Question 1
When recording assessments during the construction of the problem-oriented medical
record, the examiner should:
Response Once the examiner has a list of problems constructed, then an
Feedback:
assessment is made for each unique problem.
Question 2
What finding is unique to the documentation of a physical examination of an infant?
Response The size & characteristic of the fontanel are unique & important in the
Feedback:
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 Pain is subjective & only the patient can rate the perceived severity. Pain,
Feedback:
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 Adolescents are usually reluctant to talk; therefore, the provider should
Feedback:
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 If the patient is well known or if you have been seeing the patient for the
Feedback:
same problem over time, a focused history is appropriate.
Question 6
An example of a complementary care modality is:
Response Complementary care includes acupuncture, aromatherapy, therapeutic
Feedback:
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 Habits are included within the personal &
Feedback:
social history.
Question 8
In This
issues surrounding ethical decision making, beneficence refers to the:
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