CEN EXAM 2 PRACTICE QUESTIONS WITH DETAILED EXPLANATIONS 2026
Table of Contents
Cardiovascular Emergencies (Questions 1-15)
Respiratory Emergencies (Questions 16-30)
Neurological Emergencies (Questions 31-45)
Gastrointestinal Emergencies (Questions 46-55)
Genitourinary/Renal Emergencies (Questions 56-65)
Endocrine Emergencies (Questions 66-75)
Toxicological Emergencies (Questions 76-85)
Environmental Emergencies (Questions 86-95)
Shock and Trauma (Questions 96-110)
Psychosocial/Psychiatric Emergencies (Questions 111-120)
OB/GYN Emergencies (Questions 121-130)
CARDIOVASCULAR EMERGENCIES
Question 1
A 68-year-old male presents to the ED with acute onset substernal chest pain radiating to his left jaw, accompanied by
diaphoresis, nausea, and shortness of breath. His initial ECG shows 2-mm ST-segment elevation in leads V1-V4. Which of
the following is the MOST appropriate immediate intervention?
🔴 A) Administer sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses
🔵 B) Immediate transfer to the cardiac catheterization laboratory for percutaneous coronary intervention
🔴 C) Administer thrombolytic therapy with tenecteplase
🔴 D) Start a heparin infusion and admit to the cardiac care unit
Correct Answer: B
Rationale:
Option A (Incorrect): While nitroglycerin is indicated for chest pain, this patient has ST-elevation myocardial infarction
(STEMI) with anterior wall involvement. Nitroglycerin is an adjunctive therapy but does not address the underlying
coronary occlusion and should not delay definitive reperfusion.
Option B (Correct): The ECG findings (ST elevation in V1-V4) indicate an anterior STEMI. The 2023 ACC/AHA guidelines
recommend immediate percutaneous coronary intervention (PCI) within 90 minutes of first medical contact for STEMI
patients. Time is myocardium, and PCI is the gold standard for reperfusion.
Option C (Incorrect): Thrombolytics are indicated when PCI cannot be performed within 120 minutes of first medical
contact. This patient is at a facility with catheterization laboratory capabilities, making PCI the preferred option.
Additionally, thrombolytics carry significant bleeding risks.
Option D (Incorrect): Heparin is a component of STEMI management but is not the definitive intervention. Admit to CCU
without reperfusion would lead to ongoing myocardial necrosis and increased morbidity/mortality.
Clinical Reasoning: This patient's presentation represents an acute STEMI. Anterior wall MI (leads V1-V4) suggests left
anterior descending artery involvement, which carries a higher mortality risk. The immediate priority is restoring coronary
,perfusion through PCI. The "door-to-balloon" time should be under 90 minutes. Concurrent interventions should include
aspirin, heparin, oxygen if SpO2 < 90%, and morphine for pain control.
Exam Tip: In STEMI management, remember the "MONA" mnemonic (Morphine, Oxygen, Nitroglycerin, Aspirin) is outdated
—oxygen should only be given if hypoxic. Focus on rapid reperfusion and antiplatelet therapy.
Question 2
A 55-year-old female with a history of hypertension and diabetes presents with palpitations, chest discomfort, and
dizziness. Her ECG shows a narrow-complex tachycardia at 180 bpm with no visible P waves. She is hemodynamically stable
with a blood pressure of 110/70 mmHg. Which of the following is the MOST appropriate initial management?
🔴 A) Immediate synchronized cardioversion at 100 J
🔵 B) Vagal maneuvers followed by adenosine 6 mg IV push
🔴 C) Amiodarone 150 mg IV bolus over 10 minutes
🔴 D) Verapamil 5 mg IV push
Correct Answer: B
Rationale:
Option A (Incorrect): Synchronized cardioversion is indicated for unstable patients with narrow-complex tachycardia who
have signs of hemodynamic compromise (hypotension, altered mental status, chest pain, signs of shock). This patient is
hemodynamically stable.
Option B (Correct): This ECG pattern (narrow-complex tachycardia at 180 bpm, no visible P waves) is consistent with
supraventricular tachycardia (SVT), most commonly atrioventricular nodal reentrant tachycardia (AVNRT). The 2020 AHA
guidelines recommend vagal maneuvers as first-line therapy in stable patients, followed by adenosine 6 mg rapid IV
push. Adenosine transiently blocks the AV node and terminates reentrant arrhythmias.
