Question 1

Differential diagnoses belong in the:

Accepted Answer

A)  history. 
B)  physical examination. 
C)  assessment. 
D)  plan. 
A)  history. 
B)  physical examination. 
C)  assessment. 
D)  plan. C

Question 2

Which is an example of a problem that requires recording on the patient's problem list?

Accepted Answer

A)  Common age variations 
B)  Expected findings 
C)  Problems needing further evaluation 
D)  Minor variations 
A)  Common age variations 
B)  Expected findings 
C)  Problems needing further evaluation 
D)  Minor variations C

Question 3

George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?

Accepted Answer

A)  GM is a 22-year-old male here for "allergies." 
B)  GM came into the clinic complaining of green discharge for the past 72 hours. 
C)  GM, a 22-year-old male, states that he has allergies and wants them checked. 
D)  GM is a 22-year-old male here for having "green nasal discharge" for the past 72 hours. 
A)  GM is a 22-year-old male here for "allergies." 
B)  GM came into the clinic complaining of green discharge for the past 72 hours. 
C)  GM, a 22-year-old male, states that he has allergies and wants them checked. 
D)  GM is a 22-year-old male here for having "green nasal discharge" for the past 72 hours. D

Question 4

Which format would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Accepted Answer

A)  Brief SOAP note 
B)  Comprehensive health history 
C)  Progress note 
D)  Referral note 
A)  Brief SOAP note 
B)  Comprehensive health history 
C)  Progress note 
D)  Referral note

Question 5

Which part of the information contained in the patient's record may be used in court?

Accepted Answer

A)  Subjective information only 
B)  Objective information only 
C)  Diagnostic information only 
D)  All information 
A)  Subjective information only 
B)  Objective information only 
C)  Diagnostic information only 
D)  All information

Question 6

A detailed description of the symptoms related to the chief complaint is presented in the:

Accepted Answer

A)  history of present illness. 
B)  differential diagnosis. 
C)  assessment. 
D)  general patient information section. 
A)  history of present illness. 
B)  differential diagnosis. 
C)  assessment. 
D)  general patient information section.

Question 7

A SOAP note is used in which type of recording system?

Accepted Answer

A)  Preventive care 
B)  Problem oriented 
C)  Systems review 
D)  Traditional treatment 
A)  Preventive care 
B)  Problem oriented 
C)  Systems review 
D)  Traditional treatment

Question 8

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n):

Accepted Answer

A)  progress note. 
B)  accident report. 
C)  problem-oriented medical record. 
D)  triage note. 
A)  progress note. 
B)  accident report. 
C)  problem-oriented medical record. 
D)  triage note.

Question 9

Data relevant to the social history of older adults includes information on:

Accepted Answer

A)  family support systems. 
B)  previous healthcare visits. 
C)  over-the-counter medication intake. 
D)  date of last cancer screening. 
A)  family support systems. 
B)  previous healthcare visits. 
C)  over-the-counter medication intake. 
D)  date of last cancer screening.

Question 10

Which of the following is not a component of the plan portion of the problem-oriented medical record?

Accepted Answer

A)  Diagnostics ordered 
B)  Therapeutics 
C)  Patient education 
D)  Differential diagnosis 
A)  Diagnostics ordered 
B)  Therapeutics 
C)  Patient education 
D)  Differential diagnosis

Question 11

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to:

Accepted Answer

A)  defer or omit her comments. 
B)  have her husband call you. 
C)  quote her concerns verbatim. 
D)  refer her for psychiatric treatment. 
A)  defer or omit her comments. 
B)  have her husband call you. 
C)  quote her concerns verbatim. 
D)  refer her for psychiatric treatment.

Question 12

Allergies to drugs and foods are generally listed in which section of the medical record?

Accepted Answer

A)  History of present illness 
B)  Past medical history 
C)  Social history 
D)  Problem list 
A)  History of present illness 
B)  Past medical history 
C)  Social history 
D)  Problem list

Question 13

Regardless of the origin, discharge is described by noting:

Accepted Answer

A)  a grading scale of 0 to 4. 
B)  color and consistency. 
C)  demographic data and risk factors. 
D)  associated symptoms in alphabetic order. 
A)  a grading scale of 0 to 4. 
B)  color and consistency. 
C)  demographic data and risk factors. 
D)  associated symptoms in alphabetic order.

Question 14

Which finding is unique to the documentation of a physical examination of an infant?

Accepted Answer

A)  Fontanel size 
B)  Liver span 
C)  Prostate size 
D)  Thyroid position 
A)  Fontanel size 
B)  Liver span 
C)  Prostate size 
D)  Thyroid position

Question 15

The patient's perceived disabilities and functional limitations are recorded in the:

Accepted Answer

A)  problem list. 
B)  general patient information. 
C)  social history. 
D)  history of present illness. 
A)  problem list. 
B)  general patient information. 
C)  social history. 
D)  history of present illness.

Question 16

The review of systems is a component of the:

Accepted Answer

A)  physical examination. 
B)  health history. 
C)  assessment. 
D)  past medical-surgical history. 
A)  physical examination. 
B)  health history. 
C)  assessment. 
D)  past medical-surgical history.

Question 17

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:

Accepted Answer

A)  attention span. 
B)  developmental status. 
C)  nutritional differences. 
D)  source of information. 
A)  attention span. 
B)  developmental status. 
C)  nutritional differences. 
D)  source of information.

Question 18

Which is an effective adjunct to document the location of findings during the recording of the physical examination?

Accepted Answer

A)  Relationship to anatomic landmarks 
B)  Computer graphics 
C)  Comparison with other patients of same gender and size 
D)  Comparison to previous examinations using light pen markings 
A)  Relationship to anatomic landmarks 
B)  Computer graphics 
C)  Comparison with other patients of same gender and size 
D)  Comparison to previous examinations using light pen markings

Question 19

Drawing of stick figures is most useful to:

Accepted Answer

A)  compare findings in extremities. 
B)  demonstrate radiation of pain. 
C)  indicate consistency of lymph nodes. 
D)  indicate mobility of masses. 
A)  compare findings in extremities. 
B)  demonstrate radiation of pain. 
C)  indicate consistency of lymph nodes. 
D)  indicate mobility of masses.

Question 20

A problem may be defined as anything that will require:

Accepted Answer

A)  evaluation. 
B)  medication. 
C)  surgery. 
D)  treatment. 
A)  evaluation. 
B)  medication. 
C)  surgery. 
D)  treatment.

Exam 5: Documentation

Differential diagnoses belong in the:

Which is an example of a problem that requires recording on the patient's problem list?

George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?

Which format would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Which part of the information contained in the patient's record may be used in court?

A detailed description of the symptoms related to the chief complaint is presented in the:

A SOAP note is used in which type of recording system?

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n):

Data relevant to the social history of older adults includes information on:

Which of the following is not a component of the plan portion of the problem-oriented medical record?

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to:

Allergies to drugs and foods are generally listed in which section of the medical record?

Regardless of the origin, discharge is described by noting:

Which finding is unique to the documentation of a physical examination of an infant?

The patient's perceived disabilities and functional limitations are recorded in the:

The review of systems is a component of the:

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:

Which is an effective adjunct to document the location of findings during the recording of the physical examination?

Drawing of stick figures is most useful to:

A problem may be defined as anything that will require:

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Clinical Reasoning

Vital Signs and Pain Assessment

Mental Status

Growth, Measurement, and Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting it All Together

Emergency or Life-Threatening Situations

Filters