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CENP practice questions

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Question 1Clinical Assessment, Diagnosis, and Diagnostic Reasoning

In the ABCDE sequence of the primary survey, which assessment follows immediately after airway with cervical spine protection and breathing with ventilation?

  1. Exposure with temperature control
  2. Circulation with hemorrhage control Correct answer.
  3. Focused history and mechanism of injury
  4. Disability and pupillary check

Explanation

The primary survey proceeds in a fixed order because catastrophic hemorrhage and shock kill faster than neurological deterioration. Circulation with hemorrhage control therefore follows airway and breathing.

Question 2Clinical Assessment, Diagnosis, and Diagnostic Reasoning

An adult arrives with a Glasgow Coma Scale score of 13, systolic blood pressure of 88 mmHg, and a respiratory rate of 30/min. Using the Emergency Severity Index, which triage level fits best?

  1. ESI level 4
  2. ESI level 1
  3. ESI level 3
  4. ESI level 2 Correct answer.

Explanation

ESI level 1 is reserved for patients who need an immediate lifesaving intervention such as intubation or defibrillation. A high-risk patient who does not need such an intervention at once is assigned ESI level 2.

Question 3Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which set of adult vital signs meets the SIRS criteria?

  1. Temperature 37.9 °C, heart rate 84/min, respiratory rate 20/min
  2. Temperature 36.8 °C, heart rate 96/min, respiratory rate 16/min
  3. Temperature 37.2 °C, heart rate 88/min, respiratory rate 18/min with a normal white count
  4. Temperature 38.4 °C, heart rate 98/min, respiratory rate 22/min Correct answer.

Explanation

SIRS requires at least two of the following: temperature above 38 °C or below 36 °C, heart rate above 90/min, respiratory rate above 20/min, or an abnormal white blood cell count. Only one option contains two or more qualifying abnormalities.

Question 4Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which chest pain characteristic most suggests myocardial ischemia?

  1. Pain reproduced by palpation of the chest wall
  2. Sharp pain that worsens with deep inspiration
  3. Pleuritic pain that improves when sitting forward
  4. Pressure-like pain radiating to jaw or arm Correct answer.

Explanation

Ischemic pain is typically described as pressure, heaviness, or squeezing, and it may radiate to the jaw, neck, or arm. Pleuritic, positional, and reproducibly tender pain point toward other causes.

Question 5Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which headache feature is a red flag that warrants urgent evaluation for a secondary cause?

  1. Recurrent pain relieved by over-the-counter analgesics
  2. Unilateral pain with nasal congestion and lacrimation
  3. Bilateral throbbing pain with photophobia and nausea
  4. Abrupt onset reaching peak intensity within seconds Correct answer.

Explanation

A thunderclap headache that peaks within seconds to a minute raises concern for subarachnoid hemorrhage and requires urgent imaging. Migraine, cluster, and tension patterns have more gradual or stereotyped features.

Question 6Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which finding in an older adult with abdominal pain most strongly suggests a surgical abdomen?

  1. Discomfort limited to light palpation of the skin
  2. Diffuse cramping relieved by vomiting
  3. Involuntary guarding with rebound tenderness Correct answer.
  4. Hyperactive bowel sounds with watery diarrhea

Explanation

Involuntary guarding and rebound tenderness indicate peritoneal irritation and suggest a process requiring surgical evaluation. Older adults may lack fever or marked leukocytosis, so the abdominal examination carries extra weight.

Question 7Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient opens the eyes to painful stimulus, makes incomprehensible sounds, and withdraws from pain. What is the Glasgow Coma Scale score?

  1. 6
  2. 9
  3. 7
  4. 8 Correct answer.

Explanation

Eye opening to pain scores 2, incomprehensible sounds score 2, and withdrawal from pain scores 4. The summed score is 8, which meets the threshold for coma.

Question 8Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which laboratory test is most useful in the initial evaluation of suspected acute pancreatitis?