Option C (Incorrect): Amiodarone is a class III antiarrhythmic used for ventricular arrhythmias and atrial fibrillation with
rapid ventricular response. It is not the first-line agent for stable narrow-complex SVT. If adenosine fails, second-line
options include calcium channel blockers or beta-blockers.
Option D (Incorrect): Verapamil is a calcium channel blocker that can be used for SVT but is not the first-line agent due
to the higher efficacy and shorter half-life of adenosine. Adenosine's rapid onset and short duration make it preferred for
diagnostic and therapeutic purposes.
Clinical Reasoning: Narrow-complex tachycardia with absence of P waves suggests SVT. The reentry circuit often involves
the AV node. Adenosine's mechanism—slowing conduction through the AV node—can break the reentry circuit.
Administration requires rapid IV push followed by a saline flush, with ECG monitoring for transient asystole or bradycardia
(expected and self-limited). If adenosine fails, the dose can be repeated at 12 mg.
Exam Tip: Always differentiate between stable and unstable tachyarrhythmias. For stable SVT: vagal maneuvers →
adenosine 6 mg → adenosine 12 mg → calcium channel blockers/beta-blockers. For unstable: synchronized cardioversion.
Question 3
A 72-year-old male with a history of heart failure presents with progressive shortness of breath, orthopnea, and bilateral
lower extremity edema. On examination, he has jugular venous distention, crackles in both lung bases, and an S3 gallop. His
oxygen saturation is 88% on room air. Which of the following is the MOST appropriate INITIAL intervention?
🔴 A) Administer intravenous furosemide 40 mg
🔵 B) Apply noninvasive positive pressure ventilation (NIPPV)
,🔴 C) Administer sublingual nitroglycerin 0.4 mg
🔴 D) Place the patient in a supine position
Correct Answer: B
Rationale:
Option A (Incorrect): While furosemide is a standard treatment for acute decompensated heart failure (ADHF),
respiratory distress with hypoxia is the immediate life-threatening concern. NIPPV (e.g., CPAP or BiPAP) provides
immediate respiratory support and improves oxygenation while diuretics take effect.
Option B (Correct): This patient is in acute decompensated heart failure with pulmonary edema (evidenced by crackles,
hypoxia, S3 gallop, JVD). NIPPV is the first-line intervention for severe respiratory distress in ADHF. It reduces preload,
improves oxygenation, decreases work of breathing, and may prevent the need for intubation.
Option C (Incorrect): Sublingual nitroglycerin can reduce preload and alleviate symptoms but does not address the
immediate hypoxia and respiratory distress. In severe cases, IV nitroglycerin may be indicated, but oxygenation is the
priority.
Option D (Incorrect): Supine positioning would worsen pulmonary congestion and dyspnea. Patients with ADHF should
be positioned upright or semi-Fowler's to reduce venous return and improve ventilation-perfusion matching.
Clinical Reasoning: This patient is in acute decompensated heart failure with pulmonary edema. The presence of hypoxia
(SpO2 88%) and significant respiratory distress requires immediate intervention. NIPPV has been shown to reduce mortality
and the need for intubation in ADHF patients. It works by increasing intrathoracic pressure, which reduces preload,
decreases left ventricular afterload, and improves oxygenation. Diuretics, nitrates, and afterload reducers should be initiated
concurrently.
Exam Tip: For ADHF with respiratory failure, NIPPV is the priority before considering intubation. The "end-organ perfusion"
approach—assess respiratory status first, then hemodynamics.
Question 4
A 45-year-old male with no significant medical history presents with sudden-onset, severe "tearing" chest pain that radiates
to his back. His blood pressure is 160/95 mmHg in the right arm and 100/60 mmHg in the left arm. He has a diastolic
murmur on cardiac auscultation. Which of the following is the MOST likely diagnosis?
🔴 A) Acute myocardial infarction
🔵 B) Aortic dissection
🔴 C) Pulmonary embolism
🔴 D) Pericarditis
Correct Answer: B
Rationale:
Option A (Incorrect): While chest pain is a feature of MI, the tearing quality, radiation to the back, and blood pressure
differential between arms are more consistent with aortic dissection. MI pain is typically pressure-like or squeezing.
