Physical Disabilities and Neuromuscular Conditions: Cerebral Palsy, Spina Bifida, Muscular Dystrophy, MS, Myasthenia Gravis, and Paralysis Practice Questions

25 multiple-choice questions on Physical disabilities and neuromuscular conditions: cerebral palsy, spina bifida, muscular dystrophy, MS, myasthenia gravis, and paralysis 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. A 30-year-old woman with spastic quadriplegic cerebral palsy who does not speak cries and grimaces whenever her caregiver moves her left thigh. There was no fall. You should suspect:

   1. A. Normal muscle spasm from her CP
   2. B. Behavior seeking attention from staff
   3. C. A fracture from fragile, thin bones
   4. D. A new stroke on the right side
   Show answer

   Answer: C. A fracture from fragile, thin bones

   People with nonambulatory cerebral palsy often have low bone density (from immobility, antiseizure drugs, and poor nutrition) and can fracture a femur during routine transfers or positioning; pain behavior on movement is the clue. Splint in a position of comfort and transport. Spasms occur in CP, but new, localized pain with movement should be treated as an injury. Calling it attention-seeking is diagnostic overshadowing. A stroke does not cause pain when a limb is moved. (Henderson, Pediatrics 2002; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

2. The most common type of cerebral palsy is:

   1. A. Athetoid
   2. B. Ataxic
   3. C. Spastic
   4. D. Flaccid
   Show answer

   Answer: C. Spastic

   Spastic CP, with stiff, tight muscles and exaggerated reflexes, accounts for most cases. Athetoid (dyskinetic) CP causes slow, writhing involuntary movements, and ataxic CP affects balance and coordination.

3. A 24-year-old woman with spastic cerebral palsy has a possible hip fracture. Her legs are tightly flexed and scissored. When packaging her, you should:

   1. A. Straighten her legs to fit the long backboard
   2. B. Strap her legs together tightly to stop movement
   3. C. Use a traction splint on both legs together
   4. D. Pad her limbs in their position of comfort
   Show answer

   Answer: D. Pad her limbs in their position of comfort

   Contractures cannot be forced straight without causing pain or fractures, so pad and support the limbs as you find them, using a vacuum mattress or pillows. Traction splints do not suit a contracted limb with a suspected hip fracture.

4. Which statement about intelligence in people with cerebral palsy is correct?

   1. A. Many have normal intelligence
   2. B. Most have a severe intellectual disability
   3. C. Intelligence declines over the years
   4. D. Intelligence cannot be tested in CP
   Show answer

   Answer: A. Many have normal intelligence

   Although some people with CP have intellectual disability, many have normal intelligence; difficulty speaking (dysarthria) is not a sign of poor understanding. Speak to the patient directly rather than over him.

5. Patients with cerebral palsy have an increased risk of which complication during illness?

   1. A. Hyperthermia from high muscle tone
   2. B. Aspiration from poor swallowing
   3. C. Bleeding from fragile blood vessels
   4. D. Kidney stones from dehydration
   Show answer

   Answer: B. Aspiration from poor swallowing

   Oral-motor dysfunction and reflux make aspiration pneumonia a leading cause of illness and death in CP; keep suction ready and position the patient upright or on the side. Seizures are also common in CP.

6. Spina bifida is a defect in which the:

   1. A. Spinal cord is damaged by a birth-related injury
   2. B. Brain's ventricles enlarge after a fetal infection
   3. C. Vertebrae fuse together during early childhood
   4. D. Spinal column does not close during development
   Show answer

   Answer: D. Spinal column does not close during development

   Spina bifida is a neural tube defect in which the vertebral arches fail to close; in myelomeningocele, the most severe form, the cord and meninges protrude, causing paralysis below the lesion. A birth-related brain injury describes cerebral palsy.

