10 free Paramedic practice questions: Advanced Neurologic Emergencies

A positive Brudzinski sign when the neck is flexed: A positive Brudzinski sign is a classic meningitis finding, and it is listed for older children along with Kernig's sign. This patient is 7 months old, and the neck is already supple. In infants, meningitis shows up as fever, vomiting, irritability, lethargy, and a bulging fontanelle.

Whether the temperature falls with cooling and undressing: A falling fever can seem reassuring. How a fever responds to cooling is not one of the findings of meningitis in an infant. A temperature that comes down does not tell you the infection is gone.

The blood glucose level checked at first contact with the infant: Glucose is checked on every seizure, and a low glucose is a cause you can fix. This infant already has a fever and a full fontanelle to explain. A normal glucose level would not tell a simple febrile seizure from an infection.

Maternal antibodies are gone by this age, so infection spreads within hours: Maternal antibodies are not gone at 3 weeks. Passive immunity from the mother's antibodies lasts through the first six months of life. The risk in a newborn comes from a limited ability to fight infection, not from a lack of antibodies.

A rectal temperature of 100.8°F is too low to cause a seizure: A rectal temperature above 100.4°F is a fever in a newborn, so 100.8°F counts. The age decides this question, not how high the temperature is. Option C also leaves the sleepy infant and the poor feeding unexplained.

A newborn's temperature control is immature, so the fever reflects overheating: Newborns do have limited control of body temperature, so overheating is possible. This infant was lightly dressed in a cool room, so overheating does not fit. Overheating also would not explain the poor feeding, the sleepiness, or the seizure activity.

Nausea and sweating as the patient is lowered to the ground: Nausea and sweating as the patient goes down sound like a sick patient. They are the warning of a vasovagal faint, so they point away from the heart.

Confusion lasting under a minute after the patient wakes: Confusion after waking, with a few jerks of the arms as the patient went down, sounds like a seizure. A few jerks do not turn a faint into a seizure. Confusion lasting under a minute fits any faint, so it does not separate the two causes.

Blood pressure that normalizes once the patient is flat: A blood pressure that normalizes once the patient is flat is the vasovagal pattern. The question asks what favors a cardiac cause, and this finding favors a simple faint.

Bacterial meningitis: This headache comes back about once a month, and meningitis is a sudden, first time illness, not a pattern that repeats. Meningitis also brings fever and a stiff neck, and neither is described here.

Carbon monoxide poisoning: Only this patient is sick. No combustion source is mentioned, and no sick household member or pet is mentioned either. Carbon monoxide makes several people in a space with a fuel burning appliance sick together.

Acute viral gastroenteritis: would bring vomiting, diarrhea, and body aches, usually after contact with someone sick. Here the nausea comes with a one sided headache after a visual aura. No diarrhea or sick contact is described.

Ischemic stroke: An ischemic stroke patient usually stays awake, understands your questions, and often answers back. The skin usually looks normal. This patient only moans to a sternal rub, has pale, cool, diaphoretic skin, and has a sugar of 38 mg/dL. Fix the glucose before you assume a blocked vessel in the brain.

Hemorrhagic stroke: often brings a sudden severe headache, vomiting, and consciousness that drops fast. The blood pressure is often very high from pressure building inside the skull. A blood pressure of 108/68 is not high. The sugar of 38 mg/dL explains what you are seeing, so treat the glucose and reassess before you assume a bleed.

Postictal state: A postictal state comes after a seizure. Orientation comes back slowly, and sometimes one side is weak for a while before it gets better. Nobody here describes any seizure activity. The sugar of 38 mg/dL accounts for the unresponsiveness and the facial droop, so correct the glucose first.

Give an antihypertensive for the bleed: Lowering the blood pressure is a real hospital treatment for a bleed in the brain. You cannot tell a bleed from a clot without imaging. If this stroke is a clot, the high pressure is what pushes blood to the brain tissue around the clot. The hospital sets a pressure goal once imaging shows which stroke this is.

Hyperventilate to lower intracranial pressure: Hyperventilation lowers carbon dioxide, and low carbon dioxide narrows the blood vessels in the brain. Narrow vessels cut blood flow to a brain that is already short on it. Hyperventilation is saved for a short time when a patient shows active signs of herniation. This patient shows no signs of herniation, so ventilate to a normal carbon dioxide level.

Position the patient flat for perfusion: Laying a patient flat comes from shock care, where the goal is raising perfusion. In a stroke, lying flat slows the blood draining out of the head, and the pressure inside the skull goes up. Raise the head about 30 degrees and keep the neck in line.

A vagal response to the vomiting: Vomiting can drop the heart rate through a vagal response, and this patient did vomit. A vagal response does not come with a systolic pressure of 198 and irregular breathing. A vagal response also does not make one pupil dilate.

Decompensated shock from the bleed: Decompensated shock is low blood pressure with a fast, weak pulse. This patient's pressure is 198/78 and the pulse is 44. A bleed inside the skull kills by raising pressure in a closed space, not by the volume of blood lost.

An opioid effect on the brainstem: Slow breathing at 8 in an unresponsive patient is the pattern you see with opioids. An opioid gives you small, equal pupils. This patient has a 6 mm pupil on one side, and a sudden severe headache came before the collapse.

Midazolam: the first line benzodiazepine on almost every seizure call. A benzodiazepine only quiets the convulsion. Midazolam does not fix the spasm in the brain's blood vessels that is driving this seizure. Magnesium sulfate goes first, and midazolam follows only if the seizures keep going.

Calcium gluconate: the antidote for magnesium toxicity. No magnesium has been given yet, so there is nothing to reverse. Once magnesium is running, lost deep tendon reflexes, a falling respiratory rate, or a dropping level of consciousness send you to calcium gluconate.

Dextrose: Checking the glucose on every seizure is correct practice, and dextrose fixes a low one. This patient's glucose is 98 mg/dL, which is normal. Dextrose has nothing to correct and only delays the magnesium.

A brain disorder from a lack of thiamine: Heavy drinkers really are low on thiamine, and untreated thiamine deficiency causes Wernicke encephalopathy. Wernicke encephalopathy shows up as confusion, abnormal eye movements like nystagmus or ophthalmoplegia, and ataxia. A single generalized seizure that stops on its own after 90 seconds does not match. Nothing in this question describes eye or gait problems.

A first seizure from a new seizure disorder: A first seizure in a 44-year-old does need a workup for a new seizure disorder. Here the seizure came about 30 hours after years of heavy daily drinking stopped. A new seizure disorder does not explain that timing, and the staff already gave you the drinking history.

Alcohol intoxication making a seizure more likely: Alcohol is a CNS depressant while it is in the system, and intoxication can lower the seizure threshold. Intoxication and withdrawal do opposite things to the brain. This patient's last drink was 30 hours ago, so this patient is in withdrawal, not intoxicated.

Ignore it, since only a low glucose harms the brain: A high glucose hurts brain tissue that is short on blood flow, so this 268 is part of the injury. Most glucose checks in a stroke are looking for a low reading, because hypoglycemia is the stroke mimic you cannot miss.

Treat the high glucose as the cause of the weakness: A level of 268 does not cause weakness on one side or slurred speech. The pulse is 78, the skin is warm and dry, and the respirations are 18, so there are no signs of a hyperglycemic crisis. The high glucose did not cause this stroke.

Give a fluid bolus to bring the glucose down: Warm, dry skin and a pulse of 78 show no dehydration, so there is no volume to replace. A bolus also will not bring a 268 down much on the way in. The bolus is for diabetic ketoacidosis and hyperosmolar states, where the high glucose comes with dehydration.