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healthassessquiz1
Question | Answer |
---|---|
Subjective data, as well as symptomatic data, should be placed in the _________ section | history section |
The quality of a symptom, such as pain is ____information that should be described in the _________ section | subjective data, history |
Which is an effective adjunct to document location of findings during the recording of the physical exam | relationship to anatomic landmarks |
The position on a clock, topographic notations and anatomic landmarks are methods for ______ | recording locations of findings |
regardless of origin, discharge is described by noting | oolor and consistency |
drawing of stick figures is most useful to | compare findings in extremities |
findings of an unknown origin should be recorded on the patients _______ | problem list |
a problem may be defined as anything that will require: | evaluation |
differential diagnoses belong in the ______ | assessment |
When recording assessments during the construction of the problem-oriented medical record, the examiner should: | create an assessment for each problem on the problem list. |
Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n): | PROGRESS NOTE |
detailed description of the symptoms related to the chief complaint is presented in the: | history of present illness |
The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the medical record? | history of present ilness |
The patient’s perceived disabilities and functional limitations are recorded in the: | past medical history |
The review of systems is a component of the: | health history |
Allergies to drugs and foods are generally listed in which section of the medical record? | past medical history |
Information such as education and economic condition is part of | personal and social |
Information recorded about an infant differs from that recorded about an adult, mainly because of the infant’s: | developmental status |
In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data? | present problem |
Data relevant to the social history of older adults include information on: | family support systems |
A SOAP note is used in which type of recording system? | problem oriented |
The examiner’s evaluation of a patient’s mental status belongs in the: | physical examination |
follow-up visits for problems identified in the POMR are recorded in the_________ | progress notes |
Documentation of the _________ should always be done by using the patient’s own words in quotation marks. | chief complaint |
When using the mnemonic OLDCARTS, the A stands for ____________________. | aggravating an associated factors |
The duties of care providers established by tradition, and within the context of culture, are known as: | deontological imperatives |
When are open-ended questions generally most useful? | during the initial part of the interview |
Behaviors that diffuse anxiety during the interview include: | providing forthright answers to questions |
Periods of silence during the interview can serve important purposes, such as: | providing times for reflextion |
a woman complains that she has had crushing chest pain for the past 2 days. She seems nervous as she speaks to you. An appropriate response is to: | continue to collect information regarding the chief complaint in an unhurried manner. |
When interviewing older adults, the examiner should: | position himself facing the patient |
The iatrotropic stimulus refers to the: | the patients stimulus to seek care |
A pt complains of a headache. During the history, he mentions his use of alcohol and illicit drugs. This information would most likely belong in the: | personal and social history. |
A pt. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the: | CAGE questionnaire |
A tool used to screen adolescents for alcoholism is the: | CRAFFT |
Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of daily living (ADLs) is part of a(an): | functional assessment |
If the patient is well known or if you have been seeing the patient for the same problem over time, a __________ is appropriate | focused history |
A fixed image of any group that rejects its potential for originality or individuality is known as a(n): | sterotype |
Which group is traditionally considered to be past oriented? | eastern asians |
Which group is characterized as emphasizing accomplishments that are measured by external standards? | dominant americans |
Mr. Jones is a 45-year-old patient who presents to the office. A person’s definition of illness is likely to be most influenced by: | enculturation |
As the health care provider, you are informing a patient that he or she has a terminal illness. This discussion is most likely to be discouraged in which cultural group? | Navajo Native Americans |
Tuberculosis is an example of a "___" condition | cold |
The duties of care providers established by tradition, and within the context of culture, are known as: | deontological imperatives |