  1. D-dimer
  2. Lipase Correct answer.
  3. Alanine aminotransferase
  4. Blood urea nitrogen

Explanation

Serum lipase is the preferred marker because it is more specific to the pancreas than amylase and remains elevated longer. Transaminases and BUN inform severity and biliary etiology but do not establish the diagnosis.

Question 9Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which ECG finding is diagnostic of an ST-elevation myocardial infarction?

  1. Isolated first-degree AV block
  2. ST elevation in two contiguous leads Correct answer.
  3. Sinus tachycardia at a rate of 110/min
  4. T-wave inversion in a single lead

Explanation

ST elevation must be present in two anatomically contiguous leads to satisfy criteria for STEMI. Single-lead changes, rate abnormalities, and isolated AV block do not meet that standard.

Question 10Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which finding is the most reliable indicator of increased work of breathing in an infant?

  1. Warm, dry skin with a capillary refill of 2 seconds
  2. Heart rate of 130/min while crying
  3. Bilateral breath sounds on auscultation
  4. Intercostal and suprasternal retractions Correct answer.

Explanation

Retractions reflect accessory muscle use and are a dependable sign of increased work of breathing in infants. Heart rate varies widely with crying and is unreliable on its own.

Question 11Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 30-year-old twists an ankle. Which finding, according to the Ottawa Ankle Rules, requires radiography?

  1. Pain only with active range of motion
  2. Tenderness over the posterior medial malleolus Correct answer.
  3. Swelling without bony tenderness
  4. Pain at the lateral malleolus while bearing weight

Explanation

Radiography is indicated when there is bone tenderness at the posterior edge or tip of either malleolus or at the navicular or fifth metatarsal base, or an inability to bear weight. Tenderness over the malleolar bone therefore meets criteria.

Question 12Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 45-year-old with pleuritic chest pain has heart rate 92/min, SpO2 97%, no hemoptysis, no prior venous thromboembolism, no estrogen use, no unilateral leg swelling, and no recent surgery. What does the PERC rule indicate?

  1. PERC negative; PE is excluded in low pretest probability Correct answer.
  2. PERC is positive and anticoagulation should begin
  3. PERC is indeterminate and a D-dimer is required
  4. PERC is positive and CT pulmonary angiography is mandatory

Explanation

All eight PERC criteria are absent here, so the rule is negative. In a patient whose pretest probability is low, a negative PERC allows pulmonary embolism to be excluded without D-dimer testing or imaging.

Question 13Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with chest pain scores 1 for history, 0 for ECG, 1 for age, 1 for risk factors, and 0 for troponin on the HEART score. How should this score be interpreted?

  1. Low risk, with a score of 0 to 3 Correct answer.
  2. The score cannot be interpreted without serial troponins
  3. Moderate risk, with a score of 4 to 6
  4. High risk, with a score of 7 to 10

Explanation

The five HEART components sum to 3. Scores of 0 to 3 fall in the low-risk band, which is associated with a major adverse cardiac event rate under about 2%.

Question 14Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which finding adds a point to the Wells score for deep vein thrombosis?

  1. Pain on passive dorsiflexion of the foot
  2. Calf swelling 3 cm greater than the contralateral leg Correct answer.
  3. Long-standing superficial varicosities that are unchanged
  4. Bilateral symmetric ankle edema

Explanation

The Wells score includes measured calf swelling greater than 3 cm compared with the asymptomatic leg. Homans sign and chronic varicose veins are not scoring items.

Question 15Clinical Assessment, Diagnosis, and Diagnostic Reasoning

An arterial blood gas shows pH 7.28, PaCO2 28 mmHg, and bicarbonate 13 mEq/L. Which interpretation is most accurate?

  1. Primary metabolic alkalosis with compensatory hypoventilation
  2. Mixed respiratory and metabolic alkalosis
  3. Metabolic acidosis with appropriate respiratory compensation Correct answer.
  4. Primary respiratory acidosis

Explanation

A low pH with a low bicarbonate indicates a primary metabolic acidosis. Winter's formula predicts a PaCO2 of about 25.5 to 29.5 mmHg, so the measured 28 mmHg represents appropriate respiratory compensation.

