CH 22 Diabetic Emergencies and Altered Mental Status Flashcards
H1). Which patient has least likely suffered a disruption of the reticular activating system?
A. A patient complains of acute-onset slurred speech.
B. A patient complains of frequent absence seizures.
C. An unresponsive patient appears to have overdosed on prescribed painkillers.
D. A patient has sustained minor lacerations from falling off a bicycle.
D. A patient has sustained minor lacerations from falling off a bicycle.
Normal consciousness is regulated by a series of neurologic circuits in the brain that compose the reticular activating system. The RAS is essentially responsible for the functions of staying awake, paying attention, and sleeping. The patient least likely to be suffering a disruption to normal consciousness based on the mechanism of injury is the patient who sustained minor lacerations from a fall off a bicycle. The other patients are presenting with conditions that indicate disruption of normal consciousness.
H2) Which case of altered mental status is least likely to be rapidly correctable by treating the underlying cause?
A. An infant showing no sign of infection or trauma appears to be convulsing and unresponsive.
B. A dehydrated patient is confused.
C. An overdosing patient is unresponsive.
D. A patient suffering an asthma attack is hypoxic and is losing consciousness.
A. An infant showing no sign of infection or trauma appears to be convulsing and unresponsive.
The infant showing no sign of infection or trauma but who is convulsing and unresponsive is least likely to have a rapidly correctable case of altered mental status, because the underlying cause is unclear. The other patients have clear causes for their altered mental status: dehydration, hypoxia, or an overdose.
H3). Which of the following is least necessary for a patient to maintain consciousness? A. Oxygen B. Medication C. Glucose D. Water
B. Medication
Oxygen, glucose, and water are basic requirements for the body to maintain consciousness. A patient may take medication to manage or treat conditions that could lead to a loss of consciousness, but medication in this case is still not as basic a requirement as oxygen, glucose, or water.
H4). Which of the following is the best explanation of how dehydration leads to altered brain function?
A. Water is essential to keep the brain fully expanded.
B. Water is necessary to remove waste products from the brain.
C. Water is necessary to keep brain tissue hydrated.
D. Water is necessary for electrical signals to travel throughout the brain.
C. Water is necessary to keep brain tissue hydrated.
Oxygen, glucose, and water are essential for proper brain function. Water is necessary to keep the brain tissue properly hydrated.
H5). Which of the following statements about altered mental status in pediatric patients is correct?
A. Parents are usually poor historians regarding their children.
B. Altered mentation in pediatric patients will be obvious.
C. Parents are usually the best judges of their children’s mental status.
D. Assess mentation in children just as you would for an adult.
C. Parents are usually the best judges of their children’s mental status.
Children often cannot answer questions as adults can, and altered mental status can sometimes be difficult to assess in children. Parents are usually the best judges of their children’s mentation.
H6). In managing a patient who you have decided has an AVPU of “U,” it will be important to:
A. apply a pressure bandage.
B. administer oxygen by nasal cannula.
C. assess the patient’s position and place an airway adjunct if necessary.
D. use the Cincinnati Prehospital Stroke Scale.
C. assess the patient’s position and place an airway adjunct if necessary.
As you assess the airway and breathing of a patient with altered mental status, you should carefully watch for any indication of inadequate breathing. Remember that as mental status decreases, so may the patient’s ability to control and keep the airway open. Position may be very important in keeping an airway open in a semiconscious patient. Be alert to the possible need for suction, and use airway adjuncts if necessary.
H7). Hyperglycemia is high: A. blood sugar. B. carbohydrates. C. carbon dioxide. D. oxygen.
A. blood sugar.
H8) Diabetes mellitus is also known as: A. sugar diabetes. B. hypoglycemia. C. stroke. D. hyperglycemia.
A. sugar diabetes.
Diabetes mellitus is also called “sugar diabetes” or just “diabetes.” It is the condition brought about by decreased insulin production or the inability of the body cells to use insulin properly. The person with this condition is a diabetic.