7. A 58-year-old man with an above-knee amputation fell while wearing his prosthesis. He has pain where the socket meets his residual limb. You should:

   1. A. Tighten the socket straps to splint the limb
   2. B. Remove the prosthesis and examine the limb
   3. C. Examine his intact leg instead
   4. D. Ask him to walk to test weight bearing
   Show answer

   Answer: B. Remove the prosthesis and examine the limb

   A prosthesis hides the residual limb, where a fall can cause fractures, skin tears, or bleeding; let him guide you in removing it, inspect and splint the limb, and bring the prosthesis to the hospital. Tightening the socket compresses an injured limb and hides worsening swelling. The intact leg needs assessment too, but it is not where his pain is. Walking on a possible fracture risks more injury. (Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter; Amputee Coalition.)

8. Many adults with spina bifida have a ventriculoperitoneal shunt because of:

   1. A. Chronic seizures
   2. B. Recurrent meningitis
   3. C. Hydrocephalus
   4. D. Spinal cord compression
   Show answer

   Answer: C. Hydrocephalus

   Hydrocephalus accompanies most myelomeningoceles, and a VP shunt drains excess CSF into the abdomen. Seizures may occur but are not treated with a shunt.

9. A 24-year-old man with Duchenne muscular dystrophy has new orthopnea, leg swelling, and a rapid, irregular pulse. You should suspect:

   1. A. Cardiomyopathy with heart failure
   2. B. Pneumonia from aspiration
   3. C. Deep vein thrombosis in both legs
   4. D. An acute asthma exacerbation
   Show answer

   Answer: A. Cardiomyopathy with heart failure

   Nearly all people with Duchenne muscular dystrophy develop dilated cardiomyopathy by adulthood, and heart failure and arrhythmias are now a leading cause of death; treat the heart failure, monitor the rhythm, obtain a 12-lead, and give fluids cautiously. Aspiration pneumonia causes fever and cough, not orthopnea and edema. Bilateral DVT does not explain orthopnea or an irregular pulse. Asthma causes wheezing, and he has no such history. (Birnkrant, Lancet Neurol 2018; AHA 2017.)

10. A 22-year-old man with Duchenne muscular dystrophy has a cold and is now short of breath with a weak cough. The greatest concern is:

    1. A. An acute asthma attack with bronchospasm
    2. B. A pulmonary embolism from long immobility
    3. C. Hyperventilation caused by his anxiety
    4. D. Failure of his weak breathing muscles
    Show answer

    Answer: D. Failure of his weak breathing muscles

    Weak respiratory muscles and an ineffective cough cause rapid decline with minor infections; watch for rising ETCO2 and fatigue, and be ready to assist ventilations. Cardiomyopathy also develops and can worsen dyspnea.

11. A 38-year-old woman with multiple sclerosis has a sudden worsening of her old leg weakness along with fever and urinary frequency. A likely trigger is:

    1. A. Urinary tract infection
    2. B. Kidney stones from calcium
    3. C. Gallbladder inflammation
    4. D. Peptic ulcer disease
    Show answer

    Answer: A. Urinary tract infection

    Neurogenic bladder makes UTIs common in MS, and fever or infection can cause a pseudo-relapse in which old symptoms return. Treating the infection often brings the patient back to baseline, so do not assume every worsening is a new MS attack.

12. A 46-year-old woman with multiple sclerosis has sudden right facial droop, right arm weakness, and trouble speaking that began 40 minutes ago. You should:

    1. A. Assume it is an MS relapse needing no rush
    2. B. Cool her in case heat is worsening her MS
    3. C. Treat it as a possible acute stroke
    4. D. Give her usual MS medicine and observe
    Show answer

    Answer: C. Treat it as a possible acute stroke

    Sudden focal deficits with a clear onset time are a stroke until proven otherwise; MS does not protect against stroke, and MS relapses usually develop over hours to days. Do a stroke assessment, check glucose, and go to a stroke center within the treatment window. Assuming a relapse delays time-critical care. Heat-related worsening brings back old symptoms; it does not cause a sudden new facial droop. Her usual medicine does not treat stroke, and observing wastes time. (AHA/ASA 2019; National MS Society.)

13. Which group is most often affected by multiple sclerosis?

    1. A. Men older than 65 years of age
    2. B. Women between 20 and 40 years
    3. C. Infants younger than 2 years old
    4. D. Boys between 10 and 18 years
    Show answer

    Answer: B. Women between 20 and 40 years

    MS usually begins in young adults, and women are affected two to three times as often as men. Onset in childhood or late life is uncommon.

