Recognizing the Critical Patient: Sick vs Not Sick, Early Warning Signs, and Compensation Practice Questions

25 multiple-choice questions on Recognizing the critical patient: sick vs not sick, early warning signs, and compensation for paramedic and EMT students, from Chapter 41 (Management and Resuscitation of the Critical Patient). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The main purpose of the 'sick or not sick' decision made in the first moments of patient contact is to:

   1. A. Establish the final field diagnosis for the report
   2. B. Decide whether a full set of vital signs is needed
   3. C. Set the pace and urgency of the rest of the call
   4. D. Determine which hospital will accept the patient
   Show answer

   Answer: C. Set the pace and urgency of the rest of the call

   The early sick-versus-not-sick judgment tells you whether to move fast, call for help, and treat as you assess. It is a triage decision, not a diagnosis, and vital signs are still obtained on every patient.

2. A patient's NEWS2 total is 4, but one parameter alone scores 3 because her respiratory rate is 26. Under NEWS2 guidance, this patient:

   1. A. Needs urgent review despite the low total
   2. B. Needs monitoring at the usual 12-hour interval
   3. C. Is low risk because her total is under 5
   4. D. Can be scored again after she is discharged
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   Answer: A. Needs urgent review despite the low total

   NEWS2 flags any single parameter scoring 3 (a 'red score') as needing urgent clinical review, because one severely abnormal sign can signal serious illness even when the total is modest. A rapid respiratory rate is among the most predictive signs of deterioration and should be counted, not estimated.

3. A 58-year-old woman with a urinary tract infection is anxious and says she 'feels like something bad is happening.' HR 116, RR 26, BP 122/88 mmHg, skin cool and pale. The best interpretation is:

   1. A. She is anxious and should be calmed and reassessed
   2. B. She is in compensated shock and is critically ill
   3. C. Her normal blood pressure rules out a shock state
   4. D. She has early sepsis that does not yet need treatment
   Show answer

   Answer: B. She is in compensated shock and is critically ill

   Tachycardia, tachypnea, cool skin, and a sense of doom with a normal blood pressure describe compensated shock. Treating the normal blood pressure as reassuring is the classic trap, because hypotension appears only when compensation fails.

4. An hour ago a septic patient had an SpO2 of 94% on a nasal cannula at 2 L/min. She now has an SpO2 of 94% on a nonrebreather at 15 L/min. This means that:

   1. A. Her breathing is the same, since SpO2 is 94%
   2. B. The earlier cannula reading was falsely high
   3. C. She is improving, since her SpO2 is holding
   4. D. Her oxygenation is clearly getting worse
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   Answer: D. Her oxygenation is clearly getting worse

   A saturation is only meaningful alongside the oxygen needed to reach it: holding 94% now takes far more oxygen than before, so her gas exchange has deteriorated, which is why oxygen needs are trended along with the saturation. Look for the cause (worsening pneumonia, fluid overload, ARDS) and anticipate the need for ventilatory support. The unchanged number hides a real decline, so calling her breathing unchanged or improving is wrong. Nothing suggests that the earlier reading was falsely high.

5. A 52-year-old with a GI bleed had HR 112 and BP 118/84 mmHg on arrival. Fifteen minutes later he is confused, HR 136, BP 86/60 mmHg. This change means that:

   1. A. His compensation has failed, and he is decompensating
   2. B. He is still compensating, since his heart rate is rising
   3. C. His confusion is unrelated and likely due to alcohol
   4. D. The cuff reading is wrong because he is tachycardic
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   Answer: A. His compensation has failed, and he is decompensating

   A fall in blood pressure with new confusion shows that compensatory mechanisms can no longer maintain perfusion, so he needs immediate resuscitation and rapid transport. A rising heart rate is part of compensation, but once pressure falls, compensation has been overwhelmed.

6. A 34-year-old stabbed in the flank is anxious, with HR 124 and BP 112/70 mmHg. The best interpretation of these vital signs is:

   1. A. Reassuring, because his systolic pressure is normal
   2. B. A pain response that should be treated before transport
   3. C. A shock index above 1, suggesting major blood loss
   4. D. Minor blood loss that needs fluid if the BP falls
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   Answer: C. A shock index above 1, suggesting major blood loss

   The shock index (heart rate divided by systolic pressure) is 124 / 112, or about 1.1. A value above about 0.9 to 1.0 in trauma is associated with significant hemorrhage, transfusion needs, and higher mortality even while the systolic pressure is still normal, so he should be treated as being in compensated hemorrhagic shock: control bleeding, transport rapidly, and notify the trauma center. A normal systolic pressure is not reassuring, because compensation keeps it up until a large volume is lost. Pain and anxiety can raise the heart rate, but attributing tachycardia to pain in a penetrating torso wound is the classic error, and analgesia should not delay transport. Waiting for the pressure to fall before treating means waiting for decompensation.