Question 16Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which feature of a syncopal episode most strongly suggests a cardiac cause?

  1. Nausea and diaphoresis before the event
  2. Event during venipuncture
  3. Event while standing after prolonged fasting
  4. Event while supine without any prodrome Correct answer.

Explanation

Syncope occurring without warning while supine or during exertion points to a dysrhythmia or structural cardiac cause. Situational and prodrome-rich events are more typical of reflex syncope.

Question 17Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 70-year-old with pneumonia has blood pressure 92/54 mmHg, lactate 3.2 mmol/L, and new confusion. Which initial management step is most appropriate?

  1. Give 30 mL/kg crystalloid and early broad-spectrum antibiotics Correct answer.
  2. Administer intravenous diuretics to reduce pulmonary congestion
  3. Withhold intravenous fluids until blood cultures are finalized in the laboratory
  4. Give intravenous antihypertensives to control the blood pressure

Explanation

Hypotension, elevated lactate, and altered mentation indicate sepsis with hypoperfusion. Early isotonic crystalloid and prompt antibiotics improve survival and should not be delayed for culture results.

Question 18Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with sudden right-sided weakness arrives 45 minutes after symptom onset. Which immediate step is most appropriate?

  1. Administer aspirin before imaging
  2. Obtain a noncontrast head CT and check the blood glucose Correct answer.
  3. Start a therapeutic heparin infusion
  4. Arrange magnetic resonance imaging before any treatment decision

Explanation

Emergent noncontrast head CT excludes hemorrhage before thrombolysis, and glucose measurement excludes hypoglycemia as a stroke mimic. Antithrombotic therapy is withheld until hemorrhage is excluded.

Question 19Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A hypotensive trauma patient has free fluid in the right upper quadrant on FAST examination. What is the most appropriate next step?

  1. Repeat serial hemoglobin measurements every 4 hours
  2. Perform diagnostic peritoneal lavage to confirm the hemoperitoneum
  3. Obtain a contrast-enhanced CT of the abdomen
  4. Request emergency surgical consultation for operative exploration Correct answer.

Explanation

A positive FAST in a hemodynamically unstable patient indicates hemoperitoneum requiring operative control. Transport to CT or serial laboratory monitoring would delay hemorrhage control.

Question 20Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which combination of findings best distinguishes diabetic ketoacidosis from hyperosmolar hyperglycemic state?

  1. Ketosis with anion-gap metabolic acidosis Correct answer.
  2. Hyperglycemia with no acid-base derangement
  3. Marked hyperglycemia with minimal symptoms
  4. Normal serum osmolality with elevated glucose

Explanation

DKA is defined by ketone production and a high-anion-gap metabolic acidosis. Hyperosmolar hyperglycemic state shows severe hyperglycemia and hyperosmolality with little or no ketosis.

Question 21Clinical Assessment, Diagnosis, and Diagnostic Reasoning

An 82-year-old presents with generalized weakness and confusion but no chest pain; the ECG shows ST elevation. Which principle best explains this presentation?

  1. Older adults frequently have atypical or blunted ischemic symptoms Correct answer.
  2. ST elevation in older adults is usually an artifact
  3. Confusion reliably excludes a cardiac cause
  4. Absence of chest pain reliably excludes acute coronary syndrome

Explanation

Older adults often present with dyspnea, weakness, syncope, or confusion rather than classic chest pain. The ECG remains the decisive finding and must be obtained early in any high-risk older patient.

Question 22Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 58-year-old with 2 hours of chest pain has a normal ECG and a single early conventional troponin that is negative. Which statement about troponin testing is most accurate?

