Syncope Practice Questions

30 multiple-choice questions on Syncope 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. A 19-year-old woman has frequent lightheadedness and palpitations when she stands. Her heart rate rises from 70 to 115 within 10 minutes of standing, while her BP stays normal. What does this suggest?

   1. A. Postural tachycardia syndrome
   2. B. Classic orthostatic hypotension
   3. C. Supraventricular tachycardia
   4. D. Ventricular tachycardia
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   Answer: A. Postural tachycardia syndrome

   Postural orthostatic tachycardia syndrome (POTS) causes an excessive rise in heart rate (30/min or more in adults, 40/min or more in teens) within 10 minutes of standing without a drop in BP, often in young women. Orthostatic hypotension requires a BP drop, and supraventricular or ventricular tachycardia begins suddenly and does not depend on posture.

2. The most common cause of syncope overall is:

   1. A. Cardiac arrhythmia
   2. B. Orthostatic hypotension
   3. C. Vasovagal syncope
   4. D. Pulmonary embolism
   Show answer

   Answer: C. Vasovagal syncope

   Reflex-mediated (vasovagal) syncope is the most common type, especially in younger patients, often triggered by pain, fear, prolonged standing, or heat.

3. A 19-year-old faints while having blood drawn after feeling warm, nauseated, and lightheaded. This is most consistent with:

   1. A. Cardiac syncope
   2. B. Vasovagal syncope
   3. C. Seizure activity
   4. D. Hypoglycemic event
   Show answer

   Answer: B. Vasovagal syncope

   A clear emotional or painful trigger with prodromal warmth, nausea, and pallor followed by rapid recovery is classic vasovagal syncope.

4. A 60-year-old with COPD briefly lost consciousness during a violent coughing fit and woke within seconds. What best explains the faint?

   1. A. A seizure triggered by the coughing fit
   2. B. A small stroke in the brainstem
   3. C. Chest pressure cutting venous return
   4. D. Low blood sugar from the coughing spell
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   Answer: C. Chest pressure cutting venous return

   Cough syncope is a situational syncope. Forceful coughing raises the pressure in the chest, which reduces blood return to the heart and blood flow to the brain, and it is most common in middle-aged men with lung disease. A seizure lasts longer with postictal confusion, a brainstem stroke would leave deficits, and coughing does not lower the blood sugar.

5. A 23-year-old has had several 'faints' this week, each lasting 10 to 15 minutes with her eyes closed. During one, her HR is 84, BP 122/76 mm Hg and SpO2 99%. What does this most suggest?

   1. A. Cardiac arrhythmia syncope
   2. B. Orthostatic hypotension
   3. C. Vasovagal syncope
   4. D. Psychogenic pseudosyncope
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   Answer: D. Psychogenic pseudosyncope

   True syncope is brief, because blood flow to the brain recovers once the patient is flat. Long episodes with the eyes closed, frequent recurrences and normal vital signs during the event suggest psychogenic pseudosyncope, which still deserves a calm, respectful assessment. Arrhythmia, orthostatic and vasovagal syncope all cause low brain blood flow with abnormal vitals and quick recovery.

6. A 68-year-old who had a large heart attack 2 years ago and has a weak heart (ejection fraction 25%) fainted without warning while sitting. What cause is most concerning?

   1. A. Vasovagal syncope
   2. B. Ventricular tachycardia
   3. C. Situational syncope
   4. D. Orthostatic hypotension
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   Answer: B. Ventricular tachycardia

   Scar from an old heart attack and a weak left ventricle are strong risk factors for ventricular tachycardia, which can cause sudden syncope and cardiac arrest. These patients need monitoring and evaluation for a defibrillator. Vasovagal syncope has a trigger and warning signs, situational syncope follows a specific act such as urinating or coughing, and orthostatic hypotension occurs on standing rather than while sitting.

7. A patient with recurrent vasovagal syncope asks what she can do when she feels the warning signs while she cannot lie down. Which advice is most appropriate?

   1. A. Cross legs and tense her muscles
   2. B. Breathe fast to raise her oxygen
   3. C. Hold her breath and bear down
   4. D. Walk briskly to keep blood moving
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   Answer: A. Cross legs and tense her muscles

   Physical counterpressure maneuvers, such as crossing the legs and tensing the leg, abdominal and arm muscles or gripping the hands, push blood back toward the heart and can abort a vasovagal faint. Lying down is best when possible. Rapid breathing can cause lightheadedness, bearing down reduces venous return, and walking keeps her upright when she may soon fall.

