USMLE Step 2 Quiz
Practice Psychiatric Emergencies And Safety in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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A 45-year-old man with a history of major depressive disorder tells his psychiatrist during a routine follow-up, "It's just not worth it anymore. I've been thinking about ending it all. I have my old service pistol in a safe at home, and I think tonight is the night." He appears hopeless and has a flat affect. He has a plan, the means, and clear intent.
What is the most appropriate next step in management?
This quiz focuses on Psychiatric Emergencies And Safety, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
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A 45-year-old man with a history of major depressive disorder tells his psychiatrist during a routine follow-up, "It's just not worth it anymore. I've been thinking about ending it all. I have my old service pistol in a safe at home, and I think tonight is the night." He appears hopeless and has a flat affect. He has a plan, the means, and clear intent.
What is the most appropriate next step in management?
Explanation: This patient is expressing active suicidal ideation with a specific, lethal plan and intent, constituting a psychiatric emergency. The provider's primary responsibility is to ensure the patient's safety, which requires immediate hospitalization. Because the risk is imminent, an involuntary hold is necessary if the patient is unwilling to be admitted voluntarily. A verbal safety plan is insufficient for this level of acute risk. Starting a new medication is not an immediate intervention and will take weeks to become effective. While removing the firearm is important, it does not address the underlying acute suicidality, and the patient could find other means; hospitalization is the definitive safety measure.
A 22-year-old woman is medically stabilized in the emergency department after a serious suicide attempt via overdose. When evaluated by the psychiatrist, she states, "I'm glad it didn't work, but as soon as I get out of here, I'm going to try again. Nothing is going to get better." She refuses to sign in for voluntary psychiatric admission.
What is the most appropriate next step?
Explanation: The patient poses an imminent danger to herself, as evidenced by her recent serious attempt and her stated intent to try again upon release. When a patient with a mental illness is a danger to themselves or others and refuses voluntary treatment, an involuntary psychiatric hold (commitment) is necessary to ensure their safety. Discharging her, even with resources, would be unsafe. Her decision-making is impaired by her severe depression, so her refusal of treatment cannot be considered an autonomous choice. Outpatient management is insufficient for this level of acute risk.
A 28-year-old man with a known history of schizophrenia is brought to the emergency department by police after he was found yelling at strangers. During the interview, he is guarded and paranoid, stating he believes his neighbor is a government agent who plans to harm him. He states, "I need to get him first. I know where he lives, and I'm going to take care of it."
Which of the following factors is the strongest predictor of imminent violence in this patient?
Explanation: While a past history of violence is the single best long-term predictor of future violence, the strongest predictor of imminent violence is active homicidal ideation with a specific plan and an identified victim. This patient's direct threat against his neighbor represents an immediate and serious risk. Medication non-adherence and persecutory delusions are risk factors that increase the overall likelihood of violence, but the specific, articulated threat is the most urgent concern.
A 24-year-old man is brought to the emergency department by friends due to bizarre and aggressive behavior at a party. He is extremely agitated, diaphoretic, and paranoid. His temperature is 38.5°C (101.3°F), heart rate is 130/min, and blood pressure is 170/100 mm Hg. His pupils are dilated. Verbal de-escalation has failed, and he requires chemical restraint for safety.
Which of the following is the most appropriate medication for this patient's agitation?
Explanation: This patient's presentation (agitation, sympathomimetic signs including tachycardia, hypertension, mydriasis, and diaphoresis) is highly suggestive of stimulant intoxication (e.g., cocaine, amphetamines). Benzodiazepines, such as lorazepam, are the first-line treatment for agitation and sympathomimetic toxicity. They reduce agitation, treat hypertension and tachycardia, and prevent seizures. Antipsychotics like haloperidol or olanzapine are second-line and should be used with caution as they can lower the seizure threshold and cause QTc prolongation. Propranolol is contraindicated in cocaine toxicity due to the risk of unopposed alpha-adrenergic stimulation, which can worsen hypertension.
A 50-year-old woman with a known history of bipolar I disorder is found by police wandering in and out of traffic. She is disheveled, speaking in a pressured manner, and has not eaten or slept for several days. She is unable to provide for her basic needs of food and shelter and is unaware of the danger she is in. She denies any suicidal or homicidal ideation.
This patient meets criteria for an involuntary psychiatric hold primarily based on which of the following?
