Vascular and Hypertensive Emergencies Practice Questions

30 multiple-choice questions on Vascular and hypertensive emergencies for paramedic and EMT students, from Chapter 18 (Cardiovascular Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. A CT shows that a patient's aortic dissection involves the ascending aorta. The hospital calls it Stanford type A. Why does this matter for his care?

   1. A. It is managed with BP drugs alone
   2. B. It means the tear is in the abdominal aorta
   3. C. It means the tear starts past the subclavian
   4. D. It usually needs emergency surgery
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   Answer: D. It usually needs emergency surgery

   Stanford type A dissections involve the ascending aorta and can rupture into the pericardium, involve the coronary arteries or the aortic valve, so they generally need emergency surgery; type B dissections spare the ascending aorta and are often managed medically. Medical BP control alone is the usual plan for type B, a tear that begins beyond the left subclavian is also type B, and type A does not mean an abdominal tear.

2. A 62-year-old with hypertension has sudden tearing back pain, and minutes later he cannot move or feel his legs. His femoral pulses are weak. What should you suspect?

   1. A. A herniated lumbar disc pressing on his nerve roots
   2. B. Guillain-Barre syndrome after a recent infection
   3. C. Dissection cutting off spinal cord blood flow
   4. D. A conversion reaction caused by severe anxiety
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   Answer: C. Dissection cutting off spinal cord blood flow

   A dissection can block the arteries that supply the spinal cord or the iliac arteries, causing sudden paraplegia, weak femoral pulses and leg ischemia along with tearing pain. A disc herniation rarely causes sudden complete paralysis with weak pulses, Guillain-Barre develops over days, and a conversion reaction should never be assumed when pulses are abnormal.

3. A woman with a known left leg DVT now has a massively swollen, painful, blue-purple leg, and the foot is cool with weak pulses. What is happening?

   1. A. An arterial embolus has now blocked the leg artery
   2. B. The clot has moved to her lungs
   3. C. A massive clot is now threatening the limb
   4. D. Her leg has cellulitis from the clot site
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   Answer: C. A massive clot is now threatening the limb

   Phlegmasia cerulea dolens is a massive DVT that blocks nearly all venous outflow, causing a swollen, painful, blue limb; the pressure can cut off arterial flow, leading to gangrene and shock, so it is a limb- and life-threatening emergency. An arterial embolus causes a pale, cold leg without massive swelling, a PE would cause dyspnea rather than this leg picture, and cellulitis does not cut off arterial flow.

4. A patient with a known aortic dissection develops ST elevation in leads II, III, and aVF. What is the most important consideration?

   1. A. Fibrinolytics are contraindicated
   2. B. Heparin should be started right away
   3. C. This rules out the dissection
   4. D. Immediate PCI is the priority
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   Answer: A. Fibrinolytics are contraindicated

   A dissection can extend into a coronary artery, most often the right, causing an inferior MI. Fibrinolytics or anticoagulation can be fatal, so suspicion of dissection must be communicated. Heparin is also dangerous here, the priority is surgical repair of the dissection rather than PCI, and the inferior STEMI does not rule out the dissection.

5. Two days after a cardiac catheterization, a 70-year-old has painful, purple-blue toes on both feet, but his pedal pulses are normal. What is the most likely cause?

   1. A. Raynaud phenomenon from the cold
   2. B. A rash from a contrast allergy
   3. C. Small cholesterol emboli from the aorta
   4. D. A large clot blocking the femoral artery
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   Answer: C. Small cholesterol emboli from the aorta

   Catheter manipulation can break off cholesterol crystals from aortic plaque, which lodge in tiny vessels of the toes ('blue toe syndrome') while larger arteries stay open, so pedal pulses remain present. Raynaud phenomenon is episodic and reverses with warming, a contrast rash does not produce painful blue toes, and a large femoral clot would cause absent pulses and a cold, pale limb.

6. A patient with suspected aortic dissection develops sudden right-sided weakness. This most likely reflects:

   1. A. A seizure from hyponatremia
   2. B. Dissection into a carotid artery
   3. C. Unrelated low blood glucose
   4. D. Spinal cord ischemia from the tear
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   Answer: B. Dissection into a carotid artery

   Extension of the dissection into the arch vessels can reduce flow to the brain and cause stroke symptoms. Always check glucose, but recognize this as a complication of dissection. Spinal cord ischemia causes weakness of both legs rather than one side of the body, and nothing suggests hyponatremia.

7. In the hospital, a patient with an acute aortic dissection is given a vasodilator before any heart rate control. Why is this order a problem?