H9). Which of the following findings are commonly associated with diabetic ketoacidosis (DKA)? A. Slow breathing B. Rapid breathing C. Low blood sugar D. Overhydration
B. Rapid breathing
DKA is caused by high blood glucose levels. It results in profound dehydration and shock. The associated acidosis also leads to the accumulation of ketones, which in turn leads to rapid breathing, which is intended to “blow off” carbon dioxide.
H10). In diabetic ketoacidosis, shock is usually caused by: A. vasodilation. B. dehydration. C. blood loss. D. vasoconstriction.
B. dehydration.
DKA results in severe dehydration as the body attempts to compensate for high levels of blood glucose. Although these patients are profoundly hypovolemic, they have not lost any blood. Vasodilation or vasoconstriction are not common factors associated with DKA.
H11). Diabetic problems are a common cause of altered mental status. Which of the following statements is true of diabetes mellitus?
A. Type I diabetes is usually acquired in adulthood, and is often controlled by diet and oral medication.
B. Insulin is a hormone secreted by the liver that is needed to move glucose from the blood into the cells.
C. Hypoglycemia, or low blood sugar, may result from too much insulin, which causes glucose to be used up by the cells too rapidly.
D. All patients with type II diabetes require insulin to maintain an appropriate blood sugar level.
C. Hypoglycemia, or low blood sugar, may result from too much insulin, which causes glucose to be used up by the cells too rapidly.
If the patient has taken too much insulin, it will cause the glucose in the bloodstream to enter the cells, thereby dropping the BGL to a dangerous level. Type II diabetes typically occurs in adulthood, and is most commonly managed with diet and oral medication. Not all type II diabetics will require insulin. Insulin is secreted by the pancreas, not the liver.
H12) What is the underlying pathophysiology of DKA? A. Not enough glucagon B. Not enough glycogen C. Too much insulin D. Not enough insulin
D. Not enough insulin
The underlying pathology of DKA is that either the body’s pancreas is not making enough insulin or the insulin that is being created is not working effectively. The result is a clinical condition of elevated blood glucose.
H13) Which of the following statements about blood glucose meters is true?
A. Blood glucose meters are not commonly used.
B. Blood glucose meters are typically unreliable unless administered by specialized personnel in a hospital setting.
C. Blood glucose meters are portable and reliable.
D. People with diabetes typically use blood glucose meters no more than once a day.
C. Blood glucose meters are portable and reliable.
One of the many advances in managing diabetes has been the development of portable, reliable blood glucose meters. People with diabetes now routinely test the level of glucose in their blood at least once a day, and sometimes as often as five or six times a day.
H14) Which of the following readings on a glucometer for a symptomatic diabetic person with diaphoresis or mildly altered mental status would be of concern to the EMT? A. 118 mg/dl B. 108 mg/dl C. 78 mg/dl D. 58 mg/dl
D. 58 mg/dl
A value less than 60 mg/dL (milligrams per deciliter) in a symptomatic diabetic (i.e., a patient with a mild alteration in mental status or who is diaphoretic [sweaty]) is typical of hypoglycemia, and indicates the need for prompt administration of glucose.
H15) A 62-year-old female was found confused and diaphoretic. Her blood glucose level was assessed to be 35 mg/dl. After administering a tube of oral glucose, you should next:
A. perform a reassessment.
B. make sure the patient can swallow.
C. initiate transport.
D. administer a second tube of oral glucose.
A. perform a reassessment.
After giving oral glucose (or any medicine, for that matter), the EMT should start a reassessment phase to determine the patient’s condition and whether any changes have occurred following administration of the medication. The ability to swallow must be assessed before administering oral glucose, not afterward. Transport is reasonable, but the patient should be reassessed first, as many patients who recover their mental status will not wish to be transported. A second tube should not be administered before reassessing.
