b b b b b b b b b b b
AcquiringbMedicalbLanguage,b2eb(Jones)bCha
pterb2 IntroductionbtobHealthbRecords
1) Whatbisbthebimportancebofbhealthbrecords?
A) Theybcontainbinformationbcrucialbtobpatientbcare.
B) Theybcontainbroadmapsbtobabpatient'sbhealthbhistory.
C) Theybprovidebabclearerbpicturebofbthebbestbroutebtobtakebinbfuturebtreatmentbofbthebpatient.
D) Allbofbthese.
E) Nonebofbthese.
Answer:b D
Explanation:b Healthbrecordsbcontainbinformationbcrucialbtobpatientbcare,barebroadmapsbtobabpatient
'sbhealthbhistory,bandbprovidebabclearerbpicturebofbthebbestbroutebtobtakebinbfuturebtreatmentbofbthebpa
tient.
Difficulty:b1bEasy
Topic:bTypesbofbHealthbRecordsbBloom'
s:b Remember
LearningbOutcome:b 02.02bAccessibilit
y:bKeyboardbNavigationbEstbTime:b 0-
1bminute
2) Thebfirstbpartbofbmostbmedicalbnotesbthatbincludesbsuchbinformationbasbmedicalbhistory,bduration
bandbqualitybofbthebproblem,bandbanybexacerbatingborbrelievingbfactorsbforbthatbproblembisbknownbasb
the part.
A) subjective.
B) objective.
C) assessment.
D) plan.
E) nonebofbthese.
Answer:b A
Explanation:b Thebfirstbpartbofbmostbmedicalbnotesbthatbincludesbsuchbinformationbasbmedicalbhis
tory,bdurationbandbqualitybofbthebproblem,bandbanybexacerbatingborbrelievingbfactorsbforbthatbprob
lembisbknownbasbthebsubjectivebpartbofbthebnote.
Difficulty:b1bEasy
Topic:bThebSOAPbMethodb
Bloom's:b RememberbLearn
ingbOutcome:b 02.01
Accessibility:bKeyboardbNavigationbEst
bTime:b 0-1bminute
1
Copyrightb2019b©bMcGraw-
HillbEducation.bAllbrightsbreserved.bNobreproductionborbdistributionbwithoutbthebpriorbwrittenbconsentbofbMcGraw-
HillbEducation.
mynursytest.store
,DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd EditionJones
b b b b b b b b b b b
3) Informationbsuchbasbthebpatient'sbphysicalbexam,banyblaboratorybfindings,bandbimagingbstudiesbp
erformedbduringbthebvisitbwouldbbebcontainedbinbwhichbpartbofbthebdiagnosticbprocess?
A) Subjective
B) Objective
C) Assessment
D) Plan
E) Nonebofbthese
Answer:b B
Explanation:b Informationbsuchbasbthebpatient'sbphysicalbexam,banyblaboratorybfindings,bandbimagi
ngbstudiesbperformedbduringbthebvisitbwouldbbebcontainedbinbthebobjectivebpartbofbthebdiagnosticbp
rocess.
Difficulty:b1bEasy
Topic:bThebSOAPbMethodb
Bloom's:b RememberbLearn
ingbOutcome:b 02.01
Accessibility:bKeyboardbNavigationbEst
bTime:b 0-1bminute
4) Afterbabhealthbcarebproviderbhasbgatheredbinformationbfrombthebpatientbandbperformedbanybneces
sarybinvestigations,bthebhealthbcarebproviderbthenbformulatesba(n)
,bwhichbcouldbbebabdiagnosis,bidentificationbofbthebproblem,borbabdifferentialbdiagnosis.
A) subjective
B) objective
C) assessment
D) plan
E) nonebofbthese
Answer:b C
Explanation:bAfterbabhealthbcarebproviderbhasbgatheredbinformationbfrombthebpatientbandbperfo
rmedbanybnecessarybinvestigationsb(forbexample:bphysicalbexams,blaboratorybstudies,borbimagi
ngbstudies),bthebhealthbcarebproviderbthenbformulatesbanbassessment,bwhichbcouldbbebabdiagnos
is,bidentificationbofbthebproblem,borbabdifferentialbdiagnosis.
