NURS 522 ADVANCED HEALTH
ASSESSMENT EXAM 1 QUESTIONS AND
CORRECT ANSWERS
What is included in examination of the ears? - CORRECT ANSWER-
The Auricle. Inspect the auricle. If you suspect otitis:
■ Move the auricle up and down, and press on the tragus.
■ Press firmly behind the ear.
Ear Canal and Drum. Pull the auricle up, back, and slightly out. Inspect,
through an otoscope with speculum:
■ The canal
■ The eardrum
What is included in examination of the nose and sinuses? - CORRECT
ANSWER- Inspect the external nose.
Inspect, through a speculum, the:
■ Nasal mucosa that covers the septum and turbinates, noting its color
and any swelling
■ Nasal septum for position and integrity
Palpate the frontal and maxillary sinuses.
What is included in examination of the mouth and pharynx? -
CORRECT ANSWER- Inspect the:
■ Lips
■ Oral mucosa
■ Gums
■ Teeth
■ Roof of the mouth
■ Tongue, including:
,- Papillae
- Symmetry
- Any lesions
■ Floor of the mouth
■ Pharynx, including:
- Color or any exudate
- Presence and size of tonsils
- Symmetry of the soft palate as patient says "ah"
What is included in examination of the neck? - CORRECT ANSWER-
Inspect the neck.
- Palpate superficial and deep anterior, posterior cervical, and
supraclavicular lymph nodes.
- Inspect and palpate the position of the trachea.
Inspect the thyroid gland:
■ At rest
■ As patient swallows water
From behind the patient, palpate the thyroid gland, including the isthmus,
and first one then the opposite lobe:
■ At rest
■ As patient swallows water
List five general principles of documentation that are based on CMS
guidelines. - CORRECT ANSWER- a. The medical record should be
complete and legible.
b. The documentation of each patient encounter should include the
following:
• Reason for the encounter and relevant history, physical examination
findings, and diagnostic test results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and legible identity of the health-care provider
c. If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred.
d. Past and present diagnoses should be accessible to the treating and
consulting providers.
,e. The patient's progress, response to and changes in treatment, and
revision of diagnoses should be documented.
In addition to other health-care providers, list five different types or
groups of people who could read medical records you create. -
CORRECT ANSWER- a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. -
CORRECT ANSWER- When making a correction in a paper record,
you should draw a single line through the text that is erroneous, initial
and date the entry, and label it as an error. If there is room, you may
enter the correct text in the same area of the note. You should not write
in the margins of a page; if there is no room to enter the correct text, use
an addendum to record the information. You should never obliterate an
original note, nor should you use correction fluid or tape.
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS
guidelines? - CORRECT ANSWER- Acceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical
record? - CORRECT ANSWER- Acceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an
entry in a record? - CORRECT ANSWER- Unacceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a
patient? - CORRECT ANSWER- Acceptable
, Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record? -
CORRECT ANSWER- Unacceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"? -
CORRECT ANSWER- Unacceptable
True or False? CPT codes reflect the level of evaluation and
management services provided. - CORRECT ANSWER- False
True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination. -
CORRECT ANSWER- False
True or False? Time spent counseling the patient and the nature of the
presenting problem are two factors that affect the level of service
provided. - CORRECT ANSWER- True
True or False? ICD codes indicate the reason for patient services. -
CORRECT ANSWER- True
True or False? The ICD-10 code set has more than 155,000 codes, but it
does not have the capacity to accommodate new diagnoses and
procedures. - CORRECT ANSWER- False
True or False? The medical record must include documentation that
supports the assessment. - CORRECT ANSWER- True
True or False? Assignment of appropriate CPT and ICD codes that
support the level of E/M services provided is dependent only on
adequate documentation of the history and physical examination. -
CORRECT ANSWER- False
True or False? An ICD code should be as broad and encompassing as
possible. - CORRECT ANSWER- False
ASSESSMENT EXAM 1 QUESTIONS AND
CORRECT ANSWERS
What is included in examination of the ears? - CORRECT ANSWER-
The Auricle. Inspect the auricle. If you suspect otitis:
■ Move the auricle up and down, and press on the tragus.
■ Press firmly behind the ear.
Ear Canal and Drum. Pull the auricle up, back, and slightly out. Inspect,
through an otoscope with speculum:
■ The canal
■ The eardrum
What is included in examination of the nose and sinuses? - CORRECT
ANSWER- Inspect the external nose.
Inspect, through a speculum, the:
■ Nasal mucosa that covers the septum and turbinates, noting its color
and any swelling
■ Nasal septum for position and integrity
Palpate the frontal and maxillary sinuses.
What is included in examination of the mouth and pharynx? -
CORRECT ANSWER- Inspect the:
■ Lips
■ Oral mucosa
■ Gums
■ Teeth
■ Roof of the mouth
■ Tongue, including:
,- Papillae
- Symmetry
- Any lesions
■ Floor of the mouth
■ Pharynx, including:
- Color or any exudate
- Presence and size of tonsils
- Symmetry of the soft palate as patient says "ah"
What is included in examination of the neck? - CORRECT ANSWER-
Inspect the neck.
- Palpate superficial and deep anterior, posterior cervical, and
supraclavicular lymph nodes.
- Inspect and palpate the position of the trachea.
Inspect the thyroid gland:
■ At rest
■ As patient swallows water
From behind the patient, palpate the thyroid gland, including the isthmus,
and first one then the opposite lobe:
■ At rest
■ As patient swallows water
List five general principles of documentation that are based on CMS
guidelines. - CORRECT ANSWER- a. The medical record should be
complete and legible.
b. The documentation of each patient encounter should include the
following:
• Reason for the encounter and relevant history, physical examination
findings, and diagnostic test results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and legible identity of the health-care provider
c. If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred.
d. Past and present diagnoses should be accessible to the treating and
consulting providers.
,e. The patient's progress, response to and changes in treatment, and
revision of diagnoses should be documented.
In addition to other health-care providers, list five different types or
groups of people who could read medical records you create. -
CORRECT ANSWER- a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. -
CORRECT ANSWER- When making a correction in a paper record,
you should draw a single line through the text that is erroneous, initial
and date the entry, and label it as an error. If there is room, you may
enter the correct text in the same area of the note. You should not write
in the margins of a page; if there is no room to enter the correct text, use
an addendum to record the information. You should never obliterate an
original note, nor should you use correction fluid or tape.
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS
guidelines? - CORRECT ANSWER- Acceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical
record? - CORRECT ANSWER- Acceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an
entry in a record? - CORRECT ANSWER- Unacceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a
patient? - CORRECT ANSWER- Acceptable
, Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record? -
CORRECT ANSWER- Unacceptable
Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"? -
CORRECT ANSWER- Unacceptable
True or False? CPT codes reflect the level of evaluation and
management services provided. - CORRECT ANSWER- False
True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination. -
CORRECT ANSWER- False
True or False? Time spent counseling the patient and the nature of the
presenting problem are two factors that affect the level of service
provided. - CORRECT ANSWER- True
True or False? ICD codes indicate the reason for patient services. -
CORRECT ANSWER- True
True or False? The ICD-10 code set has more than 155,000 codes, but it
does not have the capacity to accommodate new diagnoses and
procedures. - CORRECT ANSWER- False
True or False? The medical record must include documentation that
supports the assessment. - CORRECT ANSWER- True
True or False? Assignment of appropriate CPT and ICD codes that
support the level of E/M services provided is dependent only on
adequate documentation of the history and physical examination. -
CORRECT ANSWER- False
True or False? An ICD code should be as broad and encompassing as
possible. - CORRECT ANSWER- False
