Substance Use, Special Syndromes, Legal Issues, and Special Populations Practice Questions

25 multiple-choice questions on Substance use, special syndromes, legal issues, and special populations 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. A heavy drinker who stopped 18 hours ago hears voices and sees insects on the wall, but he is alert, oriented, and has normal vital signs. This is most consistent with:

   1. A. Delirium tremens
   2. B. Schizophrenia
   3. C. Alcoholic hallucinosis
   4. D. Wernicke encephalopathy
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   Answer: C. Alcoholic hallucinosis

   Alcoholic hallucinosis begins about 12 to 24 hours after the last drink and causes hallucinations with a clear sensorium and stable vital signs. Delirium tremens comes later (about 48 to 96 hours) with confusion, fever, and marked tachycardia. A new psychosis timed to stopping alcohol is not schizophrenia. Wernicke encephalopathy causes confusion, ataxia, and eye findings.

2. A heavy drinker whose blood alcohol level is still well above the legal driving limit is tremulous, sweaty, and tachycardic. This can still be alcohol withdrawal because:

   1. A. Alcohol levels do not affect symptoms
   2. B. He must have taken another drug
   3. C. Withdrawal begins as the level falls
   4. D. Withdrawal starts only at a zero level
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   Answer: C. Withdrawal begins as the level falls

   In a person with heavy daily use, withdrawal is triggered by a falling alcohol level, not a zero level, so symptoms can begin while the level is still high. Withdrawal does need treatment, often with a benzodiazepine, and mixed intoxication should still be considered, but another drug is not required to explain these signs.

3. After days of heavy drinking, a man stopped eating and has vomited for 2 days. He has abdominal pain and deep, rapid breathing, and his glucose is 96 mg/dL. You should suspect:

   1. A. Diabetic ketoacidosis
   2. B. Anxiety hyperventilation
   3. C. Acute alcohol intoxication
   4. D. Alcoholic ketoacidosis
   Show answer

   Answer: D. Alcoholic ketoacidosis

   Alcoholic ketoacidosis follows a binge with poor intake and vomiting: ketoacids build up with a normal or low glucose, causing abdominal pain and Kussmaul breathing. Treatment is IV fluids with dextrose and thiamine. Diabetic ketoacidosis has a high glucose. Deep, rapid breathing with vomiting and pain is a metabolic acidosis, not anxiety. He has stopped drinking, so this is not simple intoxication.

4. Three days after a methamphetamine binge, a man sleeps most of the day, eats heavily, and feels deeply depressed with passing thoughts of death. This is most likely:

   1. A. Opioid withdrawal
   2. B. Stimulant withdrawal
   3. C. A manic episode
   4. D. Delirium tremens onset
   Show answer

   Answer: B. Stimulant withdrawal

   Stopping stimulants after heavy use causes a 'crash': hypersomnia, increased appetite, fatigue, and depressed mood, sometimes with suicidal thoughts that need assessment. Opioid withdrawal causes yawning, sweating, diarrhea, and dilated pupils. Mania causes decreased need for sleep. Delirium tremens follows alcohol withdrawal with confusion and autonomic instability.

5. A 17-year-old with anorexia nervosa is dizzy, with HR 38 and BP 82/50. You should:

   1. A. Treat it as a high-risk cardiac emergency
   2. B. Have her eat a snack and stay home
   3. C. Assume an athletic heart and reassure her
   4. D. Give a rapid 2-liter fluid bolus
   Show answer

   Answer: A. Treat it as a high-risk cardiac emergency

   Bradycardia, hypotension, and electrolyte loss make dysrhythmia the leading medical cause of death in anorexia. Large rapid fluid boluses can cause heart failure in a starved heart.

6. In a patient with severe anorexia nervosa, which ECG finding signals a high risk of sudden death?

   1. A. Sinus arrhythmia with breathing
   2. B. A heart rate of 62 at rest
   3. C. A prolonged QT interval
   4. D. Tall, narrow P waves in lead II
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   Answer: C. A prolonged QT interval

   Starvation, low potassium, and low magnesium can lengthen the QT interval and lead to torsades de pointes and sudden death, so a prolonged QT is a red flag in anorexia. Sinus arrhythmia is normal. A resting rate of 62 is not dangerous; marked bradycardia under about 40 is. Tall P waves suggest right atrial enlargement, not anorexia risk.

7. Which finding suggests bulimia nervosa?

   1. A. Knuckle calluses and eroded teeth
   2. B. Yellow sclerae and tense ascites
   3. C. A butterfly rash on the face
   4. D. Clubbing of the fingernails
   Show answer

   Answer: A. Knuckle calluses and eroded teeth

   Calluses from inducing vomiting (Russell sign), dental erosion, and parotid swelling are typical. Many patients with bulimia have normal body weight, so weight alone is unreliable.

