Psychosis, Schizophrenia, Delirium, and Dementia Practice Questions

25 multiple-choice questions on Psychosis, schizophrenia, delirium, and dementia for paramedic and EMT students, from Chapter 29 (Psychiatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Psychosis is best described as:

   1. A. A severely depressed mood
   2. B. A sudden surge of intense fear
   3. C. A loss of contact with reality
   4. D. A fixed pattern of personality traits
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   Answer: C. A loss of contact with reality

   Psychosis includes hallucinations, delusions, and disorganized thinking. It can occur in schizophrenia, mood disorders, delirium, and intoxication; depression alone is not psychosis.

2. Which is a positive symptom of schizophrenia?

   1. A. Auditory hallucinations
   2. B. Flat affect
   3. C. Social withdrawal and isolation
   4. D. Poverty of speech
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   Answer: A. Auditory hallucinations

   Positive symptoms are added experiences such as hallucinations and delusions. Flat affect is a negative symptom, an absence of normal function.

3. Which is a negative symptom of schizophrenia?

   1. A. Persistent paranoid delusions
   2. B. Lack of motivation (avolition)
   3. C. Disorganized, illogical speech
   4. D. Command auditory hallucinations
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   Answer: B. Lack of motivation (avolition)

   Negative symptoms include avolition, alogia, flat affect, and social withdrawal. Disorganized speech is grouped with the positive or disorganized symptoms.

4. Schizophrenia most often first appears in:

   1. A. Early childhood before school age
   2. B. Middle age, around 45 to 55 years old
   3. C. Late adolescence or early adulthood
   4. D. Late adulthood after age 70
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   Answer: C. Late adolescence or early adulthood

   Onset is typically in the late teens to early 30s, somewhat earlier in men. New psychosis after age 45 should prompt a search for medical causes such as dementia or tumor.

5. A man believes the TV news anchors are sending him private messages. This is a delusion of:

   1. A. Reference
   2. B. Grandeur
   3. C. Persecution
   4. D. Guilt
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   Answer: A. Reference

   Delusions of reference involve believing ordinary events are directed specifically at oneself. Persecution involves believing others intend harm.

6. A 23-year-old man with schizophrenia who stopped his medication believes you are a government agent. Your best approach is to:

   1. A. Agree you are an agent to gain his trust
   2. B. Argue that government agents do not exist
   3. C. Have police restrain him immediately
   4. D. Stay calm and honest; explain who you are
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   Answer: D. Stay calm and honest; explain who you are

   Clear, honest communication and a calm tone reduce paranoia. Playing along reinforces the delusion and undermines trust once he learns the truth.

7. A patient taking clozapine has had no bowel movement for a week and now has a distended abdomen and vomiting. Your main concern is:

   1. A. A side effect that will soon pass
   2. B. Bowel obstruction from slowed gut
   3. C. Neuroleptic malignant syndrome
   4. D. Simple anxiety about his weight
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   Answer: B. Bowel obstruction from slowed gut

   Clozapine has strong anticholinergic effects that slow the gut, and clozapine-induced constipation can progress to obstruction, ileus, bowel perforation, and death, so these symptoms need urgent evaluation. It is not a harmless side effect. NMS causes fever, rigidity, and confusion rather than abdominal distension and vomiting.

8. A 60-year-old started on risperidone 2 months ago now has a shuffling gait, a resting tremor, and stiff arms. This is most likely:

   1. A. Tardive dyskinesia
   2. B. Drug-induced parkinsonism
   3. C. An acute stroke
   4. D. Neuroleptic malignant syndrome
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   Answer: B. Drug-induced parkinsonism

   Antipsychotics block dopamine and can cause parkinsonism (tremor, rigidity, slow shuffling movement) within weeks to months; it often improves when the dose is reduced. Tardive dyskinesia appears after long use and causes involuntary lip, tongue, and facial movements. A stroke causes sudden focal deficits. NMS adds fever, confusion, and autonomic instability.

9. A 70-year-old who has taken antipsychotics for decades has repetitive lip-smacking and tongue thrusting. This is:

   1. A. Acute dystonic reaction
   2. B. Akathisia
   3. C. Neuroleptic malignant syndrome
   4. D. Tardive dyskinesia
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   Answer: D. Tardive dyskinesia

   Tardive dyskinesia is a late, often permanent movement disorder. Acute dystonia occurs within days of starting the drug and involves sustained contractions, not repetitive movements.

