Stroke and TIA Practice Questions

30 multiple-choice questions on Stroke and TIA for paramedic and EMT students, from Chapter 19 (Neurologic Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. Under the current tissue-based definition, a transient ischemic attack is:

   1. A. Any deficit lasting under 24 hours
   2. B. A stroke that resolves within 1 hour
   3. C. A deficit lasting under 24 hours with infarct
   4. D. Transient deficit without infarction
   Show answer

   Answer: D. Transient deficit without infarction

   TIA is now defined as transient neurologic dysfunction from focal ischemia without acute infarction on imaging. The old 24-hour time rule is no longer used because many short events still cause infarction.

2. A 66-year-old woman's slurred speech fully resolved before your arrival. Which statement is most appropriate to guide care?

   1. A. She can safely be released without transport
   2. B. Her symptoms prove no brain damage occurred
   3. C. She is at high short-term stroke risk
   4. D. She needs follow-up only if symptoms recur
   Show answer

   Answer: C. She is at high short-term stroke risk

   TIA patients carry a substantial risk of stroke in the following days, especially the first 48 hours, and need emergency evaluation. Only imaging can determine whether infarction occurred.

3. Approximately what proportion of strokes are ischemic rather than hemorrhagic?

   1. A. About 50%
   2. B. About 87%
   3. C. About 25%
   4. D. About 65%
   Show answer

   Answer: B. About 87%

   Roughly 87% of strokes are ischemic, caused by thrombosis or embolism. The remainder are intracerebral or subarachnoid hemorrhages.

4. A 34-year-old with no medical history develops sudden aphasia and right arm weakness the day after a 12-hour flight. Her left calf is swollen and tender. What mechanism best explains the stroke?

   1. A. Atherosclerotic plaque in the carotid artery
   2. B. Rupture of a small deep brain artery
   3. C. Spasm of brain arteries from a migraine
   4. D. A leg clot crossing a hole between the atria
   Show answer

   Answer: D. A leg clot crossing a hole between the atria

   A deep vein clot normally lodges in the lungs, but a patent foramen ovale (a small opening between the atria) can let it cross to the arterial side and reach the brain (paradoxical embolism). This is an important cause of stroke in young adults, especially with a DVT after long travel. Carotid atherosclerosis and small-vessel rupture are diseases of older adults with vascular risk factors, and migraine does not cause a swollen, tender calf.

5. A patient was seen normal at 10 p.m., went to bed, and woke at 6 a.m. with left-sided weakness. What is the time last known well?

   1. A. 6 a.m., on waking
   2. B. Midnight, the midpoint
   3. C. The time EMS was called
   4. D. 10 p.m.
   Show answer

   Answer: D. 10 p.m.

   For wake-up strokes, last known well is the last time the patient was observed at baseline, not the time symptoms were discovered.

6. A patient's stroke symptoms completely resolve for 30 minutes, then return. What is the correct last known well time?

   1. A. When the symptoms recurred
   2. B. When the first symptoms started
   3. C. When 911 was called
   4. D. When the symptoms first resolved
   Show answer

   Answer: A. When the symptoms recurred

   If deficits fully resolve to baseline, the clock resets to the time of new symptom onset. If they only partially improve, the original last known well time stands. The moment the first symptoms cleared is not used either; the new clock starts when the deficits come back.

7. Using the Los Angeles Motor Scale (LAMS), a stroke patient has a facial droop, an arm that falls rapidly, and no grip in that hand. What is the score and its meaning?

   1. A. 3, suggesting a small-vessel stroke
   2. B. 4, ruling out a large vessel occlusion
   3. C. 5, suggesting a large vessel occlusion
   4. D. 5, confirming a hemorrhagic stroke
   Show answer

   Answer: C. 5, suggesting a large vessel occlusion

   LAMS scores facial droop 0 to 1, arm drift 0 to 2 (2 if the arm falls rapidly), and grip 0 to 2 (2 if there is no grip). This patient scores 1 + 2 + 2 = 5. A score of 4 or more suggests a large vessel occlusion and supports transport to a thrombectomy-capable center per local triage plans. A score of 3 undercounts, a 4 would also suggest an occlusion rather than rule it out, and no field scale can confirm a hemorrhage; only imaging can.

8. The "B" and "E" added in BE-FAST stand for:

   1. A. Balance and eyes
   2. B. Breathing and extremities
   3. C. Blood pressure and EKG
   4. D. Bleeding and edema
   Show answer

   Answer: A. Balance and eyes

   BE-FAST adds sudden loss of balance and vision changes, which helps identify posterior circulation strokes that FAST alone can miss.

