Quiz 1. Building a Comprehensive Health History
Question 1
When recording assessments during the construction of the problem-oriented medical record,
... [Show More] the examiner should:
Response Feedback:
Once the examiner has a list of problems constructed, then an assessment is made for each unique problem.
Question 2
What finding is unique to the documentation of a physical examination of an infant?
Response Feedback:
The size & characteristic of the fontanel are unique & important in the assessment of an infant. Data on liver span, prostate size, thyroid position, & visual acuity are adult assessment findings.
Question 3
The quality of a symptom, such as pain, is subjective information that should be:
Response Feedback:
Pain is subjective & only the patient can rate the perceived severity. Pain, therefore, should be recorded the history using a 1-to-10 scale.
Question 4
When communicating with older children & teenagers, you should be sensitive to their:
Response Feedback:
Adolescents are usually reluctant to talk; therefore, the provider should clearly communicate a respect for their confidentiality.
Question 5
J.M. has been seen in your clinic for 5 years. She presents today with signs & symptoms of acute sinusitis. The type of history that is warranted is a(n) history.
Response Feedback:
If the patient is well known or if you have been seeing the patient for the same problem over time, a focused history is appropriate.
Question 6
An example of a complementary care modality is:
Response Feedback:
Complementary care includes acupuncture, aromatherapy, therapeutic touch, & herbal medications.
Question 7
Mr. D. complains of a headache. During the history, he mentions his use of alcohol & illicit drugs. This information would most likely belong in the:
Response Feedback:
Habits are included within the personal & social history.
Question 8
In issues surrounding ethical decision making, beneficence refers to the:
Response Feedback:
The definition of beneficence is to do good, not being paternalistic, & the need to avoid harm refers to nonmaleficence. Utilitarianism is the appropriate use of resources for the greater good of the larger community.
Question 9
Which of the following is an effective adjunct to document location of findings during recording of physical examinations?
Response Feedback:
Abnormal or normal findings are best described in relationship to universal topographic & anatomic l&marks.
Question 10
The examiner s evaluation of a patient s mental status belongs in the:
Question 11
Which of the following is considered an IADL but not an ADL?
Response Feedback:
Paying bills is an instrumental activity but not an activity of daily living.
Question 12
Constitutional symptoms in the ROS refer to:
Response Feedback:
General constitutional symptoms refer to fever, chills, malaise, fatigability, night sweats, sleep patterns, & weight (average, preferred, present, change).
Question 13
Which action would best promote accurate translations as well as confidentiality when the caregiver does not speak the patient s language?
Response Feedback:
When you do not speak the patient s language, family members or friends may pose a communication barrier & may have issues of confidentiality; a stranger as an interpreter is less biased.
Question 14
Allergies to drugs & foods are generally listed in which section of the medical record?
Response Feedback:
The past medical history section c [Show Less]