The iatrotropic stimulus refers to the: | patient’s stimulus to seek care. |
________ is used to screen adolescents for important issues in their life | PACES |
the process by which an individual assumes the traits and behaviors of a given culture | enculturation |
Penicillin is an example of a ____ medicine. | “hot” |
The ____________ position places the left ventricle closer to the chest wall and is recommended for auscultating low-pitched sounds, such as the third and fourth heart sounds. | left lateral recumbent |
Which part of the examiner's hand is best for palpating vibration | Ulnar surface |
Which part of the examiners hand is best for assessing temperature? | dorsal surgace |
which part would the examiner use to feel vibratory sensations such as thrills and fremitus? | Ulnar surface of the hand and bases of the fingers |
which part of the hand is best for palpating pulses? | finger pads and fingertips |
the _____ surface is best for assessing crepitus | palmer surface |
the _____ surface is best for assessing texture | palmer |
the _____ surfaces of the hand and fingers are best for assessing vibrations | ulnar surface |
. Less dense tissue (such as that over normal lungs) produces a ____ tone | loud |
More dense tissue such as a muscle produces a ____ tone | softer |
The more dense the medium, the _____ is the percussion tone | softer |
The more hollow the area, the _____ is the percussion tone | louder |
Percussion tones over muscle are ___ and ___ | soft and flat |
an expected normal percussion tone includes ______ over an empty stomach | tympany |
A normal lung produces _________ percussion tones | resonance |
_______ indicates atelectasis of the lung | dullness |
______ occurs over muscle | flatness |
Place the palmar surface of the nondominant hand on the body surface with the fingers slightly spread apart when using ________ or ________ percussion | mediate, indirect |
During percussion, the downward snap of the striking fingers should originate from the: | wrist |
Fist percussion is a ______ percussion technique used to elicit tenderness over organs such as the liver, gallbladder, or kidneys. | direct |
When sounds are not clear, and you are having difficulty distinguishing between respirations and heartbeats you can: | isolate each cycle segment |
Underestimation of blood pressure will occur if the cuff’s width covers: | more than two thirds of the upper arm |
A blood pressure cuff bladder should be long enough to: | cover 75% to 80% of the arm circumference |
Rotating the lens selector compensates for______ or ______ in both the examiner and the patient | myopia or hyperopia |
The _________ permits recognition of hemorrhages. | red-free filter |
the _____ estimates the size of lesions | grid |
The _______ examines the anterior eye and assesses the elevation of lesions | slit lamp |
the _______ is used with small pupils. | small aperture |
Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure: | hearing range of normal speech |
To perform a deep tendon reflex measurement, you should: | briskly tap the tendon with the rubber end of the hammer. |
A variant of a percussion hammer is a ____ hammer | neurologic |
a neurologic hammer is equipped with a _____ and ______ | brush and needle |
The most effective procedure to ensure correct serial measurements is to: | mark the borders of the tape at several intervals on the skin with a pen. |
___________ functions to differentiate between various media in a cavity. It can distinguish between air, fluid, and tissue. | Transillumination |
if the patient is experiencing symptoms of autonomic hyperreflexia, then the first reaction should be for the examiner to: | remove the source of the stimulation. |
Reactions to a cold, hard examination table or cold stirrups; insertion of a speculum; and pressure during pelvic examinations can cause ___________. | autonomic hyperreflexia |
The stethoscope’s diaphragm is most useful in the assessment of __________ sounds. | high-pitched |
When recording assessments during the construction of the problem-oriented medical record, the examiner should: | create an assessment for each problem on the problem list |
A differential diagnosis is part of the __________ phase. | assessment |
A second visit with the clinician is always recorded on a ________, noting any updates to the condition. | progress note |
The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the medical record? | History of present illness |
The patient’s perceived disabilities and functional limitations are recorded in the: | past medical history. |
The review of systems is a component of the: | health history |
to drugs and foods are generally listed in which section of the medical record? | past medical history |
A SOAP note is used in which type of recording system? | problem oriented |
Mental status assessment, including cognitive and emotional stability and speech and language, is part of the __________. | physical examination |
Follow-up visits for problems identified in the ____ are recorded in the progress notes. | POMR |