Option B (Correct): The classic presentation of aortic dissection includes sudden, severe, tearing chest or back pain,
blood pressure differential between arms (>20 mmHg difference), and a new aortic regurgitation murmur. The difference
in blood pressures suggests involvement of the aortic arch with branch vessel compromise. This is a life-threatening
emergency requiring immediate surgical consultation.
Option C (Incorrect): Pulmonary embolism typically presents with pleuritic chest pain, dyspnea, tachycardia, and hypoxia.
The tearing pain and blood pressure differential are not characteristic of PE.
Option D (Incorrect): Pericarditis presents with sharp, pleuritic chest pain that is positional (worse supine, better sitting
forward). It may have a friction rub. The tearing quality and blood pressure differential are not typical.
, Clinical Reasoning: Aortic dissection is a catastrophic emergency with high mortality. The Stanford classification
distinguishes Type A (ascending aorta involvement) requiring emergent surgery and Type B (descending aorta) often
managed medically. This patient's blood pressure differential and diastolic murmur (aortic regurgitation) suggest Type A
dissection involving the aortic root. Immediate interventions include pain control, blood pressure management (target SBP
100-120 mmHg), and surgical consultation. CT angiography is the diagnostic study of choice.
Exam Tip: Patients with aortic dissection require rapid blood pressure reduction using beta-blockers (e.g., esmolol) to
decrease dP/dt, followed by vasodilators (e.g., nitroprusside) if needed. Pain is managed with opioids. Do not delay imaging
for stable patients.
Question 5
A 62-year-old female with a history of atrial fibrillation not on anticoagulation presents with acute onset of right-sided
weakness, facial droop, and aphasia. Her symptoms began 45 minutes ago. Her blood pressure is 185/100 mmHg. Which of
the following is the MOST appropriate management?
🔴 A) Administer IV alteplase and accept the blood pressure
🔵 B) Lower blood pressure to <180/105 mmHg before considering alteplase
🔴 C) Administer aspirin 325 mg chewed
🔴 D) Delay alteplase due to atrial fibrillation history
Correct Answer: B
Rationale:
Option A (Incorrect): Alteplase is contraindicated if blood pressure is >185/110 mmHg due to increased risk of
hemorrhagic conversion. Blood pressure must be controlled prior to thrombolytic administration.
Option B (Correct): This patient presents with acute ischemic stroke symptoms within the 4.5-hour window (45 minutes).
She is a candidate for IV alteplase if eligible. However, her blood pressure of 185/100 mmHg exceeds the threshold for
thrombolysis (systolic >185 or diastolic >110). The AHA guidelines recommend lowering blood pressure to <185/105
mmHg before administering alteplase using agents like labetalol or nicardipine.
Option C (Incorrect): Aspirin is indicated for acute ischemic stroke but should be withheld for 24 hours if the patient
receives thrombolytics due to bleeding risk. Administering aspirin before ruling out hemorrhage or before alteplase
would be inappropriate.
Option D (Incorrect): Atrial fibrillation is a common cause of cardioembolic stroke and does not contraindicate alteplase.
The decision to use thrombolytics is based on time from symptom onset, blood pressure, and other exclusion criteria, not
the presence of atrial fibrillation.
Clinical Reasoning: Acute ischemic stroke management begins with rapid assessment using the NIH Stroke Scale. The "time
is brain" principle mandates rapid decision-making. For patients presenting within 4.5 hours, IV alteplase is the standard of
care if no contraindications exist. Blood pressure control is crucial—the target before thrombolysis is <185/110 mmHg. In
this case, controlled blood pressure reduction (e.g., labetalol 10-20 mg IV) should be initiated immediately.
Exam Tip: Remember the BP thresholds for acute stroke: If a patient is a candidate for thrombolysis, target BP is <185/110.
If not a candidate (outside window or contraindication), permissive hypertension is generally allowed up to 220/120 before
treatment is initiated.
Question 6
A 58-year-old male presents with chest pain, diaphoresis, and nausea. His ECG shows ST depression in leads V1-V4 with T-
wave inversion. Cardiac troponin is elevated at 2.5 ng/mL (normal <0.04). Which of the following is the MOST appropriate
management?