H16) If a patient becomes unresponsive during administration of oral glucose, the EMT should: A. insert a tongue depressor. B. give oxygen via a nonrebreather mask. C. reassess the airway and breathing. D. repeat the oral glucose.
C. reassess the airway and breathing.
Because there is a risk that an unresponsive patient may aspirate the thick gel, if the patient becomes unresponsive during or after administration, the EMT should closely watch the airway to ensure patency.
H17) A hypoglycemic 15-year-old female has been found unconscious. You should not administer oral glucose, because:
A. the patient needs to consent to glucose administration.
B. the patient is not awake enough to swallow.
C. the patient is severely hypoglycemic.
D. the patient’s problem is too little insulin.
B. the patient is not awake enough to swallow.
The most important decision point in choosing to give oral glucose is the patient’s ability to swallow. Although a severely hypoglycemic patient may desperately need sugar, if she is unable to protect her airway, the administration of oral gel may be the worst thing you can do. We only administer oral glucose to those patients we feel can swallow it and protect their airway from aspiration.
H18) You have a patient with an altered mental status that has developed over the past 23 days, according to family members. He is wearing a medical alert tag that is inscribed with the letters "DM." What is your initial field impression? A. Hyperinsulin episode B. Hyperglycemic episode C. Hypertension episode D. Hyperosmolar episode
B. Hyperglycemic episode
The medical identification tag indicates that this patient is diabetic. A diabetic patient with a slow onset of mental status changes is more likely hyperglycemic then hypoglycemic, owing to the pathology of the disease process and the accumulation of acids that occurs in the hyperglycemic patient.
H19) Which of the following statements is true?
A. A complex partial seizure is often preceded by an aura, which might be a rising sensation in the stomach.
B. A patient tends to experience an aura during the tonic phase of a convulsive seizure.
C. Auras involving bright lights always precede all seizures, whether partial or generalized.
D. A patient tends to experience an aura during the clonic phase of a convulsive seizure.
A. A complex partial seizure is often preceded by an aura, which might be a rising sensation in the stomach.
A complex partial seizure is often preceded by an aura, which might be a rising sensation in the stomach. Auras do not always precede seizures, and they do not always involve a sensation of bright lights, although they might. Auras happen prior to seizures, not during them.
H20) The phase of the seizure in which muscles become contracted and tense is called the: A. tonic phase. B. postictal phase. C. clonic phase. D. preictal phase.
A. tonic phase.
The tonic phase is characterized by muscle rigidity. The patient’s muscles become contracted and tense, and the patient exhibits extreme muscular rigidity with arching of the back. The clonic phase usually involves convulsions. The postictal phase is a period of depressed altered mental status following the clonic phase.
H21) You witness an adult patient experiencing a seizure in which a progressive twitching of his right arm leads to his entire body’s twitching. What can you reasonably say about the seizure’s origin?
A. The beginning of the seizure in the arm has no clinical relevance.
B. The seizure was caused by a stroke on the right side of the brain.
C. The seizure focus likely began in the right hemisphere of his brain.
D. It was a partial seizure that became generalized to the entire body.
D. It was a partial seizure that became generalized to the entire body.
The localized twitching indicates that the seizure began in only one hemisphere. Therefore, you may reasonably conclude that this was a partial seizure that became generalized to the entire body. Remember that the effects of one hemisphere are usually seen on the opposite side of the body, so a problem in the right hemisphere would most commonly be seen on the left side.
H22) A 12-year-old boy experienced a tonic-clonic seizure after being struck in the head with a baseball. Which of the following would most likely be the cause of the seizure? A. Hypoxia B. Epilepsy C. Traumatic brain injury D. Toxins
C. Traumatic brain injury
Given the most recent trauma to the head, you should first suspect traumatic brain injury. Although each of the other issues can cause seizures, here the mechanism of injury specifically points to traumatic brain injury.