  1. An early negative troponin does not exclude infarction; serial sampling is needed Correct answer.
  2. Troponin levels accurately track infarct size in real time
  3. A single negative troponin excludes acute myocardial infarction
  4. Troponin levels rise within 30 minutes of symptom onset in every patient without exception

Explanation

Troponin may remain normal early after symptom onset, so a single negative value in a patient with a concerning presentation cannot exclude infarction. Serial sampling or a validated high-sensitivity algorithm is required.

Question 23Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with an unstable pelvic fracture becomes hypotensive during the primary survey. Which action is most appropriate?

  1. Send the patient to radiology for a pelvic CT scan before starting resuscitation
  2. Apply a pelvic binder and begin balanced resuscitation with blood products Correct answer.
  3. Give 2 L of crystalloid before considering blood products
  4. Place the patient in Trendelenburg position and observe

Explanation

Pelvic binding reduces pelvic volume and bleeding, and balanced resuscitation with blood products limits the dilutional and coagulopathic effects of large crystalloid volumes. Definitive imaging waits until hemodynamic control is addressed.

Question 24Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with suspected bacterial meningitis has papilledema and a new focal neurological deficit. What is the most appropriate sequence of care?

  1. Blood cultures, empiric antibiotics and dexamethasone, then head CT before lumbar puncture Correct answer.
  2. Delay antibiotics until the lumbar puncture has been completed
  3. Start antiviral therapy alone and observe the neurological examination
  4. Perform lumbar puncture first and start antibiotics only if the cerebrospinal fluid is abnormal

Explanation

Papilledema and a focal deficit raise the risk of herniation with lumbar puncture, so imaging precedes the tap. Antibiotics and dexamethasone must still be given first, because delaying them worsens outcomes.

Question 25Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with a high pretest probability of pulmonary embolism has a negative D-dimer. How should this result be interpreted?

  1. It should be repeated in 6 hours before any imaging is performed
  2. It justifies starting anticoagulation without further testing
  3. It excludes pulmonary embolism regardless of the pretest probability
  4. It does not exclude pulmonary embolism, and imaging should be obtained Correct answer.

Explanation

The D-dimer is only useful for exclusion when pretest probability is low or intermediate. With high pretest probability, imaging is required because a negative result carries an unacceptable false-negative rate.

Question 26Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which three components make up the pediatric assessment triangle?

  1. Heart rate, respiratory rate, and blood pressure
  2. Appearance, work of breathing, skin perfusion Correct answer.
  3. Mental status, pupil size, and blood glucose
  4. Airway patency, breathing effort, and central pulses

Explanation

The pediatric assessment triangle is a rapid, from-the-doorway assessment using appearance, work of breathing, and circulation to the skin. It is designed to identify sick children quickly before vital signs and a full examination are obtained.

Question 27Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which change in vital signs best meets the definition of orthostatic hypotension?

  1. Systolic pressure falls by 25 mm Hg within 3 minutes of standing Correct answer.
  2. Heart rate increases by 15 beats/min on standing
  3. Systolic pressure rises by 20 mm Hg on standing
  4. Diastolic pressure falls by 5 mm Hg within 3 minutes of standing

Explanation

Orthostatic hypotension is defined as a fall in systolic pressure of at least 20 mm Hg or a fall in diastolic pressure of at least 10 mm Hg within 3 minutes of standing or head-up tilt. A systolic fall of 25 mm Hg therefore meets the criterion.

Question 28Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient describes a headache that reached maximum intensity within seconds. Which diagnosis should be considered first?

  1. Tension-type headache disorder
  2. Cluster headache
  3. Subarachnoid hemorrhage Correct answer.
  4. Migraine without aura

Explanation

A thunderclap headache that peaks within seconds to a minute is a red flag for subarachnoid hemorrhage and requires urgent evaluation. Tension, migraine, and cluster headaches typically build over minutes to hours rather than seconds.

Question 29Clinical Assessment, Diagnosis, and Diagnostic Reasoning

Which physical examination finding most directly indicates peritoneal irritation?