   1. A. The vasodilator will raise the BP even higher
   2. B. Reflex tachycardia adds stress on the aortic wall
   3. C. A vasodilator slows the heart to dangerous levels
   4. D. Vasodilators are not used in aortic dissection
   Show answer

   Answer: B. Reflex tachycardia adds stress on the aortic wall

   Current aortic disease guidance recommends IV beta-blockade first to lower heart rate (about 60 to 80) and then vasodilators to bring the systolic BP to about 120 or lower, because a vasodilator alone causes reflex tachycardia that increases shear on the torn aorta. Vasodilators lower, not raise, BP, they do not slow the heart, and they are used after rate control.

8. A 58-year-old smoker has pain in both buttocks and thighs when walking, erectile dysfunction, and weak femoral pulses on both sides. What is the most likely cause?

   1. A. Blocked lower aorta and iliac arteries
   2. B. A herniated lumbar disc compressing the cord
   3. C. A deep vein clot (DVT) in both of his legs
   4. D. Arthritis of both hip joints from overuse
   Show answer

   Answer: A. Blocked lower aorta and iliac arteries

   Aortoiliac occlusive disease (Leriche syndrome) narrows the distal aorta and iliac arteries, causing buttock and thigh claudication, weak femoral pulses and erectile dysfunction from reduced pelvic blood flow. A disc problem does not weaken pulses, a deep vein clot (DVT) causes swelling rather than claudication, and hip arthritis does not affect pulses or erections.

9. For a patient with suspected ruptured AAA and hypotension, what fluid strategy do many protocols recommend?

   1. A. Large boluses to a normal blood pressure
   2. B. Vasopressors before giving fluid
   3. C. Limited fluids, permissive hypotension
   4. D. Fluids to keep the MAP above 90
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   Answer: C. Limited fluids, permissive hypotension

   Aggressive fluids can raise pressure, dilute clotting factors, and worsen bleeding. Many protocols target a lower SBP (often about 80 to 90 mm Hg) or adequate mentation until surgical control. Vasopressors are not the first step in hemorrhage, and a MAP above 90 is far higher than the permissive target.

10. When assessing a patient with a suspected AAA, how should you palpate the abdomen?

    1. A. Firmly, to measure the mass size
    2. B. Repeatedly, to check for change
    3. C. Gently, without deep palpation
    4. D. Deeply in all four quadrants
    Show answer

    Answer: C. Gently, without deep palpation

    Vigorous or repeated palpation of a suspected aneurysm could worsen a leak or rupture. Gentle assessment is enough; the diagnosis is confirmed with imaging.

11. Which destination is most appropriate for a patient with a suspected ruptured AAA?

    1. A. A hospital with vascular surgery capability
    2. B. The closest clinic for initial stabilization
    3. C. A cardiac catheterization lab without surgeons
    4. D. Any facility with a CT scanner available
    Show answer

    Answer: A. A hospital with vascular surgery capability

    Survival depends on rapid surgical or endovascular repair. Transport to a facility that can perform emergency vascular surgery and notify early, per local destination protocols.

12. A 66-year-old gets dizzy and has left arm aching when he paints a ceiling with his left arm. His left arm BP is 30 mm Hg lower than the right. What is the likely cause?

    1. A. A narrowed left subclavian artery 'stealing' flow
    2. B. Inner ear vertigo from looking up at the high ceiling
    3. C. A pinched nerve in the neck from his posture
    4. D. Normal fatigue in an older man who works hard
    Show answer

    Answer: A. A narrowed left subclavian artery 'stealing' flow

    In subclavian steal, a blockage near the origin of the subclavian artery makes the arm draw blood backward from the vertebral artery during arm exercise, causing dizziness and arm pain, with a lower BP on that side. Vertigo and a pinched nerve do not cause a 30 mm Hg pressure difference, and normal fatigue does not cause dizziness with arm use.

13. A woman has a tender, red, firm cord along a visible vein on the surface of her calf. Her leg is not swollen. What is the most likely condition?

    1. A. An acute arterial embolism
    2. B. Superficial thrombophlebitis
    3. C. Lymphedema of the lower leg area
    4. D. A ruptured Achilles tendon
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    Answer: B. Superficial thrombophlebitis

    Superficial thrombophlebitis is a clot with inflammation in a surface vein, felt as a tender, red cord; it can extend into deep veins, so it still needs evaluation. Arterial embolism causes a cold, pale, pulseless limb, lymphedema causes swelling without a red cord, and an Achilles rupture affects the heel tendon, not a vein.

14. When caring for a patient with a suspected lower-extremity DVT, you should avoid:

    1. A. Massaging the affected leg
    2. B. Elevating the head of the stretcher
    3. C. Elevating the affected leg
    4. D. Checking the distal pulses
    Show answer

    Answer: A. Massaging the affected leg

    Massaging or rubbing the limb could theoretically dislodge the clot. Watch for signs of PE such as sudden dyspnea, tachycardia, and chest pain. Elevating the leg, checking distal pulses and raising the head of the stretcher are all acceptable.