H23) If your patient is actively seizing, it may be necessary to:
A. insert a bite block.
B. place the patient on the floor or ground.
C. forcibly restrain the patient.
D. insert a tongue depressor.
B. place the patient on the floor or ground.
Place the actively seizing patient on the floor or ground, but do not try to forcibly restrain the patient. You may position the patient on the side for drainage from the mouth if there is no possibility of spine injury. You should not insert any object into a seizing patient’s mouth.
H24) Which of the following statements about a seizure that is unusually long in duration is correct?
A. Prolonged seizures mean that the patient has a history of seizures.
B. Patients with prolonged seizures have a history of epilepsy, and often require no medical care.
C. Patients with prolonged seizures should be suspected of being off their anti-seizure medication.
D. Prolonged seizures can be life-threatening.
D. Prolonged seizures can be life-threatening.
It is important for the EMT to recognize that seizures that are prolonged, or are associated with life-threatening conditions or injuries such as head injury or stroke, are abnormal and dangerous. Your prompt intervention in the prolonged or abnormal seizure may be lifesaving.
H25) A 52-year-old male complains of not feeling well. Family members state that upon awakening this morning, they noticed that the patient had right-sided facial droop and was slurring his words slightly. The patient states that he is a diabetic, and 5 minutes ago, his blood glucose was 88 mg/dL. After completing the primary assessment, you should next:
A. administer oral glucose.
B. recheck the patient’s blood glucose.
C. complete a Cincinnati Prehospital stroke assessment.
D. administer high-concentration oxygen.
C. complete a Cincinnati Prehospital stroke assessment.
Although the patient is a diabetic, his blood glucose level was within normal limits. You should next complete a Cincinnati Prehospital Stroke assessment. Oxygen is not necessary unless the patient is found to be hypoxic.
H26) A stroke refers to the death or injury of: A. brain tissue. B. a major artery. C. heart muscle. D. a patient.
A. brain tissue.
A stroke refers to the death or injury of brain tissue that is deprived of oxygen. This can be caused by blockage of an artery that supplies blood to part of the brain, or by bleeding from a ruptured blood vessel in the brain.
H27) Which of the following conditions is most likely to lead to a stroke? A. Anemia B. Low blood pressure C. Asthma D. Longstanding high blood pressure
D. Longstanding high blood pressure
Longstanding high blood pressure is a common cause of hemorrhagic stroke.
H28) What mechanism is responsible for most strokes?
A. An artery occluded by a clot or embolism
B. Prolonged hypertension
C. Low blood sugar
D. High blood sugar
A. An artery occluded by a clot or embolism
A stroke caused by a blockage, called an ischemic stroke, can occur when a clot or embolism occludes an artery. This mechanism is responsible for most strokes.
H29) For a stroke patient, what is the most important treatment priority?
A. Rapid transport to an appropriate destination
B. Keeping the patient calm
C. Administering supplemental oxygen, if necessary
D. Monitoring the patient’s airway
A. Rapid transport to an appropriate destination
Stroke is a time-sensitive disorder. That is, the longer a vessel is blocked, the more damage occurs. You should keep this in mind when thinking about your overall treatment plan. Although there may be life threats that need immediate attention, and all of these interventions are important, commonly the most important treatment priority will be rapid transport to an appropriate destination.
H30). Why is it necessary to take the patient to the hospital if the symptoms of a stroke have subsided by the time you arrive on the scene?
A. The patient is likely to start seizing.
B. The patient will need a period of bed rest.
C. The patient still needs assessment and treatment for stroke.
D. The patient will probably need to be given insulin.
C. The patient still needs assessment and treatment for stroke.
If you suspect the patient has had a stroke, it is important to transport the patient promptly and notify the hospital of symptoms you see and the results of the Cincinnati Prehospital Stroke Scale. If you have a choice of hospitals, your protocols may direct you to a hospital capable of providing the most recent stroke treatments.