9. Why do many EMS systems use a severity scale such as RACE, LAMS, VAN, or FAST-ED for suspected stroke?

   1. A. To exclude hemorrhagic stroke
   2. B. To confirm alteplase eligibility
   3. C. To rule out a stroke mimic
   4. D. To screen for an LVO
   Show answer

   Answer: D. To screen for an LVO

   These scales estimate the likelihood of a large vessel occlusion that may benefit from endovascular thrombectomy, which guides destination decisions. They cannot exclude a hemorrhage or decide alteplase eligibility, which requires brain imaging and a hospital assessment, and a positive scale does not rule out mimics such as hypoglycemia or a postictal state, so the glucose check is still needed.

10. Your suspected stroke patient screens positive for a large vessel occlusion. Per many protocols, the preferred destination is:

    1. A. The closest emergency department
    2. B. Any hospital with a CT scanner
    3. C. A thrombectomy-capable center
    4. D. The hospital the patient usually uses
    Show answer

    Answer: C. A thrombectomy-capable center

    When an LVO is suspected and transport time is acceptable per local protocol, guidelines favor direct transport to a center that can perform thrombectomy, avoiding delays from interfacility transfer. The hospital the patient usually uses may not offer thrombectomy, so choosing it for familiarity can delay treatment.

11. A stroke patient who is within the alteplase window has a BP of 212/118 mm Hg. Why is this BP important to report to the stroke team?

    1. A. It confirms the stroke is hemorrhagic
    2. B. It must be lowered before alteplase
    3. C. It rules out an ischemic stroke
    4. D. It calls for field nitroglycerin
    Show answer

    Answer: B. It must be lowered before alteplase

    Guidelines require the BP to be below 185/110 mm Hg before alteplase is started (and kept below 180/105 afterward), so the hospital team must lower it carefully first. Reporting it early speeds treatment. High BP is common in both ischemic and hemorrhagic stroke, so it neither confirms a bleed nor rules out ischemia, and prehospital lowering with nitroglycerin is not recommended because it can reduce blood flow to the penumbra.

12. For an otherwise uncomplicated suspected ischemic stroke, supplemental oxygen is indicated when the SpO2 is below:

    1. A. 94%
    2. B. 98%
    3. C. 90%
    4. D. 85%
    Show answer

    Answer: A. 94%

    Current guidelines recommend oxygen to keep saturation at or above 94%. Routine oxygen in non-hypoxic stroke patients has not shown benefit.

13. A stroke patient with a normal blood glucose needs an IV line kept open during transport. Which fluid is most appropriate?

    1. A. Dextrose 5% in water
    2. B. Normal saline
    3. C. Half-normal saline
    4. D. Dextrose 10% infusion
    Show answer

    Answer: B. Normal saline

    Isotonic normal saline is preferred in stroke. Dextrose 5% in water and half-normal saline are hypotonic once the sugar is used, so free water can move into injured brain cells and worsen swelling. Giving dextrose when the glucose is normal can cause hyperglycemia, which is linked to worse stroke outcomes. Dextrose is given only to treat a low glucose.

14. For IV alteplase in acute ischemic stroke, the standard treatment window from last known well is up to:

    1. A. 1.5 hours
    2. B. 6.5 hours
    3. C. 4.5 hours
    4. D. 12 hours
    Show answer

    Answer: C. 4.5 hours

    Alteplase may be given within 3 hours, extended to 4.5 hours for many eligible patients. Thrombectomy has a longer window in selected patients.

15. Mechanical thrombectomy for large vessel occlusion may be offered to selected patients up to how long after last known well?

    1. A. 3 hours
    2. B. 24 hours
    3. C. 4.5 hours
    4. D. 72 hours
    Show answer

    Answer: B. 24 hours

    Imaging-selected patients can benefit from thrombectomy up to 24 hours after last known well, which is why LVO recognition matters even outside the thrombolytic window.

16. Why is it important to identify a witness or family member and their phone number on a stroke call?

    1. A. To obtain consent for transport
    2. B. To verify the patient's identity
    3. C. To get consent to share records
    4. D. To confirm onset and history
    Show answer

    Answer: D. To confirm onset and history

    A witness can confirm the time last known well, the history and medications, and the stroke team may need to call them to decide on alteplase or thrombectomy. A competent patient consents for himself. Identity can be confirmed in other ways and is not why the stroke team needs a callback number, and privacy rules allow information to be shared with the treating team without a separate family consent.