Explanation: The criteria for involuntary commitment are typically danger to self, danger to others, or grave disability. This patient, due to her manic episode, is unable to provide for her basic needs (food, shelter, safety), which is the definition of grave disability. While wandering in traffic is dangerous, the core issue is her inability to care for herself due to mental illness, not a specific intent to self-harm. She is not expressing threats towards others. Refusal of treatment is not a criterion in itself for commitment, but rather a consequence of the underlying condition that meets one of the three main criteria.
A 42-year-old woman being treated with sertraline for depression and linezolid for a skin infection presents to the emergency department with confusion and agitation. On examination, she is diaphoretic with a temperature of 39.0°C (102.2°F). She has inducible clonus and hyperreflexia in her lower extremities.
What is the most likely diagnosis?
Explanation: This patient presents with the classic triad of serotonin syndrome: autonomic dysfunction (hyperthermia, diaphoresis), altered mental status (confusion, agitation), and neuromuscular hyperactivity (clonus, hyperreflexia). This was likely precipitated by the combination of an SSRI (sertraline) and linezolid, which has MAOI properties. NMS is caused by dopamine antagonists and features lead-pipe rigidity. Malignant hyperthermia is related to anesthetics. Anticholinergic toxicity presents with dry skin and mucous membranes, not diaphoresis.
A 26-year-old woman with a history of schizophrenia is brought to the hospital by her family. For the past four days, she has been largely immobile and mute. On examination, she is awake but does not respond to questions. She holds awkward postures for prolonged periods, and when a clinician lifts her arm, it remains in the new position (waxy flexibility). Her vital signs are stable.
What is the most appropriate initial diagnostic and therapeutic intervention?
Explanation: This patient's presentation with mutism, immobility, posturing, and waxy flexibility is classic for catatonia. The lorazepam challenge is a key step in management; a rapid (within 5-10 minutes) and significant improvement in catatonic symptoms after an IV dose of lorazepam (1-2 mg) confirms the diagnosis and is also therapeutic. High-potency antipsychotics can worsen catatonia and may precipitate NMS. An EEG is useful to rule out nonconvulsive status epilepticus, but the lorazepam challenge is the more specific first step. ECT is a highly effective treatment for catatonia, especially malignant catatonia or cases refractory to benzodiazepines, but it is not the initial intervention.
A 72-year-old woman with mild cognitive impairment and no prior psychiatric history is hospitalized for pneumonia. On hospital day 2, she develops acute-onset confusion, anxiety, and visual hallucinations of children playing in her room. Her symptoms are worse in the evening, and her attention is difficult to maintain during the examination.
Which of the following clinical features most strongly suggests delirium over a primary psychotic disorder?
Explanation: The hallmark of delirium is a disturbance in attention and awareness that develops over a short period and tends to fluctuate in severity during the course of the day. While acute onset, visual hallucinations, and lack of prior psychiatric history are all suggestive of delirium, the fluctuating course is the most specific and classic feature that distinguishes it from most primary psychotic disorders, which tend to have a more consistent presentation throughout the day.
A 19-year-old college student presents to the emergency department reporting intense hopelessness for the past month. He states, "I keep thinking about how easy it would be to just walk into traffic." He denies a specific plan or timeline but says he feels unsafe and is afraid he might act on these thoughts. He is willing to accept help.
What is the most appropriate disposition for this patient?
Explanation: This patient has active suicidal ideation with a method, and he explicitly states that he feels unsafe. This meets the criteria for inpatient hospitalization to ensure his safety and initiate treatment. Since he is willing to accept help, voluntary admission is the appropriate and least restrictive option. Discharging him would be unsafe, given his stated fear of acting on his thoughts. Observation in the ED is not a substitute for specialized inpatient psychiatric care. Involuntary commitment is not necessary as he is willing to be admitted voluntarily.
A 35-year-old man is recovering on a medical ward after a serious overdose attempt. A psychiatric consultant finds the patient to be remorseful, stating, "I'm so glad I'm alive. I want to get help so I never get to that place again." He has a strong family support system and has agreed to a detailed safety plan and intensive outpatient treatment upon discharge.
Which of the following is the strongest protective factor against imminent suicide in this patient?
Explanation: Protective factors can buffer individuals from suicidal behavior. While family support and a safe environment are important, the strongest protective factors are internal to the patient. His expression of remorse, future orientation ("never get to that place again"), and willingness to engage in treatment indicate a shift in his mental state and a capacity to form a therapeutic alliance, which significantly lowers his imminent risk. A previous attempt, even if unsuccessful, is a strong risk factor for future suicide, not a protective one.