10. A patient taking clozapine has a fever and sore throat. Your greatest concern is:

    1. A. Neuroleptic malignant syndrome
    2. B. Acute lithium toxicity from fever
    3. C. Severe neutropenia with infection
    4. D. Acute dystonic reaction
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    Answer: C. Severe neutropenia with infection

    Clozapine can cause agranulocytosis, so fever may mean life-threatening sepsis. NMS also causes fever but with rigidity and altered mental status, not a sore throat.

11. A 26-year-old develops hallucinations and disorganized speech after a sudden family death. The symptoms resolve completely after 10 days. This pattern best fits:

    1. A. Brief psychotic disorder
    2. B. Schizophrenia
    3. C. Bipolar I with psychosis
    4. D. Early-onset dementia
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    Answer: A. Brief psychotic disorder

    Brief psychotic disorder is psychosis lasting at least 1 day but less than 1 month with full return to baseline, often after a major stressor. Schizophrenia requires signs lasting at least 6 months. Bipolar I disorder with psychosis requires a manic episode, which she does not have. Dementia is a slow, progressive decline in cognition, not a short psychosis in a young adult.

12. A patient has had psychosis with hallucinations for years and also has distinct episodes of major depression or mania. This combination is called:

    1. A. Postpartum psychosis
    2. B. Delusional disorder
    3. C. Borderline personality disorder
    4. D. Schizoaffective disorder
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    Answer: D. Schizoaffective disorder

    Schizoaffective disorder combines the psychotic symptoms of schizophrenia with major mood episodes, and psychosis also occurs outside the mood episodes. Postpartum psychosis begins after childbirth. Delusional disorder involves delusions without the other features of schizophrenia or major mood episodes. Borderline personality disorder involves unstable relationships and emotions, not chronic psychosis.

13. An 80-year-old nursing home resident has become confused over 2 days, picking at her sheets and alternating between drowsy and agitated. Her urine is foul-smelling. The most likely cause is:

    1. A. Delirium from a urinary tract infection
    2. B. Progression of her Alzheimer disease
    3. C. New-onset schizophrenia
    4. D. A major depressive episode
    Show answer

    Answer: A. Delirium from a urinary tract infection

    Rapid onset and fluctuation point to delirium, and infection is a leading cause in older adults. Dementia progresses over months, not days.

14. A patient with catatonia is mute and rigid and has not eaten or drunk for 2 days. The medication class that often relieves catatonia is:

    1. A. Antipsychotics
    2. B. Benzodiazepines
    3. C. Opioid analgesics
    4. D. Antihistamines
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    Answer: B. Benzodiazepines

    Benzodiazepines such as lorazepam are first-line for catatonia and often produce dramatic improvement. Antipsychotics can worsen catatonia and raise the risk of neuroleptic malignant syndrome. Opioids and antihistamines do not treat it. Because she has not been drinking, also look for dehydration and other medical complications.

15. Five days after starting high-dose prednisone for an asthma flare, a man with no psychiatric history is euphoric, sleepless, and paranoid. The most likely cause is:

    1. A. New-onset schizophrenia
    2. B. Low blood oxygen from asthma
    3. C. Steroid-induced psychosis
    4. D. Opioid withdrawal
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    Answer: C. Steroid-induced psychosis

    High-dose corticosteroids can cause mood changes, mania, and psychosis, usually within the first days to weeks; it improves when the dose is reduced. Schizophrenia rarely begins this suddenly in an adult with no history and a clear drug trigger. Hypoxia causes confusion and agitation, not euphoria and sleeplessness over days, though his SpO2 should still be checked. Nothing suggests opioid use.

16. A 50-year-old works normally but has firmly believed for a year that a coworker is secretly in love with him. He has no hallucinations or disorganized speech. This is most consistent with:

    1. A. Schizophrenia
    2. B. Hypomania
    3. C. Delusional disorder
    4. D. Early frontotemporal dementia
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    Answer: C. Delusional disorder

    Delusional disorder involves one or more fixed false beliefs lasting at least a month while daily functioning is otherwise fairly normal and other psychotic symptoms are absent. Schizophrenia adds hallucinations, disorganized speech or behavior, or negative symptoms with a decline in function. Hypomania is a mood episode. Frontotemporal dementia causes progressive personality change and loss of judgment, so he would not keep working normally.

