airway care usually suffices. Flumazenil and naloxone do not reverse it.

11. Flumazenil is most appropriate in which situation?

    1. A. An unknown overdose in a chronic benzodiazepine user
    2. B. A mixed overdose of a benzodiazepine and a tricyclic
    3. C. A patient with a history of a seizure disorder
    4. D. Reversing midazolam in a nondependent patient
    Show answer

    Answer: D. Reversing midazolam in a nondependent patient

    Flumazenil can precipitate seizures in dependent patients and those with TCA coingestion. It is safest for known iatrogenic oversedation in a patient not on long-term benzodiazepines.

12. Barbiturate overdose differs from benzodiazepine overdose in that barbiturates:

    1. A. Cause more respiratory depression, hypotension
    2. B. Can be reversed reliably by giving flumazenil
    3. C. Rarely cause coma even in large doses
    4. D. Produce dilated pupils and heavy sweating
    Show answer

    Answer: A. Cause more respiratory depression, hypotension

    Barbiturates have a narrow safety margin and depress breathing and circulation. Flumazenil reverses benzodiazepines only.

13. Alcohol is classified as a:

    1. A. Central nervous system stimulant drug
    2. B. Central nervous system depressant
    3. C. Hallucinogen and psychedelic
    4. D. Cholinergic agent
    Show answer

    Answer: B. Central nervous system depressant

    Ethanol enhances GABA activity. Early disinhibition can look like stimulation, but the drug depresses the CNS and breathing at higher levels.

14. A malnourished alcoholic has a glucose of 38 mg/dL. Thiamine is not yet available in your unit. You should:

    1. A. Give dextrose without any delay
    2. B. Wait until thiamine can be given first
    3. C. Give oral fluids and recheck later
    4. D. Withhold sugar to avoid Wernicke
    Show answer

    Answer: A. Give dextrose without any delay

    Severe hypoglycemia injures the brain within minutes, so dextrose should never be delayed to wait for thiamine; give thiamine as soon as it is available. The risk that one dose of dextrose triggers Wernicke encephalopathy is small compared with the harm of untreated hypoglycemia. Oral fluids do not treat a glucose of 38, and withholding sugar is dangerous.

15. An intoxicated patient's blood glucose is 48 mg/dL. Alcohol contributes to hypoglycemia by:

    1. A. Increasing insulin release from the pancreas
    2. B. Impairing gluconeogenesis in the liver
    3. C. Blocking glucose absorption in the gut
    4. D. Raising cortisol and glucagon levels
    Show answer

    Answer: B. Impairing gluconeogenesis in the liver

    Ethanol metabolism uses up the cofactors the liver needs to make glucose, especially in malnourished patients and children. It does not stimulate insulin release.

16. A patient who appears simply drunk should still be carefully assessed because:

    1. A. Alcohol odor reliably confirms the cause of altered mentation
    2. B. Drunk patients cannot legally refuse medical care
    3. C. Alcohol always raises the blood glucose level
    4. D. Head injury, hypoglycemia, and coingestions mimic it
    Show answer

    Answer: D. Head injury, hypoglycemia, and coingestions mimic it

    Assuming intoxication causes missed subdural hematomas, hypoglycemia, and overdoses. Odor tells you alcohol was consumed, not that it explains the findings.

17. A 52-year-old heavy drinker stopped drinking 12 hours ago and has tremors, anxiety, sweating, and HR 112. He is alert and oriented. This is most consistent with:

    1. A. Delirium tremens
    2. B. Wernicke encephalopathy
    3. C. Minor alcohol withdrawal
    4. D. Alcoholic hallucinosis episode
    Show answer

    Answer: C. Minor alcohol withdrawal

    Tremor and autonomic hyperactivity within 6 to 24 hours with a clear sensorium is early withdrawal. Delirium tremens involves confusion and usually begins 48 to 96 hours after the last drink.

18. Alcohol withdrawal seizures most commonly occur:

    1. A. Within 30 minutes of the last drink
    2. B. Between 7 and 10 days after stopping
    3. C. Within 6 to 48 hours of the last drink
    4. D. Only after delirium tremens has resolved
    Show answer

    Answer: C. Within 6 to 48 hours of the last drink

    Withdrawal seizures are typically brief and generalized and occur early. A seizure outside this window or with focal features suggests another cause such as head trauma.