8. A 70-year-old lost consciousness while lying in bed watching television. Why is this detail concerning?

   1. A. It suggests a heart rhythm problem
   2. B. It is typical of vasovagal syncope
   3. C. It points to orthostatic hypotension
   4. D. It rules out a cardiac cause
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   Answer: A. It suggests a heart rhythm problem

   Vasovagal and orthostatic syncope happen when the patient is upright, so losing consciousness while lying down points to a cardiac cause, especially an arrhythmia, and needs monitoring and evaluation. It is not typical of vasovagal or orthostatic syncope, and it makes a cardiac cause more likely rather than less.

9. A 74-year-old fainted suddenly without warning. His 12-lead shows a right bundle branch block with left anterior fascicular block. Why is this important?

   1. A. It is a normal finding in people over 70
   2. B. It proves the faint was vasovagal
   3. C. It may signal intermittent heart block
   4. D. It reflects a slow sinus node
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   Answer: C. It may signal intermittent heart block

   A right bundle branch block plus a left anterior fascicular block (bifascicular block) means only one conduction pathway remains. Syncope in such a patient raises concern for intermittent high-grade or complete AV block, so keep him on the monitor with pacing pads available. It is not a normal aging finding, it does not prove a vasovagal cause, and it is not a sinus node problem.

10. A man faints while urinating at night. This is an example of:

    1. A. Orthostatic syncope
    2. B. Cardiac syncope
    3. C. Situational syncope
    4. D. Psychogenic pseudosyncope
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    Answer: C. Situational syncope

    Situational syncope is a reflex syncope triggered by specific actions such as urination, coughing, defecation, or swallowing.

11. An older man faints while shaving his neck. Which mechanism is most likely?

    1. A. Vertebral artery stroke
    2. B. Carotid sinus hypersensitivity
    3. C. Seizure from razor stimulation
    4. D. Sudden hypoglycemia
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    Answer: B. Carotid sinus hypersensitivity

    Pressure on a hypersensitive carotid sinus triggers bradycardia and vasodilation, a type of reflex syncope seen mainly in older men.

12. Which assessment should be performed on every syncope patient?

    1. A. A stroke severity score
    2. B. A 12-lead ECG
    3. C. Carotid sinus massage
    4. D. Spinal motion restriction
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    Answer: B. A 12-lead ECG

    A 12-lead ECG can identify arrhythmias, blocks, ischemia, pre-excitation, Brugada pattern, long QT, and other dangerous causes of syncope. Carotid sinus massage is a monitored diagnostic test rather than a field assessment, and it can cause long pauses or, rarely, a stroke. Spinal motion restriction is used when the fall or mechanism suggests a spine injury, and a stroke scale is needed when there are focal deficits, so neither applies to every patient.

13. A 66-year-old with long-standing diabetes feels faint on standing. His BP drops from 138/80 to 104/66 mm Hg, but his heart rate stays at 72. What best explains the unchanged heart rate?

    1. A. Severe dehydration from a stomach bug
    2. B. Autonomic nerve damage from diabetes
    3. C. Slow bleeding into the stomach
    4. D. A normal response to standing
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    Answer: B. Autonomic nerve damage from diabetes

    Normally, when the BP falls on standing the heart rate rises to compensate. A BP drop without any rise in heart rate suggests neurogenic orthostatic hypotension from autonomic nerve damage, common in long-standing diabetes and Parkinson disease, or from rate-slowing drugs. Dehydration from a stomach bug and slow bleeding into the stomach usually cause a strong compensatory rise in heart rate, and a fall of more than 20 mm Hg is not normal.

14. A syncope patient's ECG shows a coved ST elevation in V1-V2 with a right bundle branch pattern. This suggests:

    1. A. Wellens syndrome
    2. B. Pericarditis
    3. C. Brugada syndrome
    4. D. Left ventricular hypertrophy
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    Answer: C. Brugada syndrome

    Brugada pattern indicates a sodium channel disorder associated with polymorphic VT and sudden death; syncope in these patients is high risk.

15. A patient who fainted is pale and sweaty with HR 128 and BP 78/48 mm Hg while lying down. Your partner wants to stand him up to check orthostatic vital signs. What should you do?

    1. A. Stand him up for a full 3 minutes
    2. B. Skip orthostatics; he is unstable
    3. C. Sit him upright, then recheck
    4. D. Check orthostatics after a fluid bolus
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    Answer: B. Skip orthostatics; he is unstable

    Orthostatic vital signs add nothing when a patient is already hypotensive and tachycardic while lying down, and standing him up could cause another faint or a fall. Treat the shock and look for its cause, such as bleeding. Standing him, or sitting him upright to recheck, is unsafe, and orthostatic testing is not needed to guide fluid treatment here.