17. An 86-year-old being transported for a long distance is at risk of delirium. Which simple step helps prevent it?

    1. A. Keep the cabin dark and silent
    2. B. Keep her talking and oriented
    3. C. Hold her hands down to keep her still
    4. D. Give a sleep aid to help her rest
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    Answer: B. Keep her talking and oriented

    Nondrug measures prevent delirium: regular reorientation, conversation, glasses and hearing aids in place, a familiar person, and avoiding restraints and sedatives. Darkness and silence remove the cues she needs. Restraint and sedating drugs, especially anticholinergic sleep aids, are themselves causes of delirium.

18. An agitated patient with Lewy body dementia has visual hallucinations. He is at particular risk of a severe reaction to:

    1. A. Haloperidol
    2. B. Acetaminophen
    3. C. Ondansetron
    4. D. Glucagon
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    Answer: A. Haloperidol

    Patients with Lewy body dementia are extremely sensitive to antipsychotics, which can cause severe rigidity or NMS-like reactions. Haloperidol is a common but dangerous choice for their agitation. Acetaminophen, ondansetron, and glucagon do not block dopamine, so they do not carry this risk; ondansetron is in fact a preferred antiemetic in these patients.

19. Methamphetamine use can produce:

    1. A. Pinpoint pupils and a slow respiratory rate
    2. B. Flat affect with prolonged excessive sleep
    3. C. Bradycardia and a low body temperature
    4. D. Paranoid psychosis resembling schizophrenia
    Show answer

    Answer: D. Paranoid psychosis resembling schizophrenia

    Stimulants commonly cause paranoia and hallucinations, sometimes lasting days. Pinpoint pupils and slow breathing suggest opioids.

20. A patient with schizophrenia drinks large amounts of water daily and has a seizure. The most likely cause is:

    1. A. Hypernatremia from severe dehydration
    2. B. Hypoglycemia from poor food intake
    3. C. Hyponatremia from excess water intake
    4. D. Hypercalcemia from antipsychotic use
    Show answer

    Answer: C. Hyponatremia from excess water intake

    Psychogenic polydipsia dilutes serum sodium, causing confusion and seizures. Hypernatremia is the opposite problem, from water loss.

21. An agitated, delirious older woman keeps pulling at her IV. The best first approach is to:

    1. A. Reorient her, reduce stimuli, involve family
    2. B. Apply four-point soft restraints right away
    3. C. Give haloperidol 10 mg IM before transport
    4. D. Turn on bright lights and the TV to wake her
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    Answer: A. Reorient her, reduce stimuli, involve family

    Nonpharmacologic measures are first-line for delirium. Restraints and antipsychotics can worsen delirium and cause injury, so they are reserved for danger.

22. A 74-year-old has trouble remembering recent conversations, but she still manages her money, cooking, and medications on her own. This best fits:

    1. A. Moderate Alzheimer dementia
    2. B. Mild cognitive impairment
    3. C. Acute delirium
    4. D. Normal pressure hydrocephalus
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    Answer: B. Mild cognitive impairment

    Mild cognitive impairment is a decline in memory or thinking greater than normal aging but without loss of independence in daily activities; dementia is diagnosed when the decline interferes with independent function. Delirium is acute and fluctuating with inattention. Normal pressure hydrocephalus adds gait change and incontinence.

23. A 78-year-old has stopped eating, sleeps poorly, says 'I don't know' to most memory questions, and seems sad. Her family fears dementia. Another treatable cause to consider is:

    1. A. Vascular dementia
    2. B. Normal aging
    3. C. Early Alzheimer disease
    4. D. Depression
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    Answer: D. Depression

    Depression in older adults can mimic dementia (sometimes called pseudodementia): poor concentration, slowed thinking, and 'I don't know' answers from low effort and mood rather than true memory loss. It improves with treatment. Vascular and Alzheimer dementia are what the family already fears, and neither is reversible. Normal aging does not cause loss of appetite and pervasive sadness.

24. A patient answers your questions with a jumble of unrelated words. This is called:

    1. A. Pressured speech
    2. B. Echolalia
    3. C. Clang association
    4. D. Word salad
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    Answer: D. Word salad

    Word salad is the most severe form of disorganized speech. Echolalia is repeating the examiner's words, and clang association links words by sound.

25. Which statement about people with schizophrenia is accurate?

    1. A. They are victims of violence more often than violent
    2. B. Most of them are violent toward strangers they meet
    3. C. They have a split or multiple personality disorder
    4. D. Most are unable to live independently in the community
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    Answer: A. They are victims of violence more often than violent

    People with schizophrenia are far more likely to be victims of violence than to be violent. Most are not violent toward strangers. The 'split personality' idea confuses schizophrenia with dissociative identity disorder. Many live independently in the community with treatment and support.