Speech Impairments, Intellectual Disability, Autism Spectrum Disorder, and Down Syndrome Practice Questions

25 multiple-choice questions on Speech impairments, intellectual disability, autism spectrum disorder, and Down syndrome 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 68-year-old man has had expressive aphasia since a stroke 2 years ago. His wife says his speech is his usual today, but he cannot lift his right arm, which is new. You should:

   1. A. Treat the new weakness as a possible stroke
   2. B. Attribute the new weakness to his old stroke
   3. C. Wait to act until his speech worsens too
   4. D. Advise a clinic visit later in the week
   Show answer

   Answer: A. Treat the new weakness as a possible stroke

   Old deficits set his baseline, and any new deficit is a possible new stroke: perform a stroke assessment, establish the last known well time, check glucose, and go to a stroke center. Blaming the weakness on the old stroke is diagnostic overshadowing. Waiting for his speech to change wastes treatment time, since a new stroke may spare speech. A clinic visit next week would miss the window for thrombolysis or thrombectomy. (AHA/ASA 2019 stroke guideline.)

2. A 50-year-old woman with multiple sclerosis speaks in a slurred, slow way but writes clear, correct answers to your questions. This pattern suggests:

   1. A. Receptive aphasia from a stroke
   2. B. Expressive aphasia from a stroke
   3. C. Dysarthria, with language intact
   4. D. A global loss of language skills
   Show answer

   Answer: C. Dysarthria, with language intact

   Aphasia affects language in every form, including writing, while dysarthria is a motor problem with the speech muscles; correct written answers show that her language is intact, which fits the dysarthria common in MS. Still compare her speech with her baseline. Receptive aphasia impairs understanding, and her writing would not make sense. Expressive aphasia also disrupts writing. Global aphasia impairs both understanding and expression. (ASHA; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

3. After three tries, you still cannot understand what a man with cerebral palsy and slurred speech is telling you. The best response is to:

   1. A. Nod and move on so he is not embarrassed
   2. B. Ask his roommate to answer for him instead
   3. C. Say so and ask him to show or spell it
   4. D. Repeat your question louder and faster
   Show answer

   Answer: C. Say so and ask him to show or spell it

   Admit that you did not understand and offer other ways: spelling, writing, pointing, gestures, or his communication device. Pretending to understand risks recording wrong information and is disrespectful. A roommate may help with his permission, but answering for him bypasses him. His hearing and understanding are not the problem, so a louder, faster question does not help. (Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter; ASHA communication tips.)

4. A 30-year-old man with a severe stutter is having trouble giving his history. A helpful strategy is to:

   1. A. Ask questions that can be answered briefly
   2. B. Ask him to speak faster to finish sooner
   3. C. Tell him to relax and start over each time
   4. D. Speak to him in a louder, slower voice
   Show answer

   Answer: A. Ask questions that can be answered briefly

   Short-answer or yes-no questions, writing, or gestures reduce the burden of speaking. Telling him to relax or speed up adds pressure and usually worsens the stutter.

5. Intellectual disability is characterized by:

   1. A. A sudden loss of memory and thinking in an adult
   2. B. Limited intellect and adaptive skills from childhood
   3. C. Normal intellect with poor social skills and attention
   4. D. Temporary confusion caused by an acute illness
   Show answer

   Answer: B. Limited intellect and adaptive skills from childhood

   Intellectual disability involves significantly below-average intellectual function and adaptive behavior, beginning in the developmental period. Sudden cognitive loss in an adult points to delirium, stroke, or dementia instead.

6. A 30-year-old woman with a mild intellectual disability lives on her own and has no guardian. She understands that her cut needs stitches but declines transport. You should:

   1. A. Transport her, since a disability voids refusal
   2. B. Call her mother for consent to transport her
   3. C. Treat her as a minor who cannot refuse care
   4. D. Assess her capacity as you would any adult
   Show answer

   Answer: D. Assess her capacity as you would any adult

   Adults are presumed to have decision-making capacity, and without a court-appointed guardian a diagnosis of intellectual disability does not remove her right to decide. Check whether she can understand the information, appreciate the risks, reason, and state a choice, using plain language and teach-back; document, and contact medical direction if she lacks capacity for this decision. A disability does not cancel a refusal. Her mother has no legal authority unless she is the guardian. She is an adult, not a minor. (Appelbaum, NEJM 2007; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

7. A 35-year-old woman with an intellectual disability seems more confused than usual, according to her group-home staff. The most important question for them is:

   1. A. What is her normal level of functioning?
   2. B. What was her IQ score on her last test?
   3. C. Who is her legal guardian for consent?
   4. D. How long has she lived in the group home?
   Show answer

   Answer: A. What is her normal level of functioning?

   A change from baseline is the key finding, and caregivers know her usual speech, mobility, and behavior. Confusion beyond baseline may signal hypoxia, infection, hypoglycemia, or head injury and must not be blamed on her disability.