17. Which medication history is most important to report to the receiving stroke team?

    1. A. Daily statin use
    2. B. Anticoagulant use
    3. C. Daily thyroid medicine
    4. D. A daily blood pressure pill
    Show answer

    Answer: B. Anticoagulant use

    Anticoagulants such as warfarin or direct oral anticoagulants increase hemorrhage risk and may affect eligibility for thrombolytics, so report the drug and the time of the last dose. Statins, thyroid replacement and blood pressure pills belong on the medication list, but they do not change eligibility for alteplase or thrombectomy.

18. During an interfacility transfer, a stroke patient receiving an alteplase infusion develops a severe headache, vomiting and a falling level of consciousness. What should you do first?

    1. A. Stop the infusion; call medical control
    2. B. Speed up the infusion to finish it sooner
    3. C. Give aspirin 325 mg by mouth now
    4. D. Give ondansetron and continue unchanged
    Show answer

    Answer: A. Stop the infusion; call medical control

    A new severe headache, vomiting, worsening neurologic status or a sharp rise in BP during alteplase suggests intracranial hemorrhage. The infusion must be stopped at once and medical control or the receiving team notified, because emergency imaging and reversal may be needed. Speeding up the infusion adds more drug, aspirin adds bleeding risk and is not given within 24 hours of alteplase, and treating only the nausea misses a possible bleed.

19. You are transferring a patient with a newly diagnosed ruptured brain aneurysm that has not yet been secured. Which complication is the greatest danger during the first hours?

    1. A. Delayed spasm of brain arteries
    2. B. A pulmonary embolism from bed rest
    3. C. Rebleeding from the aneurysm
    4. D. Low sodium from hormone changes
    Show answer

    Answer: C. Rebleeding from the aneurysm

    After aneurysmal subarachnoid hemorrhage, the risk of rebleeding is highest in the first hours to day, and a rebleed carries a high death rate. That is why pain, agitation and BP are controlled and the aneurysm is secured quickly. Vasospasm usually begins around day 3 and peaks over the following week or so. Clots from bed rest and sodium problems also develop later, not in the first hours.

20. Which feature most suggests intracerebral hemorrhage rather than ischemic stroke in the field?

    1. A. Headache, vomiting, rapid decline
    2. B. Gradual onset over several days
    3. C. Isolated, mild facial droop
    4. D. Symptoms present only on waking
    Show answer

    Answer: A. Headache, vomiting, rapid decline

    Hemorrhage commonly presents with headache, vomiting, very high BP, and decreasing consciousness, though only CT can reliably distinguish stroke types.

21. A patient with a right hemispheric stroke typically has eyes deviated:

    1. A. Toward the left side
    2. B. Upward and outward
    3. C. In different directions
    4. D. Toward the right
    Show answer

    Answer: D. Toward the right

    In a hemispheric stroke, the eyes deviate toward the side of the lesion and away from the weak side. Gaze deviation is a sign often used in LVO scales.

22. A patient with a right hemisphere stroke has a paralyzed left arm, yet insists he is fine and that his arm works normally. How is this best explained?

    1. A. Stroke damage limits his awareness
    2. B. He is using denial to cope with fear
    3. C. He is pretending to avoid the hospital
    4. D. He is confused from low blood sugar
    Show answer

    Answer: A. Stroke damage limits his awareness

    Damage to the right parietal lobe can cause anosognosia, an inability to recognize one's own deficit, often together with neglect of the left side. It is a sign of the stroke itself, not a choice, and it matters because the patient may lack the understanding needed to refuse care. Psychological denial and pretending are conscious or emotional responses, and low glucose would be found on a fingerstick and cause more general confusion.

23. Over 2 days, a 66-year-old had brief episodes of double vision and slurred speech that cleared. Now he is drowsy, with weakness in all four limbs. What should you suspect?

    1. A. Guillain-Barre syndrome
    2. B. A sudden myasthenic crisis
    3. C. Bilateral Bell palsy
    4. D. Basilar artery occlusion
    Show answer

    Answer: D. Basilar artery occlusion

    The basilar artery supplies the brainstem. Its occlusion often follows a stuttering course of brief brainstem symptoms (double vision, slurred speech, vertigo) and then causes decreased consciousness and weakness of all four limbs. It is a large vessel occlusion with a very high death rate, so it needs rapid transport to a thrombectomy-capable center. Guillain-Barre and myasthenia do not reduce the level of consciousness, and Bell palsy affects only the face.

