Terminal Illness and Hospice, Poverty and Health Care Disparities, Homelessness, and Cultural and Language Barriers Practice Questions

25 multiple-choice questions on Terminal illness and hospice, poverty and health care disparities, homelessness, and cultural and language barriers 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 hospice patient's family asks whether calling EMS will end his hospice benefits. You should know that hospice patients:

   1. A. Can leave hospice and resume curative care
   2. B. Lose their insurance coverage if they call 9-1-1
   3. C. Are required to stay at home until death
   4. D. Cannot receive pain medication from EMS
   Show answer

   Answer: A. Can leave hospice and resume curative care

   Hospice is a voluntary choice: patients can revoke it at any time to pursue curative treatment and can re-enroll later. Calling 9-1-1 does not cancel insurance coverage, although care should respect the patient's current goals. Hospice care can be given at home, in facilities, or in inpatient units, and patients are not confined to home. EMS can treat pain and other symptoms per protocol while contacting the hospice team. (CMS Medicare hospice benefit.)

2. A 70-year-old hospice patient with end-stage lung cancer has severe air hunger at rest despite oxygen. She has a comfort-care order. The most effective symptom treatment is usually:

   1. A. Intubation and mechanical ventilation
   2. B. A low-dose opioid such as morphine
   3. C. A large fluid bolus to improve perfusion
   4. D. Nebulized albuterol every 20 minutes
   Show answer

   Answer: B. A low-dose opioid such as morphine

   Low-dose opioids are the most effective drug treatment for dyspnea in advanced illness and, when titrated, do not hasten death; add upright positioning, a fan, and calm reassurance, per protocol and the hospice plan. Intubation conflicts with her comfort-care order. A fluid bolus can worsen effusions and edema. Albuterol helps only bronchospasm, which is not the problem here. (ATS 2012; ASCO 2021.)

3. A terminally ill cancer patient takes high-dose oral morphine daily and now has severe pain. Compared with an opioid-naïve patient, he will likely need:

   1. A. Smaller doses because he is at risk of overdose
   2. B. No opioids because he may become addicted
   3. C. Larger opioid doses to achieve pain relief
   4. D. Naloxone before any opioid is given
   Show answer

   Answer: C. Larger opioid doses to achieve pain relief

   Patients on chronic opioids develop tolerance, so standard doses may barely touch their pain; titrate per protocol and medical direction. Fear of addiction is not a reason to undertreat pain at the end of life.

4. An 88-year-old hospice patient's family says her breathing now has long pauses followed by deep breaths, and her knees and feet look blotchy and purple. You should explain that:

   1. A. These are common signs that death is near
   2. B. She is in shock and needs IV fluid now
   3. C. She needs naloxone for an opioid overdose
   4. D. These signs prove she is in severe pain
   Show answer

   Answer: A. These are common signs that death is near

   Periodic (Cheyne-Stokes) breathing with pauses and mottling of the knees and feet are common signs that death is likely within hours to days. Explain this gently, check her comfort, contact hospice, and follow her advance directives. Mottling from slowing circulation at the end of life is not a shock state that IV fluid will reverse, and periodic breathing with deep breaths between pauses is not the slow, shallow pattern of opioid overdose. These signs do not show pain, although you should still look for signs of distress such as grimacing or moaning. (Hui, Oncologist 2014.)

5. A 61-year-old man with pancreatic cancer has a swollen, painful left calf. His cancer raises his risk of:

   1. A. Compartment syndrome
   2. B. Deep vein thrombosis
   3. C. Muscle rupture
   4. D. Acute gout flare
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   Answer: B. Deep vein thrombosis

   Many cancers, especially pancreatic, create a hypercoagulable state, and chemotherapy and immobility add to the risk; a swollen, painful calf suggests DVT, which can progress to PE. Compartment syndrome follows trauma or crush injury, not a gradually swollen calf.

6. A homeless man with a deep hand infection refuses transport because he will lose his shelter bed and his belongings if he leaves. The best response is to:

   1. A. Accept his refusal without asking him why
   2. B. Tell him he is not allowed to refuse
   3. C. Have police take him in for his safety
   4. D. Address the barrier and look for options
   Show answer

   Answer: D. Address the barrier and look for options

   Practical barriers drive many refusals. Offer options: bring his belongings, contact the shelter or an outreach worker about holding his bed, or arrange community paramedicine follow-up, while explaining the risk of the infection; if he still refuses with capacity, document it and give return advice. Accepting the refusal without asking misses a fixable problem. A competent adult can refuse. Police custody is not appropriate for a patient with capacity. (National Health Care for the Homeless Council.)