  1. Hyperactive bowel sounds
  2. Voluntary abdominal guarding
  3. Rebound tenderness Correct answer.
  4. Diffuse abdominal distention

Explanation

Rebound tenderness is elicited when the abdominal wall is released, producing pain from movement of the inflamed peritoneum. It is a classic sign of peritoneal irritation and possible peritonitis.

Question 30Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A screening test has a sensitivity of 95% and a specificity of 40%. What is the most appropriate clinical use of this test?

  1. Confirming the diagnosis when the result is positive
  2. Excluding the diagnosis when the result is negative Correct answer.
  3. Replacing the reference standard
  4. Estimating disease severity

Explanation

A highly sensitive test is most useful for ruling out disease when the result is negative, because few patients with disease will test negative. Its low specificity means a positive result cannot reliably confirm the diagnosis.

Question 31Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A diagnostic test has a positive likelihood ratio of 10. How should this be interpreted?

  1. A positive result substantially raises probability Correct answer.
  2. The test has a 10% false-negative rate
  3. A positive result rules out disease
  4. The test is positive in 10% of healthy patients

Explanation

The positive likelihood ratio is the ratio of the probability of a positive test in diseased patients to that in nondiseased patients. A value of 10 produces a large increase in the post-test probability of disease.

Question 32Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 40-year-old with right upper quadrant pain has inspiratory arrest during deep palpation below the right costal margin. Which condition does this finding most support?

  1. Acute cholecystitis Correct answer.
  2. Acute pancreatitis
  3. Peptic ulcer disease
  4. Acute appendicitis

Explanation

Inspiratory arrest during deep palpation of the right upper quadrant is a positive Murphy sign, which supports acute cholecystitis. The inflamed gallbladder descends against the examiner's hand during inspiration and produces pain.

Question 33Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A 55-year-old has colicky abdominal pain, vomiting, and inability to pass flatus. Examination shows a distended tympanic abdomen with high-pitched bowel sounds. Which diagnosis is most likely?

  1. Acute mesenteric ischemia
  2. Small bowel obstruction Correct answer.
  3. Large bowel obstruction
  4. Gastroenteritis

Explanation

Colicky pain, vomiting, obstipation, distention, and high-pitched bowel sounds are classic for small bowel obstruction. The tympanic abdomen reflects gas-filled loops.

Question 34Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with a tibial fracture has severe pain worsened by passive stretch of the toes. Which complication is most likely developing?

  1. Osteomyelitis
  2. Deep vein thrombosis
  3. Peroneal nerve compression injury
  4. Compartment syndrome Correct answer.

Explanation

Pain with passive stretch of the compartment muscles is an early and important sign of compartment syndrome. It reflects ischemia and irritation of muscle within a closed fascial space.

Question 35Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with a minor leg wound has rapidly spreading erythema, severe pain out of proportion to examination, and systemic toxicity. Which diagnosis should be suspected?

  1. Cellulitis
  2. Contact dermatitis
  3. Necrotizing fasciitis Correct answer.
  4. Superficial thrombophlebitis

Explanation

Pain out of proportion to findings, rapid spread, and systemic toxicity are warning signs of necrotizing fasciitis. This is a surgical emergency that requires urgent debridement and antibiotics.

Question 36Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A trauma patient has a heart rate of 110 beats/min and a systolic blood pressure of 100 mm Hg. What does the shock index suggest?

  1. Need for immediate transfusion
  2. Occult hypoperfusion Correct answer.
  3. Isolated pain response
  4. Normal hemodynamic status

Explanation

The shock index is calculated by dividing heart rate by systolic blood pressure; here it is 1.1. A value above 0.9 suggests occult hypoperfusion and increased risk even when blood pressure appears acceptable.

Question 37Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with suspected adrenal crisis has hypotension, hyponatremia, and hyperpigmentation. Which additional laboratory finding is most consistent?

  1. Hypercalcemia
  2. Hypokalemia
  3. Hyperkalemia Correct answer.
  4. Metabolic alkalosis

Explanation

Primary adrenal insufficiency causes aldosterone deficiency, leading to sodium loss, potassium retention, and hypotension. Hyperkalemia is therefore a characteristic finding.