A 21-year-old patient is brought to the emergency department after a witnessed seizure. The patient is postictal and confused. His friend reports that the patient recently ran out of his "anxiety medication." The patient has a heart rate of 115/min, blood pressure of 150/95 mm Hg, and hand tremors. He is agitated when aroused.
Withdrawal from which of the following substances is the most likely cause of this patient's presentation?
Explanation: This patient's presentation of a seizure, autonomic hyperactivity (tachycardia, hypertension), tremor, and agitation is a medical emergency characteristic of abrupt withdrawal from a CNS depressant. Short-acting benzodiazepines, like alprazolam, are commonly prescribed for anxiety and carry a high risk of a severe withdrawal syndrome, including seizures. Withdrawal from SSRIs like sertraline can cause a discontinuation syndrome (flu-like symptoms, dizziness) but not seizures. Buspirone and propranolol withdrawal do not typically cause seizures.
An 82-year-old man who underwent hip replacement surgery two days ago becomes acutely agitated and confused. He is pulling at his IV lines and yelling for his wife, who passed away several years ago. He is disoriented to time and place. He has no prior psychiatric history.
Which of the following medications is most appropriate for managing this patient's acute agitation?
Explanation: This patient is experiencing delirium, likely secondary to his recent surgery, hospitalization, and potential underlying medical issues. The first-line management of delirium is to identify and treat the underlying cause. For severe agitation that poses a risk to the patient or staff, low-dose antipsychotics (e.g., haloperidol, risperidone, olanzapine) are the preferred pharmacologic treatment. Benzodiazepines like lorazepam can worsen confusion and increase the risk of paradoxical agitation in the elderly. Diphenhydramine has strong anticholinergic properties that will exacerbate delirium. Trazodone is a sedative but is not typically used for acute agitation in delirium.
A 55-year-old man with a history of severe alcohol use disorder is on hospital day 3 following a cholecystectomy. He becomes acutely agitated, tremulous, and diaphoretic. His heart rate is 125/min and blood pressure is 165/100 mm Hg. He is disoriented and reports seeing snakes in the corner of his room.
What is the most appropriate pharmacologic treatment for this patient's condition?
Explanation: This patient is exhibiting signs and symptoms of delirium tremens (DTs), a severe form of alcohol withdrawal. The cornerstone of treatment for alcohol withdrawal and DTs is a benzodiazepine (e.g., lorazepam, diazepam, chlordiazepoxide), which potentiates GABAergic inhibition to counteract the glutamatergic hyperactivity of withdrawal. IV administration is often preferred in severe cases. Antipsychotics like haloperidol can be used for hallucinations but do not treat the underlying withdrawal and can lower the seizure threshold. Alpha-2 agonists (clonidine) and beta-blockers can help control autonomic symptoms but do not prevent seizures or delirium and are not first-line therapy.
A 33-year-old man with acute mania becomes physically aggressive in the emergency department, striking a nurse. He is placed in four-point physical restraints and administered intramuscular olanzapine. An immediate evaluation by a physician is performed.
Which of the following must occur for the continued use of these restraints?
Explanation: The use of physical restraints is a high-risk intervention that requires strict safety protocols. One of the most critical requirements is continuous, in-person, one-to-one monitoring to assess for patient safety, comfort, and readiness for restraint removal. This is mandated to prevent injury, aspiration, or other complications. While a physician order is required (typically within one hour) and regular reassessment is necessary, continuous monitoring is the key procedural safeguard during the restraint episode. A psychiatric consult is appropriate but not the immediate requirement for continuing the restraints. Consent is not required in an emergency, and a court order is not needed for emergency restraint use.
A 34-year-old patient with chronic schizophrenia treated with fluphenazine presents with a temperature of 40.5°C (104.9°F), severe generalized muscle rigidity, confusion, and a blood pressure of 180/110 mm Hg. Laboratory studies show a creatine kinase level of 15,000 U/L.
In addition to discontinuing the offending medication, which of the following is the most important next step in management?