14. Which factor commonly triggers a myasthenic crisis?

    1. A. A respiratory infection
    2. B. A high-protein meal
    3. C. Regular mild exercise
    4. D. Exposure to cold weather
    Show answer

    Answer: A. A respiratory infection

    Infection, surgery, stress, and certain drugs (such as aminoglycosides, fluoroquinolones, and magnesium) can tip a patient with myasthenia gravis into crisis with respiratory failure. Cold tends to improve myasthenic weakness, whereas heat worsens it.

15. A patient with myasthenia gravis has weak speech, trouble swallowing secretions, and shallow breathing. The priority is to:

    1. A. Give oral fluids to help clear secretions
    2. B. Encourage her to rest and recheck later
    3. C. Support the airway and assist ventilation
    4. D. Have her walk to the ambulance
    Show answer

    Answer: C. Support the airway and assist ventilation

    This is myasthenic crisis, with weakness of the bulbar and respiratory muscles; suction, positioning, and early assisted ventilation may be needed. Oral fluids risk aspiration when she cannot swallow.

16. A 35-year-old man with C5 tetraplegia has a chest cold and cannot cough up thick secretions. A technique that can help him clear them is:

    1. A. Having him lie flat and hold his breath
    2. B. Giving him a cough suppressant to rest
    3. C. Encouraging him to cough harder
    4. D. Assisted cough with abdominal pressure
    Show answer

    Answer: D. Assisted cough with abdominal pressure

    Paralysis of the abdominal and intercostal muscles prevents an effective cough. In an assisted ('quad') cough, you push inward and upward below the ribs in time with his exhalation; avoid it after a meal or with abdominal injury, and suction and assist ventilation as needed. Lying flat and breath-holding worsens secretion clearance. A cough suppressant keeps secretions in. Urging him to cough harder fails because he cannot generate enough force, which is the problem. (Consortium for Spinal Cord Medicine.)

17. When transporting a patient with paraplegia, you should take extra care to:

    1. A. Keep the patient flat to protect the spine
    2. B. Pad pressure points and check the skin
    3. C. Rely on the patient to report sore spots
    4. D. Warm the legs with hot packs for comfort
    Show answer

    Answer: B. Pad pressure points and check the skin

    Without sensation, the patient cannot feel pressure or injury, so skin breaks down quickly over the sacrum, hips, and heels; pad well and look for injuries the patient may not feel. Hidden fractures and burns are easy to miss. Relying on the patient to report sore spots fails, because pain or pressure that is not felt cannot be reported, and hot packs on insensate legs can cause burns. A chronic, stable spinal injury does not require keeping the patient flat.

18. A 30-year-old woman with osteogenesis imperfecta slid out of her wheelchair onto the floor. She has mild thigh pain. When moving and assessing her, you should:

    1. A. Check range of motion by bending each joint fully
    2. B. Handle her gently, since her bones break easily
    3. C. Have her stand to see if the leg bears weight
    4. D. Use usual handling, since adults outgrow OI
    Show answer

    Answer: B. Handle her gently, since her bones break easily

    Osteogenesis imperfecta is a genetic disorder of collagen that makes bones fragile; fractures can occur with minor falls, normal handling, or even a tightly inflated BP cuff. Ask her and her caregivers how she is best moved, support limbs fully, avoid twisting, and pad well. Forced range-of-motion checks can cause new fractures. Fractures become less frequent after puberty, but the bones stay fragile in adults, and testing weight bearing on a painful thigh risks completing a fracture.

19. A 42-year-old man with paraplegia from a T10 injury has a swollen, warm left calf and thigh. He feels no pain in the leg. You should suspect:

    1. A. Normal dependent edema
    2. B. Spasticity from his injury
    3. C. A torn calf muscle
    4. D. Deep vein thrombosis
    Show answer

    Answer: D. Deep vein thrombosis

    Spinal cord injury causes venous stasis, and DVT is common; without sensation there is no pain, so one-sided swelling and warmth may be the only signs. Do not massage the leg, watch for signs of pulmonary embolism, and transport. Dependent edema is usually in both legs and is not warm. Spasticity does not cause swelling. A torn muscle needs an injury and usually bruises. (Consortium for Spinal Cord Medicine, VTE prevention.)