7. A 17-year-old with complex heart disease and a feeding tube has a fever. His mother hands you a one-page form listing his diagnoses, baseline vital signs, and an emergency plan. You should:

   1. A. Set it aside and rely on your own exam
   2. B. Follow it after a physician signs on scene
   3. C. Use it to guide care and bring it along
   4. D. Give it to the hospital without reading it
   Show answer

   Answer: C. Use it to guide care and bring it along

   An emergency information form, endorsed by the AAP and ACEP, summarizes a patient's diagnoses, baseline vital signs and neurologic status, devices, medications, allergies, and specific emergency guidance; use it alongside your assessment and bring it to the hospital. Your exam still matters, but setting the form aside throws away the baseline you need. No on-scene physician signature is required. Handing it over unread wastes information you need now. (AAP/ACEP joint policy statement.)

8. Many hospice patients keep a 'comfort kit' at home. It typically contains:

   1. A. Equipment and drugs for emergency intubation
   2. B. Medications for pain, dyspnea, and agitation
   3. C. A course of antibiotics for any new infection
   4. D. Supplies and fluid for peritoneal dialysis
   Show answer

   Answer: B. Medications for pain, dyspnea, and agitation

   Comfort kits usually include liquid morphine, a benzodiazepine such as lorazepam, and drugs for secretions or nausea, so symptoms can be treated at home under hospice direction. Families may need help using them; follow your protocols and contact hospice.

9. A 48-year-old man with diabetes says he has been taking half his prescribed insulin because he cannot afford it. This illustrates:

   1. A. Cost-related medication nonadherence
   2. B. Intentional self-harm behavior
   3. C. A drug-seeking pattern
   4. D. Poor health literacy
   Show answer

   Answer: A. Cost-related medication nonadherence

   Rationing medication because of cost is common and leads to DKA, uncontrolled hypertension, and repeated EMS calls. Asking about cost and connecting the patient with social services or assistance programs addresses the real cause.

10. A 50-year-old man with diabetes has his third low glucose reading this month, each near the end of the month. He says his food money runs out by then. This pattern reflects:

    1. A. Normal monthly changes in insulin need
    2. B. Insulin that spoils late in the month
    3. C. Intentional overdose of his insulin
    4. D. Food insecurity causing low glucose
    Show answer

    Answer: D. Food insecurity causing low glucose

    When food runs out but insulin or sulfonylureas continue, hypoglycemia follows; admissions for hypoglycemia among low-income adults rise at the end of the month when food budgets are exhausted. Treat the low, note the food insecurity, and refer to food resources or social work. Insulin needs do not follow a monthly cycle. Spoiled insulin causes high, not low, glucose. Nothing in his history suggests intent. (Seligman, Health Aff 2014; ADA 2025.)

11. Your EMS agency receives federal funding. A patient speaks only Haitian Creole. Under federal civil rights law, the agency must:

    1. A. Provide language help at no cost to her
    2. B. Require the family to bring an interpreter
    3. C. Bill the patient for the interpreter's time
    4. D. Use English, since it is the main language
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    Answer: A. Provide language help at no cost to her

    Title VI of the Civil Rights Act, HHS limited English proficiency guidance, and Section 1557 of the Affordable Care Act require agencies that receive federal funds to give meaningful language access, such as phone or video interpreters, free to the patient. The agency cannot require the family to provide an interpreter. It cannot charge the patient. Insisting on English is national-origin discrimination under these rules. (HHS LEP guidance; 45 CFR 92.201.)

12. Patients living in poverty may call EMS for nonurgent problems mainly because they:

    1. A. Prefer ambulance care to clinic or office care
    2. B. Lack a primary care provider or transport
    3. C. Are trying to avoid hospital bills
    4. D. Receive free ambulance rides by law
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    Answer: B. Lack a primary care provider or transport

    Without a regular doctor, insurance, or a car, the ambulance and ED can become the only accessible point of care. Nonjudgmental care and referrals to community resources serve these patients better than labeling them as abusers of the system.