Table of Contents
Cardiovascular Emergencies (Questions 1-15)
Respiratory Emergencies (Questions 16-30)
Neurological Emergencies (Questions 31-45)
Gastrointestinal Emergencies (Questions 46-55)
Genitourinary/Renal Emergencies (Questions 56-65)
Endocrine Emergencies (Questions 66-75)
Toxicological Emergencies (Questions 76-85)
Environmental Emergencies (Questions 86-95)
Shock and Trauma (Questions 96-110)
Psychosocial/Psychiatric Emergencies (Questions 111-120)
OB/GYN Emergencies (Questions 121-130)
CARDIOVASCULAR EMERGENCIES
Question 1
A 68-year-old male presents to the ED with acute onset substernal chest pain radiating to his left jaw, accompanied by
diaphoresis, nausea, and shortness of breath. His initial ECG shows 2-mm ST-segment elevation in leads V1-V4. Which of
the following is the MOST appropriate immediate intervention?
🔴 A) Administer sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses
🔵 B) Immediate transfer to the cardiac catheterization laboratory for percutaneous coronary intervention
🔴 C) Administer thrombolytic therapy with tenecteplase
🔴 D) Start a heparin infusion and admit to the cardiac care unit
Correct Answer: B
Rationale:
Option A (Incorrect): While nitroglycerin is indicated for chest pain, this patient has ST-elevation myocardial infarction
(STEMI) with anterior wall involvement. Nitroglycerin is an adjunctive therapy but does not address the underlying
coronary occlusion and should not delay definitive reperfusion.
Option B (Correct): The ECG findings (ST elevation in V1-V4) indicate an anterior STEMI. The 2023 ACC/AHA guidelines
recommend immediate percutaneous coronary intervention (PCI) within 90 minutes of first medical contact for STEMI
patients. Time is myocardium, and PCI is the gold standard for reperfusion.
Option C (Incorrect): Thrombolytics are indicated when PCI cannot be performed within 120 minutes of first medical
contact. This patient is at a facility with catheterization laboratory capabilities, making PCI the preferred option.
Additionally, thrombolytics carry significant bleeding risks.
Option D (Incorrect): Heparin is a component of STEMI management but is not the definitive intervention. Admit to CCU
without reperfusion would lead to ongoing myocardial necrosis and increased morbidity/mortality.
Clinical Reasoning: This patient's presentation represents an acute STEMI. Anterior wall MI (leads V1-V4) suggests left
anterior descending artery involvement, which carries a higher mortality risk. The immediate priority is restoring coronary
,perfusion through PCI. The "door-to-balloon" time should be under 90 minutes. Concurrent interventions should include
aspirin, heparin, oxygen if SpO2 < 90%, and morphine for pain control.
Exam Tip: In STEMI management, remember the "MONA" mnemonic (Morphine, Oxygen, Nitroglycerin, Aspirin) is outdated
—oxygen should only be given if hypoxic. Focus on rapid reperfusion and antiplatelet therapy.
Question 2
A 55-year-old female with a history of hypertension and diabetes presents with palpitations, chest discomfort, and
dizziness. Her ECG shows a narrow-complex tachycardia at 180 bpm with no visible P waves. She is hemodynamically stable
with a blood pressure of 110/70 mmHg. Which of the following is the MOST appropriate initial management?
🔴 A) Immediate synchronized cardioversion at 100 J
🔵 B) Vagal maneuvers followed by adenosine 6 mg IV push
🔴 C) Amiodarone 150 mg IV bolus over 10 minutes
🔴 D) Verapamil 5 mg IV push
Correct Answer: B
Rationale:
Option A (Incorrect): Synchronized cardioversion is indicated for unstable patients with narrow-complex tachycardia who
have signs of hemodynamic compromise (hypotension, altered mental status, chest pain, signs of shock). This patient is
hemodynamically stable.
Option B (Correct): This ECG pattern (narrow-complex tachycardia at 180 bpm, no visible P waves) is consistent with
supraventricular tachycardia (SVT), most commonly atrioventricular nodal reentrant tachycardia (AVNRT). The 2020 AHA
guidelines recommend vagal maneuvers as first-line therapy in stable patients, followed by adenosine 6 mg rapid IV
push. Adenosine transiently blocks the AV node and terminates reentrant arrhythmias.