8. A 40-year-old man with an intellectual disability lives in a group home and is on a pureed diet ordered by a speech therapist. The diet most likely protects him from:

   1. A. Weight gain and diabetes
   2. B. Tooth decay and gum disease
   3. C. Choking and food aspiration
   4. D. Drug and food interactions
   Show answer

   Answer: C. Choking and food aspiration

   Swallowing problems are common in people with intellectual and developmental disabilities, and choking and aspiration pneumonia are among their leading causes of death; texture-modified diets and supervised meals reduce that risk. Follow the diet order (do not give other food or drink) and bring it to the hospital. A pureed texture does not prevent weight gain or diabetes. It does not protect the teeth or gums. Food texture has little effect on drug interactions. (LeDeR annual report.)

9. Autism spectrum disorder is characterized by:

   1. A. Progressive muscle weakness beginning in early childhood
   2. B. Social communication deficits and repetitive behaviors
   3. C. Seizures that are triggered by flashing lights
   4. D. An extra copy of chromosome 21
   Show answer

   Answer: B. Social communication deficits and repetitive behaviors

   ASD is a developmental condition with differences in social communication and restricted, repetitive behaviors or interests, often with sensory sensitivities. An extra chromosome 21 is Down syndrome.

10. You ask a 24-year-old man with autism a question, and he pauses for several seconds without answering. The most helpful response is to:

    1. A. Rephrase it several new ways right away
    2. B. Assume he cannot understand you and move on
    3. C. Ask his mother to answer the question
    4. D. Wait, then repeat the same words if needed
    Show answer

    Answer: D. Wait, then repeat the same words if needed

    Many people with autism need extra time to process spoken language; wait, and if needed repeat the question in the same words, because a new wording restarts the processing. Rapid rephrasing adds to the overload. A delayed answer does not mean he cannot understand. Speak to him directly and let caregivers add information only when needed. (National Autistic Society, communicating with autistic people; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

11. When assessing a patient with autism who dislikes being touched, you should:

    1. A. Do a full head-to-toe exam quickly to finish
    2. B. Defer the assessment until you arrive
    3. C. Have several crew members hold him still
    4. D. Explain each step and touch only as needed
    Show answer

    Answer: D. Explain each step and touch only as needed

    Tell him what you will do before you do it, show equipment first, and limit the exam to what is necessary; caregivers can help or demonstrate. A rapid full exam overwhelms him and adds touch that is not needed. Deferring the assessment entirely could miss an injury or illness. Holding him down escalates fear and is a last resort for safety. (Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

12. Patients with autism may interpret language very literally. This means you should:

    1. A. Use everyday sayings so that he feels at ease
    2. B. Speak in general, vague terms to avoid alarming him
    3. C. Use plain language and avoid figures of speech
    4. D. Use medical terms so the meaning is exact
    Show answer

    Answer: C. Use plain language and avoid figures of speech

    A phrase like 'hop up on the cot' may be taken literally or cause confusion. Clear, concrete instructions given one at a time work best. Everyday sayings are often figures of speech that may be taken literally, vague terms leave him unsure what you mean, and medical jargon is exact to you but not plain to him.

13. Which statement about pain in patients with autism is most accurate?

    1. A. They may react to pain in unusual or muted ways
    2. B. They do not feel pain the way others do
    3. C. They usually exaggerate how severe their pain is
    4. D. Their pain can be judged by facial expression
    Show answer

    Answer: A. They may react to pain in unusual or muted ways

    Pain expression can be atypical, from little visible distress with a fracture to extreme distress with minor discomfort, so rely on caregivers and a careful exam. Facial expression may be unreliable.

14. People with autism have a high rate of injury and death from:

    1. A. Sudden cardiac arrhythmias
    2. B. Drowning after wandering away
    3. C. Spontaneous pneumothorax
    4. D. Allergic reactions to latex
    Show answer

    Answer: B. Drowning after wandering away

    Wandering (elopement) is common, and many people with autism are drawn to water, so drowning is a leading cause of death. Latex allergy is linked to spina bifida, not autism.

15. A comfort item, such as a favorite blanket or tablet, belonging to a patient with autism should generally be:

    1. A. Removed so that it does not distract from your care
    2. B. Left at home to prevent contamination
    3. C. Taken away until the patient calms down
    4. D. Allowed to stay with the patient if it is safe
    Show answer

    Answer: D. Allowed to stay with the patient if it is safe

    Familiar objects reduce anxiety and can make assessment and transport much easier. Taking them away often triggers escalation.

16. You are preparing to intubate a 14-year-old with Down syndrome. Compared with other children of the same age, you should anticipate that he may need:

    1. A. A larger tube because of a wide trachea
    2. B. A smaller endotracheal tube
    3. C. Routine nasal intubation
    4. D. A double dose of the paralytic
    Show answer

    Answer: B. A smaller endotracheal tube

    Children and adults with Down syndrome often have a narrower subglottis and trachea than age-based formulas predict, so have tubes one-half to one size smaller ready; also limit neck movement because of atlantoaxial instability. The trachea is not wider than usual. Nasal intubation is not routine and is harder with midface hypoplasia. Paralytic doses are standard. (Shott, Laryngoscope 2000; AAP 2022.)