15. A 72-year-old smoker with a known thoracic aortic aneurysm has new hoarseness and a dull ache in his chest and back over the past day. Why are these findings worrying?

    1. A. They point to a brainstem stroke
    2. B. They suggest reflux irritating the larynx
    3. C. They are expected side effects of his BP medicines
    4. D. The aneurysm may be growing and pressing a nerve
    Show answer

    Answer: D. The aneurysm may be growing and pressing a nerve

    An enlarging thoracic aneurysm can stretch the left recurrent laryngeal nerve, causing hoarseness, and new chest or back pain suggests expansion or impending rupture, so he needs urgent evaluation at a center with aortic surgery. A brainstem stroke would bring other neurologic signs, reflux does not explain new chest and back pain in a known aneurysm, and BP medicines do not cause this pattern.

16. A 68-year-old with untreated atrial fibrillation has sudden severe pain in the right leg. The leg is cold and pale with no pedal pulse. The most likely cause is:

    1. A. An arterial embolus
    2. B. Deep vein thrombosis
    3. C. Varicose vein spasm
    4. D. Sciatic nerve injury
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    Answer: A. An arterial embolus

    Atrial fibrillation allows clots to form in the left atrium, which can embolize to peripheral arteries. A cold, pale, pulseless limb indicates arterial, not venous, occlusion.

17. How should you position a limb with suspected acute arterial occlusion?

    1. A. Elevated well above heart
    2. B. Wrapped tightly in ice
    3. C. Level or slightly dependent
    4. D. Wrapped with a heat pack
    Show answer

    Answer: C. Level or slightly dependent

    Keeping the limb level or slightly lower uses gravity to aid what little flow remains. Elevation reduces perfusion, and heat or cold can injure ischemic tissue.

18. A 68-year-old smoker with leg claudication has had months of abdominal pain about 30 minutes after every meal. He now avoids eating and has lost weight. What should you suspect?

    1. A. Narrowed arteries limiting blood flow to the gut
    2. B. A stomach ulcer that improves when he eats meals
    3. C. Lactose intolerance that started late in his life
    4. D. Gallstones that cause pain mostly in the morning
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    Answer: A. Narrowed arteries limiting blood flow to the gut

    Chronic mesenteric ischemia ('intestinal angina') occurs when atherosclerosis narrows the arteries to the gut, so digestion triggers pain after meals; fear of eating and weight loss are typical, and it can progress to acute bowel ischemia. Ulcer pain from the duodenum is often relieved by food, lactose intolerance causes bloating and diarrhea, and gallstone pain is not tied to the morning.

19. Which finding suggests chronic venous insufficiency rather than arterial disease of the leg?

    1. A. Shiny, hairless skin with weak pulses
    2. B. Leg pain that worsens with elevation
    3. C. Brownish skin and edema near the ankle
    4. D. A cool, pale foot when it is elevated
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    Answer: C. Brownish skin and edema near the ankle

    Venous insufficiency causes edema, brownish discoloration, and ulcers near the medial ankle. Shiny hairless skin, weak pulses, and pallor on elevation point to arterial insufficiency.

20. A man with sudden severe chest pain that started between his shoulder blades now says the pain has moved down into his lower back and abdomen. Why is this change important?

    1. A. It points to a kidney stone rather than the aorta
    2. B. It suggests a perforated ulcer
    3. C. Migrating pain suggests a spreading dissection
    4. D. Pain moving down rules out a cardiac cause
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    Answer: C. Migrating pain suggests a spreading dissection

    Aortic dissection pain often migrates as the tear extends along the aorta, and new abdominal or back pain may signal involvement of the abdominal branches, such as the mesenteric or renal arteries. A kidney stone or perforated ulcer does not begin as tearing pain between the shoulder blades, and the change raises rather than lowers concern for a cardiovascular emergency.

21. A 55-year-old has BP 214/128, a severe headache, confusion, vomiting, and blurred vision. No focal deficits are present. These findings most suggest:

    1. A. Migraine with visual aura
    2. B. Hypertensive encephalopathy
    3. C. Hypertensive urgency
    4. D. Acute angle-closure glaucoma
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    Answer: B. Hypertensive encephalopathy

    Severe hypertension with headache, altered mental status, vomiting, and visual changes indicates cerebral edema from failed autoregulation, a hypertensive emergency. Urgency has no acute organ damage. Migraine and acute glaucoma can cause headache, vomiting and blurred vision, but neither explains the confusion with a BP of 214/128.

22. A woman's fingers turn white, then blue, then red when she goes into a cold store, with numbness that resolves after warming. What best explains this?