20. A 50-year-old man with C6 tetraplegia has had vomiting and a firm, distended abdomen since morning. He feels no abdominal pain. You should know that in chronic spinal cord injury, an acute abdomen:

    1. A. Causes the same pain as in other patients
    2. B. Cannot occur below the level of injury
    3. C. Can present without pain or tenderness
    4. D. Is unlikely without a fever over 39°C
    Show answer

    Answer: C. Can present without pain or tenderness

    Loss of visceral sensation means an acute abdomen may show only distension, vomiting, increased spasticity, autonomic dysreflexia, fever, or tachycardia, sometimes with vague shoulder pain; treat it as a possible surgical emergency. Pain is often absent rather than typical. The organs below the injury can still obstruct, perforate, or become inflamed. A high fever is not required, and its absence does not rule out a serious cause. (Bar-On 1995; Ebert 2012.)

21. A 40-year-old woman who uses a power wheelchair needs transport. The best way to move her from the wheelchair is to:

    1. A. Ask her how she prefers to be moved
    2. B. Lift her by the arms on a count of three
    3. C. Tilt the wheelchair back onto the stretcher
    4. D. Have her slide out without any assistance
    Show answer

    Answer: A. Ask her how she prefers to be moved

    People who use wheelchairs often know the safest transfer technique for their bodies, including where they lack strength or have pain. Lifting by the arms risks shoulder injury and falls.

22. Before leaving the scene with a patient who uses a power wheelchair, you should:

    1. A. Leave the wheelchair, because it will not be needed
    2. B. Load the power chair into the patient compartment
    3. C. Plan how the wheelchair will get to the hospital
    4. D. Send her charger and leave the chair behind
    Show answer

    Answer: C. Plan how the wheelchair will get to the hospital

    The wheelchair is the patient's mobility, and without it she may be stranded at the hospital. Power chairs are heavy and usually need separate transport arranged with family or a wheelchair van. A heavy power chair cannot be safely secured in the patient compartment, and sending the charger alone still leaves her without her mobility.

23. A 64-year-old man with advanced ALS uses home BiPAP most of the day. He is in mild respiratory distress, and you need to move him to the ambulance. You should:

    1. A. Take off the BiPAP mask until he is in the unit
    2. B. Switch him to a nasal cannula for transport
    3. C. Stop ventilation support to check his effort
    4. D. Keep his BiPAP on or bag him during the move
    Show answer

    Answer: D. Keep his BiPAP on or bag him during the move

    A patient who depends on noninvasive ventilation can decompensate within minutes without it, because his diaphragm is too weak; bring his device (on battery) and settings, or assist with a BVM, and respect his advance directives. Removing the mask for the move invites hypoventilation and arrest. A nasal cannula gives oxygen but no ventilation. Stopping support to test his effort is dangerous. (AAN practice parameter, ALS care.)

24. A 63-year-old man with advanced ALS is in respiratory distress. His wife shows you a valid advance directive declining intubation. You should:

    1. A. Give comfort care consistent with his directive
    2. B. Intubate him because the distress is reversible
    3. C. Ignore the directive until medical control agrees
    4. D. Withhold oxygen because he has declined care
    Show answer

    Answer: A. Give comfort care consistent with his directive

    A valid directive refusing intubation must be honored, but comfort measures such as oxygen, positioning, and suctioning are still provided. Declining intubation is not declining all care.

25. A 27-year-old man with spina bifida has fever and confusion. He self-catheterizes several times a day. A likely source of infection is:

    1. A. The middle ear
    2. B. The urinary tract
    3. C. The appendix
    4. D. The gallbladder
    Show answer

    Answer: B. The urinary tract

    Neurogenic bladder and intermittent catheterization make urinary tract infection and urosepsis very common in spina bifida. A shunt infection is the other key concern when fever comes with headache or altered mental status.