Explanation: This patient's presentation is classic for neuroleptic malignant syndrome (NMS), a life-threatening reaction to dopamine antagonists. The first step is to stop the offending agent. The immediate next priority is aggressive supportive care, including IV fluids for hydration to prevent renal failure from rhabdomyolysis (indicated by the high CK), and cooling measures. Specific treatments like dantrolene or bromocriptine may be considered, but supportive care is paramount. Benztropine is used for dystonia, not NMS. Starting another antipsychotic would worsen the condition. Brain imaging is not the primary intervention.
A 65-year-old woman with a history of depression tells her primary care physician, "With my husband gone and all my health problems, sometimes I just wish I wouldn't wake up in the morning." Upon further questioning, she denies any specific plan, has never made an attempt, and states she would never actively do anything to hurt herself because of her religious beliefs. She has a daughter she speaks to daily.
What is the most appropriate management for this patient?
Explanation: This patient is expressing passive suicidal ideation without a specific plan or intent. She also has strong protective factors, including religious beliefs against suicide and good social support. This level of risk does not typically require inpatient hospitalization. The most appropriate management is to increase the level of outpatient support, such as more frequent visits, ensuring she is engaged in therapy, and developing a safety plan. Dismissing her comments is inappropriate as all suicidal ideation must be taken seriously. An ED visit is not necessary given the lack of acute, high-risk features.
A 29-year-old man with a history of bipolar disorder presents to the emergency department with pressured speech, flight of ideas, and psychomotor agitation. He has not slept for three nights. After verbal de-escalation fails, the decision is made to use chemical restraint. The patient has a history of prolonged QTc on a previous ECG.
Which medication regimen should be avoided in this patient?
Explanation: Many antipsychotics, particularly typical antipsychotics like haloperidol and some atypicals like ziprasidone, are known to prolong the QTc interval, which increases the risk of Torsades de pointes. Given this patient's known history of QTc prolongation, haloperidol carries the highest risk among the options and should be avoided. Olanzapine and risperidone have a lower risk of QTc prolongation than haloperidol. Lorazepam, a benzodiazepine, does not affect the QTc interval and is a safe option for sedation, often used in combination with an antipsychotic.
A 40-year-old man is brought to the clinic by his wife due to increasing anger and paranoia. During the interview, he calmly but firmly states, "My boss is plotting to ruin my life. If he fires me, I will be waiting for him in the parking lot, and I will end him." The patient has access to firearms.
What is the physician's most important legal and ethical responsibility in this situation?
Explanation: This scenario represents a "Tarasoff" situation, where a patient has made a credible, specific threat of serious harm to an identifiable third party. In this case, the physician's "duty to protect" the potential victim overrides patient confidentiality. The physician must take reasonable steps to protect the intended victim, which typically involves notifying the potential victim and law enforcement. While involuntary commitment may also be necessary, the immediate duty is to warn and protect. Prescribing medication is not a sufficient response to an acute homicidal threat.
A 30-year-old man with an unknown medical history is brought to the emergency department by police for agitated behavior. He is pacing, yelling incoherently, and appears suspicious of the medical staff. He is not currently physically threatening anyone but is not cooperative with assessment.
What is the most appropriate initial step in managing this patient's agitation?
Explanation: The initial management of an agitated patient should always begin with the least restrictive intervention possible. Verbal de-escalation, using a calm and non-confrontational approach, should be attempted first as long as the situation is safe for both the patient and staff. If this fails or the patient becomes physically aggressive, chemical or physical restraints may be necessary. Obtaining diagnostic tests is important for determining the underlying cause of agitation but is secondary to ensuring immediate safety.
A 68-year-old man with severe, untreated major depression has a gangrenous diabetic foot ulcer. The surgical team recommends a life-saving below-the-knee amputation. The patient refuses, stating, "It doesn't matter, I'm a worthless person and I deserve to die anyway." He can repeat the risks of refusal but consistently links his decision to feelings of worthlessness.
What is the most appropriate next action?
Explanation: While adults generally have the right to refuse medical treatment, this right depends on their having decision-making capacity. Capacity can be compromised by a psychiatric condition like severe depression. Because the patient's refusal is directly linked to depressive cognitions ("I deserve to die"), there is a strong reason to suspect he lacks capacity to make this specific decision. The most appropriate next step is to obtain a formal psychiatric consultation to assess capacity. Proceeding with a court order is premature without this assessment. Respecting the decision would be inappropriate if it is not capacitous. Waiting for an SSRI to work is not feasible given the urgent, life-threatening nature of the gangrene.