16. A family says their father 'had a stroke' because he briefly passed out at dinner and then was completely normal. How should you think about this?

    1. A. Brief fainting is a classic TIA sign
    2. B. This proves a brainstem stroke
    3. C. Fainting rules out a heart problem
    4. D. A TIA rarely makes people pass out
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    Answer: D. A TIA rarely makes people pass out

    A TIA rarely makes a person pass out: loss of consciousness requires a drop in blood flow to both hemispheres or to the brainstem's arousal system, so a TIA in one carotid territory almost never causes it. Brief loss of consciousness with full recovery is far more likely to be syncope, often cardiac, and needs an ECG and monitoring. Fainting is not a classic TIA sign, it does not prove a brainstem stroke, and it does not rule out a cardiac cause.

17. A 48-year-old collapsed briefly right after a sudden, severe headache. She is now awake but vomiting and has a stiff neck. What should you suspect?

    1. A. Subarachnoid hemorrhage
    2. B. Vasovagal syncope
    3. C. Orthostatic hypotension
    4. D. A tension headache
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    Answer: A. Subarachnoid hemorrhage

    A sudden severe headache with brief loss of consciousness at onset, vomiting and neck stiffness suggests a subarachnoid hemorrhage. The sudden rise in intracranial pressure can cause a brief collapse. Vasovagal and orthostatic syncope do not begin with a severe headache, and a tension headache does not cause collapse, vomiting or neck stiffness.

18. A 75-year-old with intermittent atrial fibrillation fainted just as her fast palpitations suddenly stopped. What is the most likely mechanism?

    1. A. A pause as the fast rhythm ended
    2. B. A vasovagal response to her fear
    3. C. A drop in BP from mild dehydration
    4. D. A seizure from low oxygen levels
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    Answer: A. A pause as the fast rhythm ended

    In tachy-brady syndrome, a form of sick sinus syndrome, the diseased sinus node fails to restart promptly when a fast rhythm such as atrial fibrillation stops, causing a long pause and syncope. These patients often need a pacemaker, so monitor closely. Fear-induced vasovagal syncope, dehydration and seizures do not explain fainting at the exact moment the palpitations stopped.

19. A patient faints after several days of black, tarry stools. The syncope is most likely caused by:

    1. A. Vasovagal reflex
    2. B. GI blood loss
    3. C. Seizure activity
    4. D. Carotid sinus reflex
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    Answer: B. GI blood loss

    Melena indicates upper GI bleeding; volume loss causes orthostatic changes and syncope. Look for tachycardia, pallor, and hypotension.

20. A patient fainted and now has sudden dyspnea, tachycardia, and hypoxia after a long flight. Which cause should be considered?

    1. A. Pulmonary embolism
    2. B. Vasovagal syncope
    3. C. Anxiety attack
    4. D. Simple dehydration
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    Answer: A. Pulmonary embolism

    A large PE can cause syncope by obstructing pulmonary blood flow; risk factors include immobility, recent surgery, and long travel.

21. Which component is part of the San Francisco Syncope Rule's high-risk criteria?

    1. A. Age over 65 years
    2. B. A prodrome of nausea
    3. C. A heart rate over 100/min
    4. D. History of heart failure
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    Answer: D. History of heart failure

    The San Francisco Syncope Rule (CHESS) flags congestive heart failure history, hematocrit under 30%, abnormal ECG, shortness of breath, and systolic BP under 90 mm Hg. Older age raises risk in other scores but is not a criterion of this rule, a heart rate above 100 is not one of its five criteria, and a prodrome of nausea points toward a lower-risk vasovagal faint.

22. A syncope patient is now fully alert with normal vitals. What is the most appropriate approach?

    1. A. Release him after one normal set of vitals
    2. B. Give oral fluids and release him
    3. C. Advise a routine clinic visit next week
    4. D. Assess fully; advise transport
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    Answer: D. Assess fully; advise transport

    Even a patient who looks well after syncope may have a dangerous cause, such as an arrhythmia, bleeding or a structural heart problem. Complete the assessment, including a 12-lead ECG, encourage transport and document any refusal carefully. One normal set of vitals does not exclude a dangerous cause, oral fluids treat only dehydration, and a routine clinic visit next week delays evaluation of a possibly cardiac cause.