Option C (Incorrect): Amiodarone is a class III antiarrhythmic used for ventricular arrhythmias and atrial fibrillation with
rapid ventricular response. It is not the first-line agent for stable narrow-complex SVT. If adenosine fails, second-line
options include calcium channel blockers or beta-blockers.
Option D (Incorrect): Verapamil is a calcium channel blocker that can be used for SVT but is not the first-line agent due
to the higher efficacy and shorter half-life of adenosine. Adenosine's rapid onset and short duration make it preferred for
diagnostic and therapeutic purposes.
Clinical Reasoning: Narrow-complex tachycardia with absence of P waves suggests SVT. The reentry circuit often involves
the AV node. Adenosine's mechanism—slowing conduction through the AV node—can break the reentry circuit.
Administration requires rapid IV push followed by a saline flush, with ECG monitoring for transient asystole or bradycardia
(expected and self-limited). If adenosine fails, the dose can be repeated at 12 mg.
Exam Tip: Always differentiate between stable and unstable tachyarrhythmias. For stable SVT: vagal maneuvers →
adenosine 6 mg → adenosine 12 mg → calcium channel blockers/beta-blockers. For unstable: synchronized cardioversion.
Question 3
A 72-year-old male with a history of heart failure presents with progressive shortness of breath, orthopnea, and bilateral
lower extremity edema. On examination, he has jugular venous distention, crackles in both lung bases, and an S3 gallop. His
oxygen saturation is 88% on room air. Which of the following is the MOST appropriate INITIAL intervention?
🔴 A) Administer intravenous furosemide 40 mg
🔵 B) Apply noninvasive positive pressure ventilation (NIPPV)
,🔴 C) Administer sublingual nitroglycerin 0.4 mg
🔴 D) Place the patient in a supine position
Correct Answer: B
Rationale:
Option A (Incorrect): While furosemide is a standard treatment for acute decompensated heart failure (ADHF),
respiratory distress with hypoxia is the immediate life-threatening concern. NIPPV (e.g., CPAP or BiPAP) provides
immediate respiratory support and improves oxygenation while diuretics take effect.
Option B (Correct): This patient is in acute decompensated heart failure with pulmonary edema (evidenced by crackles,
hypoxia, S3 gallop, JVD). NIPPV is the first-line intervention for severe respiratory distress in ADHF. It reduces preload,
improves oxygenation, decreases work of breathing, and may prevent the need for intubation.
Option C (Incorrect): Sublingual nitroglycerin can reduce preload and alleviate symptoms but does not address the
immediate hypoxia and respiratory distress. In severe cases, IV nitroglycerin may be indicated, but oxygenation is the
priority.
Option D (Incorrect): Supine positioning would worsen pulmonary congestion and dyspnea. Patients with ADHF should
be positioned upright or semi-Fowler's to reduce venous return and improve ventilation-perfusion matching.
Clinical Reasoning: This patient is in acute decompensated heart failure with pulmonary edema. The presence of hypoxia
(SpO2 88%) and significant respiratory distress requires immediate intervention. NIPPV has been shown to reduce mortality
and the need for intubation in ADHF patients. It works by increasing intrathoracic pressure, which reduces preload,
decreases left ventricular afterload, and improves oxygenation. Diuretics, nitrates, and afterload reducers should be initiated
concurrently.
Exam Tip: For ADHF with respiratory failure, NIPPV is the priority before considering intubation. The "end-organ perfusion"
approach—assess respiratory status first, then hemodynamics.
Question 4
A 45-year-old male with no significant medical history presents with sudden-onset, severe "tearing" chest pain that radiates
to his back. His blood pressure is 160/95 mmHg in the right arm and 100/60 mmHg in the left arm. He has a diastolic
murmur on cardiac auscultation. Which of the following is the MOST likely diagnosis?
🔴 A) Acute myocardial infarction
🔵 B) Aortic dissection
🔴 C) Pulmonary embolism
🔴 D) Pericarditis
Correct Answer: B
Rationale:
Option A (Incorrect): While chest pain is a feature of MI, the tearing quality, radiation to the back, and blood pressure
differential between arms are more consistent with aortic dissection. MI pain is typically pressure-like or squeezing.