7. In a child in shock, which finding is an ominous sign of impending cardiac arrest?

   1. A. Tachycardia
   2. B. Tachypnea
   3. C. Thirst
   4. D. Bradycardia
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   Answer: D. Bradycardia

   Bradycardia in a hypoxic or shocked child signals exhausted compensation and imminent arrest. Tachycardia is the expected compensatory response and is an earlier, less ominous sign.

8. A 79-year-old man taking metoprolol has fever, confusion, HR 82, RR 24, and BP 104/70 mmHg. His usual BP is 160/90 mmHg. The most accurate statement is:

   1. A. His heart rate is normal, so he is not in shock
   2. B. His BP may be low for him, and the drug masks tachycardia
   3. C. His blood pressure is above 90 mmHg, so it is still adequate
   4. D. His confusion is most likely from baseline dementia
   Show answer

   Answer: B. His BP may be low for him, and the drug masks tachycardia

   Beta-blockers blunt the tachycardic response, and a chronically hypertensive patient can be hypoperfused at a pressure that looks normal. Relying on a normal heart rate is the tempting error in older adults on rate-controlling drugs.

9. The National Early Warning Score 2 (NEWS2) is calculated from:

   1. A. HR, SBP, GCS, blood glucose, temperature, and a pain score
   2. B. Age, GCS, SBP, and the mechanism of injury
   3. C. RR, SBP, and altered mentation
   4. D. RR, SpO2, oxygen use, temperature, SBP, HR, and alertness
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   Answer: D. RR, SpO2, oxygen use, temperature, SBP, HR, and alertness

   NEWS2 scores respiratory rate, oxygen saturation, supplemental oxygen, temperature, systolic pressure, heart rate, and level of consciousness, including new confusion. The three-item list of RR, SBP, and mentation is qSOFA, a much narrower sepsis screen.

10. A NEWS2 total of 7 or more indicates:

    1. A. High risk that calls for an emergency response
    2. B. Low risk that is suitable for routine observation
    3. C. A need for repeat scoring within 24 hours
    4. D. Moderate risk handled by the primary nurse
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    Answer: A. High risk that calls for an emergency response

    A NEWS2 of 7 or more identifies high clinical risk and triggers an emergency assessment by a critical care-capable team. Scores of 5 to 6 are the urgent-response threshold, so a 7 is beyond that, not routine.

11. A 60-year-old man with a GI bleed has HR 118 and BP 112/78 mmHg. Which finding would be the earliest sign that his brain is becoming underperfused?

    1. A. Fixed and dilated pupils with no light response
    2. B. Anxiety, restlessness, or new confusion
    3. C. Decorticate or decerebrate posturing
    4. D. A GCS of 8 or less
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    Answer: B. Anxiety, restlessness, or new confusion

    Subtle changes in mental status, such as anxiety or restlessness, appear early as cerebral perfusion falls. Fixed pupils and posturing are late findings that indicate severe, often irreversible, injury.

12. A 33-year-old man was stung by a wasp and has hives only. He is talking normally, RR 16, HR 92, BP 128/80 mmHg, SpO2 99%. The most appropriate general impression is:

    1. A. Critical, needing immediate intubation
    2. B. Sick, with impending airway obstruction from swelling
    3. C. Not sick, but needs reassessment for progression
    4. D. Not sick, and needs no further monitoring
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    Answer: C. Not sick, but needs reassessment for progression

    Isolated urticaria with normal airway, breathing, and circulation is not critical, but an allergic reaction can progress, so serial reassessment is required. Calling him critical overtreats; releasing him from monitoring ignores the risk of progression.

13. A 30-year-old who has vomited for two days has a BP that has gone from 124/80 to 110/92 mmHg. The narrowing pulse pressure most likely reflects:

    1. A. Increasing left ventricular stroke volume
    2. B. Peripheral vasodilation
    3. C. Improving cardiac output
    4. D. Rising systemic vascular resistance
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    Answer: D. Rising systemic vascular resistance

    As stroke volume falls, the systolic pressure drops while vasoconstriction keeps the diastolic pressure up, narrowing the gap. Peripheral vasodilation widens the pulse pressure, as seen in early septic shock.