H31) While assessing a patient using the Cincinnati Prehospital Stroke Scale, you note that the patient has acute-onset facial droop on the left side. This indicates:
A. a normal finding for older patients.
B. that the patient had a previous stroke.
C. a likelihood that the patient is experiencing a stroke.
D. the likelihood that the patient experienced a seizure.
C. a likelihood that the patient is experiencing a stroke.
An abnormal finding in the Cincinnati Prehospital Stroke Scale indicates a strong likelihood of a stroke. The acute onset means that the facial droop is not from a previous stroke.
H32) In assessing a possible stroke patient for arm drift, it is important to have the patient: A. keep both eyes open. B. close both eyes. C. blink rapidly. D. keep one eye open.
B. close both eyes.
H33). For an unconscious stroke patient, you would provide oxygen based on saturation readings and transport the patient as soon as possible. What else should you do?
A. Administer fluids by mouth in order to keep the patient hydrated
B. Refrain from aggressive treatment, to avoid overtreatment
C. Maintain an open airway
D. Administer a clot-busting thrombolytic drug
C. Maintain an open airway
You need to maintain the airway of an unconscious stroke patient in addition to providing oxygen as necessary and transporting the patient. Overtreatment of a suspected stroke patient is always better than ignoring an actual stroke. You would not administer a thrombolytic or administer fluids by mouth to an unconscious patient.
H34). Syncope due to gastrointestinal bleeding is especially common in: A. diabetic patients. B. younger patients. C. older patients. D. otherwise healthy patients
C. older patients.
H35) A 70-year-old male was sitting comfortably when he suddenly had a brief syncopal episode. His vital signs are P 46, R 20, BP 96/60, indicating a slow heart rate but normal respiration and a blood pressure that is not elevated. Which of the following do you suspect caused the syncopal episode? A. Hypovolemia B. DKA C. Cardiac dysrhythmia D. Hypertension
C. Cardiac dysrhythmia
The patient has a slow heart rate on your arrival. This bradycardia is a likely cause of syncope. His blood pressure is not hypertensive. He may be hypovolemic, but the dysrhythmia is more likely. No signs of DKA are present.
H36). A 24-year-old female who has been ill with diarrhea reports increasing dizziness that is made worse by standing up. She has a rapid pulse rate and is diaphoretic. She has no history of diabetes and takes no medications. What is the most likely source of her dizziness? A. Use of recreational drugs B. Low blood sugar C. Hypovolemia D. Stroke
C. Hypovolemia
While there are a few possibilities, hypovolemia is the most likely cause. Although hypoglycemia is possible, her lack of diabetes makes this less likely. Drugs are a possible cause but are also less likely. A stroke is possible, but there are no other neurological findings.
A 73-year-old female complains of a new onset of vertigo, and states that she almost passed out when she tried to stand. She is alert but weak. Her vital signs are P 70, R 20, BP 100/60. Her pulse oximeter reads 95%. The action among the following that it is least necessary to take for this patient is to:
A. administer oxygen.
B. assess the patient’s likelihood to remain stable.
C. lay the patient flat.
D. loosen any tight clothing around the neck.
A. administer oxygen.
The goal for a patient is at least a 94% oxygen saturation level with no signs of respiratory distress, so administering oxygen to this patient is not necessary. The other actions would be necessary to perform.
H38). For a patient complaining of dizziness, what would you ask regarding vomiting?
A. ”Was the vomiting accompanied by an urge to urinate?”
B. ”Is the vomit clear or opaque?”
C. ”Is there blood or material resembling coffee grounds?”
D. ”Is the vomit black and tarry?”
C. ”Is there blood or material resembling coffee grounds?”
PT1) A patient was running a riding lawnmower in a closed garage and experienced dizziness. Immediately after opening the garage door, the patient experienced syncope that lasted for several moments. It is most likely that the cause of the patient's syncope was: A. toxicological. B. metabolic. C. structural. D. hypovolemic.