Difficulty:b1bEasy
Topic:bThebSOAPbMethodb
Bloom's:b RememberbLearn
ingbOutcome:b 02.01
Accessibility:bKeyboardbNavigationbEst
bTime:b 0-1bminute
2
Copyrightb2019b©bMcGraw-
HillbEducation.bAllbrightsbreserved.bNobreproductionborbdistributionbwithoutbthebpriorbwrittenbconsentbofbMcGraw-
HillbEducation.
mynursytest.store
,DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd EditionJones
b b b b b b b b b b b
5) Thebcoursebofbactionbconsistentbwithbabhealthbcarebprovider'sbassessmentbisbknownbasba(n):
A) subjective.
B) objective.
C) assessment.
D) plan.
E) nonebofbthese.
Answer:b D
Explanation:bThebcoursebofbactionbconsistentbwithbabhealthbcarebprovider'sbassessmentbisbknownbas
babplan.
Difficulty:b1bEasy
Topic:bThebSOAPbMethodb
Bloom's:b RememberbLearn
ingbOutcome:b 02.01
Accessibility:bKeyboardbNavigationbEst
bTime:b 0-1bminute
6) WhichbofbthebfollowingbisbFALSEbaboutbthebSOAPbmethod?
A) Diagnosticbworkbinbmedicinebisbverybsimilarbtobthebinvestigativebworkbofbabdetective;bthusbthebS
OAPbmethodbbeginsbwithbanbanalysisbandbendsbwithbcollectingbdatabtobconfirmbthebdiagnosis.
B) MostbmedicalbnotesbsharebabconsistentbpatternbinbtheirborganizationbandblayoutbthatbreflectsbthebS
OAPbthoughtbprocess.
C) SOAPbisbanbacronymbthatbstandsbforbSubjective,bObjective,bAssessment,bandbPlan.
D) SOAPbreflectsbabgeneralbthoughtbprocessbusedbbybmostbmedicalbprofessionals.
E) ThebSOAPbmethodbisbrepeatedbinbeverybhealthbcarebvisitbacrossballbdisciplinesbofbmedicine.
Answer:b A
Explanation:bDiagnosticbworkbinbmedicinebbeginsbwithbdatabcollectionbandbconcludesbwithbanbanalys
is.
Difficulty:b1bEasy
Topic:bThebSOAPbMethodb
Bloom's:b RememberbLearn
ingbOutcome:b 02.01
Accessibility:bKeyboardbNavigationbEst
bTime:b 0-1bminute
3
Copyrightb2019b©bMcGraw-
HillbEducation.bAllbrightsbreserved.bNobreproductionborbdistributionbwithoutbthebpriorbwrittenbconsentbofbMcGraw-
HillbEducation.
mynursytest.store
, DOWNLOAD THE Test Bank for NR Acquiring Medical Language 2nd EditionJones
b b b b b b b b b b b
7) Thebstorybofbthebpatient'sbproblembisbknownbas:
A) chiefbcomplaint.
B) familybhistory.
C) historybofbpresentbillness.
D) reviewbofbhistory.
E) socialbhistory.
Answer:b C
Explanation:b Thebstorybofbthebpatient'sbproblembisbknownbasbthebhistorybofbpresentbillness.bDifficulty:
b1bEasy
Topic:bTypesbofbHealthbRecordsbBloom'
s:b Remember
LearningbOutcome:b 02.03bAccessibilit
y:bKeyboardbNavigationbEstbTime:b 0-
1bminute
8) Abreviewbofbsystemsbis:
A) abdescriptionbofbindividualbbodybsystemsbinborderbtobdiscoverbanybsymptomsbnotbdirectlybr
elatedbtobthebmainbproblem.
B) abrecordbofbhabitsblikebsmoking,bdrinking,bdrugbabuse,bandbsexualbpracticesbthatbcanbimpactbh
ealth.
C) anybsignificantbillnessesbthatbrunbinbthebpatient'sbfamily.
D) otherbsignificantbpastbillnesses,blikebhighbbloodbpressure,basthma,borbdiabetes.
E) thebstorybofbthebpatient'sbproblem.
Answer:b A
Explanation:b Abreviewbofbsystemsbisbabdescriptionbofbindividualbbodybsystemsbinborderbtobdiscoverb
anybsymptomsbnotbdirectlybrelatedbtobthebmainbproblem.
Difficulty:b1bEasy
Topic:bTypesbofbHealthbRecordsbBloom'
s:b Remember
LearningbOutcome:b 02.03bAccessibilit
y:bKeyboardbNavigationbEstbTime:b 0-
1bminute
4
Copyrightb2019b©bMcGraw-
HillbEducation.bAllbrightsbreserved.bNobreproductionborbdistributionbwithoutbthebpriorbwrittenbconsentbofbMcGraw-
HillbEducation.
mynursytest.store