8. Refeeding syndrome after prolonged starvation is caused mainly by a sudden drop in:

   1. A. Sodium
   2. B. Ionized calcium
   3. C. Glucose
   4. D. Phosphate
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   Answer: D. Phosphate

   Feeding shifts phosphate, potassium, and magnesium into cells, causing heart failure and dysrhythmias. Glucose levels rise, not fall, with refeeding.

9. A pattern of unstable relationships, fear of abandonment, impulsivity, and recurrent self-harm suggests:

   1. A. Antisocial personality disorder
   2. B. Borderline personality disorder
   3. C. Narcissistic personality disorder
   4. D. Schizoid personality disorder
   Show answer

   Answer: B. Borderline personality disorder

   Borderline personality disorder involves emotional instability and self-injury. Schizoid personality is marked by detachment and little interest in relationships.

10. A patient with borderline personality disorder alternately praises you and calls your partner incompetent. The best approach is to:

    1. A. Take her side to keep her cooperative
    2. B. Stay calm and consistent; set clear limits
    3. C. Argue with her about your partner's skill
    4. D. Refuse to provide care until she apologizes
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    Answer: B. Stay calm and consistent; set clear limits

    This 'splitting' is managed with consistent, respectful boundaries and a united team. Taking sides reinforces the pattern and divides the crew.

11. A persistent disregard for others' rights, deceitfulness, and lack of remorse are features of:

    1. A. Avoidant personality disorder
    2. B. Dependent personality disorder
    3. C. Obsessive-compulsive personality
    4. D. Antisocial personality disorder
    Show answer

    Answer: D. Antisocial personality disorder

    Antisocial personality disorder involves manipulation and rule-breaking. Avoidant personality disorder is marked by social inhibition and fear of rejection.

12. Two months after losing her job, a woman is tearful, anxious, and sleeping poorly. Her distress is more than expected but she does not meet criteria for major depression. This best fits:

    1. A. Adjustment disorder
    2. B. Bipolar II disorder
    3. C. Panic disorder
    4. D. Brief psychotic disorder
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    Answer: A. Adjustment disorder

    Adjustment disorder is emotional or behavioral distress that begins within 3 months of an identifiable stressor, is out of proportion to it or impairs function, and does not meet criteria for another disorder. Bipolar II requires hypomania and major depression. Panic disorder involves recurrent panic attacks. She has no psychosis.

13. A patient demands to be seen first, says he deserves special treatment, and shows no concern for others in the waiting area. A pattern of grandiosity, need for admiration, and lack of empathy suggests:

    1. A. Antisocial personality disorder
    2. B. Borderline personality disorder
    3. C. Narcissistic personality disorder
    4. D. Dependent personality disorder traits
    Show answer

    Answer: C. Narcissistic personality disorder

    Narcissistic personality disorder features grandiosity, a need for admiration, entitlement, and lack of empathy. Antisocial personality disorder centers on disregard for others' rights with deceit and lack of remorse, often with law breaking. Borderline involves unstable relationships, fear of abandonment, and self-harm. Dependent personality involves excessive need to be cared for.

14. A patient refuses to let you touch his medication bag, says the hospital staff are plotting against him, and believes your questions are a trick. He has no hallucinations and has acted this way for years. This pattern best suggests:

    1. A. Acute schizophrenia
    2. B. Histrionic personality disorder
    3. C. Delirium from infection
    4. D. Paranoid personality disorder
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    Answer: D. Paranoid personality disorder

    Paranoid personality disorder is a long-standing pattern of distrust and suspicion, reading hidden threats into ordinary actions, without hallucinations or a formal thought disorder. Schizophrenia adds psychosis such as hallucinations and disorganized thinking. Histrionic personality is dramatic attention seeking. Delirium is acute and fluctuating, not years long. Explain what you are doing plainly and honestly.

15. A woman is dramatic and flirtatious with the crew, speaks in vague, emotional terms, and seems upset whenever she is not the center of attention. This pattern best suggests:

    1. A. Paranoid personality disorder
    2. B. Histrionic personality disorder
    3. C. Schizoid personality disorder
    4. D. Obsessive-compulsive personality disorder
    Show answer

    Answer: B. Histrionic personality disorder

    Histrionic personality disorder involves excessive emotion and attention seeking, dramatic and sometimes seductive behavior, and vague, impressionistic speech. Paranoid personality involves distrust and suspicion. Schizoid personality involves detachment and little interest in relationships. Obsessive-compulsive personality disorder involves perfectionism, rigidity, and a need for control. Assess her complaint as carefully as any other.