14. A 45-year-old woman with three days of fever has warm, flushed skin, HR 124, RR 28, and BP 98/42 mmHg. Her skin findings are best explained by:

    1. A. Early distributive shock with peripheral vasodilation
    2. B. Adequate perfusion, since her skin is warm and pink
    3. C. A normal fever response without shock
    4. D. Late hypovolemic shock with intense vasoconstriction
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    Answer: A. Early distributive shock with peripheral vasodilation

    In early septic shock, inflammatory mediators dilate vessels, so the skin is warm and the pulse pressure is wide despite poor tissue perfusion. Warm skin is not proof of good perfusion in sepsis, which is why it misleads crews.

15. A 3-year-old with a fever and two days of poor intake has a capillary refill time of 4 seconds in a warm room. This finding suggests:

    1. A. A normal refill time for a febrile toddler
    2. B. An expected effect of fever on the skin vessels
    3. C. Poor perfusion that may signal early shock
    4. D. Dehydration too mild to need treatment
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    Answer: C. Poor perfusion that may signal early shock

    In a warm environment, a capillary refill time over 2 seconds in a child is abnormal and is an early sign of shock, often present before hypotension. Fever flushes the skin but does not explain a delayed refill, so a slow refill in a febrile toddler should be treated as poor perfusion (consider sepsis or dehydration) rather than blamed on the fever. Dismissing it as mild dehydration that needs no treatment ignores an early warning sign.

16. The 'pre-arrest' patient is best described as one who:

    1. A. Has normal vital signs but rates his pain 9/10
    2. B. Shows failing compensation, such as hypotension
    3. C. Has a shockable rhythm on the monitor
    4. D. Has stable vital signs and ongoing chest discomfort
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    Answer: B. Shows failing compensation, such as hypotension

    A pre-arrest patient shows signs that compensation is failing, such as falling blood pressure, altered mental status, a slowing heart rate, or agonal or absent breathing. Recognizing this state is the chance to intervene before cardiac arrest occurs. Severe pain with normal vital signs needs treatment but does not signal imminent arrest. A shockable rhythm on the monitor in a pulseless patient is cardiac arrest itself, not pre-arrest. Stable vital signs with ongoing chest discomfort call for a 12-lead and close watching, but they do not show failing compensation.

17. A 27-year-old woman who is 34 weeks pregnant was in a crash. She is alert, HR 104, BP 108/68 mmHg. Why might her vital signs underestimate blood loss?

    1. A. Pregnancy blunts the heart rate response to blood loss
    2. B. Her larger blood volume delays changes in vital signs
    3. C. Her uterus raises blood pressure by squeezing the aorta
    4. D. Progesterone constricts vessels and holds up the BP
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    Answer: B. Her larger blood volume delays changes in vital signs

    Blood volume rises by up to about 50% in late pregnancy, so a woman can lose 30% or more of it before her vital signs change, and the fetus may be hypoperfused first. Pregnancy raises, not lowers, the resting heart rate and does not blunt the tachycardic response to blood loss. Progesterone relaxes rather than constricts vascular smooth muscle, and the supine uterus lowers pressure by compressing the vena cava.

18. A 66-year-old man with pneumonia is speaking in two-word phrases, SpO2 86% on a nonrebreather, RR 38, and is now drowsy. The drowsiness most likely indicates:

    1. A. Sepsis-related confusion with adequate breathing
    2. B. Improvement as his work of breathing finally settles
    3. C. Respiratory failure with rising CO2 and fatigue
    4. D. Hypoglycemia from the work of breathing
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    Answer: C. Respiratory failure with rising CO2 and fatigue

    Decreasing consciousness in a patient working hard to breathe signals hypercarbia and fatigue, a sign of impending respiratory arrest. Mistaking this for relaxation or improvement is a common and deadly error. Sepsis can cloud thinking, but with an RR of 38 and an SpO2 of 86% his breathing is clearly not adequate, and hypoglycemia, while worth checking, does not explain the falling consciousness as well as tiring with CO2 retention.

19. Why is a single set of normal vital signs a weak basis for deciding a patient is stable?

    1. A. Trends reveal decline that one snapshot can miss
    2. B. Vital signs are inaccurate in most field settings
    3. C. Hospital monitors are needed to detect shock
    4. D. A normal set rules out cardiac problems
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    Answer: A. Trends reveal decline that one snapshot can miss

    Shock and respiratory failure evolve, and serial measurements show the direction of change. A compensating patient can have a normal-looking first set, so a single reading should not end your concern.