13. A 2-year-old with vomiting and irritability had a high blood lead level found last week. Her family gives her a bright orange folk powder for stomach upset. You should suspect:

    1. A. A viral illness unrelated to the lead
    2. B. Iron poisoning from the orange powder
    3. C. Mercury from the orange folk powder
    4. D. Lead from the folk remedy powder
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    Answer: D. Lead from the folk remedy powder

    Traditional remedies such as azarcon and greta, used for 'empacho' (stomach upset), are bright orange or yellow powders that can be almost pure lead; ask about home remedies without judgment, bring the product, and tell the hospital so public health can follow up. A viral illness does not explain a known high lead level. Iron or mercury poisoning can cause vomiting, but neither explains the high blood lead level, and azarcon and greta are lead salts. (CDC, lead in folk remedies.)

14. During Ramadan, a 56-year-old Muslim man with type 2 diabetes on insulin is fasting from dawn to sunset. He is confused and sweaty in the late afternoon. You should first:

    1. A. Wait until sunset so he can break his fast
    2. B. Assume heat illness and cool him down
    3. C. Check his glucose and treat if it is low
    4. D. Give him his usual insulin dose early
    Show answer

    Answer: C. Check his glucose and treat if it is low

    Fasting while taking insulin or a sulfonylurea raises the risk of hypoglycemia, and confusion with sweating calls for an immediate glucose check. Islamic teaching exempts the sick and allows breaking a fast for treatment, so explain respectfully and give oral or IV glucose per protocol. Waiting until sunset risks seizure and brain injury. Heat illness is possible, but the glucose is checked first. More insulin would deepen the low. (IDF-DAR 2021; ADA 2025.)

15. A woman in cardiac arrest wears a religious medallion on a chain over her chest. Her husband asks you not to take it off. The best approach is to:

    1. A. Cover the medallion with gauze, then shock
    2. B. Shift it aside for the pads, keep it on her
    3. C. Pause CPR while her husband takes the medallion off
    4. D. Place the pads directly over the medallion
    Show answer

    Answer: B. Shift it aside for the pads, keep it on her

    Move the medallion away from the pad sites (sliding it to the side or taping it) so the pads touch bare skin and no metal lies under them, and keep it with her or give it to her husband. Gauze over the metal does not insulate it and worsens pad contact. Pausing CPR while family removes it interrupts compressions and delays the shock when a simple move works. A pad over metal gives poor contact and can cause burns. (AHA 2025 adult life support.)

16. A 62-year-old woman who takes warfarin has new nosebleeds and easy bruising. She recently started an herbal product recommended by a traditional healer. You should:

    1. A. Tell her to stop using traditional remedies
    2. B. Ignore it, since herbal products are safe
    3. C. Ask about the product and bring it along
    4. D. Assume the warfarin dose was too low
    Show answer

    Answer: C. Ask about the product and bring it along

    Many herbal products, such as ginkgo, dong quai, and garlic supplements, can increase warfarin's effect and cause bleeding; ask about it without judgment, bring the container, and report it so the hospital can check her INR. Ordering her to stop all traditional care dismisses her beliefs and may end her trust; the decision belongs with her and her clinicians. 'Natural' does not mean safe. A low warfarin dose causes clotting, not bleeding. (Tan, Br J Clin Pharmacol 2021.)

17. When caring for a homeless patient, a helpful step that respects his circumstances is to:

    1. A. Leave his bags with a bystander at the scene
    2. B. Assume his symptoms stem from alcohol or drug use
    3. C. Leave him at a shelter instead of the ED
    4. D. Ask what he needs and safeguard his belongings
    Show answer

    Answer: D. Ask what he needs and safeguard his belongings

    A homeless person's bags may hold everything he owns, including medications and documents, and losing them can be devastating. Asking about his needs builds trust and uncovers barriers to care. Leaving his bags with a bystander risks losing all of it, and assuming alcohol or drug use is a bias that leads to missed illness.

18. A woman from rural Guatemala answers your Spanish questions with only a few words, though she speaks easily with her husband in another language. The most likely problem is that she:

    1. A. May speak an Indigenous language instead
    2. B. Has a new stroke affecting her speech
    3. C. Is hiding information from the ambulance crew
    4. D. Has an intellectual disability
    Show answer

    Answer: A. May speak an Indigenous language instead

    Many people from Guatemala speak a Mayan language, such as K'iche', Mam, or Q'eqchi', as their first language and limited Spanish, so ask which language she prefers and request an interpreter for that language. Fluent speech with her husband argues against a stroke. Limited answers in a second language are not evidence of hiding something. Nor do they suggest an intellectual disability. (HHS LEP guidance.)