16. Over several months, a 52-year-old has become apathetic and socially inappropriate and now has morning headaches and vomiting. His family calls it a 'midlife crisis.' You should be concerned about:

    1. A. Late-onset schizophrenia
    2. B. The normal stress of middle age
    3. C. A brain tumor raising pressure
    4. D. A new personality disorder
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    Answer: C. A brain tumor raising pressure

    A new personality change in midlife with morning headaches and vomiting suggests a mass, often frontal, with rising intracranial pressure, and needs a neurologic exam and transport. Schizophrenia rarely begins at this age and does not cause morning headaches with vomiting. Personality disorders are lifelong patterns, not new changes at 52. Never attribute new behavior with neurologic symptoms to stress.

17. Police bring you a man on an emergency psychiatric hold and ask you to take him to the psychiatric facility. Your responsibilities include:

    1. A. A full medical assessment as usual
    2. B. None, since police hold custody now
    3. C. Only checking the paperwork is signed
    4. D. Sedating him before every transport
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    Answer: A. A full medical assessment as usual

    A legal hold authorizes evaluation and transport but does not replace a medical assessment; many patients on holds have medical causes or injuries, and you remain responsible for his care while he is with you. Checking paperwork matters but is not enough. Sedation is used only when medically needed, not routinely.

18. Competence differs from decision-making capacity in that competence is:

    1. A. Decided by the paramedic on scene
    2. B. Measured by a GCS of 15
    3. C. The same thing as being alert
    4. D. A legal ruling made by a court
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    Answer: D. A legal ruling made by a court

    Competence is a legal status decided by a judge, while capacity is a clinical judgment about one decision at one time, which paramedics assess in the field. A GCS of 15 or being alert does not prove capacity, because intoxication, psychosis, or dementia can impair reasoning in an alert patient.

19. A calm 40-year-old with schizophrenia understands the risks of leaving a small laceration untreated and wants to refuse care. You should:

    1. A. Refuse to accept it because of his diagnosis
    2. B. Accept his refusal because he has capacity
    3. C. Transport him against his will for safety
    4. D. Ask police to place him under arrest
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    Answer: B. Accept his refusal because he has capacity

    A psychiatric diagnosis does not remove the right to refuse. If he demonstrates capacity, document the assessment and the refusal as for any patient.

20. A restrained patient has been calm and cooperative for 30 minutes during a long transport. The best approach to the restraints is to:

    1. A. Leave them on until the hospital doors
    2. B. Remove every restraint at once
    3. C. Reassess and remove them gradually
    4. D. Add more straps to be safe instead
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    Answer: C. Reassess and remove them gradually

    Restraint is used only as long as it is needed. When a patient is calm and cooperative, reassess and release restraints one at a time, watching his response, and document the decision. Keeping restraints on when they are no longer needed is not justified, and removing all of them at once removes the chance to stop if he becomes agitated again. Adding straps is unnecessary.

21. The force used to restrain a patient must be:

    1. A. The minimum needed to prevent harm
    2. B. Applied before verbal methods are tried
    3. C. Equal to the force used by the patient
    4. D. Decided by the patient's family members
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    Answer: A. The minimum needed to prevent harm

    Only reasonable force to protect the patient and others is justified. Matching the patient's force is not the standard and can lead to injury and liability.

22. A 9-year-old boy with autism is screaming and hitting himself after a minor car crash and appears uninjured. You should:

    1. A. Hold him down to finish a complete exam
    2. B. Reduce noise and light; let a parent help
    3. C. Speak loudly to get his full attention
    4. D. Separate him from his parent to assess him
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    Answer: B. Reduce noise and light; let a parent help

    Sensory overload drives many meltdowns, and caregivers know what calms the child. Holding him down increases distress and the risk of injury.

23. In a child with a sudden change in behavior, you should first consider:

    1. A. Attention-seeking as the usual reason
    2. B. Poor discipline at home as the cause
    3. C. A normal phase that will soon pass
    4. D. Ingestion, abuse, or a medical cause
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    Answer: D. Ingestion, abuse, or a medical cause

    Toxic ingestions, head injury, infection, hypoglycemia, and abuse can all present as behavior change. Assuming attention-seeking can miss a life-threatening cause.

24. A 15-year-old with suicidal thoughts needs transport, and her parents cannot be reached. You should:

    1. A. Treat and transport by implied consent
    2. B. Wait on scene until a parent is reached
    3. C. Release her to the care of a neighbor
    4. D. Have her sign her own refusal of care
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    Answer: A. Treat and transport by implied consent

    A minor at risk of serious harm may be treated under implied consent when a guardian is unavailable. Waiting for a parent leaves a high-risk patient without care.

25. In an older adult with new behavioral changes, a common reversible cause is:

    1. A. Normal aging of the brain and nerves
    2. B. A new personality disorder of late life
    3. C. Medication side effects or interactions
    4. D. Late-onset schizophrenia in older age
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    Answer: C. Medication side effects or interactions

    Polypharmacy, anticholinergics, sedatives, and drug interactions frequently cause confusion in older adults. Normal aging does not cause sudden behavioral change.