23. Brief jerking movements of the limbs lasting a few seconds during a faint most likely represent:

    1. A. A generalized seizure
    2. B. Convulsive syncope
    3. C. Status epilepticus
    4. D. Psychogenic seizure
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    Answer: B. Convulsive syncope

    Brief myoclonic jerks commonly occur from cerebral hypoperfusion during syncope. Unlike seizures, recovery is quick with little or no confusion.

24. Presyncope is best described as:

    1. A. Near-fainting without LOC
    2. B. Fainting with a long recovery
    3. C. Loss of consciousness while sitting
    4. D. Syncope caused by a seizure
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    Answer: A. Near-fainting without LOC

    Presyncope involves lightheadedness, dimming vision, and weakness without actual loss of consciousness and has the same causes as syncope.

25. What is the most appropriate initial position for a conscious patient who feels faint?

    1. A. Semi-Fowler
    2. B. Standing, legs crossed
    3. C. Supine
    4. D. Seated upright
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    Answer: C. Supine

    Lying supine, with legs elevated if no contraindication, improves venous return and cerebral perfusion and prevents injury from a fall. Semi-Fowler and seated positions keep the head above the heart and leave less blood flow to the brain, and crossing the legs and tensing the muscles while upright is a counterpressure maneuver for when lying down is not possible, not the best position once the patient can lie flat.

26. An 82-year-old taking warfarin fainted and fell in her bathroom. She now feels fine. Which additional concern is most important?

    1. A. A small skin tear on her arm
    2. B. Her missed warfarin dose today
    3. C. Her low daily fluid intake
    4. D. A head injury from the fall
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    Answer: D. A head injury from the fall

    Syncope in older adults often causes injuries, and anticoagulants such as warfarin raise the risk of intracranial bleeding even after a minor head strike, so assess carefully for head injury and transport. A skin tear needs dressing but is not the main danger, a single missed warfarin dose does not cause immediate harm, and poor fluid intake may help explain the faint but is less urgent than a possible brain bleed.

27. A marathon runner collapses just after crossing the finish line. He is alert, his temperature is normal, and his BP is low when he stands but improves when lying flat. What is the most likely cause?

    1. A. Exertional heat stroke from the race
    2. B. Blood pooling after he stopped
    3. C. Severe hyponatremia from drinking
    4. D. A sudden cardiac arrhythmia
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    Answer: B. Blood pooling after he stopped

    When a runner stops suddenly, the leg muscle pump stops pushing blood back to the heart, and blood pools in the dilated leg vessels, causing exercise-associated postural hypotension. Lying him flat with legs raised usually helps quickly. Heat stroke causes a high temperature and confusion, severe hyponatremia causes confusion or seizures, and a cardiac arrhythmia usually strikes during exertion without recovery on lying flat. Collapse during the race, rather than after, is more concerning for a cardiac cause.

28. A dialysis patient fainted an hour after a session in which several liters of fluid were removed. Her BP is 86/50 mm Hg. What is the most likely cause?

    1. A. Fluid overload from missed dialysis
    2. B. Low blood volume from fluid removal
    3. C. Excess potassium from a missed session
    4. D. A seizure from the dialysis
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    Answer: B. Low blood volume from fluid removal

    Removing fluid during dialysis can leave the patient volume depleted, and BP may fall during or after the session, causing lightheadedness or syncope. Lay her flat, give fluids per protocol and check for other causes such as an arrhythmia. She just had dialysis, so fluid overload and high potassium from a missed session are unlikely, and nothing suggests a seizure.

29. Why is a blood glucose check useful in a patient who is unresponsive after a reported faint?

    1. A. Hypoglycemia mimics syncope
    2. B. Low glucose is the usual cause of syncope
    3. C. It can replace the 12-lead ECG
    4. D. It identifies an arrhythmia
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    Answer: A. Hypoglycemia mimics syncope

    Hypoglycemia can mimic syncope, and true syncope recovers on its own within moments, so persistent unresponsiveness suggests another cause such as hypoglycemia. Low glucose is not the usual cause of syncope, the glucose check does not replace the 12-lead ECG, and it cannot identify an arrhythmia.

30. A syncope patient now feels well and wants to sit up in the ambulance. Why should she stay on the cardiac monitor during transport?

    1. A. It treats arrhythmias automatically
    2. B. An arrhythmia may recur
    3. C. It measures her glucose
    4. D. It replaces the 12-lead ECG
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    Answer: B. An arrhythmia may recur

    Arrhythmias that cause syncope are often brief and intermittent, so a normal rhythm at the moment does not rule them out. Continuous monitoring can capture a recurrence and guide immediate treatment. A monitor does not treat an arrhythmia by itself, it does not measure glucose, and it does not replace a 12-lead ECG.