24. A lacunar stroke typically results from occlusion of:

    1. A. Small penetrating arteries
    2. B. The basilar artery
    3. C. The internal carotid artery
    4. D. Superficial cortical veins
    Show answer

    Answer: A. Small penetrating arteries

    Lacunar infarcts are small, deep strokes from occlusion of penetrating arterioles, commonly linked to chronic hypertension and diabetes, often producing pure motor or pure sensory deficits.

25. A 70-year-old with poorly controlled hypertension suddenly has a headache, repeated vomiting and cannot stand or walk. Over 20 minutes he becomes drowsy. Which diagnosis is most concerning?

    1. A. Cerebellar hemorrhage
    2. B. Benign positional vertigo
    3. C. Vestibular neuritis
    4. D. Viral gastroenteritis
    Show answer

    Answer: A. Cerebellar hemorrhage

    Sudden headache, vomiting and inability to walk in a hypertensive patient suggest bleeding into the cerebellum. Because the cerebellum sits in a tight space next to the brainstem, swelling can compress the brainstem or block CSF flow, and a falling level of consciousness signals that emergency surgery may be needed. Inner-ear disorders such as positional vertigo and vestibular neuritis do not cause headache or drowsiness, and gastroenteritis does not prevent walking.

26. A 30-year-old has tingling that started in her fingers and spread slowly up her arm over 20 minutes, along with zigzag lights in her vision. A headache followed. Which feature most favors a migraine aura over a TIA?

    1. A. Symptoms on one side of the body
    2. B. A sudden onset at full strength
    3. C. Gradual spread over many minutes
    4. D. A normal blood pressure reading
    Show answer

    Answer: C. Gradual spread over many minutes

    A migraine aura typically builds and spreads gradually over 5 minutes or more, with positive symptoms such as tingling or flashing lights, and is often followed by headache. A TIA usually begins suddenly with maximal loss of function, such as numbness or weakness. One-sided symptoms occur in both conditions, and a normal BP does not separate them. A first aura-like episode still needs medical evaluation.

27. Why are suspected stroke patients kept NPO in the field?

    1. A. Food raises blood pressure
    2. B. Swallowing may be impaired
    3. C. Fluids worsen cerebral edema
    4. D. Fasting is needed for CT
    Show answer

    Answer: B. Swallowing may be impaired

    Dysphagia is common after stroke and increases aspiration risk; a formal swallow screen is done at the hospital before anything is given by mouth.

28. What is the main purpose of hospital pre-notification for a suspected stroke?

    1. A. Activate the stroke team
    2. B. Reserve an inpatient bed
    3. C. Get orders for field alteplase
    4. D. Request orders to lower the BP
    Show answer

    Answer: A. Activate the stroke team

    Pre-notification allows the stroke team and CT to be ready on arrival, shortening door-to-imaging and door-to-treatment times. Alteplase is given after brain imaging, not by a standard ambulance crew, and prehospital BP lowering in suspected stroke is not recommended, so neither is the purpose of the call. A bed is arranged later, once the team knows what treatment is needed.

29. A suspected stroke patient has a BP of 94/60 mm Hg. His usual BP is about 150/90. Why is this finding concerning?

    1. A. It confirms a hemorrhagic stroke
    2. B. Low flow can enlarge the infarct
    3. C. It means alteplase is unsafe
    4. D. It is a normal stroke response
    Show answer

    Answer: B. Low flow can enlarge the infarct

    The brain tissue around an infarct (the penumbra) depends on adequate blood pressure because its normal autoregulation is lost. Low BP can widen the injury, and it is unusual in acute stroke, so look for a cause such as dehydration, bleeding, sepsis or a cardiac problem and treat it per protocol. Low BP does not confirm a hemorrhage and does not by itself make alteplase unsafe. Most stroke patients are hypertensive, so hypotension is not a normal response.

30. Which LAPSS criterion would exclude a patient from a positive screen?

    1. A. Age of 72 years
    2. B. Unilateral arm weakness
    3. C. Glucose of 42 mg/dL
    4. D. Symptom onset 2 hours ago
    Show answer

    Answer: C. Glucose of 42 mg/dL

    The Los Angeles Prehospital Stroke Screen requires a glucose between 60 and 400 mg/dL; a low glucose suggests hypoglycemia as the cause of the deficit.