19. A patient who stopped drinking 3 days ago is disoriented, hallucinating, hyperthermic, and tachycardic at 150. The most likely diagnosis is:

    1. A. Alcoholic hallucinosis
    2. B. Minor alcohol withdrawal
    3. C. Wernicke encephalopathy
    4. D. Delirium tremens
    Show answer

    Answer: D. Delirium tremens

    DTs combine delirium with severe autonomic instability and carry significant mortality. Alcoholic hallucinosis features hallucinations with a clear sensorium and stable vital signs.

20. The prehospital drug of choice for severe alcohol withdrawal is:

    1. A. Haloperidol given intramuscularly for agitation
    2. B. A benzodiazepine, e.g., midazolam or diazepam
    3. C. Naloxone given intravenously
    4. D. Phenytoin given as a slow IV infusion
    Show answer

    Answer: B. A benzodiazepine, e.g., midazolam or diazepam

    Benzodiazepines replace the missing GABA effect and treat agitation and seizures. Haloperidol lowers the seizure threshold, and phenytoin does not prevent withdrawal seizures.

21. Disulfiram causes flushing, vomiting, and hypotension when the patient:

    1. A. Drinks alcohol while on the drug
    2. B. Stops taking the drug abruptly
    3. C. Takes it with an opioid painkiller
    4. D. Misses a dose by more than a day
    Show answer

    Answer: A. Drinks alcohol while on the drug

    Disulfiram blocks aldehyde dehydrogenase, so acetaldehyde builds up after drinking. Metronidazole can cause a similar reaction.

22. An intoxicated patient is vomiting and has a decreased level of consciousness. The most important intervention is to:

    1. A. Give oral fluids to dilute the alcohol
    2. B. Position to protect the airway and suction
    3. C. Have the patient walk to the ambulance
    4. D. Give activated charcoal to absorb the alcohol
    Show answer

    Answer: B. Position to protect the airway and suction

    Aspiration of vomit is a major cause of death in intoxication, so lateral positioning and suction are key. Charcoal does not bind alcohol and adds aspiration risk.

23. A patient on long-term oxycodone for cancer pain is drowsy with RR 6. When giving naloxone, you should:

    1. A. Titrate small doses to breathing to preserve analgesia
    2. B. Give a full 4 mg IV dose to reverse the opioid at once
    3. C. Withhold naloxone because they need the pain relief
    4. D. Give flumazenil because the drug is a sedative
    Show answer

    Answer: A. Titrate small doses to breathing to preserve analgesia

    Small titrated doses of naloxone restore ventilation while avoiding a severe pain crisis and withdrawal in a patient who depends on opioids for cancer pain. A full 4 mg IV dose given at once to reverse the opioid can cause abrupt withdrawal and uncontrolled pain. Withholding naloxone in a patient who is hypoventilating is not acceptable, even when they need pain relief. Giving flumazenil because the drug is a sedative is wrong: flumazenil reverses benzodiazepines, not opioids, and can cause seizures.

24. Signs of chronic alcohol abuse include:

    1. A. Pinpoint pupils and track marks
    2. B. Perforated nasal septum and weight loss
    3. C. Spider angiomas, jaundice, and ascites
    4. D. Cyanosis of the lips and clubbed fingers
    Show answer

    Answer: C. Spider angiomas, jaundice, and ascites

    These signs reflect liver cirrhosis from long-term drinking. A perforated septum suggests chronic cocaine snorting, and track marks suggest injection drug use.

25. An injection drug user with fever has cough, pleuritic chest pain, and several round lesions throughout both lungs on a chest x-ray. These most likely came from:

    1. A. Air entering the veins during use
    2. B. Left heart failure from the drug
    3. C. Talc crystals blocking the airways
    4. D. Tricuspid vegetations breaking off
    Show answer

    Answer: D. Tricuspid vegetations breaking off

    Endocarditis in people who inject drugs usually involves the tricuspid valve on the right side, so infected vegetations break off into the pulmonary arteries and cause septic pulmonary emboli with cough, pleuritic pain, and multiple lung lesions. Air in the veins causes a sudden air embolism, not scattered lesions with fever. Left heart failure causes pulmonary edema. Talc lodges in small blood vessels, not airways, and does not cause fever with round lesions.