17. When positioning the airway of an adult with Down syndrome, you should avoid:

    1. A. Excessive neck flexion and extension
    2. B. Using an oropharyngeal airway adjunct
    3. C. Providing supplemental oxygen
    4. D. Placing the patient upright
    Show answer

    Answer: A. Excessive neck flexion and extension

    Atlantoaxial instability (laxity at C1-C2) in Down syndrome means aggressive head positioning can injure the spinal cord, so position gently and use adjuncts. An OPA is appropriate and often helpful given the large tongue.

18. Adults with Down syndrome are at increased risk for:

    1. A. Early-onset osteoarthritis
    2. B. Early-onset macular degeneration
    3. C. Early-onset Alzheimer disease
    4. D. Early-onset multiple sclerosis
    Show answer

    Answer: C. Early-onset Alzheimer disease

    Chromosome 21 carries the amyloid precursor protein gene, so Alzheimer disease often appears in the 40s or 50s. A new decline in skills in a middle-aged adult with Down syndrome may reflect dementia, but treatable causes must be ruled out first.

19. After a minor crash, a 27-year-old man with autism avoids eye contact, answers in a flat tone, and repeats your questions back to you. These behaviors most likely reflect:

    1. A. Deliberate deception about the crash
    2. B. Intoxication with alcohol or drugs
    3. C. His usual way of communicating
    4. D. Defiance of your authority
    Show answer

    Answer: C. His usual way of communicating

    Reduced eye contact, a flat tone, and echolalia (repeating words back) are common features of autism. Confirm his baseline with someone who knows him, and still assess for injury. Reading these behaviors as deception or defiance can escalate the encounter. Nothing here suggests intoxication. (CDC, signs of autism; DSM-5-TR; Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)

20. A 40-year-old woman with Down syndrome has loud snoring and daytime sleepiness. This is commonly caused by:

    1. A. Narcolepsy
    2. B. Cataplexy
    3. C. Central sleep apnea
    4. D. Obstructive sleep apnea
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    Answer: D. Obstructive sleep apnea

    Macroglossia, midface hypoplasia, low muscle tone, and obesity make OSA very common in Down syndrome. Central sleep apnea is a failure of respiratory drive and is much less common.

21. An adult with a moderate intellectual disability needs transport for a leg fracture, and his court-appointed guardian is present. Consent for care should come from:

    1. A. The patient alone, because he is over 18 years old
    2. B. The guardian, while still involving the patient
    3. C. The group-home staff member on duty
    4. D. Medical control, before any treatment
    Show answer

    Answer: B. The guardian, while still involving the patient

    A legal guardian has authority to consent for an adult ward, but you should still explain things to the patient and seek his cooperation. Group-home staff do not have consent authority unless legally designated.

22. A 45-year-old man who had a traumatic brain injury years ago becomes impulsive and irritable during your assessment. You should:

    1. A. Ask family whether this is his baseline behavior
    2. B. Assume he is intoxicated and treat him accordingly
    3. C. Leave the scene because he is uncooperative
    4. D. Restrain him to prevent a sudden outburst
    Show answer

    Answer: A. Ask family whether this is his baseline behavior

    Prior TBI can cause lasting personality change, poor impulse control, and memory problems; knowing his baseline lets you spot new deficits from a new injury, hypoglycemia, or intoxication. Assuming intoxication can miss a medical cause.

23. Which phrase reflects person-first language?

    1. A. A Down's case from the group home
    2. B. A woman who has Down syndrome
    3. C. The Down syndrome sufferer
    4. D. A Down syndrome victim
    Show answer

    Answer: B. A woman who has Down syndrome

    Person-first language names the person before the condition and avoids terms like 'victim' or 'sufferer' that imply pity. Calling someone 'a case' reduces the patient to a diagnosis.

24. A 26-year-old woman with cerebral palsy uses a speech-generating device to communicate. When you transport her, you should:

    1. A. Bring the device and allow her time to use it
    2. B. Pack it away and use yes-or-no nods
    3. C. Rely on her mother to answer for her
    4. D. Bring it and type in her answers for her to save time
    Show answer

    Answer: A. Bring the device and allow her time to use it

    Augmentative and alternative communication devices are the patient's voice; without one she cannot report pain or give consent. Packing it away limits her to yes-or-no answers, and typing her answers for her replaces her words with yours. Speaking only to her mother ignores her ability to communicate for herself.

25. A 22-year-old man with autism needs transport to the hospital. Which approach is most likely to keep him calm?

    1. A. Apply soft restraints early in case he panics en route
    2. B. Have a new crew member sit beside him
    3. C. Talk to him the whole way to keep him distracted
    4. D. Let a familiar caregiver ride along with him
    Show answer

    Answer: D. Let a familiar caregiver ride along with him

    A trusted caregiver provides reassurance and knows his calming strategies and how he communicates distress. Unfamiliar people and constant talking add sensory and social stress, and restraints applied in advance tend to cause the panic they are meant to prevent.