A. toxicological.
PT2) A 26-year-old female complains of 6 hours of vomiting and diarrhea. She is dizzy and lightheaded but feels better while lying down. What follow-up question would be best to ask if the patient answers yes to the question “Have you had any similar episodes in the past?”
A. ”Do you have panic attacks or anxiety?”
B. ”Do you have a history of substance abuse?”
C. ”What cause was found?”
D. ”Are you diabetic?”
C. ”What cause was found?”
PT3) Which of the following statements is true of paralysis caused by stroke?
A. Typically, paralysis from strokes affects only one side of the body.
B. It is difficult to distinguish stroke from spinal injury, as both can cause paralysis to both legs.
C. It is a good sign when patients experience only weakness in the extremities, as they will not deteriorate further.
D. It is common for both sides of the body to be paralyzed from stroke.
A. Typically, paralysis from strokes affects only one side of the body.
PT4) Aphasia is often seen in: A. hyperglycemic patients. B. hypoglycemic patients. C. syncope patients. D. stroke patients.
D. stroke patients.
PT5) During your physical examination of a diabetic patient, you discover a small device on the patient's belt. There is a catheter from the device into the patient's abdomen. This device is likely: A. an implanted glucometer. B. a pacemaker. C. a feeding tube. D. an insulin pump.
D. an insulin pump.
PT6). A 62-year-old male complains of weakness on one side of his body and slurred speech. After you arrive and evaluate the patient, you notice that the symptoms are beginning to subside. What is the likely cause of the patient's condition? A. Status epilepticus B. Transient ischemic attack C. Acute coronary syndrome D. Subdural hematoma
.B. Transient ischemic attack
PT7). A person in a hypoxic state experiences an altered mental status because in the reticular activating system, oxygen is needed to: A. perfuse the brain tissue. B. nourish the brain tissue. C. hydrate the brain tissue. D. protect the brain tissue.
A. perfuse the brain tissue
PT8). A 66-year-old female displays two findings from the Cincinnati Prehospital Stroke Scale. What do these findings indicate? A. A 100% chance of an acute stroke B. A previous stroke C. Very little chance of an acute stroke D. A 70% chance of an acute stroke
D. A 70% chance of an acute stroke
PT9). A 45-year-old male presents agitated and confused. Your assessment identifies an oxygen saturation of 90%. You should next:
A. administer oxygen.
B. restrain the patient for safety.
C. conduct a Cincinnati Prehospital stroke examination.
D. administer oral glucose.
A. administer oxygen.
PT10). Which of the following substances specifically nourishes the brain to enable consciousness? A. Water B. Glucose C. Oxygen D. Carbon dioxide
B. Glucose
PT11) To optimize the care of a stroke patient who is a potential candidate for thrombolytics, an EMT can determine and document the exact time of: A. arrival on scene. B. taking the patient's vital signs. C. packaging the patient for transport. D. onset of symptoms
D. onset of symptoms.
PT12) The postictal phase of a tonic-clonic seizure involves the patient's transitioning from full loss of consciousness to: A. full mental status. B. hypoxia. C. brain death. D. stroke.
A. full mental status. (Page 635)
Postictal Phase - the period of time immediately following a tonic-clonic seizure in which the patient goes from full loss of consciousness to full mental status
PT13). Which of the following is characterized by sudden, temporary loss of consciousness caused by insufficient blood flow to the brain, with return of consciousness almost immediately on becoming supine?
A. Concussion
B. Transient ischemic attack (TIA)
C. Vasovagal syncope
D. Reversible ischemic neurological disorder (RIND)
C. Vasovagal syncope
PT14). A patient experiencing disorientation and a lowered state of alertness is experiencing a failure of the reticular activating system (RAS), which is responsible for: A. urinary output. B. blood glucose levels. C. hormone levels. D. consciousness.
D. consciousness.