20. Which 15-minute trend in a septic patient most strongly suggests that her compensation is failing?

    1. A. HR 112 to 96, RR 24 to 18, SBP 108 to 118
    2. B. HR 90 to 94, RR 18 to 18, SBP 142 to 138
    3. C. HR 104 to 98, RR 22 to 22, SBP 118 to 124
    4. D. HR 112 to 130, RR 24 to 34, SBP 108 to 96
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    Answer: D. HR 112 to 130, RR 24 to 34, SBP 108 to 96

    A rising heart rate and respiratory rate with a falling systolic pressure show that the body is working harder and still losing ground, the pattern that comes just before decompensation; she needs escalation of care now. A falling heart rate and respiratory rate with a rising pressure is the trend you hope to see after fluid. A stable heart rate, rate, and pressure in a normal range show no deterioration. A slight fall in heart rate with a rising pressure and an unchanged rate also suggests improvement. Single readings in any of these sets could look acceptable, which is why the trend matters.

21. A 50-year-old man with chest pain is pale and diaphoretic, HR 48, BP 78/50 mmHg, and confused. Your initial general impression should be:

    1. A. Stable, since he is awake and talking
    2. B. Not sick until a 12-lead is acquired
    3. C. Potentially sick, pending a full history
    4. D. Critical, with a perfusion problem
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    Answer: D. Critical, with a perfusion problem

    Hypotension, bradycardia, diaphoresis, and confusion are signs of shock, so he is critical and you treat as you assess. Delaying that label until a 12-lead or history is obtained wastes the time when intervention helps most.

22. A 24-year-old is breathing 34 times per minute, says her hands tingle, and appears panicked. HR is 118 and SpO2 is 97%. Before attributing this to anxiety, you should:

    1. A. Have her rebreathe into a paper bag for relief
    2. B. Check glucose and look for causes like PE or DKA
    3. C. Coach slow breathing and release her at the scene
    4. D. Withhold oxygen since her saturation is normal
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    Answer: B. Check glucose and look for causes like PE or DKA

    Fast breathing with tingling can come from anxiety, but it is also the body's response to metabolic acidosis (DKA, sepsis, toxic ingestions) and to hypoxia or dead space (pulmonary embolism), and tachycardia makes a medical cause more likely. Anxiety is a diagnosis of exclusion, so check glucose, look at the history, and assess for clots, infection, and ingestions. Paper-bag rebreathing is unsafe because it can worsen hypoxia and hides compensation for acidosis. Releasing her after coaching risks missing a critical illness. A normal SpO2 does not exclude a serious cause; oxygen is titrated to need, and the decision here is about finding the cause.

23. Your patient's blood pressure is 112/70 mmHg, but her urine output has been minimal all day and she is newly confused. The best explanation is that:

    1. A. Organ perfusion can be poor despite a normal blood pressure
    2. B. Her low urine output is caused by fluid restriction
    3. C. Confusion with a normal pressure points to a stroke instead
    4. D. Organ perfusion is assured by any pressure above 90 mmHg
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    Answer: A. Organ perfusion can be poor despite a normal blood pressure

    Blood pressure is a proxy, not a measure, of tissue perfusion; low urine output and confusion are signs that organs are underperfused. A normal reading does not guarantee adequate flow to the brain and kidneys.

24. The single most important action once you recognize a patient as critical is to:

    1. A. Complete the full secondary assessment first
    2. B. Obtain a full medication list from the family
    3. C. Treat life threats while you continue assessing
    4. D. Wait for a second set of vital signs to confirm
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    Answer: C. Treat life threats while you continue assessing

    With a critical patient, you identify and correct immediate threats in parallel with the assessment rather than finishing a full exam first. Waiting to confirm a trend before acting lets the patient decompensate.

25. From the doorway, you judge a 150-kg man in an upstairs bedroom to be critically ill with probable septic shock. The action that best fits this impression is to:

    1. A. Finish a full secondary exam before calling for help
    2. B. Call now for lifting help and other resources
    3. C. Wait for a second set of vitals to confirm he is sick
    4. D. Have him walk down the stairs to save extraction time
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    Answer: B. Call now for lifting help and other resources

    A 'sick' general impression should change what you do right away: treat life threats, and request the help you will need (lifting assistance, ALS backup, or an intercept) early, because extraction of a large patient from upstairs takes time and staff. Completing a full secondary exam first delays both treatment and help. Waiting for a second set of vitals to confirm your impression wastes the time when early action matters most. Walking a patient in shock down stairs risks syncope, a fall, and collapse; he should be moved by the crew.