    1. A. Frostbite from a short time in the cold store
    2. B. An embolus to the arteries of the hand
    3. C. Carpal tunnel syndrome from her work
    4. D. Raynaud phenomenon from cold-triggered spasm
    Show answer

    Answer: D. Raynaud phenomenon from cold-triggered spasm

    Raynaud phenomenon is an exaggerated spasm of the small arteries of the fingers triggered by cold or stress, producing white (spasm), blue (low oxygen) and red (return of flow) color changes that resolve with warming. Frostbite needs longer, colder exposure and causes tissue injury, an embolus affects one hand and does not cycle, and carpal tunnel causes numbness without color change.

23. A patient has BP 196/118, a mild headache, and no signs of organ damage. He ran out of his BP medication 3 days ago. This is best classified as:

    1. A. Hypertensive emergency needing rapid IV drugs
    2. B. Severe hypertension without organ damage
    3. C. Hypertensive encephalopathy in early form
    4. D. A hypertensive crisis needing nitro on scene
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    Answer: B. Severe hypertension without organ damage

    Severely elevated BP without acute target organ damage (previously called hypertensive urgency) is usually managed by gradual oral therapy. Aggressive field BP lowering is not indicated.

24. A patient with an acutely cold, pale, pulseless leg from an embolus asks whether the timing of treatment matters. What is the best answer?

    1. A. Muscle survives for about 24 hours
    2. B. Timing matters mainly if the leg is painful
    3. C. Damage begins after about 12 hours
    4. D. Muscle can be lost within about 6 hours
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    Answer: D. Muscle can be lost within about 6 hours

    In acute limb ischemia, nerves and muscle begin to suffer irreversible damage within roughly 4 to 6 hours, so rapid transport to a center that can restore flow is essential to save the limb. Muscle does not survive 24 hours, and damage does not wait 12 hours. Timing matters even without pain, because the absence of pain may signal worsening nerve injury, and delayed reperfusion after many hours often fails.

25. Which finding in a patient with severe hypertension indicates target organ damage to the heart?

    1. A. Facial flushing when upset
    2. B. Nosebleed that stops alone
    3. C. A pounding mild headache
    4. D. Chest pain with ST changes
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    Answer: D. Chest pain with ST changes

    Acute coronary syndrome or pulmonary edema in a hypertensive patient indicates cardiac target organ damage. Epistaxis and flushing alone do not define a hypertensive emergency.

26. A patient with a suspected acute ischemic stroke has BP 190/104. What is the appropriate prehospital approach to BP per most protocols?

    1. A. Give nitroglycerin to 120/80
    2. B. Do not aggressively lower it
    3. C. Give IV fluids until it rises
    4. D. Lower it 50% before arrival
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    Answer: B. Do not aggressively lower it

    Elevated BP may help maintain perfusion to the ischemic penumbra. Prehospital lowering of BP in suspected stroke is generally not recommended; hospital teams manage it based on treatment plans.

27. Which statement about abdominal aortic aneurysms is correct?

    1. A. Most cause constant pain for years
    2. B. They are most common in young women
    3. C. They cannot occur without symptoms
    4. D. Most are asymptomatic until they leak
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    Answer: D. Most are asymptomatic until they leak

    Most AAAs are silent and found incidentally or at rupture. Risk increases with age, male sex, smoking, hypertension, and family history.

28. A patient with suspected thoracic aortic dissection develops a new diastolic murmur. What does this suggest?

    1. A. Mitral valve stenosis
    2. B. Normal flow murmur
    3. C. Aortic valve regurgitation
    4. D. Pulmonary hypertension
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    Answer: C. Aortic valve regurgitation

    A proximal dissection can disrupt the aortic valve, causing acute aortic regurgitation. It may also extend into the pericardium and cause tamponade.

29. A patient with suspected aortic dissection has a BP of 150/90 in the right arm and 104/70 in the left. Which reading should guide BP treatment decisions?

    1. A. The lower reading, from the left arm
    2. B. The higher reading, from the right arm
    3. C. The average of the two arm readings
    4. D. Neither, since leg pressures are best here
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    Answer: B. The higher reading, from the right arm

    When arm pressures differ in a dissection, the arm with the higher pressure better reflects central aortic pressure, because the other arm's artery may be compressed by the dissection; using the lower reading could lead to under-treatment. Averaging hides the problem, and leg pressures are not the standard guide.

30. Cocaine use is associated with aortic dissection mainly because it causes:

    1. A. Chronic, sustained low blood pressure
    2. B. Marked slowing of the heart rate
    3. C. Sudden surges in heart rate and BP
    4. D. Severe anemia from slow bleeding
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    Answer: C. Sudden surges in heart rate and BP

    Cocaine's sympathomimetic effects produce abrupt spikes in BP and shear force on the aortic wall, which can tear the intima.