Option B (Correct): The classic presentation of aortic dissection includes sudden, severe, tearing chest or back pain,
blood pressure differential between arms (>20 mmHg difference), and a new aortic regurgitation murmur. The difference
in blood pressures suggests involvement of the aortic arch with branch vessel compromise. This is a life-threatening
emergency requiring immediate surgical consultation.
Option C (Incorrect): Pulmonary embolism typically presents with pleuritic chest pain, dyspnea, tachycardia, and hypoxia.
The tearing pain and blood pressure differential are not characteristic of PE.
Option D (Incorrect): Pericarditis presents with sharp, pleuritic chest pain that is positional (worse supine, better sitting
forward). It may have a friction rub. The tearing quality and blood pressure differential are not typical.
, Clinical Reasoning: Aortic dissection is a catastrophic emergency with high mortality. The Stanford classification
distinguishes Type A (ascending aorta involvement) requiring emergent surgery and Type B (descending aorta) often
managed medically. This patient's blood pressure differential and diastolic murmur (aortic regurgitation) suggest Type A
dissection involving the aortic root. Immediate interventions include pain control, blood pressure management (target SBP
100-120 mmHg), and surgical consultation. CT angiography is the diagnostic study of choice.
Exam Tip: Patients with aortic dissection require rapid blood pressure reduction using beta-blockers (e.g., esmolol) to
decrease dP/dt, followed by vasodilators (e.g., nitroprusside) if needed. Pain is managed with opioids. Do not delay imaging
for stable patients.
Question 5
A 62-year-old female with a history of atrial fibrillation not on anticoagulation presents with acute onset of right-sided
weakness, facial droop, and aphasia. Her symptoms began 45 minutes ago. Her blood pressure is 185/100 mmHg. Which of
the following is the MOST appropriate management?
🔴 A) Administer IV alteplase and accept the blood pressure
🔵 B) Lower blood pressure to <180/105 mmHg before considering alteplase
🔴 C) Administer aspirin 325 mg chewed
🔴 D) Delay alteplase due to atrial fibrillation history
Correct Answer: B
Rationale:
Option A (Incorrect): Alteplase is contraindicated if blood pressure is >185/110 mmHg due to increased risk of
hemorrhagic conversion. Blood pressure must be controlled prior to thrombolytic administration.
Option B (Correct): This patient presents with acute ischemic stroke symptoms within the 4.5-hour window (45 minutes).
She is a candidate for IV alteplase if eligible. However, her blood pressure of 185/100 mmHg exceeds the threshold for
thrombolysis (systolic >185 or diastolic >110). The AHA guidelines recommend lowering blood pressure to <185/105
mmHg before administering alteplase using agents like labetalol or nicardipine.
Option C (Incorrect): Aspirin is indicated for acute ischemic stroke but should be withheld for 24 hours if the patient
receives thrombolytics due to bleeding risk. Administering aspirin before ruling out hemorrhage or before alteplase
would be inappropriate.
Option D (Incorrect): Atrial fibrillation is a common cause of cardioembolic stroke and does not contraindicate alteplase.
The decision to use thrombolytics is based on time from symptom onset, blood pressure, and other exclusion criteria, not
the presence of atrial fibrillation.
Clinical Reasoning: Acute ischemic stroke management begins with rapid assessment using the NIH Stroke Scale. The "time
is brain" principle mandates rapid decision-making. For patients presenting within 4.5 hours, IV alteplase is the standard of
care if no contraindications exist. Blood pressure control is crucial—the target before thrombolysis is <185/110 mmHg. In
this case, controlled blood pressure reduction (e.g., labetalol 10-20 mg IV) should be initiated immediately.
Exam Tip: Remember the BP thresholds for acute stroke: If a patient is a candidate for thrombolysis, target BP is <185/110.
If not a candidate (outside window or contraindication), permissive hypertension is generally allowed up to 220/120 before
treatment is initiated.
Question 6
A 58-year-old male presents with chest pain, diaphoresis, and nausea. His ECG shows ST depression in leads V1-V4 with T-
wave inversion. Cardiac troponin is elevated at 2.5 ng/mL (normal <0.04). Which of the following is the MOST appropriate
management?