Question 38Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient has a low pretest probability of a disease. A test with a positive likelihood ratio of 10 is positive. What is the most accurate interpretation?

  1. The result increases probability, but post-test probability may still be moderate Correct answer.
  2. The result essentially confirms the disease regardless of pretest probability
  3. The result proves the disease is absent
  4. The result should be ignored because pretest probability is low

Explanation

Post-test probability depends on both the pretest probability and the test's likelihood ratio. A positive likelihood ratio of 10 shifts probability upward substantially, but from a low pretest probability the final probability may still be below the treatment threshold.

Question 39Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A test has a negative likelihood ratio of 0.05. A patient with moderate pretest probability tests negative. What is the best interpretation?

  1. The negative result has no meaningful effect on probability
  2. The negative result is likely a false positive
  3. The negative result confirms disease
  4. The negative result substantially lowers probability Correct answer.

Explanation

A negative likelihood ratio of 0.05 is very low and markedly reduces the odds of disease when the test is negative. In a patient with moderate pretest probability, this can move the post-test probability into a range where the diagnosis is effectively excluded.

Question 40Clinical Assessment, Diagnosis, and Diagnostic Reasoning

A patient with acute focal neurological deficits has a noncontrast head CT that is normal 2 hours after symptom onset. What is the most accurate conclusion?

  1. The patient has a transient ischemic attack
  2. Ischemic stroke is excluded
  3. Further imaging is unnecessary
  4. Intracranial hemorrhage is excluded Correct answer.

Explanation

A noncontrast head CT is highly sensitive for acute intracranial hemorrhage and is obtained initially to exclude bleeding before reperfusion therapy. Early ischemic changes may not be visible, so a normal CT does not exclude ischemic stroke.

Question 41Management of Acute and Episodic Medical Emergencies

A patient with suspected acute coronary syndrome has no aspirin allergy and no active bleeding. Which aspirin dose and route is recommended as the initial dose?

  1. 650 mg given rectally
  2. 162 to 325 mg non-enteric-coated, chewed Correct answer.
  3. 81 mg enteric-coated, swallowed whole
  4. 1000 mg given intravenously

Explanation

Chewing a non-enteric-coated loading dose of 162 to 325 mg produces rapid platelet inhibition through prompt buccal and gastric absorption. The loading dose is used because the goal is immediate inhibition of thromboxane-mediated platelet aggregation.

Question 42Management of Acute and Episodic Medical Emergencies

An awake, alert patient with a blood glucose of 48 mg/dL can swallow safely. Which is the most appropriate initial treatment?

  1. 1 mg of intramuscular glucagon
  2. 50 mL of 50% dextrose intravenously
  3. A subcutaneous insulin sliding scale dose
  4. 15 to 20 g of fast-acting oral carbohydrate Correct answer.

Explanation

When the patient is conscious and able to swallow, oral glucose is the safest first intervention because it avoids the risks of IV access and needlestick injury. The dose is repeated after 15 minutes if the glucose remains low.

Question 43Management of Acute and Episodic Medical Emergencies

A patient develops urticaria, wheezing, and a blood pressure of 80/45 minutes after a bee sting. Which medication is the priority?

  1. IV diphenhydramine 50 mg plus famotidine
  2. IM epinephrine 0.3 to 0.5 mg (1:1000) Correct answer.
  3. Nebulized albuterol 2.5 mg repeated
  4. IV methylprednisolone 125 mg push

Explanation

Intramuscular epinephrine into the lateral thigh is the first-line treatment for anaphylaxis because it reverses mast cell mediator release, bronchospasm, and vasodilation within minutes. Antihistamines, bronchodilators, and steroids are adjuncts that do not treat airway edema or shock.

Question 44Management of Acute and Episodic Medical Emergencies

Which history element most directly determines eligibility for intravenous thrombolysis in a patient with acute ischemic stroke?