19. A family from a culture that values group decision making wants the eldest son consulted before their mother is treated. She is competent. You should:

    1. A. Refuse to speak with the son at all
    2. B. Let the son decide without asking her opinion
    3. C. Ask the patient how she wants decisions made
    4. D. Proceed without consent to avoid delay
    Show answer

    Answer: C. Ask the patient how she wants decisions made

    Asking the patient whom she wants involved respects both her autonomy and her cultural values, and many patients choose to defer to family. Letting the son decide without asking her bypasses a competent adult's right to choose.

20. An Orthodox Jewish woman with abdominal pain prefers a female provider, but none is available, and she needs an abdominal exam now. You should:

    1. A. Skip the exam until you reach the hospital ED
    2. B. Examine her without explaining to save time
    3. C. Ask her husband to perform the exam for you
    4. D. Explain why, ask consent, and limit exposure
    Show answer

    Answer: D. Explain why, ask consent, and limit exposure

    When a same-gender provider is not available and an exam is needed, explain why it matters, ask her permission, expose only what is necessary, and offer a chaperone or family member at her side. Skipping the exam could miss a surgical emergency. Examining her without explanation violates consent and trust. Her husband cannot perform a clinical assessment. (Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter; Joint Commission.)

21. Viewing your own culture's values as superior to those of other cultures is called:

    1. A. Ethnocentrism
    2. B. Cultural humility
    3. C. Cultural competence
    4. D. Acculturation
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    Answer: A. Ethnocentrism

    Ethnocentrism can lead providers to dismiss patients' beliefs and practices. Cultural humility is the opposite: ongoing self-reflection and willingness to learn from each patient.

22. Expecting a patient to accept your beliefs about treatment because you think they are best is called:

    1. A. Cultural humility
    2. B. Cultural imposition
    3. C. Cultural assessment
    4. D. Cultural relativism
    Show answer

    Answer: B. Cultural imposition

    Cultural imposition is forcing your own values on a patient, such as insisting on a treatment that conflicts with the patient's beliefs without discussion. Cultural relativism is the opposite view, that practices should be understood within their own culture.

23. A 55-year-old Vietnamese man has linear red marks across his back. He says his family rubbed coins on his back to treat his fever. You should:

    1. A. Report the family to police for physical abuse
    2. B. Recognize a folk remedy and assess his fever
    3. C. Treat the marks as burn injuries
    4. D. Tell him to stop using traditional remedies
    Show answer

    Answer: B. Recognize a folk remedy and assess his fever

    Coining (cao gio) leaves linear bruises and is a common Southeast Asian remedy, not abuse; ask about it nonjudgmentally and document it. Then focus on the underlying illness.

24. When you hand a refusal form to a 45-year-old man, he says, 'I left my glasses at home; can you just tell me what it says?' He also cannot name his medications. You should consider that he:

    1. A. Is trying to hide a drug problem
    2. B. Has an acute stroke affecting vision
    3. C. Does not want to sign anything
    4. D. May have limited reading skills
    Show answer

    Answer: D. May have limited reading skills

    Common cues of limited literacy include 'forgetting' glasses, asking to read forms later, and naming pills by color or shape rather than name; read the form aloud in plain language and confirm understanding with teach-back. Nothing suggests he is hiding drug use. A stroke would bring other neurologic findings. He is asking to hear the form, not refusing to sign. (AHRQ Health Literacy Toolkit.)

25. A patient with signs of sepsis refuses transport because she cannot afford the ambulance bill. Your best response is to:

    1. A. Explain the risk and discuss her cost worries
    2. B. Accept the refusal without further discussion
    3. C. Tell her that the bill will be waived
    4. D. Transport her against her will
    Show answer

    Answer: A. Explain the risk and discuss her cost worries

    Financial fear is a common reason for refusal; explaining the danger of sepsis, the hospital's duty to treat regardless of ability to pay, and options such as billing assistance may change her decision. Accepting the refusal without discussion misses a barrier you might solve. Promising that the bill will be waived is not yours to promise. A competent adult cannot be transported against her will. (Caroline, Emergency Care in the Streets, 9th ed., Patients With Special Challenges chapter.)