  1. The time the patient was last known to be well Correct answer.
  2. The presenting blood pressure
  3. The initial NIH Stroke Scale score
  4. The fingerstick glucose value

Explanation

Thrombolysis eligibility is anchored to the interval since the patient was last known to be well, because benefit falls and hemorrhage risk rises with time. The other items affect safety screening but do not define the treatment window.

Question 45Management of Acute and Episodic Medical Emergencies

An adult with septic shock and a lactate of 5 mmol/L remains hypotensive after cultures and antibiotics are ordered. Which initial fluid strategy is recommended?

  1. 500 mL of 5% albumin over one hour
  2. 250 mL of packed red blood cells
  3. Maintenance crystalloid at 75 mL per hour
  4. 30 mL/kg balanced crystalloid Correct answer.

Explanation

Guidelines recommend at least 30 mL/kg of balanced crystalloid within the first three hours for sepsis-induced hypoperfusion, given rapidly in boluses with reassessment. Colloid, blood products, and maintenance-rate fluids do not achieve the needed early volume resuscitation.

Question 46Management of Acute and Episodic Medical Emergencies

An adult in diabetic ketoacidosis has a glucose of 480 mg/dL and a blood pressure of 98/60. Which intervention should come first?

  1. IV sodium bicarbonate 1 mEq/kg
  2. Rapid IV infusion of 0.9% sodium chloride Correct answer.
  3. IV regular insulin bolus of 0.1 units/kg
  4. IV potassium chloride 40 mEq over one hour

Explanation

Volume resuscitation with isotonic crystalloid precedes insulin in DKA, because these patients are profoundly volume depleted and insulin shifts fluid intracellularly. Insulin is then started after potassium is known to be at least 3.3 mEq/L.

Question 47Management of Acute and Episodic Medical Emergencies

Which systemic medication should be given early in a moderate-to-severe acute asthma exacerbation?

  1. Oral montelukast
  2. Subcutaneous terbutaline
  3. IV furosemide
  4. Systemic corticosteroids Correct answer.

Explanation

Systemic corticosteroids reduce airway inflammation and are given early to decrease hospitalization and relapse in moderate-to-severe exacerbations. They work in hours and complement, rather than replace, inhaled bronchodilators.

Question 48Management of Acute and Episodic Medical Emergencies

Which is the most common cause of acute upper gastrointestinal bleeding in adults?

  1. Peptic ulcer disease Correct answer.
  2. Esophageal varices
  3. Gastric antral vascular ectasia
  4. Mallory-Weiss tear

Explanation

Peptic ulcer disease accounts for the largest share of acute upper gastrointestinal bleeding. Varices and Mallory-Weiss tears are important but far less common causes.

Question 49Management of Acute and Episodic Medical Emergencies

A patient with an inferior STEMI becomes hypotensive and bradycardic after receiving sublingual nitroglycerin. Which mechanism best explains this response?

  1. Reflex tachycardia from tachyphylaxis
  2. Preload-dependent right ventricular ischemia Correct answer.
  3. Acute papillary muscle rupture with severe regurgitation
  4. Nitrate-induced coronary artery vasospasm, reducing perfusion

Explanation

Inferior infarctions often involve the right ventricle, whose output depends heavily on venous return. Nitrates reduce preload and can precipitate profound hypotension and bradycardia in that setting.

Question 50Management of Acute and Episodic Medical Emergencies

A patient with a confirmed type B aortic dissection has a heart rate of 105 and a blood pressure of 170/95. Which agent is preferred for initial rate and pressure control?

  1. IV esmolol Correct answer.
  2. IV norepinephrine
  3. IV hydralazine
  4. IV nitroglycerin

Explanation

A short-acting beta-blocker such as esmolol is first-line because reducing heart rate lowers the shear stress that propagates the dissection. A vasodilator is added afterward, since vasodilation before rate control can trigger reflex tachycardia and extend the tear.